Koda Integrative Therapy Group

Therapeutic Massage and Health Partners for Recovery and Performance

Myofascial Therapy and Stretching: Part of a Recipe for Fascial Release

Myofascial Therapy is a type of technique used to release muscle tissue and focus on reducing muscular shortness and tightness. There are a number of conditions and symptoms that myofascial therapy addresses effectively. Because many of my patients seek myofascial treatment after losing flexibility, or function following a surgery or injury the focus is on returning the muscles around the joint to a more ‘neutral’ place. If you are experiencing ongoing back, shoulder, hip, or virtually pain in any area containing soft tissue - myofascial therapy will help release the adhesion, tension and pain.

Other conditions can also be treated by myofascial therapy include Temporo-Mandibular Joint (TMJ) disorder, Plantar Fasciitis, Carpal Tunnel Syndrome, or symptoms of fibromyalgia or migraine headaches.

A patient’s symptoms can be defined in several ways to include:

  • Tightness of the tissues that restricts motion or pulls the body out of alignment, and this causes individuals to favor and overuse one hip, ankle or shoulder, for example.

  • Pain and tightness that does not allow normal strength or unexplained weakness around a specific joint

  • A sense of excessive pressure on muscles or joints that produces pain and discomfort when moving

  • Pain in any part or parts of the body on a regular basis - this includes headaches or back pain and plantar fascia pain.

Causes of Myofascial Pain

Myofascial pain can have two sources: Pain can be generated from the skeletal muscle or connective tissues (1), because they are 'bound down' by tight or short fascia fibers; or the pain can also be generated from damaged myofascial tissue itself, where a 'trigger point' (2) contracts the muscle fibers over a longer period. In either case, the restriction or contraction inhibits blood flow to the affected structures, thus accentuating the contraction further, and unless the area is treated the constant shortness will create extreme sensitization. Research shows that the most common sport injuries occur connective tissues - joint capsules, ligaments, tendons and other 'fascial structures' can also have this constant tightness and pain. This is everything OTHER than muscles and bones (Schleip 2015a, 2015b). Funny thing is that they are composed basically of the same components as muscles. 

Recent proposals in the sports medicine industry have begun to make fascia a specific target of training, and research. This focus would not only help prevent many injuries but also contribute to longer athletic careers - if the extent of the impact of fascial connections and transmissions of tension between joints and muscles were possible. Continuous participation in fitness activities that many people stop due to injury and aging, would no longer be a decision. When focusing only on the athlete's strength, cardiopulmonary conditioning - for fitness plans, the recovery should focus on increased neuromuscular ability after workouts.

Fascial tissues are getting more deserved attention in the field of sports medicine, because a better understanding of their adaptive dynamics and how they impact mechanical loading is invaluable when making recommendations for bio-mechanical improvements to injury prevention, athletic performance and sports-related rehabilitation. The role of fascial tissues in sports medicine, aims to (1) provide an overview of the contemporary state of knowledge regarding the fascial system from the microlevel (molecular and cellular responses) to the macrolevel (mechanical properties), (2) summarize the responses of the fascial system to altered loading caused by physical exercise, examine (3) the long term changes that lead to injury and other physiological challenges including ageing, (4) outline the methods of interventions that target fascial tissue in sport and exercise medicine.

A comprehensive approach to treating fascial structures in sport training is different than traditional training techniques. The following are examples that show differences (Schleip and Muller 2012; Schleip 2015a, 2015b)

  • Movement to improve elastic recoil

  • Landing as quietly and as softly as possible in jumping activities

  • Controlled bouncing at varied frequencies

  • Emphasis on undulating and rhythmic movement

  • Sensory and proprioceptive refinement in all movement (external methods like 'skin taping,' scraping, rolling, brushing, and including internal methods such as 'breath-initiated' movement).

  • Preparatory counter-movements before primary movements (example, deep squat before jumping; increased shoulder rotation right before you swing a bat)

  • Fascial Stretching - think Active Isolated Stretching (AIS) and Fascial Stretch Therapy (FST)

Fascial Training is included to augment other forms of training, but it is essential to the full spectrum of training possibilities - like cardiovascular, neuromuscular and hypertrophic - it is a tool for recovery. Understanding of mechanical aspects of connective tissue function is important because it depends on the result of interconnected and interwoven connective tissues beyond the sheets or bands of muscles. There is enormous potential to be gained from understanding the concepts of biology that impact the adaptation, function and pathology of the fascia and tissues.

The fascial system includes adipose tissue, adventitia, neurovascular sheaths, aponeuroses, deep and superficial fascia, dermis, epineurium, joint capsules, ligaments, membranes, meninges, myofascial expansions, periostea, retinacula, septa, tendons (including endotendon or peritendon or epitendon or paratendon), visceral fascia, and all the intramuscular and intermuscular connective tissues, including endomysium or perimysium or epimysium.

ELASTIC RECOIL

New research in fascia shows this ‘tissue’ has the ability through tendons, ligaments and aponeuroses, or ligamentous sheaths, to change the distance between muscles and skeletal attachments and allow, or impede, the body to store and release kinetic energy (Schliep, 2015b, 96).

Research evidence supports the idea that aging, injury and over training without proper preparation and recovery can result in a significant decrease in the kinetic energy potential of the body. In other words, changes to muscle tissue like the formation of additional collagen 'cross-links' in the musculoskeletal (i.e. think adhesion or trigger point) impedes the structure or reduces the ‘functional movement.’

Looking at a whole chain of muscles, throughout the body, and their shared stress can show reduction in mobility, range of motion, strength and elasticity and weakness. The adhesions in any of these tissues can reduce the ability of muscles to slide easily past each other, and the missing elasticity can increase risk of tissue tears and other injuries. Increasing stretching is designed to to stimulate and then preserve the elastic recoil enhances optimal performance.

AGING AND FLEXIBILITY

Physiological ageing is a highly individual, the process is characterized by a progressive degeneration (or loss of flexibility) of tissues. Age-related alterations in fascial tissues include densification (altered ‘laxity’ of loose connective tissue - tendons and ligaments) and the fibrosis is altered ‘adhesion’ of collagen or fibrous bundles.  Functional impact of these pathological changes can modify the mechanical properties of fascial tissues and skeletal muscle, AND their impact on the joints. This change in the relationship, whereby the muscles must work harder - or are less adaptable to environmental changes - contributes to pain-related and age-related reductions in muscle force or range of motion. These changes cannot be solely explained by the loss of muscle mass. The ECM - extracellular matrix - becomes the structure between molecules and cellular components that influences much of the connectivity throughout the body. The cross links between joints and muscles and my impact the structural, biochemical, cellular and functional changes occur during ageing.

Age related symptoms are characterized by chronic, low-grade inflammation—the so-called inflammaging most often associated with muscle pain (ie. arthritis, tendonitis, etc).19  As the ECM is the main site of inflammatory responses in tissues, it is not surprising that imflammation in the ECM can interact with immune cells to change their function. This plays an important role in growth and regeneration of tissues (specifically recovery).

Adipose tissue is also a potential source of pro-inflammatory cytokines and has been implicated in a range of musculoskeletal conditions. Osteoarthritis can result from the constant impact to the joints .69 Regardless of the underlying mechanism, fibrotic changes in the muscle have a substantial potential impact on tissue dynamics and force generation capacity.

Stretching of fascial tissues can promote resolution of the inflammation whether in vivo or in vitro. 71  Manual therapy can prevent overuse- and repetitive stress induced fibrosis at several levels of fascial tissues regardless of the age.72 In terms of muscle changes, resistance exercise is necessary to reverse fatty changes (and perhaps fibrosis) in chronic conditions,73 whereas gentle muscle activation is sufficient to reverse early muscle atrophy,74 and whole body exercise can prevent inflammatory changes in back muscles that follow intervertebral disc injuries.75

PLANTAR FASCIA STRETCHES AND RELEASE TECHNIQUES

PLANTAR FASCIA STRETCHES AND RELEASE TECHNIQUES

Balancing the Muscle Movement...Reciprocal Inhibition

The concept of balanced movement is NOT just for Yoga. It appears throughout the body, as a way for functional muscles to prevent injury where the joint fits its function and follows the form of the muscles called into use for posture, exercise, and daily movement. Consider again the shape of the hip and knee...so that we reinforce the action.

Myofascial Trigger Points (MTPs) are associated with reduced efficiency of reciprocal inhibition in the opposing muscles. Muscles exhibiting MTPs may contribute to delayed and incomplete muscle relaxation following exercise, confusion of excellent movement control, and unbalanced muscle activation. Eliminating latent MTPs and prevention of active MTPs from latent motion inhibition will improve motor functions and reduce pain in all situations. I will also prevent further challenges for your clients.

Cycle of Degeneration

When muscles pain develops, because muscles are attached and closely influence joint function in the human body, the impact of dysfunction and pain are interconnected. Myofascial Pain (MFP) caused by motion at one joint is related to actions at adjacent joints, abnormal movements, or compensation. From the lower to upper attachments - and in closer into the core, the more challenged muscles are the more compensation created from, the lower limbs and lower trunk into the upper arms and upper chest the harder the body has to work.

When MFP persists for a reasonable time without treatment, adjacent structures may also evolve secondary problems called satellites TrPs. MFP can impede normal joint motion, cause joint and muscle dysfunction, and lead to joint degeneration, as well a chronic pain.

The Biomechanical Yin/Yang of Muscles in Movement

Muscles fall into three primary groups, and these depend on what they are doing at any given moment. When looking at the bending of the knee: the quadriceps are the agonists and create the movement, during standing while the hamstrings are the antagonists and allow the action to lengthening and support. Vise versa, the Hamstrings become the agonist muscles when the knee bends - or when you sit down, the Quads allow the movement by balancing the contraction of the hamstrings. The adductors are the synergists (and go along for the ride), as do the abductors like the Glutes and Hip Flexors...except they all exert influence throughout the movement to produce the bending and extension of the knee.

Here's the point, for the knee to flex and extend without pain a comfortable range of motion - these muscles have to be balanced. If the hamstrings are too tight, there is an excessive pull at the hips and knee - which doesn't allow contraction (in some cases without pain). If the quads are too tight, then the pull into the hip bones may be too much for the hamstrings to balance the adductors and quadriceps without extra effort. Have you ever wondered by you suddenly feel that your knee 'gives' way, or that your legs are super weak after extended sitting while playing video games? This is the effect of the level of tension being too tight to allow the muscles to move in the way you expected.

The Physiology of Reciprocal Inhibition - and the Balance

The corresponding physiological, biomechanical processes that contribute to pain include prolonged dynamic exercise, and sustained isometric contractions induce muscle fatigue, as manifested by task failure and a reduction in the maximum voluntary contraction force [1,2]. Lower muscle strength and accelerated fatigue development are commonly reported in patients with chronic musculoskeletal pain [3,4], where both latent and active myofascial trigger points (MTPs) contribute significantly to the generation of pain and motor dysfunction [5–7].

Muscle fatigue is prevalent in acute and chronic musculoskeletal pain conditions where Myofascial trigger points (MTPs) are involved and have evolved due to postural and joint laxity. The study aimed to investigate the association of latent MTPs and if muscle fatigue was directly related to the presence of MTPs that are latent - not showing pain referrals. Muscle fatigue may arise not only from peripheral changes at the level of the muscle but also from the central nervous system [10]. Central fatigue may be affected by psychological factors, such as perceived effort or physiological factors, such as inhibition of pathways that prevent efficient activation of motor neuron pools [10]. The fatigue of the shoulder muscles can come from multiple areas of the joint

Of all the shoulder pain trigger points that I have treated, the infraspinatus trigger points are the most effective because they resolve immediate pain. Many patients think that it’s magic when I recreate the pain in the front of their shoulder by pressing on top of the shoulder blade. It’s not magic, of course, it’s just good myofascial pain techniques. If you are not familiar with the “magical” infraspinatus and the symptoms that create pain in opposite areas of the shoulder joint.

The Infraspinatus Muscle

Anatomy & Biomechanics: Let’s begin with a few anatomical and biomechanical details of this muscle. The infraspinatus muscle is found on the back of the shoulder blade and extends laterally to attach to the posterior aspect of the head of the humerus (upper arm) bone. This muscle has two important jobs:

  • Lateral Rotation of the Arm: Contraction of this muscle rotates the arm to the outside at the shoulder. The simple act of raising your hand to wave hello to someone is a good example of the infraspinatus muscle at work (among others).

  • Stabilize the Shoulder Joint: As one of the rotator cuff muscles, the infraspinatus contracts to stabilize the shoulder joint and keep the head of the humerus from slipping out of its socket during shoulder movement.

Syngeristic Muscles: The infraspinatus gets some help with its jobs from some of the other muscles in the shoulder girdle. The teres minor and deltoid (posterior head) muscles assist with lateral rotation of the arm, and the other rotator cuff muscles team up to assist with stabilizing the glenohumeral joint during various arm movements. The major antagonists to the infraspinatus are the subscapularis and pectoralis major muscles, both of which act to medially rotate the arm.

The Infraspinatus Trigger Points & Referred Pain

This muscle has three trigger points, arranged in a triangular pattern within the belly of the muscle. Typically, the lower trigger point is the most common and most active in shoulder pain complaints. Referred pain from these trigger points is experienced deep in the front of the shoulder joint and along the upper arm. The pain may also spill down into the forearm and hand regions in severe cases.

Associated Trigger Points: Prolonged referred pain from these trigger points can activate the deltoid trigger points on the front of the shoulder. Referred pain in the forearm region may also activate wrist trigger points over time, because of the relationship to the subscapularis (discussed in our other blog post).

What Causes Infraspinatus Trigger Points?

As detailed in the “Muscles and Stretching: Trigger Points” article, trigger points are activated (or reactivated) primarily by some form of muscular overload. In the infraspinatus muscle, overload can occur with any activity or event that requires a person to reach backwards with the arm or that keeps the arm raised to the front for long periods. The other is the same motion at lower intensity during a long period of time. Examples include:

  • throwing a baseball or football

  • forehand stroke in tennis

  • walking a large dog that pulls on the leash

  • long hours working at a computer keyboard with no elbow support

  • bracing for a fall or slip by reaching behind the body

  • long drives with the hands positioned on the top of the steering wheel

  • beginning a new resistance training (weight lifting) routine will often overload any of the rotator cuff muscles

Infraspinatus Symptoms & Disorders

Patients/clients with active trigger points in this muscle will present with the following symptoms:

  • Front of Shoulder Pain: This is the hallmark symptom for the infraspinatus trigger points. The pain feels deep within the shoulder joint, causes many clients concern for “strains or sprains” in the shoulder joint itself.

  • Inability to Reach Behind the Back: Clients will report that they are unable to reach behind their back to put on a shirt, or get the purse out of a back seat These movements require significant internal rotation of the shoulder, which stretches the tense muscle and aggravates the trigger points.

  • Inability to Raise Arm Up To Head: Clients will report that they are unable to raise their arm above shoulder height without extreme pain, this prohibits them from brush their teeth, or even to bring food to their mouth without pain.

  • Inability to Push With Arms: Clients will complain of shoulder pain when using their arms to push up when trying to stand out of a chair, or when rising up out of bed in the morning they can’t support their weight. Weight lifting exercises like the bench press, inclined bench press, and military press are nearly impossible with active infraspinatus trigger points.

  • Shoulder Pain at Night: Infraspinatus trigger points can be a double-edged sword when trying to sleep on the side. If the client lays on the affected shoulder, the weight of the upper body can compress the trigger points and produce referred pain. If the client lays on the unaffected shoulder, the upper arm may hangs down in front of the body and places the affected infraspinatus in a prolonged stretched state, aggravating the trigger points again. In severe cases, the client may be forced to sleep in a sitting position to prevent the pain from disturbing their sleep.

  • Bicepital Tendonitis: The role that infraspinatus trigger points play in many cases of bicepital tendonitis deserves special mention. This is characterized by tenderness and pain in the biceps brachii, or the front region of the upper arm, near the shoulder joint. It is prevalent in baseball pitchers, gymnasts, volleyball players, football quarterbacks, and tennis players.

Treatment of the Infraspinatus Trigger Points

It is important for the therapist to check for and address any trigger point activity in the supraspinatus and deltoid muscles after treatment of the infraspinatus trigger points. Deltoid trigger points are likely to form in response to the referred pain from infraspinatus trigger points, and supraspinatus trigger points are nearly always conspicuous in rotator cuff issues.

Myofascial pain syndrome is an important health problem. It affects a majority of the general population, impairs mobility, causes pain, and reduces the overall sense of well-being. Underlying this syndrome is the existence of painful taut bands of muscle that contain discrete, hypersensitive locations called myofascial trigger points. In spite of the significant impact on public health, a clear mechanistic understanding of the disorder does not exist. This is likely due to the complex nature of the disorder which involves the integration of cellular signaling, excitation-contraction coupling, neuromuscular inputs, local circulation, and energy metabolism. The difficulties are further exacerbated by the lack of an animal model for myofascial pain to test mechanistic hypothesis. In this review, current theories for myofascial pain are presented and their relative strengths and weaknesses are discussed. Based on new findings linking mechanoactivation of reactive oxygen species signaling to destabilized calcium signaling, we put forth a novel mechanistic hypothesis for the initiation and maintenance of myofascial trigger points. It is hoped that this lays a new foundation for understanding myofascial pain syndrome and how current therapies work, and gives key insights that will lead to the improvement of therapies for its treatment.

At the cellular level, limitations in energy supply, including the energy available from phosphocreatine hydrolysis, anaerobic glycolysis and oxidative metabolism, as well as the intramuscular build up of metabolic by-products, such as hydrogen ions, become the critical factors of the fatigue in the muscles of the body[11]. MTPs have been reported to showing an increased concentration of algesic substances, including hydrogen ions [12] and muscle ischemia [13] - lack of oxygen associated with sympathetic hyperactivity [14]. Apart from the sensory hypersensitivity at MTPs, latent MTPs are related to abnormal muscle activation pattern [15] and increased resting motoneuron excitability [16]. These mechanisms may predispose taut muscle fibers harboring MTPs to an early onset of muscle fatigue in sustained isometric contractions.

Looking at predisposing and perpetuating factors from chronic overuse or stress injury on muscles helps eliminate the source of the pain. If possible. Pharmacologic treatment of patients with chronic musculoskeletal pain includes analgesics and medications to induce sleep and relax muscles. Antidepressants, neuroleptics, or nonsteroidal anti-inflammatory drugs are often prescribed for patients. Furthermore, the manual treatments above can be used for immediate pain relief.

Nonpharmacologic treatment modalities include acupuncture, osteopathic manual medicine techniques, massage, acupressure, ultrasonography, application of heat or ice, diathermy, transcutaneous electrical nerve stimulation, ethyl chloride Spray and Stretch technique, dry needling, and trigger-point injections with local anesthetic, saline, or steroid. The long-term clinical efficacy of various therapies is not clear, because data that incorporate pre- and post-treatment assessments with control groups are not available.

Infraspinatus in Movement

Infraspinatus in Movement

Self-Care with Trigger Point Ball on the Infraspinatus

Self-Care with Trigger Point Ball on the Infraspinatus

Compression on the Skin for Manual Therapy release.

Compression on the Skin for Manual Therapy release.

Muscles, Stretching and the Opposing Forces - Pt 1

Other posts have introduced the mechanics of a movement - and why stretches work to balance action. It was an essential discussion, but let's say for the sake of argument that if we keep this to the things that you can impact - it's better for everyone. We don't typically use ballistic stretching outside of PT and Strength Training appointments. Massage and Neuromuscular therapy do use Passive, and PNF stretches regularly.

We mentioned before that one of the benefits of massage is increased circulation, an increase in the movement of nutrients and lymph (by-product movement) for up to 72 hours after a therapy treatment. The additional impact of stretching is in the production of endorphins, which are the feel-good products involved in the neuroendocrine system. The output of these 'endocrine' factors is responsible for the feeling right, response to relaxing muscles that most people associate with relaxation. The release of these molecules provides 'lock-and-key' receptors on the surface of ALL cells within the central nervous system. Gates on the cell membrane allow endorphins to pass into the nerve cell, where they affect the system by attaching to receptors at the synaptic cleft. In short, they unleash a response or wave of 'resting' potential via the muscle if the rest of the energy and molecules like Na (Sodium) and ATP are present. So the motor end-plate and therefore the muscle belly can return to the non-contracted length and prepare for the next movement from a neutral position (ideal).

The Muscle Spindle Stretch Receptor is the modified muscle cell located in the 'belly' of the muscle of all skeletal muscles. It detects a change in the length and the tension (tone) within the tissue. When a  muscle moves, or is stretched, the muscle spindle sends a signal to the spinal cord. This then signals the muscle to contract and resist the stretch - or create the opposing forces which support the movement just far enough - so that there is no over-stretching or tearing or strain on the muscle, tendons or joints. This is known as the 'spinal cord' reflex arc that we started talking about last time.

Forcing a stretch, or overworking a muscle can intensify the firing of the muscle spindle and cause it to contract. This mechanism can block deepening or lengthening of any stretch or movement. The best option when faced with 'tense' muscles or a lack of flexibility or length is to gradually and slowly remove this blockage by working with the spinal cord reflex arc and tissue messaging to decrease the reflex contraction of the muscle (protecting the joint and the attachments of the muscle to the bone). This will allow you to stretch further and go into more profound movement.

The figure at the bottom of the page illustrates a spinal cord reflex arc of the muscle spindle - when talking a muscle into a stretch or extension. In this case we are talking about the latissimus dorsi for the shoulder. This muscles works in opposition to the rotator cuff and pectoralis major (at the clavicle). In addition, we are showing the hamstrings, as these are the muscles previously mentioned in the 'activation' of the knee - that work in opposition to the quads. A signal is being sent from the muscle spindle receptor to the spinal cord, and this signal is then relayed to the motor nerve via the spinal cord - it is signaling the muscle to contract under extension and resist the stretch. This primitive reflex occurs unconsciously in response to a movement, including a lengthening of the tissue. Holding a stretch for 30-60 seconds causes the muscle spindle to decrease it's firing. It is at this threshold of activity that the muscle begins to release - and relax into further movement. Stopping a movement or stretch part-way, or using multiple shorter stretches, also decreases the firing of the muscle spindle and allows the muscle to relax into a deeper stretch.

We can actually 'reassure' a muscle to go further into a stretch, but using up to four shorter stretches and decrease the 'protective' firing of the muscle spindle as we are beginning a movement. It may seem counter intuitive, but by first backing off, or using multiple actions to decrease the reflex contraction of the muscle we are trying to stretch. This allows a more extended Range of Motion or more stretch - which is the philosophy of the PNF. Helping the body move into a higher degree, but helping retrain the muscles into a more extended stretch or less of a reflex contraction. This movement is the opposition we were talking about - the lengthening of muscle to support the main activity of the contracting muscles. In this case, the example of the quads and the latissimus dorsi, and the reflex contraction that occurs to move the hip and shoulder joints is a perfect example. The movement of the joint can activate the tension of the muscles creating the action, but inhibiting and establishing if the lengthening muscles don't allow the activity or if there is so much tension that the Golgi Tendon organs pull too hard in the attachments at the joints and attachments at the bone.

The concept that we want to reinforce is that multiple groups of muscles create the full movement of muscles in their function of posture, exercise, and relaxation. They all have to work together to get the final product we seek, fully flexible and easy muscle contraction and release. We will have more on this next...so let's take one bite of this elephant at a time.

Since we are focusing a different joint - 'let's show this impact to the shoulder, back, rotator cuff and upper chest muscles and the pain of muscles that have overworked for one reason or another. After seeing more than enough frozen shoulder complaints over the years, each case of frozen shoulder is always a little different. They all have one thing in common, which is subscapularis trigger points. To understanding of the impact of these trigger points, releasing them goes a long way towards "removing the nagging pain" of a frozen shoulder.

The Subscapularis Muscle Description

A discussion of anatomy & biomechanics should include a description of the muscle to the shoulder - as the name suggests. The subscapularis muscle is found be neath the scapula or shoulder blade, and between the ribcage. The muscle extends out to the lateral edge, and up to the front of the humeral head in the shoulder joint where it attaches. The contraction of the subscapularis rotates the arm bone (humerous) inward and pulls the arm towards the body (adduction). The purpose of the muscles is to keep the humerous in the shoulder joint, and it is one of the rotator cuff muscles, the subscapularis that acts to hold the glenohumeral joint together during movements of the shoulder joint. To be explicit, it counters the tendency of the humeral head (top of the bone) to slip upward - and hamming the joing - during abduction movements (away from the body).

The Synergy of supporting Muscles: The subscapularis muscle is assisted by the teres major and pectoralis major during medial rotation of the arm, and by the other rotator cuff muscles during stabilization of the glenohumeral joint.

Why the Subscapularis develops Trigger Points and Referred Pain

The subscapularis can harbor up to three trigger points, where the two most common occur near the outer edge of the muscle. The trigger point on the inside edge of the tissue, near the spine is much less common. It is nearly impossible to contact this location by palpation and manual release.

Image of The Subscapularis Trigger Points & Referred Pain

Referred pain from trigger points in the subscapularis is concentrated in the posterior shoulder region. The second area of discomforts spillovers into shoulder blade region and down the back of the upper arm. A unique "symptom" of referred pain around the wrist may occur as well near the watch band may also occur. The typical client is aware of this wrist pain but does not think it is related to their shoulder pain.

Causes of Subscapularis Trigger Points and Pain?

The Causes of Trigger Point pain occurs when trigger points are activated by some form of muscular overload. Some examples of muscular overload specific to the subscapularis muscle include:

- Bracing a fall by extending the arm out at shoulder level, Foosh - or Fall-on-outstretched-had as to grab for a railing, countertop, or another person.

- Repetitive use injuries in sports, such as swimming, throwing a baseball or playing tennis and occur after long periods of arm immobilization, after wearing a cast on the arm

- Sleeping on the side, with the affected shoulder down and the arm pushed forward across the body. The effectively pins the muscle between two bones with a lot of weight on it, for extreme periods of time

Subscapularis Symptoms & Disorders

Symptoms and dysfunctional pain associated with trigger point activity in the subscapularis muscle:

- Severe Pain in the Posterior Shoulder Region: This pain occurs during shoulder movement or when resting. It is generally felt as being deep within the joint.

- Inability to Lift Arm Past 45 Degrees: A client with chronic subscapularis trigger points will be unable to abduct arm (lift it to the side) past about 45 degrees. In early stages, clients may be able to raise their arm but will be unable to reach backward.

- Unable to Reach Across The Body: Client complaints of being unable to reach across the front of the body to their other armpit. This stretch will extend the muscle and aggravate its trigger points.

- Frozen Shoulder or Adhesive Capsulitis: This term 'frozen shoulder' is an overused label for a vague discomfort and lack of movement. The condition that frequently has no evidence of injury or disease to supporting the diagnosis. The symptoms of a subscapularis trigger points are identical to those attributed to frozen shoulder. Which includes shoulder pain coupled with the limited shoulder joint movement possibility. Trigger points are easily diagnosed and treated, and the pain associated with adhesive capsulitis is generally less severe than the pain from active subscapularis trigger points. These conditions both tend to coexist and reinforce each other - the balance between all aspects of the shoulder is vitally important. So what to do? Treat the trigger points first, and then imagine the surprise if the other condition goes away as well.

Treatment Advice for the Subscapularis Trigger Points

Any soft tissue activity should iinclude the assessment of what stage the tissue is at, and where the greatest challenges to the joint are - a neuromuscular assessment.

In the acute stage of extreme pain and 'loss of motion' of frozen shoulder, subscapularis trigger points play the dominant role. If the condition progresses, the pectoralis trigger points will develop as a secondary location. This is followed by trigger point activity in the teres major muscle and the Latissimus dorsi. In clients diagnosed with Adhesive Capsulitis, therapists should be aware of trigger points in the supraspinatus and deltoid muscles as well.

spindle_organ.jpg
supraspinatus_4.19.jpg
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Plantar Fasciitis...and Why Walking Hurts

When your first steps in the morning cause a stabbing pain in your foot or the bottom of your foot - anywhere from the toe box into the heel or your foot, you may have plantar fasciitis, which is an inflammation of the plantar fascia, otherwise known as the tissue connecting your heel to your toes. Because this lies over the muscles underneath it, these symptoms are common when people are on their feet, especially for runners. But, most people don't realize that they can use natural solutions for self-treatment.

With the proper attention and regular treatments, this condition usually goes away in several months, but to ensure rapid and steady improvement during your treatment. Recovery techniques and to rule out other injuries see your doctor.

Diagnosis

Your doctor will examine your foot to pain-point where the pain is coming from. This exam, along with your medical history, will help her diagnose the condition.

Your doctor may also recommend imaging test like M.R.I.s and X-Rays to rule out another cause of the pain, which could be other things like a broken bone or pinched nerve.

Treatments

A few options include several things done at home to ease your pain and reduce inflammation in your foot. The techniques might even recommend you try a few 'self-care' therapies at the same time. These include:

PRICE - Protection, Rest, Ice, Compression, and Elevation

P.R.I.C.E. treatments should occur shortly after the injury or pain starts. Which may be particularly helpful during the first 24 to 72 hours.

P: Protection is meant to prevent further injury. Protecting the foot and ankle by limiting or avoiding weight-bearing through partially immobilizing the injured area by using a sling, splint, or brace may be a means of protection.

R: Rest is essential to allow for healing. Sports medicine specialists use the term "relative rest," meaning rest that allows for healing but does not limit enough that recovery is compromised or slowed. Other people refer to "active recovery." Anyone should avoid activities that stress the injured area to the point of pain, or that delay or prevent healing - this includes sitting all day. Some movement, however, is beneficial. Gentle, pain-free, range-of-motion and necessary, and isometric contractions (or movement without movement) of the joints and muscles around an injury. This 'restorative process' is shown to have sped-up muscle recovery.

I: Ice refers to the use of cold or 'sub-zero' temperatures as part of the treatment. It is also known as cryotherapy to treat acute injuries. Ice is intended to minimize swelling and reduce circulation. It will be too important to realize that by to decrease the pain you are constricting the nerves. To use cryotherapy at home, the most common and convenient method is a simple plastic bag of crushed ice placed over a towel on the affected area. This is essential to protect the skin and limit the cold exposure, so work within increments of 10 to 15-minute increments. Cycles of 10 to 15 minutes on over a 1 to 2 hours period are generally useful and safer than more extended periods. Continuous ice application also tends to contract muscles that are in pain - a good benchmark for discomfort is the successful use of ice - this is more beneficial for joints and nerves. Muscles respond better to heat for releases.

Skin sensitivity or over-exposure can occur. It manifests as skin that becomes mottled, red, and raised when the ice is in contact with the skin for more extended periods. If this is happening, the ice treatments should be discontinued. Always follow ice-treatments with heat, around the muscles of the injury site -after a few minutes of re-warming to get circulation restarted.

Medication during treatments - includes Non-steroidal anti-inflammatory drugs (NSAIDs), which will help the pain and reduce inflammation of the tissues of plantar fascia and ankle joint and arches. Your doctor may prescribe multi-dose days over several weeks.

Steroid injection is recommended if your pain is severe or doesn't respond to prescribed NSAIDs, you might want to think about getting a steroid injection.

The cortical steroid is injected into the most painful part, and multiple shots may be required for different areas of plantar fascia pain. It may help ease your pain for about a month, and it keeps the inflammation down for even longer.

Physical therapy can be used if medication, rest, and ice don't help enough. Once your doctor recommends you see a physical therapy first - consider some other types of manual, like manual adjustment from chiropractic (D.C.) or Osteologists (DO) or Neuromuscular Therapists (C.N.M.T.) as well. They will asses the situation before they do anything else - use these referral to go to a physical therapist or chiropractor that specializes in the type of injury unique to you (i.e. sports related, posture, or repetitive stress) and go with the intent of understanding the skeletal and muscular impact of the injury and pain.

Once you have decided to work with a professional - and yes, it will take more than one appointment, you should expect to learn how to perform exercises to stretch and strengthen your plantar fascia, Achilles tendon, and lower leg muscles at home. A manual therapist may also use massage, contrast baths, or ultrasound/electrical stimulation to help with long-term healing.

If you don't show progress after several months (say 7-10 appointments), your doctor may recommend a more involved procedure or even surgery. These other options include:

Shock-wave therapy. This literally "shocks" your plantar fascia with sound waves. One of the other areas where it is useful to reduce pain on the foot is around the ‘heel,’ or the Achilles tendon. It can be used stimulates blood flow in the foot and helps the tissue heal in both muscles, tendons, and ligaments. Chiropractors I know that use it, sweat they can even mend minor 'breaks' in bones. It also stuns your nerves to stop the pain.

Tenex procedure. You only need a small cut in the surface of the fascia, and it's usually over in a few minutes - it does, however, require more than one to impact larger areas like the entire underside of the foot. I also heard it used on areas like the Achilles, and the patella and ultrasound are used following the incision to target and remove scar tissue, which develops with any incision. This procedure allows you to get back to your routine in as little as ten days.

Surgery. This operation removes the plantar fascia from the heel bone. Surgery is usually the last resort, but if the severity of the pain or a stubborn injury doesn't subside with other treatments, they can be useful. You will probably go home the same day, and the doctor may ask you to wear a splint or walking cast-boot and not put weight on your foot for a certain amount of time.

When your range of motion is restricted, and your muscle fibers of the legs get used to staying in a shortened position - like when your sitting or standing for long period. You allow your tissues to contract - and they forget how to lengthen. This is a form of compensation. But let’s talk about ‘how’ this happens through a little physiology: In the deepest part of the muscle fiber, there are units called sarcomeres are composed of little "bands" (or filaments) that line up and move past each other as your muscles contract and relax. The parts of the muscle that interact by creating ‘movement bridges’ act like interlacing of fingers together—the closer your hands get to each other, the tighter the weave is. That’s how these filaments line up, explains Schroeder.

"When a joint doesn't go through a full range of motion, the sarcomeres in your muscles get tighter and tighter, so they overlap more and more," says Schroeder. Plus, she adds, when you consistently restrict movement as in sitting all day at work your neuromuscular system isn't as efficient either. You are essential training them to be active (supporting against gravity) without moving, and essentially, your brain sends the signal to your muscles saying it's not safe to move through bigger ranges of motion, ie. normal movement. So the continuous shortening cycle continues.

The simplest solution is to learn to stretch your calves - and make this a regular routine as part of your lifestyle. Get up and move every 60 - 90 minutes, and do these six basic stretches:

1) Downward facing Dog

2) Seated calf stretch with resistance band

3) Lunging Calf Stretch - standing

4) Runners Lunge - kneeling

5) Heel drop stretches

6) Standing calf/hamstring stretch

Achilles tendinitis, shin splints, knee pain, plantar fasciitis can all originate from tight calf muscles," says Schroeder. Because the shortened muscle fibers actually pull on other ligaments and joints—in the case of the knee (upper) and the foot and arches (lower), tight calves can pull down on the ligaments on the back of your knee and up on the muscles in your foot. With plantar fasciitis, tight calves can pull up on the fascia (connective tissue) on the bottom of your feet.

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Muscle Pain, Sprain or Strain...or just plain tired?

We've all experienced the agony of muscle fatigue, but some people immediately jump to the conclusion that 'they've sprained or sprained something.' I even had one of my clients tell me over the phone…my lung collapsed - I can't breathe. Luckily that was not the case! However, the pain of trying to get out of your car, wobble up the stairs, or frequently move after a hard workout is genuine. Post workout soreness is called delayed onset muscle soreness (DOMS), and if you've been exercising long enough, you've probably felt it sometime. Some athletes relish this discomfort, as they see it as an indicator of successful workouts, but is that true?

Why does DOMS occur?

Frequently DOMS occurs after a daunting workout day - whether it is in strength training, circuit training, or hill workouts. It can happen in experienced sprinters, Cross-fitters - or when you've taken a few weeks off. Research studies show (1) that it's not restricted to any particular muscle group, but some people tend to experience it more in specific muscle groups. These are people who are trying to increase their workout volume faster than their body can adjust (2) - more than 10-15% of their volume or weight.

Technical descriptions of DOMS show it is primarily caused by a type 1 muscle strain – and although there is a degree of fiber damage, it is not anything serious. Predominantly it is a result of different exercise that overloads a specific group of muscles after they have been used previously through unusual activity. Some workout sequences do this intentionally, but remember, as you may have experienced DOMS before, there is also a range from slight muscle discomfort to severe pain - both can limit the range of motion. Beware this last situation - you might need to do something about this.

Generally, muscle soreness becomes noticeable about 8 hours post-workout and peaks 48-72 hours later, although the exact course of the recovery process varies. You should also have your muscles reset naturally after a good night sleep and light stretching. Beware muscles that do not recover on their own - this will impact the next workout and push you into ‘potential’ injuries.

For athletes, there is no doubt that DOMS is correlated to exercise-induced muscle damage, whether in not small, or microscopic. Measurement of muscle damage at the microscopic level is poorly associated with reports of soreness. If you're sore, it doesn't mean you completely "shredded" your muscles. MRI images show little damage to some tissues post-exercise, but more to others. Not only does the time progression change with the course of post-workout recovery, but the markers of muscle damage also differ from one another in each muscle. The muscle indicators also don't match the recovery time in the course of muscle soreness reduction (Newham, 1988).

Severe DOMS can develop with little or no indication of muscle damage, and severe damage can occur without DOMS pain. Certain exercise types or workouts can cause significant muscle damage, which is illustrated in the image below - taken after an extensive eccentric (lengthening or stretch) exercise protocol. As you can see, the muscle fiber below look messed up - almost like there is scar tissue developing. The majority of studies examining exercise-induced muscle injuries look at DOMS and how new subjects are injured undertaking large amounts of unfamiliar eccentric (loaded under lengthening) exercises. This model is unlikely to reflect the circumstances of people who workout and experience DOMS pain. It does give us some information into what happens in the muscle when there is a 'breakdown' during overuse.

Muscle image is from an electron microscope after eccentric exercise. Disruption in the muscle pattern tissue is visible. (http://jap.physiology.org/content/107/2/570)

Another DOMS-induced stimulus occurs during exercise tempo or length creates overuse, and high levels of metabolic stress (and this is not the build-up of lactic acid, which does not cause DOMS). When you think that lactic acid causes muscle soreness, this is thoroughly outdated and flat-out wrong. After high levels of exercise, including High-Intensity sessions, rest alone will return blood lactate to baseline levels within the reasonable period required between training sessions. However, evidence shows that hydrogen ions and reactive oxygen – both increase in concentration during exercise – may contribute to DOMS (2) - when the pressure comes from "inside" the cells of the tissue. Metabolic stress during exercise causes changes on the basic level at the cell membrane called the sarcolemma. The disruption in the tissue allows fluids and other factors to enter each cell, which promotes inflammation (3).

Cellular swelling occurs during exercise-induced muscle by bringing fluid and plasma proteins that exceed the capacity of the drainage - which causes the damage. The result is edema in the tissue, with significant swelling lasting ~48 hours post-exercise.

Does DOMS mean more muscle growth?

The presence of DOMS symptoms after long-distance run workout indicates it doesn't just occur during resistance training. The pain is more an indicator that DOMS isn't a good gauge of muscle growth. Running causes minimal hypertrophy and 'muscle build-up.'

People who are new to workouts often have the most pronounced DOMS because they also happen to grow the most. As you can see, the two growth and 'build-up' of tissue damage may be intertwined. This is because of the new stimulus that exercise provides - which is making more tissue based on resistance. When they get sore, it's because they are not accustomed to exercise – not because they are growing like gangbusters. There is no 'sex-based' difference in DOMS, even for beginners (4).  There is also a more pronounced 'growth' factor in youth attempting to begin building up, and returnees from a layoff.

DOMS may negatively affect future workouts if they alter movement patterns in subsequent exercises session - based on evidence from highly competitive athletes. Imbalance in the 'muscle group' could cause reduced activation of the desired muscle (5) - the idea is that some 'impaired' potential, doesn't allow the optimum level of development due to imbalance. Hence, DOMS could hinder your next workout. Furthermore, severe DOMS can decrease force capacity by up to 50% (6) due to the lack of 'strength' from edema or extended contraction. This causes functional muscle deficiency, that may impair training at a certain level. Without consistent rest or recovery focus, this could hinder muscle growth over a long term training plan.

Exercise with DOMS does not seem to make muscle damage worse (7), but it may interfere with the recovery process. As you work harder with less effort, there is 'greater' pressure on the muscle tissue. Exercise-induced muscle damage in extreme and isolated cases can cause rhabdomyolysis, a severe condition that can lead to renal failure. As a newbie, don't go into an advanced program – especially if you've never exercised at all. You could do some severe damage.

"No pain, No gain" theory is wrong, when it comes to muscle growth.

How do I feel DOMS?

Nociceptor

If the pain you feel isn't the muscles destroying the tissue or burning them up with lactic acid, then why do they hurt? In recent discussions of pain, and this concept is based on how the body 'feels' or registers pain.

Nociceptors are sensory free nerve endings that respond to damage - when stimuli are sending pain signals to the brain. In muscle tissue, the ends of these receptors can sense chemical stimuli like inflammation or disturbances in microcirculation to blood vessels and capillaries. The receptors are not inside the muscle because muscle cell death is not painful, but tearing a muscle tissue can be extremely painful - and the idea to tell the brain of damage when it occurs. The feeling of pain is due to the release of muscle substrates into the space around the 'injury' site, near the nociceptors location. This also helps us appreciate that DOMS does not occur due to something inside the muscle (i.e., like the contractile apparatus) (7) which is sending warnings back to the brain.

How to reduce DOMS?

The best ways to decrease the risk of DOMS symptoms is to slow the progress, vary the repetition for a muscle in a new exercise program - no more than 10-15% increase every week - and increase rest periods. If you've worked on advancing the workout program, you'll notice the first week or two may have reduced volume (either weight or reps). The "intro" phase of programs have two levels: 1) allow the muscles time to adjust to a new movement, and 2) leave room for more adaptative performance.  

We all know that warming-up properly will allow improvement in movements and reset neutral postural starting points. Surprisingly, warming muscles don't help reduce DOMS. While it may prepare you for exercise (highly suggested), neither warm-up or stretching before exercise has been shown to reduce or prevent DOMS.

A lot of people use foam rolling techniques to relieve DOMS - or trigger point focus work. However, this has only been shown to improve DOMS in some studies. During compression of foam rolling, you use body weight and gravity on the muscle mass on a foam roller, and exert pressure on an area of soft tissue that is stuck together - or uncomfortable. The motion places a direct burden on any area and stretches the fibers like self-induced massaging because the pressure resembles the compression exerted on muscles by a massage therapist (different angles). Only a few studies have measured the effects of foam rolling on improved performance. These studies found foam rolling enhances the recovery after DOMS by alleviating muscle tenderness. Self-massage through foam rolling can benefit people wanting to recover in an affordable, easy, and time-efficient way.  

Another 'muscle tissue' intervention is Myofascial Therapy massage. Some researchers have focused on the decrease in pain associated with DOMS after a massage (8) include breaking apart the adhesion and muscles side-by-side. However, massage does not affect reducing muscle metabolites like glycogen or lactate - except moving them out of the body. One study showed massage decreased the production of the inflammatory cytokines by mitigating cellular stress - or systemic stress from muscle injury (8). Many people believe massage can increase blood flow to specific areas, reduced muscle tension, nervous system levels, and mood enhancement. Some massage techniques produce direct pressure, which may increase ROM and stiffness, and discomfort on overworked tissues can be intense. However, the benefits provided are expected to help athletes and enhance performance in a training plan by reducing the risk of injury.  The effects of timing a massage (pre- or post-exercise) on performance, injury recovery, or injury prevention are unclear because the mechanisms of different massage technique have not been widely studied, or compared.

Supplements that impact DOMS

Caffeine is known to increase alertness and endurance, but the average person's morning grumpiness translates into a direct impact on the muscles as well as the brain. A recent study by Hurley et al. reported caffeine reduces DOMS because it increases the circulation and speed at which tissues are affected by changes to the cellular membrane. They measured the perceived soreness in males one hour before a workout and found a lower level of pain in the biceps on day 2 and three. The results were compared to a placebo given to subjects who then completed a bicep curl workout.  Using a dosage of 5mg/kg body weight, a beneficial effect of caffeine on soreness was noticed. Comparing, a 185lb (~84kg) male it takes about 420mg of caffeine pre-workout. That is a ton of caffeine - when an 8oz Red Bull contains roughly 85mg. Most pre-workout supplement levels don't have that much caffeine, do they? Probably not. If caffeine peaks in the blood, about one-hour post-ingestion, that's a lot of pre-workout liquid. Caffeine is an adenosine antagonist and affects the activity of the central nervous system (CNS), and it blocks the adenosine receptors, resulting in decreased levels of soreness - or lack of receptive activity. Therefore short-term caffeine ingestion before a strenuous workout may reduce the overall level of pain.  However, the athletes who took caffeine were able to perform more reps than the control group, which could be a disrupter of the results.

Taurine is found in muscles and has multiple biological functions. If you remember the energy drive Red Bull I mentioned earlier, it has about 1,000mg of taurine - as well. 3,000mg a day of supplemental taurine is considered safe. In one double-blind study (10) of males completed over 21 days - they measured the effects of 50mg of taurine (20x less than the content in a Red Bull) after seven days of eccentric exercise protocols.  The researchers found a reduction in DOMS and oxidative stress markers with use. There was no effect on inflammatory markers - or the cellular changes mentioned in the first part of the article.

But it would be interesting, as oxidative stress is the result of the imbalance between reactive oxygen species (ROS) formation and enzymatic and non-enzymatic antioxidants. Biomarkers of oxidative stress are relevant in the evaluation of the disease status and of the health-enhancing effects of antioxidants. In conclusion, the clinical significance of biomarkers of oxidative stress in humans must come from a critical analysis of the markers that should give an overall index of redox status in particular conditions. If inflammation is one component to DOMS and oxidative stress is another component, we need a study to combine the two. That probably won't happen soon to use a synergistic review.

An omega-3 fatty acid is found in fish and is increasingly used to fortify foods. EPA/DHA can be found in those pills that make you burp continuously. Several studies reporting definite increase with the effect of omega-3 fatty acids on DOMS assumes that there was a decrease in pro-inflammatory factors such as IL-6 and TNF-alpha as well. There are a ton of studies to show taking an omega-3 supplement is right for you in many ways. These results seem to hold for DOMS as well, see the effects, the main table from Jouris et al. 2013 below.

Other Variable Recovery Activities

Cryotherapy, or icing on the muscles, probably doesn't reduce DOMS.  Directly against the current assumption of athletes - jumping in a tube surrounded by liquid nitrogen to help recovery - this is related to the slowing of the whole recovery process. Whole body cryotherapy exposes athletes to cold, dry air below -100C for between two and four minutes in a specialized chamber. A recent Cochrane Review by Costello et al. found insufficient evidence to determine whether cryotherapy can reduce muscle DOMS or improve recovery process only by decreasing the ambient temperature of ALL muscles.  

No guidelines currently exist for its clinical effectiveness or safe usage. Cryotherapy is thought to work by reducing the temperature in the skin, muscle, and core at once. The theory assumes that muscle soreness, and inflammation increase created by muscle activity, is relieved by reducing muscle metabolism, skin microcirculation, nerve conductivity, and receptor sensitivity. There could be a placebo effect by reducing the subjective feeling of DOMS post-exercise - only by lowering the level edema in the cells (i.e., less pressure on the cellular membrane). Using a meta-analysis based on four studies shows cryotherapy does not reduce DOMS or improve recovery.

Additional evidence exists on whether cold water emersion -post-exercise can decrease the rate of muscle growth. For the time being, focus on

Conclusion

Soreness provides insight, but don't use it as a marker for a good workout progression. High levels of pain indicate the muscles have exceeded the capacity for the tissue to undergo repair in an organized manner. Indeed, soreness can impede the ability to train correctly, especially if it impacts sleep and 'proper movement and posture,' and it may decrease motivation.

Research consensus is that there is no single component that causes DOMS. Instead, several complex events may explain this phenomenon, creating an impact on exercise performance and recovery that include decreased muscle strength and range of motion. There should be several factors that help increase the 'good effects' of works - and reduce the impact of symptoms like DOMS.

1) Drink Lots of Fluids and Hydrate

Any fitness guru knows the importance of proper hydration prior, during, and after an intensive dose of physical activity. Hydration will support increased circulation and movement of nutrients throughout the body.

2) Good, restful sleep

With plenty of rest, as a key to both mental and physical health, lack thereof is also unfortunate. Lack of it can significantly hinder not only the course of muscle recovery but also your overall athletic performance because all natural body processes are negatively impacted by lack of sleep. According to a 2008 study, sleep deprivation is detrimental to recovery and inhibits the body's natural processes.

3) Focus on Your Protein Intake

Protein is the number one muscle repairing nutrient in your diet. Instead of adding supplements to your smoothies, focus on getting your daily intake of protein from whole foods such as eggs, Greek yogurt, cottage cheese, and lean cuts of meat. These versatile ingredients make great snacks or full meals - ensure that they are used throughout the day to help with your recovery.

Also essential is consuming a snack rich in protein before bed so that your muscles repair over time. The essential amino acids that are metabolized from this macronutrient are vital to rebuilding tissues.

4) Plan Your Rest Days Accordingly

When it comes to rest days, the general rule is to maintain a healthy gap of 48 hours - and with fans of more physically demanding routines. Of course, this is instead a guideline that you can tailor to suit your personal needs and preferences.

Never forget the stretching, especially during recovery days. This habit will help with your muscle recovery, and won't burden the tissue any longer than necessary - and will remind the muscles of their neutral length and flexibility.

Depending on your age and skill, you might require less time to rest or more. Taking longer pauses will allow you to try to squeeze in a couple of active recovery days each week. These days consist of light exercises, such as yoga or tai chi, actual muscle release can also help you stay on track to fitness goals while relaxing and recharging your muscles at the same time.

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The impact of the Lower Cross Syndrome on Back Pain

Lower Crossed Syndrome: From the Core Out - Six Steps to Improve Lower Cross Syndrome

Poor posture, muscle imbalance resulting in pain symptoms in back and knee affect a large number of people in our society today. Other disorders of the musculoskeletal system disrupt lifestyle and activities to the extent that people spend millions of dollars on pharmaceuticals and other treatments and gadgets to address symptoms caused by our misalignment and imbalance in our bodies. The reliance on "the quick fix" is unfortunate, because proper exercise is a far better treatment for postural and musculoskeletal issues. Coaches, trainers, and manual health practitioners who know functional rehabilitation and corrective exercise know how to apply proper practices.

Logical steps to correct the imbalance and faulty movement patterns that create the development of muscle imbalance like Upper Cross Syndrome (UCS) and Lower Cross Syndrome (LCS) makes it possible to turn the vicious cycle underneath these conditions into a productive one. Typical activities for dealing with LCS and UCS can be taught to clients as guides which give average (experience) in clients a general idea of how to treat the symptoms and alleviate these painful conditions.

These guides are general information, and are should not be considered exhaustive. People who suffer from muscle imbalances and the LCS and UCS syndromes should seek out the help of therapists who have experience with treating these disorders. I'm not saying this because I work as a therapist, but my experience shows me that a lot of people find it very difficult to correct their postural imbalance, and then train their muscles effectively.

Besides the Upper Crossed Syndrome (UCS), the next most common muscle imbalance pattern is related through the Spiral Anatomy Train - creates the Lower Crossed Syndrome (LCS) is the opposition as it supports the upper chest and trunk. This condition is prevalent, particularly among females and people who sit for extremely long periods - think anyone in the IT field.

As sitting for prolonged periods leads to shortening of the hip flexors, increased tension on the lower back, and glute muscle atrophy. This is especially true when there is an underdevelopment of abdominal core strength, hip flexor tension and lack of support from the lower diaphragm - yes, the pelvic floor. No surprise that LCS is so conventional in our desk-bound society today, that when the problem develops over time, there is no warning. Suddenly a daily activity, like tying your shoes, causes pain or there is just 'lower back' pain, hip pain, or reduced ranges of motion that are concerning.

As with UCS, it's essential to be aware of and able to correct muscle imbalance patterns before they create more significant compensation in movements. These 'modifications' in progress set the stage for poor exercise techniques, injuries, lower back pain, impaired physical performance, and some more painful disorders such as osteoarthritis and degenerative joint disease. Poor posture, in general, isn't aesthetically appealing, but exercises and mobility drills can be aimed at treating UCS and LCS - and may also improve your physical appearance when a better posture.

Lower Crossed Syndrome

Lower-Crossed Syndrome (LCS) is also pervasive tightness of pelvic floor and rotated pelvis creating the symptom pain. With LCS the tightness of the thoracolumbar extensors is over-stretched from the dorsal (back) side that crosses over to the front with the tightness in the iliopsoas and rectus femoris. Weakness from the deep abdominal muscles reduces the balance in the ‘front' line' of muscles as they limit the movement pattern with weakness in the gluteus maximus and medius muscles. The problems created by this pattern of imbalance show in symptoms of joint dysfunction, particularly for the spine at the L4-L5 and L5-S1 segments of the lower back, as well as SI joint, and hip joint. (1) These are all common complaints of lower back pain.

What does this mean exactly for people with this postural problem?

It means that there is a weakness and lengthened stress in the abdominals and gluteals; at the same time, there is tightening and shortening of the hip flexors and lower back muscles. LCS create reciprocal inhibition or the process where opposing muscles on one side of a joint are relaxing to allow contraction on the other side of that joint.

Causes

- Prolonged sitting, particularly with bad posture

- Physical inactivity

- Regular workouts, movement, and activities that involve an uneven stimulation of the muscles that are engaged in LCS

- Poor exercise mechanics (e.g., lumbar hyperextension in the deadlift, press, and squat).

- Imbalanced strength training (e.g., a lot lower back and hip flexor training rather than glute and abdominal strengthening)

- Genetic predispositions

The development of LCS creates a vicious cycle because the gluteals and abdominals are weakened, they force overuse in the hamstrings and lower back. When their function is compromised, other muscles are recruited to assist in performing the activities that they are required to keep the body upright against gravity. The majority of these functions are walking or running, and includes squatting or sitting result in a high level of overuse or repetitive stress. Because these happen through a great deal of the hours in the day, this leads to chronic pain symptoms. When muscles are tired and tight, they stretch muscles like the hamstrings and lower back muscles, when in discomfort' ‘ force more compensation,’ and further weakness into the abdominals and gluteals.

Common signs and symptoms

- Anterior Pelvic Tilt (APT) can be a good trait, but at a certain degree of APT leads to poor posture. Exercise techniques to compensate for this fundamental challenge, and retrain the muscles impacted (hamstrings and lower back) will build the strength in the glutes and abdominals while taking the "stretch" for hamstrings and lower back.

This 'pressure' to maintain a compensation in the pelvic bones creates an increased risk of knee pain, reduced ranges of motion in hips and knees, and lower back pain or injuries, as well as other musculoskeletal disorders that run rampant in the modern world.

- Increased lower back curve (sway back)

- "Bulging" (not necessarily fat) abdomen

- Knee hyperextension

- Lower back pain

- Poor exercise technique; especially with displays of poor movement patterns in exercises such as the squat and deadlift. This pattern is characterized by an overextension of the lumbar spine, and knees - while lack of glute involvement drives the overcompensation into the quad and low-back dominance muscle groups.

These signs and symptoms of discomfort reveal that stiff hip flexors, weak gluteal muscles, and lack of abdominal muscle strength, and compensatory movements are reliable indicators of LCS.

How to improve your posture

Some health practitioners and coaches say that treatment of muscle imbalance patterns requires a series of Complimentary Alternative Medical appointments to "change" the imbalance - chiropractic intervention, myofascial release, trigger-point therapy, and a wide variety of exercises and mobility drills to strengthen and lock-in the changes. More straightforward mindfulness should be based mainly on postural awareness, exercises, and strengthening of the weakened muscles through stretching and activities with the opposing muscles is also useful.

This may be all that is needed, which is the point of most manual therapy - bring things to their attention and stimulate change. Research studies show that exercise interventions can modify lumbar posture and relieve musculoskeletal pain associated with poor posture if done regularly. The body will remember the newer stimulus - not old habits. But the "slow healing," is more time consuming than most people's patience allows.

Being a good coach requires an understanding that all exercises, mobility drills, etc. should be included only if they serve a purpose or help the client meet a goal. This more critical when training clients with muscle imbalance patterns, because 'improper' exercise technique and selection will aggravate the problem.

After trying various approaches to deal with LCS, there's only so much you can learn from readings and theory on the subject, I've discovered that there are specific patterns of exercise that work - and other's that don't. Although there isn't one standard approach for every client, there are certain general principles that your clients use to succeed in changing the imbalance. These protocols serve as essential guidelines and can build a foundation through a step-by-step workout.

Hip flexor stretches are considered essential for the 'releasing' muscles during the treatment of LCS. But, in general, it's more important to strengthen the muscles that produce Posterior Pelvic Tilt (PPT) and reinforce proper movement patterns at the same time. The order generally is specific to the individual.

Since there is a range of spinal alignments that are considered "normal," and quite a lot can be done to strengthen muscles through training, some people will naturally have a greater anterior tilt to the pelvis regardless of what they do (female hip alignment is different). Also, it's important to remind people that creating change with LCS symptoms requires persistence and effort. Only doing some light pull through at the gym occasionally is not going to get you very far with the solution. If you don't have the will or experience to attack this problem through your self-care and are severely affected by LCS, then I recommend that you work with an experienced coach, trainer or therapist that can treat this condition with the proper workout strategy

1) Mechanics of the lying pelvic tilt

LCS suffers often have no idea that their low back sways, abdomen bulges, and that back pain are manifestations of a series of the muscle imbalance that creates these patterns to a great extent - or that they can be treated. Moreover, these individuals have typically forgotten how to tilt their pelvis posteriorly do to the LCS posture. For these people, step 1 should help them learn how to get the pelvis into a neutral position and understand what the posterior tilt feels like. The lying pelvic tilt is an excellent exercise for achieving this, as "push the lower back into the ground" is a natural cue, and will help people to understand where that neutral position is.

Instructions: Lie on the floor and have the client push the lower back into the ground, then anteriorly tilt the pelvis by creating the curve in the lower back; repeating the exercise several times.

2) Mechanics of the standing pelvic tilt and glute squeeze

When you manage the proper lying pelvic tilt and understand how to control the alignment of your pelvis, proceeding with the standing pelvic tilt is the next step.

Instructions: Stand with your feet at shoulder width apart and squeeze the glutes, which will trigger you to tilt the pelvis posteriorly. Hold this contraction for 30 seconds, and then relax. Repeat the exercise several times.

3) Learn the feel of the hip-hinge position

The pull through is an excellent exercise to learn how to feel the hip hinge during movement patterns. The movement in the pull through closely resembles that of the deadlift, or kettlebell swing, or other hip dominant exercises. However, there's one key difference. In the pull through with the band or cable is attached behind you, this "forces" you into a posterior tilt and shift of the weight.

Instructions: Concentrate on keeping the chest high, but focus on NOT overarching the lower back. Push the hips back, rather than bending the knees and entering into a quad-dominant squat, and finish the movement by squeezing the glutes for several seconds.

4) Strengthening the muscles that produce posterior pelvic tilt (PPT):

Focus on the obliques, abdominals, gluteal attachments with different movements, and the opposition to the lower back and hamstring

Cable pull throughs and a modified version of the plank are among the most effective exercises for treating LCS. PPT hip thrusts, American deadlifts, and other activities can be used to strengthen the PPT movement patterns and develop weak muscle groups like glutes and abdominals with regular practice.

Varieties of lunges and planks can be great add ons.

Instructions for the modified plank: Perform a regular plank, but also focus on squeezing the glutes all you can during alternate repetitions. Try to work from the core out.

Instructions for the cable pull through: Concentrate on keeping the chest high, and the back should not overarch the lower muscles. Push the hips back, rather than bending the knees and entering into a quad-dominant squat, and finish the movement by squeezing the glutes for 2-3 seconds.

5) Proper performance of squats, deadlifts, presses

In addition to other multi-joint exercises proper execution of these positions helps retrain muscles.

When lifters tend to round their backs during dominant hip exercises, the "arch!" is often a cue to get people into better movement patterns - because this is incorrect posture for these exercises. However, when working with someone who possesses APT, this cue does more harm than good, typically, because the lift position ends up with an exaggerated lumbar curve and overstretched muscles.

While many new lifters, including those with no apparent postural problems, tend to overextend their backs when locking out the deadlift at the top of the motion, people with LCS often display excessive back arch during the entire movement. This lift position is considerably more damaging than the spinal flexion commonly seen.

People with LCS typically overextend their lumbar spine during presses, pulldowns, and a wide range of other exercises. This creates back strain and pain when the muscles tighten and lose flexibility. In combination with dominant quad lifts, reduced glute involvement, and forward knee drift (e.g., in the squat), the poor alignment of the spine allows strengthening of muscle groups that are already strong enough and increases the risk of injury.

While some lifters prefer a rounded because their experience has taught them that upper back position can be modified in the deadlift, the general recommendation for MOST lifts is to keep the spine neutral. The best way to achieve this position varies from person to person. For someone with a standard (neutral or slight APT) or posteriorly tilted pelvis, use your posture and think about arching the back. Even better would be to pulling the chest tall - or upwards. Anyone with excessive APT has to get the chest up to change the pelvis orientation around the center of gravity fundamentally. Focus on arching the back may be a mistake because this can quickly lead to overextension of the lumbar spine.

The position of the neck/head, tucking the chin and maintaining a neutral neck position is always a safety tip. However, many of the strongest deadlifters and squatters in the world look straight ahead during the lift. There is an argument that the body is most durable when lifting with a neutral neck position, but if there is an advantage to this position, then it is quite small.

Besides the focus on spinal alignment, other top tips for a perfect deadlift and squat position are to spread the floor apart and push against the outside of your heels. Try to pull the floor apart beneath you. Dive through the heels down, and position the bar should travel up-and-down in a vertical line over the mid-foot.

Don't just focus on during lower body exercises, because the alignment of the pelvis and spine is essential. Don't forget to squeeze the glutes and posteriorly tilting the pelvis during activities such as the press, push-up, chin-up, pushdown, and bicep curl is an excellent bio-mechanic recommendation. Posterior tilt of the pelvis during these types of exercises stabilizes the spine and even gives you some static glute training to increase your strength. Also, when performing dominant hip exercises such as the deadlift, hip thrust, and box squat, always finish the contraction part of the lift by squeezing the glutes.

6. Pay attention to your everyday posture,

By incorporating some mobility drills, stretches, and strength exercises into your daily life, you will reinforce these good habits.

- test your posture by putting you heals, pelvis and lower back against the wall. Then see if you can place the back and upper back/shoulders against the wall as well. Finally, move the head back and see if you can stand there comfortably for 6 - 8 breaths.

Besides performing the activities above, it can help to include some mobility drills, stretches for the lower back and hip flexors, and strength exercises into your daily life. The isometric glute squeeze showed in step 2, for example, asily can be performed at home every day. This will provide you with postural awareness and stronger glutes every time you practice. When using several repetitions and holding the contraction for 20-40 sec. Every time.

Finally, postural training is an integral part of treating LCS.

Pay special attention to sitting posture is vital to retraining the muscles. Incorporate this plan for better body mechanics into a training program. To include these steps into a workout routine:

1) Resistance training

Incorporate step 1, 2, and three into your warm-up routine before strength training sessions.

Spend 10-20 minutes on step 4 during a workout by a focus on exercises that target the muscles that produce PPT. When you're training the lower body one day, perform these movements as part of your workout. If you're not, include the pull through, plank, and other exercises movements that strengthen the PPT movement pattern at the end of the training session. Remember to squeeze the glutes, as well, during activities such as the press, push-up, etc. (step 5).

2) Endurance workouts and group training

Spend 15-30 minutes after you complete your endurance workout and group training session where you go through step 1, 2, 3, and 4. Spend the most time on level 4.

Workouts with the sole purpose to treat LCS should include

10-20 minutes on step 1, 2, and 3, and then move on to the cable pull through, box squat, and other exercises that target the weakened musculature.

3) Stretching opposing muscles

Spend 10-15 minutes after completion of the workouts ‘releasing’ tense muscles like Hamstrings through a series of stretches for both the upper and lower attachments. The other thing to focus on is releasing the muscle adhesions through self-myofascial release.

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Benefits of Salt Therapy

Promising or Placebo? Is Halo Salt Therapy Successful Treatment

A personal or mental health day is something we all need. It's meant to relax and revitalize the body and mind, but what about the lungs and skin. A new trend increasingly found at modern spas is halotherapy, or salt therapy—breathable salt particles intended to improve breathing. There has been news buzzing with the supposed benefits of salt therapy or halotherapy for lung conditions like COPD and asthma. But what exactly is salt therapy, and is it helpful or harmful?

Turns out, salt therapy isn't new at all. Back in 1843, a Polish physician by the name of Feliks Boczkowski noticed that salt mine workers did not experience respiratory issues or lung disease vs other miners. Almost a hundred years later, a German named Karl Hermann Spannagel noticed that his patients' health improved after hiding out in the salt caves improved, while avoiding heavy bombing during WWII. The news of the benefits of salt therapy spread across Eastern Europe where you can find many locations offering these giant salt rooms today, from Poland to Germany to the UK. It's even catching on in the States at Korean bathhouses where you can sit back, relax and breathe in the salty air while in a room made entirely out of giant slabs of Himalayan sea salt.

So how does exposure to the salt work? Well, the scientific community isn't really sure. There are a lot of theories on the how, and how much from the tiny salt particles being inhaled killing off microorganisms in the lungs to reducing inflammation and decreasing mucus, or a mixture of these reduced symptoms. There is a relaxing effect, as well as a drying and antiseptic effect that can be transmitted through the skin and down the lungs. You literally absorb the molecules into every part of your body.

Dr. Norman Edelman, Senior Scientific Advisor to the American Lung Association, suggests that potentially, it could be more than just a placebo effect. Most people with obstructive lung disease such as asthma or COPD produce a cough sputum (a thick mixture of saliva and mucus), and trying to bring it up can be distressing and challenging to the lungs, muscles of the neck and check. When you think about the last time you had bronchitis, for instance, the discomfort from coughing can impact the entire upper back, lungs and neck tension. Dr. Edelman suggests that it's possible that salt therapy offers relief to these symptoms.

"When fine salt particles are inhaled, they will fall on the airway linings and draw water into the airway, thinning the mucus and making it easier to raise, thus making people feel better," said Dr. Edelman. "Also, these environments are allergen-free and thus good for people with allergies affecting their lungs."

Salt Therapy and Cystic Fibrosis

As Salt therapy is becoming increasingly popular, we would describe a typical session involves sitting comfortably in a specially designed salt room and breathing in microscopic particles of salt. Sound relaxing? Well, it’s also proven to be effective for not only cleansing the respiratory system, reducing inflammation, enhancing athletic performance, and opening up air passages, but also for clearing up congestion by thinning out excessive mucus—a great boon for those suffering from respiratory illnesses. New salt therapy spa rooms have been opening up across Canada and the United States, as an increasing number of people begin to recognize its many health benefits. More recently, people suffering from illnesses such as cystic fibrosis are increasingly turning to salt therapy to complement their ongoing treatment.

We’re constantly under threat by an influx of irritants, pollutants, and allergens. This is especially true for those of us living in the city. Those suffering from illnesses such as cystic fibrosis are particularly vulnerable, leading to such symptoms as irritation and persistent cough. Breathing in salt provides a soothing respite that works to clear up air-passages by unclogging the bronchi and bronchioles from air-borne pollutants. Salt therapy also reduces inflammation of the respiratory tract by absorbing edema from the mucosa lining of the air passages. This makes it easy for thick and sticky mucus to be easily eliminated from the body, which helps prevents the blocking of air-passages (a common problem for those with cystic fibrosis) and works to alleviate discomfort.

While breathing in salt does not represent a complete solution for cystic fibrosis, implementing it into your total care strategy can enhance your overall treatment plan. The key to achieving this is by being diligent with your ongoing maintenance. Being consistent with your application of salt therapy is key for dealing with your symptoms because you’ll be repeatedly cleansing your respiratory system which prevents bacteria and infections from proliferating.

Depending on the severity of your case, one salt therapy session per week is often a good amount for most people. This schedule can be modified according to your individual needs. For instance, if you happen to catch a cold or feel under the weather, you could also add a couple extra sessions in the week in order to help accelerate your recovery; or, at the very least, provide you with some relief.

10 BENEFITS OF SALT THERAPY

  1. Stress relief

  2. Fewer headaches

  3. Boost in confidence

  4. Increased focus

  5. Additional energy

  6. Improved relationships with others

  7. Clearer thoughts

  8. Improved organization skills

  9. Improved attention span

  10. Relief from common ailments such as hypertension, stomach pain, depression, and joint pain

At this point, there are no evidence-based findings to create guidelines for patients and clinicians about treatments such as salt therapy, which begs the question—should people be using a therapy without current medical guidance? We have taken the approach to offer this technique through a medication room, where the mind can be quieted and restful breaks from long and stressful days.There is also the question of how well maintained the rooms are since warm rooms could provide ideal conditions for the growth of bacteria. Reducing this risk through regular cleaning and reducing contact with street wear helps, but the bottom line: salt therapy should definitely be discussed with your doctor.

Come visit us at Koda Therapy Group in Palo Alto and try it for yourself.

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Related Topic: Health & Wellness

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Newsletter-November 2018

We are pleased to announce our first Newsletter - Koda Therapy, Helping Chronic Pain.

If you have a musculoskeletal injury or movement dysfunction, your doctor may refer you to manual therapy – you can get a ‘prescription for massage,’  as it is the same medical coding as physical therapy. Both can be used to help decrease pain and improve mobility. Your symptoms may be mild, or you may have symptoms that severely limit your functional mobility – the muscles and joints may just not move.

Many treatment options exist for patients who are referred to manual therapy. Physical agents and modalities (techniques and treatments) are often used by your therapist to augment the therapeutic process, and to help achieve rehab goals.

Releasing 'tight' Muscles - and the Real Reason to Care

The funny thing about research - you might actually find what you are looking for. There is this machine that I've been trying to find - and the question has been from the beginning, "why, is it here?" and "how is it being used?" Then I met a coach who has been helping sprinters with training. He introduced me to the Charlie Francis Training System.

MUSCLE TIGHTNESS IS NOT NORMAL

It is not normal or desirable to have sore and tight muscles, especially 'hamstrings' 7 days a week, 24 hours a day. I am not talking about bodybuilding, cross-fit, training to have an instagram rear end, power lifting or anything other 'sport' specific training. He was speaking about speed training - as in sprinting and literally kicking out across the finish line often, Charlie Francis was the Canadian National Sprint Coach with 9 Gold Medal Olympians under his care and feeding. If sprinters can’t walk from tightness and soreness of the hamstrings, or if you are always feeling post-workout soreness, he assumed that…. the speed and training workouts suffered. In the worst case you could get injured, for the simple reasons that tight muscles have to work harder, and don't have the full Range of Motion available.

In other ways this shows up in the impact to other muscle groups - that get tight to 'protect' the overuse or unavailable space in your Hamstrings (or Hip Flexors, lower back, etc). Although Charlie was specifically interested in the Hamstrings, ALL muscles should be naturally able to reach their full Range of Motion - this is called flexibility, pliability, elasticity. It means that no one muscle need pick-up the slack for the under performing and abnormal tightness. Here I will focus on the Lateral Leg Anatomy chain and the Spiral Anatomy chain, because when I'm working on people who run fast, and a lot, there needs to be balance between Hamstring, Quadriceps, Adductors, Glutes and Hip Flexors.

"Speed training is different than anything else, when it comes to sports training," and it’ has unique way to progress to ultimately gain speed consistently," or continue progressive improvements over the long term training plan. So Charlie Francis maintained in his coaching program - but he was also careful to do regular assessments of his athletes in between workouts, and used Manual Therapy or Massage as part of their recovery process.

 Sure almost anyone can get faster, or stronger, by making simple routine improvements in the warm up as an example, but to max out consistently operate at max speed, top weight, top distance/time, athletes need to call upon 'more muscle performance,' on a regular basis. Athletes, and by extension Massage Therapists (or Regeneration Specialists!), will need to pay attention to each variable below in order to perform optimally over the long term. These often get overlooked in sports.

Muscle tightness and soreness can be managed, and these 'factors' need to be managed to be fast, strong and limber and/or flexible. Some people refer to this as 'elasticity,' or the ability for muscles to return to normal and neutral Range of Motion with the MOST amount of flexibility and pliability possible. To get faster, stay fast and become faster these characteristics need to be available at every workout. This applies to strength and endurance muscles as well - they just have a different composition (we'll talk about that next blow)!

Some soreness of the hamstrings will be natural when doing speed work or high volumes (increasing volumes may also create Delayed Onset Muscle Soreness - DOMS) of work. Whether it is predominately speed work or the strength development to help develop speed - is important, but not the only thing. Chronic tightness will never end well at ANY AGE. I deal with younger athletes who believe that tightness is a thing related to age - yes, maybe - because the recovery time takes longer after say 40-ish, but anyone can be overly tight. Pay Attention to what your body is telling you.

When you have a balanced training program, the muscle loading and recovery needs to become faster. This means you will need to learn to manage soreness and tightness proactively. This will help athletes manage the speed at which they 'feel full recovery.' This will be key to helping with injury prevention. Coaches, soft-tissue experts (read therapeutic massage), and athletes need to learn the factors effecting hamstring health - for sprinters, Quadriceps for Cyclists, Hip Flexors and lower back for power lifters. When these factors are addressed they create an ideal environment for training. 

FACTORS TO BE ADDRESSED TO PREVENT TIGHTNESS.

All the factors discussed her are part of Charlie Francis' training structure - I'm just modifying the impact of his recovery program that it can be leveraged and use what he recommends for planning and supporting methodical work outs for ANY Type ofTraining that include:

If you wish to be competitive, have a plan to improve your muscle development and it will be your job to know which methods of training and recovery you respond to best. Repeating successful methods will be the most efficient way to make the most of your annual training-recovery-regeneration plan. 

  • Think about running more reps at any speed, and this will bring success to becoming a higher performing athlete.

  • Monitor quality and rest intervals of training for key performance.

  • Successful methods of training might create muscle tightness and soreness but managing active regeneration will be key to continuing workouts without injury.

  • Diverging from what might be written down for training in response to how individual sessions play out will help you keep your body healthy and prevent injury.

1- The Annual Plan:

To create one of the best workouts on the planet, look at people like the athletes coached by Charlie who eventually broke the world record and won the gold medal at the Olympics in a record breaking time.

Note: Annual plans need to be customized for individuals. Beginners will have a more generalized plan, and the increased for 'non-competition' increases needs to be no more than 10-15% to prepare all athletes in sport. 

2-Continual Improvement of Personal Nutrition: 

Eating well has never been as important for athletes due to increased processed foods devoid of nutrients. Environmental stress depletes our food chain due to damaged soil and pollution.  Athletes proactively managing their diets will be rewarded with more consistent training gains and improved recovery so adding work becomes seamless. Muscle recovery requires protein - because this is the building blocks of muscle tissue. As muscles work, the proper nutritional base needs to be available.

3-Practicing Rest and Active Recovery:

Learning to be good at doing nothing, not 'resting' with no activity was how I first observed the essence Active Recovery. In Charlie's philosophy regarding rest and recovery, the trick is to add varied methods of 'active rest and recovery,' including soft-tissue treatments into your training cycle. You need to place the 'post' workout activity the same way you routinely practice other training variables. The rewards are more effective training, injury prevention - any as you will experience once you are prepared to put in the time and work.

4- Massages Don’t Have to Be 1 Hour:

One of the most innovative aspects behind Charlie Francis’s training methods was born out of the idea of his own experience, when he had to quit sport prematurely because he was suffering constant hamstring injuries due to tightness and soreness Finding ways to keep muscles loose with short and consistently preformed massages, as well as Regeneration Assessments - between workouts (most Neuromuscular Therapists can do this) is key. Any therapists with orthopedic or neuromuscular training has received the same training at Physical Therapists and Orthopedic Therapists - we just don't have a medical degree. We also don't create THAT much pain. We are interested in working under the level of the Parasympathetic Nervous System - where muscle tension develops.

Simple Things First and Consistently

Tight muscles means circulation of blood flow has been compromised, and that muscle by-products like glycogen and lactic acid are being replaced by the healthy proteins and minerals (Na, K) needed for rebuilding muscle efficiently. Creating circulation can happen manually with massage or contrast baths or perform low intensity exercises - or a sequence of all of these. Promoting blood flow, teaching muscles to stop working after workouts, will reduce tension. Continued tightness restricts motion and prevents routine high performance within daily workouts.

A Diary:

Log raining habits to record patterns that will impact training goals. Identify when 'pain, tenderness and soreness' show up - including when (post-workout, before bed, in the morning on getting out of bed, etc) and where. It helps to identify which muscles are reacting first.

Water Consumption:

Fatigue can be one of the first signs of dehydration. Muscles that aren't properly hydrated become less flexible - as the circulation decrease inhibits the protein, sodium and water are not available when the muscles need to 'rebuild.' It’s easy to be lazy about drinking water but it is not a difficult thing to make sure you are drinking enough water before, during and after training. Include this as part of your daily routine.

Make a List of Your Routine Self-Care (Regenerative) Habits:

As you begin to understand what helps you recovery 'faster,' and how to encourage muscles to relax after work or workouts, create a list, and then check them off or list them in your diary once you have completed each action.

Stretching: 

This should be in capital letters - but let's just say that stretching before and after intense workouts, and regularly as part of your Annual Plan will do as much to propel your workout to the next level as anything else. Counteracting the movements and activities in your workout may look like - Hip Flexors stretches, Glute work with a trigger point ball after hill workouts. There are any number of stretching activities - what you should be doing is anything that 'doesn't activate' the Myostatic Stretch reflex, which is the protective tightening of the muscles.

Stay Off Your Feet: 

Part of managing fatigue and energy as an athlete is building in a routine where you are not always on your feet or active. Find ways to get things done while resting at the same time and prioritize all things that effect your performance.

Are You an Sleeping?  

Sleep is the best and most natural way to heal and keep your body recovered. Muscle recovery and release of workout tension happens in REM sleep - there are different levels of sleep, but this is the deepest and is actually where 'subconscious' release and local twitch responses let go of tension acquired during the day.

Also learn about eating foods to regulate and optimize your hormones, and reduce blue lights from electronics and phones before bed, and understand how blood sugar management (think adrenal impact and cortisol impact) is one of the most important ways in the prevention of food cravings as well as eliminating energy drain which deprives consistent training goals achievement.

Low-Key Active Workouts

Low Intensity workouts to alleviate, treat and prevent constant muscle tightness and soreness from HIT training ( low intensity is performing work at 75 percent or less your maximum effort or speed, and body weight only)

Bike/Row Tempo:

You don’t need to have resistance on the bike and/or rowing machine to get the blood flowing. Creating tension on the bike or rowing maching (ergometer) may have adverse effects to promoting needed circulation to tight muscles. 

Grass Tempo:

Performing recovery runs or tempo at 70 to 75% your max effort on grass in flats will promote cardio vascular fitness and provide a flush of your tight muscles. Finish the last runs at the same speed you began. 

Water Tempo: 

Using an interval of 45 seconds of running in deep end preferably with floatation belt. Start with 1 set of 10 reps of 45 seconds with 15 seconds of rest and build up to 2 sets of 45 seconds over time. Aquatherapy is an excellent way to remove muscle compensation and balance and develop muscles that have weakened over time. Balance is key to increase overall muscle strength.

Alternating high intensity training with low or very low intensity: 

Elite sprinters are able to handle 2 or 3 high intensity speed sessions per week, (HI is defined as 95% - 100 percent of your best time), this is less than 10% of the population. Most other fitness athletes and sprinters, need to focus on 1-2. Beginners or people building up should start at 1x week, and then increase length of HI workouts quarterly to be able to meet this 1-2x week by end of the Annual Training calendar.

To optimize speed work allow alternation of high and low intensity work, (low intensity work defined as 75 % of best time or slower). The muscles that are the 'prime mover' - like hamstrings - as well as the central nervous system need 48 to 72 hours recovery in order to repeat speed work. This time is the best application of low intensity or cross-training efforts.

Stuff - Before You Start

Wear Layers: 

Make a habit of wearing layers to begin training especially keeping your muscles warm - especially those impacted by outdoor weather (wind, rain). Hamstring and glutes need to be warm before starting intense workouts. Extra layers can be taken off once training begins.

Wrap With Heat and Plastic Wrap: 

Apply heat and or anti inflammatory creams depending on severity of tightness and soreness. Wrap with plastic food wrap and tensor bandages (compression garments AFTER workout only) and covered by tights loose fitting sweat pants to bed). Do not wear anything that restricts circulation for more than a couple of hours (especially NOT to bed) Repeat in the morning for training sessions. We used to do this routinely for hamstrings, glutes, calves and low back.

Use of organic 'icy-hot' therapeutic lotions can be used to topically induce the vasoconstriction and vasodilation.

Epson Salt Baths Are Awesome: 

After training Epson can minimize the increase of salt levels in the epidermis and top layers of muscles. This will increase the circulation of water into the areas where lactic acid develops after workouts - the idea is to replace the nutrients and water with the lactic acid in your muscles. Keep baths away from competition prep.

Use Water To Bounce Back: 

Swim in it, drink it, and use it to heat you up in a bath or cool you down to contrast showers and baths. Water can promotes circulation by submerging yourself in it, exercising in or drinking it because it accelerates the removal of waste products in your system.

Actively keeping your muscle healthy and loose, and this will save you a great deal of time and heart ache due to injury and discomfort from overuse. It will allow you to train successfully and consistently. Your hamstrings, quads, glutes are the largest muscles in your body and when you have a problem your legs it will creates other issues that ultimately prevent you from sprinting your best.

Bottom Line: Plan Your Recovery like you Plan Your Workouts.

Active Isolated Stretching for the Head, Neck and Shoulders

I’ve had several clients with neck pain and ‘stiffness.’ Some have been unable to move their head, neck and shoulders – which throughout the day could be inconvenient. The Active Isolated Stretching (AIS) method of muscle lengthening and fascial release allows me to use a type of Athletic Stretching Technique to provide dynamic and effective self-care and facilitated stretching of major muscle groups for my clients in pain. I have expanded into this area of Kinesiotherapy to provide better results for my clients, and more importantly AIS provides functional muscle balance and physiological restoration of superficial and deep fascial planes Range of Motion.

As I recently learned, over the past few decades many experts have advocated that stretching should last up to 60 seconds. Physical Therapists have published studies comparing, 15-60 seconds of static stretching on improving muscle length. For years, this prolonged static stretching technique was the gold standard. However, prolonged static stretching decreases the blood flow within the tissue creating localized ischemia and lactic acid buildup. This can cause potential irritation or injury of local muscular, tendinous, lymphatic, as well as neural tissues. These are similar to the effects and consequences of trauma and overuse syndromes.

The AIS Technique – Performs Functional Muscle Release for Deep, Superficial Fascial Lines throughout the body.

Using an Active Isolated Stretch program, either active or assisted, performs a series of stretches in the functional muscle group – each repetition should last no longer than two seconds per repetition. This movement, and assisted movement, allows the target muscles to optimally lengthen without triggering the protective stretch reflex and subsequent reciprocal antagonistic muscle contraction of the joint or movement. The isolated muscle achieves a state of relaxation, and with subsequent repetitions these stretches provide maximum benefit, more lengthening and can be accomplished without opposing tension or resulting trauma.

Myofascial Release to Achieve Optimal Flexibility

Aaron Mattes' myofascial release technique, which also incorporates Active Isolated Stretching and Strengthening uses active movement and reciprocal inhibition to achieve optimal flexibility. Using a 2.0 second stretch he has been proven there is key to avoiding reflexive contraction of the antagonistic muscle and regain length throughout the functional muscle group. The sequence of repetitions allows increased circulation, warmth to the muscle and lengthening to the End-of-the-Range-of-Motion, without activating muscle group contraction, restoration of full range of motion and flexibility can be successfully achieved.

Many rehabilitation clinics use AIS after surgery with excellent outcomes. But, using AIS for re-conditioning to bring movement to limbs and digits damaged by stroke, nervous system disorders and surgical procedures. Hypermobility patients benefit from strengthening areas that are strained from compensation patterns. Some of the most impressive results are using AIS as ‘pre-habilitation’ or preparation for upcoming events. Using AIS to prepare for surgery, many patients have realized substantial benefits:

-         Reducing recovery time after surgery by 50% of predicted time frame

-         Preventative ‘flexibility’ facilitates alleviation of pain symptoms,

-         Improve conditions in the musculoskeletal condition, that surgery may not be necessary.

Since flexibility is not a general body situation, but it is specific to each joint in the body- there can be work or exercise to undo the movements or effort that produces repeated overuse of the same muscles each day - that leads to a restriction in the Range of Motion and reduced flexibility. Eventually this reduced flexibility may exhibit pain patterns in many ways, because the muscles have to work harder still to produce normal results.

 

I.    Standardized Stretch and Strengthen Format - Shoulder

List of muscles and stretches

a.      SCM – head and neck stretch

b.      Scalenes – head and neck stretch

c.      Rotator Cuff: Supraspinatus, Infraspinatus, Subscapularis and Teres Minor– shoulder and upper strengthening

d.      Trapezius, all fibers

e.      Latissimus Dorsi

f.       Pectoralis Major/Minor

g.       Biceps Brachii

  1.  Frozen Shoulder/Adhesive Capsulitis Treatment with Summary Treatment – with Active Isolated Stretching

There is usually consistent irritation in the subacromial region, which will increase the tension in the scapular thoracic region. Extrinsic causes such as an acromial spur, tendon calcification, a curved or hooked acromion, or acromioclavicular osteophytes may be present. Most frequently impingement involves the musculotendinous portion of the supraspinatus, the infraspinatus, the subscapularis, or the long head of the biceps.

Benefits of AIS on Condition: The program should include the entire shoulder AIS stretching program and emphasizing shoulder sideward elevation, having the palm of the hand facing backward. The strength program should include the rotator cuff muscles, shoulder stabilization exercises, and posterior shoulder adduction using a band or pulley and pulling downward toward the buttock, having the body face away from the mechanism of overload.

2. Medial Epicondylitis (Golfer’s Elbow) Summary Treatment with Active Isolated Stretching

Summary of Condition: Medial epicondylitis is also called “little league” elbow.  Medial epicondylitis illustrates a snapping motion of the elbow in pronation or a motion such as throwing breaking balls in baseball causing stress on the medial side of the elbow. This may result in Inflamation and Edema that make movement of the olecranon difficult, extremely painful. This results in an injuring of the radioulnar pronator cuff muscle inserting on the inner condylar ridge of the humerus.

Benefits of AIS on Condition: After the elbow is healed and free movement is permitted by the physician, restore the range of motion with gentle AIS stretching. If the injury is mild, begin stretching of the elbows, radioulnar, wrists and hands. Strengthen the elbow flexors and extensors, radioulnar pronators and supinators with small weights. Progression to stretching bands or surgical tubing is permitted when the subject is pain free. Incorporate the use of a rubber band and a soft ball for the hands and fingers. Ice massage and stretch the muscles frequently. An ace wrap for gentle support is helpful.

Wrist Flexion

The wrists are a complex joint full of bone, ligaments, connective tissue, muscles and nerves. Muscles stretched are over the wrist and into forearm - either extensor or flexor muscles. The Arm Lines are, posturally speaking, a bit different from the other myofascial meridians. The Deep Front Arm Line is a stabilizing line; in poses like the yoga plank, it manages side to side movement of the upper body. In the open movement of the arm, the DFAL controls the angle of the hand, generally through the thumb, as well as the thumb's grip. So they are active at all times - both agonist and antagonist muscles - depending on the movement. Stretching these vital muscles is imperative.

You begin the stretch by extending the elbow, slowly flexing the wrist downward by contracting the wrist flexor muscles. Apply a gentle stretch across the posterior (dorsal) hand with the opposite hand. (Excerpt from Active Isolated Stretching: The Mattes Method. Pg. 33)It also has multiple ranges of movement—flexion and extension (moving the palm backward or forward relative to the forearm), adduction and abduction (moving the hand from side to side). Compare this to the movement of, for example, the knee joint, which only has flexion and extension. It also marks the area of transition between the forearm and the hand—so the health of the wrist can directly impact your grip strength and dexterity in the hand.

Another thing to consider is that if we lack motion at the wrist, we’ll try to make the motion up at the shoulder and elbow. Conversely, if we lack shoulder mobility, we’ll try to make it up at the elbow and wrists. It is therefore just as important to focus on scapular and shoulder mobility as it is on the wrist, as the two are interconnected and focusing on one may not alleviate the problem for the other. As an example, in the catch phase of a clean, we need to have adequate wrist extension, forearm pronation and external rotation of the shoulder to allow us to receive the bar on the front of the shoulders and fingertips dorsal) hand with the opposite hand. (Excerpt from Active Isolated Stretching: The Mattes Method. Pg. 33)

Upper back and chest stretch-Mattes Method

Upper back and chest stretch-Mattes Method

Pectoralis, Trapezius and Lat Stretch - Mattes Method (AIS)

Pectoralis, Trapezius and Lat Stretch - Mattes Method (AIS)

Hamstring vs. Gluteus Minimus (Hidden Relationship)

It has been demonstrated that although stretching daily has been measured by Bandy, Irion & Biggler in the Journal of Physical Therapy, Vol 77, 10/1997, the outcomes they defined established that a 30 second duration once a day was an effective amount of time (better than 15 sec, the same as 60 sec) to sustain an increased Range of Motion (ROM) when executing Hamstring Stretches. There was no additional benefit or increase for longer times or more frequency per day.

One of the key areas for athlete complaints are the areas below:

1)     Hamstring Pain (tightness, sprain or strain feeling)

2)     Patelofemoral Pain (knee pain and lack of movement)

Since there are multiple muscles that contribute to both these issues, we can assume that a couple key muscles are the ones impacting both the range of motion of the Hamstring and the Hip Joint (these muscles attach at multiple joints) and the knee or Patelofemoral joint. Because there is an overlap of the symptoms showing up in both cases. Quadriceps, Hamstrings, and Adductors and Abductors, we will look at these pain patterns together. There are also ‘non-related’ muscles that stabilize each of these areas separately: Quadratus Femoris, Piriformis (Hamstring) and Gastrocnemius/Soleus and Tibialis Anterior (Patelofemoral) that are impacting the performance of these joints.

Interpreting Leg and Knee Pain Symptoms

Many of trigger points that cause hamstring, knee and hip pain can be identified from a client’s presenting symptoms, medical history, and postural presentation. Listed below are some examples of these clues and some information about how each might relate to trigger point activity.

Hamstrings are a great example of how trigger points can create a confusing referral pattern that leaves you chasing the wrong muscle.

When people grab their hamstring and talk about how painful it is. They are often quite careful about not stretching their ham too aggressively. They may spasm easily when the knee if flexed, as they try to touch the heel to their hip (quad stretch), or they have a problem getting up after long periods of sitting. I’ve seen a lot of this problem over the years, especially from runners. This seizing hamstring can really shut down their activity and confuse them. Their hamstring goes into painful spasm even though they continue to stretch it as directed. This can be debilitating and discouraging.

The problem is that the seizing hamstring is a referral pattern of another muscle, the gluteus minimus. The gluteus minimus is located on the side of the hip. The goal is to help you to see that seizing hamstring pain is really the referral of the gluteus minimus and not the lateral hamstring itself. By eliciting the pattern for the hamstring first, an easy way to elicit trigger point referral is to stretch the muscle. Lay on your back, straighten your knee and stretch your hamstring by pulling your leg back toward your chest while keeping the knee straight. If you want to focus the stretching on the lateral hamstring, turn the toe out. That’s right! You feel it behind the knee.

     

Comparing the referral pattern for the lateral hamstring, and notice how it extends down the side of the leg but is mostly felt in the back of the knee. You can also press into your hamstring near those green spots in the pic and you’ll feel it in the back of knee too, but this is harder to do to yourself.

Now, elicit the pattern from the gluteus minimus. Look at the picture above to see where you should place the ball. Take a tennis (or lacrosse) ball and lay it on the floor. Now, lay on the tennis ball so that it presses into this spot. You may need to squirm around on it a bit to find the specific spot.  Most people guess too far back and need to turn onto their side a bit more with the ball farther forward. There are several trigger points in this area that produce different pain patterns into the hip and down the leg.  Referral means the ‘feeling of pain’ somewhere distant to the site of injury or muscle work being done in manual therapy (where the therapist touches).

A study by Dr. Lars Bendtsen (2000) following on the work of Janet Travell confirmed the role of central sensitization in chronic pain. Certain muscles were tender even when the subject was not experiencing a muscle pain at the time. Bendtsen theorized that long-term inputs from trigger points eventually lead to central sensitization in specific areas of the spinal cord and lumbar/sacral plexus including the nerves around the sciatic nerve and the lower spine (L5-S1). This causes additional changes in the affected muscles, a self-perpetuating cycle that converts periodic headaches into chronic pain. Because of this, even if the original initiating factor causing episodic pain s is eliminated, the trigger point-central sensitization cycle can continue and worsen on its own. This means that whatever causes the lower pain threshold in some people may also cause them to have chronic or recurring pain.

Trigger point pain is a failure at the motor-end plate (see picture above), where the nerve touches the muscle and share both in-bound and outbound messages to move/contract and move/relax. Remember that there is a two part motion in any muscle movement creating the motion and returning to neutral. The failure of the muscle to return to neutral means that it is still active. Active muscles that don’t rest, and continue to be in the heightened state for years become over-used (think repetitive stress).

Trigger points in the hips, anterior and lateral hip flexor and leg muscles will increase tension around the nerves as they leave the spinal cord of the lumbar/sacral plexus, go through the sacrum under the bottom of the pelvis (ischial tuberosity) and then down the leg. With a reduction in the functional space of the nerve, the tingling, neuropathy (lack of feeling) and pain will occur.

Weakness in this area can be a direct result of trigger points in multiple areas, like the Gluteal muscles, hip flexors are the high hamstrings which are one of the multiple areas of pain and weakness that impact the area around the Nerve plexus. Anytime there is consistent chronic pain investigate the nerve plexus or septum between the muscles.

What are some causes of “overactive” Hamstrings or Quads? If you have weakened abdominal muscles along with weakened lower-back stabilizing muscles (QL or Psoas) to assist in your movement or to compensate for the weakness, to allow you to do what you need to do, your other muscle will attempt to ‘work harder’ to balance weakness.

Trigger points of the Nerve plexus that result in reduced ROM and active or latent pain. You can identify the source through either Active or Passive muscle testing, and orthopedic special tests to help target treatments. These results should be treated through a series of Soft Tissue treatments like Active Release, Trigger Point therapy or Clinical Deep Tissue. Tigger point release or ‘local twitch’ response on the affected muscles will allow normal range of motion and return to active training cycle within 24-48 hours. Monitoring and ‘management’ of muscle tension should prohibit return of trigger point pain and weakness even during peak training.

Referral pattern of the Gluteus Minimus directly impacts the Hamstring

To find this pattern that you should look around the green spot for the location of trigger point pain. The sensation of a seizing hamstring can be felt strongly when it is elicited. Again, pay attention to the subtle parts of the pattern, and it becomes obvious that the pain and referral from the Gluteus Minimus is creating a secondary point (or causing another Trigger Point) in the Hamstring. Notice the tension in the calf and the tension in the lower hip, and the why is the function of the muscle. The tension will run all the way down into the knee and foot along the back side - because of the back anatomy train of the leg.

The gluteus minimus is one of the secondary muscles that can produce hip extension. This muscle is located deep and somewhat anterior to (in front of) the gluteus medius. The gluteus minimus and gluteus medius are separated by deep branches of the superior gluteal neurovascular bundle, a group of nerves and blood vessels.

The gluteus minimus emerges from the external surface of the ilium, part of the large pelvic bone, between the base and the front of the gluteal lines, bony ridges on the ilium that are used to mark the attachments of different gluteal muscles. It inserts into the greater trochanter of the femur, which is a bony prominence located at the top of the thigh bone, near the hip joint.

Along with the gluteus medius and tensor fasciae latae, the gluteus minimus serves as the primary internal rotator of the hip joint. The gluteus minimus helps with abduction (movement away from the midline of the body) and medial (inward) rotation of the thigh at the hip. Together with the gluteus medius, it acts to stabilize the hip and pelvis when the opposite leg is raised from the ground. Meanwhile, the complimentary action of abdominal muscle (rectus abdominis) is illustrated while lifting the right lower limb. (A) With normal activation of the abdominal muscles, the pelvis is stabilized and prevented from anterior tilting by the downward pull of the hip flexor muscles. (B) With reduced activation of the abdominal muscles, contraction of the hip flexor muscles is shown producing a marked anterior tilt of the pelvis (increasing the lumbar lordosis – and increasing the extension of the hamstrings). The reduced activation in the abdominal muscle is indicated by the lighter red color. Reproduced with permission from Neumann DA, Kinesiology of the Musculoskeletal System: Foundations for Rehabilitation, 2nd ed, Elsevier, 2010

The hip extensor muscles, as a group, produce the greatest torque across the hip than any other muscle group (FIGURE 3). The extensor torque is often used to rapidly accelerate the body upward and forward from a position of hip flexion, such as when pushing off into a sprint, arising from a deep squat, or climbing a very steep hill. The position of flexion naturally augments the torque potential of the hip extensor muscles. Furthermore, with the hip markedly flexed, many of the adductor muscles produce an extension torque, thereby assisting the primary hip extensors.

With an anterior tilt, because it affecting the stabilization and balance of the pelvis, a movement that changes the muscles in this cross, impacts the support of the hips and increases the stress on the opposing muscles that maintain the balance in the torso and lower legs. When the abdominals and gluteal muscles are weak the tension appears in hip flexors and lower back.

As a stabilizing function, the skeletal muscles work to support the body against gravity, therefore the muscles are active when you are NOT in motion as well. So you are using them when you are working out (1), when you are driving/sitting (2) and while you are sleeping (different intensities), but constantly active. So this pull against the ‘lower back’ which affect the attachments for the Gluteus Minimus, Medius and Maximus as well as the Tensor Fasciae Latae (TFL), the Piriformis and Iliopsoas.

By Releasing the muscles that are exerting to much tension (stretch and roll) and developing strength in the muscles that are weaker (not necessarily weak), this. will return the balance of use between the four groups

Releasing Hamstring Trigger Points...and the Gluteus Minimus Role

Study of myofascial performance has demonstrated that although stretching daily has been effective and when measured by Bandy, Irion & Biggler in the Journal of Physical Therapy, Vol 77, 10/1997, the outcomes supported that that a 30 second duration (per muscle) once a day was the minimum effective amount of time (better than 15 sec, the same as 60 sec) to sustain an increased Range of Motion (ROM) when executing Hamstring Stretches. There was no additional benefit or increase for longer times or more frequency per day.

 The areas that we are discussing in the session:

1)     Hamstring Pain

2)     Patelofemoral (knee) Pain

Since there are multiple muscles that impact both the range of motion of the Hamstring and the knee - or Patelofemoral Joint (since these muscles attach at multiple joints) we sould look at common influence of the pain. There is an overlap of the symptoms showing up in both cases. Quadriceps, Hamstrings, and Adductors and Abductors. There are also ‘non-related’ muscles that stabilize each of these areas separately: Quadratus Femoris, Piriformis (Hamstring) and Gastrocnemius/Soleus and Tibialis Anterior (Patelofemoral).

Interpreting Leg and Knee Pain Symptoms

Many trigger points that cause hamstring, knee and hip pain can be identified individually from a client’s presenting symptoms, medical history, and postural presentation. The patterns for each muscle are distinctive, and can be demonstrated simply by access to the general source points listed in Travel and Simon’s work on Myofascial Pain (1993). Listed below are some examples of these clues and some information about how each might relate a client’s pain symptoms to trigger point activity.

Hamstrings, specifically the biceps femoris, are a great example of how trigger points can create a confusing referral pattern that leaves you chasing the wrong muscle.

When people grab their hamstring and talk about how painful it is. They are often quite careful about not stretching their hamstring muscle too aggressively. I have watched clients after a massage (including ART protocols) get up, lift their leg gingerly to stretch their legs - and have this overwhelming tension that prohibits movement. Is is mental…probably more than half. They may also spasm easily when the knee if flexed, as they try to touch the heel to their hip (quad stretch), or they have a problem getting up after long periods of sitting. I’ve seen a lot of this problem over the years, especially from runners of long AND short distances, hurdlers and lacrosse and soccer players suffer from long days of tense hamstrings and reduced flexibility.  This seizing hamstring can really shut down their activity and confuse them. Their hamstring goes into painful spasm even though they continue to stretch it as directed. This can be debilitating, injury producing and discouraging.

The only other problem is that the seizing hamstring is a referral pattern of another muscle, the gluteus minimus. The gluteus minimus is located on the side of the hip deep to three layers of muscles. The goal in this discussion is to help you to see that seizing hamstring pain is really part or secondary to the referral of the gluteus minimus and not the lateral hamstring itself. By eliciting the pattern for the hamstring first, an easy way to elicit trigger point referral is to stretch the muscle. Lay on your back, straighten your knee and stretch your hamstring by pulling your leg back toward your chest while keeping the knee straight. If you want to focus the stretching on the lateral hamstring, turn the toe out. That’s right! You feel it behind the knee.

Here is the referral pattern for the lateral hamstring. Notice how it extends down the side of the leg but is mostly felt in the back of the knee. You can also press into your hamstring near those green spots in the pic and you’ll feel it in the back of knee too, but this is harder to do to yourself.

Now, elicit the pattern from the gluteus minimus. Look at the picture above to see where you should place the ball. Take a tennis (or lacrosse) ball and lay it on the floor. Now, lay on the tennis ball so that it presses into this spot. You may need to squirm around on it a bit to find the specific spot.  Most people guess too far back and need to turn onto their side a bit more with the ball farther forward. There are several trigger points in this area that produce different pain patterns into the hip and down the leg. Referral means the ‘feeling of pain’ somewhere distant to the site of injury or muscle work being done in manual therapy (where the therapist touches).

A study by Dr. Lars Bendtsen (2000) following on the work of Travell and Symons confirmed the role of central hyper-sensitization of the myofascial endplate in chronic pain. Certain muscles were tender even when the subject was not experiencing a muscle pain at the time. This tenderness and pain is the ‘energy crisis,’ and continuous loop of the triggerpoint.

Bendtsen theorized that long-term inputs from trigger points eventually lead to central sensitization in specific areas of the spinal cord and lumbar/sacral plexus including the nerves around the sciatic nerve and the lower spine (L5-S1). This causes additional changes in the affected muscles, a self-perpetuating cycle that converts periodic headaches into chronic pain. Because of this, even if the original initiating factor causing episodic pain is eliminated, the trigger point-central sensitization cycle can continue and worsen on its own. This means that whatever causes the lower pain threshold in some people may also cause them to have chronic or recurring pain.

Trigger point pain is a failure at the motor-end plate (see picture above), where the nerve touches the muscle and share both in-bound and outbound messages to move/contract and move/relax. Remember that there is a two part motion in any muscle movement creating the motion and returning to neutral. The failure of the muscle to return to neutral means that it is still active. Active muscles that don’t rest, and continue to be in the heightened state for years become over-used (think repetitive stress) and tired. It takes more effort to do normal movements, and heaviness and deep pain are common.

Trigger points in the hips, anterior and lateral hip flexor and leg muscles will increase tension around the nerves as they leave the spinal cord of the lumbar/sacral plexus, go through the sacrum under the bottom of the pelvis (ischial tuberosity) and then down the leg. With a reduction in the functional space of the nerve, the tingling, neuropathy (lack of feeling) and pain will occur.

Weakness in this area can be a direct result of trigger points in multiple areas, like the Gluteal muscles, hip flexors are the high hamstrings which are one of the multiple areas of pain and weakness that impact the area around the lower Nerve plexus. Anytime there is consistent chronic pain and resistant muscle tension investigate the nerve plexus or septum between the muscles in order to understand the source and the impact of the chain of muscles in that area.

What are some other causes of “overactive” Hamstrings or Quads? If you have weakened abdominal muscles along with weakened lower-back stabilizing muscles (QL or Psoas) to assist in your movement or to compensate for the weakness, to allow you to do what you need to do, your other muscle will attempt to ‘work harder’ to balance weakness.

Trigger points of the Nerve plexus that result in reduced ROM and active or latent pain. You can identify the source through either Active or Passive muscle testing, and orthopedic special tests to help target treatments. These results should be treated through a series of Soft Tissue treatments like Active Release, Trigger Point therapy or Clinical Deep Tissue. Trigger point release or ‘local twitch’ response on the affected muscles will allow normal range of motion and return to active training cycle within 24-48 hours. Monitoring and ‘management’ of muscle tension should prohibit return of trigger point pain and weakness even during peak training.

Referral pattern of the Gluteus Minimus

To find this pattern that you should place the green spot where the trigger point is located. The sensation of a seizing hamstring can be felt strongly when it is elicited. Again, pay attention to the subtle parts of the pattern. Notice the tension in the calf and the tension in the lower hip, and the why is the function of the muscle.

The gluteus minimus is one of the secondary muscles that produces hip extension. This muscle is located deep and somewhat anterior to (in front of) the gluteus medius. The gluteus minimus and gluteus medius are separated by deep branches of the superior gluteal neurovascular bundle, a group of nerves and blood vessels.

The gluteus minimus emerges from the external surface of the ilium, part of the large pelvic bone, between the base and the front of the gluteal lines, bony ridges on the ilium that are used to mark the attachments of different gluteal muscles. It inserts into the greater trochanter of the femur, which is a bony prominence located at the top of the thigh bone, near the hip joint.

Along with the gluteus medius and tensor fasciae latae, the gluteus minimus serves as the primary internal rotator of the hip joint. The gluteus minimus helps with abduction (movement away from the midline of the body) and medial (inward) rotation of the thigh at the hip. Together with the gluteus medius, it acts to stabilize the hip and pelvis when the opposite leg is raised from the ground. Meanwhile, the complimentary action of abdominal muscle (rectus abdominis) is illustrated while lifting the right lower limb. (A) With normal activation of the abdominal muscles, the pelvis is stabilized and prevented from anterior tilting by the downward pull of the hip flexor muscles. (B) With reduced activation of the abdominal muscles, contraction of the hip flexor muscles is shown producing a marked anterior tilt of the pelvis (increasing the lumbar lordosis – and increasing the extension of the hamstrings). The reduced activation in the abdominal muscle is indicated by the lighter red color. Reproduced with permission from Neumann DA, Kinesiology of the Musculoskeletal System: Foundations for Rehabilitation, 2nd ed, Elsevier, 2010

The hip extensor muscles, as a group, produce the greatest torque across the hip than any other muscle group (FIGURE 3). The extensor torque is often used to rapidly accelerate the body upward and forward from a position of hip flexion, such as when pushing off into a sprint, arising from a deep squat, or climbing a very steep hill. The position of flexion naturally augments the torque potential of the hip extensor muscles. Furthermore, with the hip markedly flexed, many of the adductor muscles produce an extension torque, thereby assisting the primary hip extensors.

With an anterior tilt, because it affecting the stabilization and balance of the pelvis, a movement that changes the muscles in this cross, impacts the support of the hips and increases the stress on the opposing muscles that maintain the balance in the torso and lower legs. When the abdominals and gluteal muscles are weak the tension appears in hip flexors and lower back.

As a stabilizing function, the skeletal muscles work to support the body against gravity, therefore the muscles are active when you are NOT in motion as well. So you are using them when you are working out (1), when you are driving/sitting (2) and while you are sleeping (different intensities), but constantly active. So this pull against the ‘lower back’ which affect the attachments for the Gluteus Minimus, Medius and Maximus as well as the Tensor Fasciae Latae (TFL), the Piriformis and Iliopsoas.

By Releasing the muscles that are exerting to much tension (stretch and roll) and developing strength in the muscles that are weaker (not necessarily weak), this. will return the balance of use between the four groups

I. Anterior Tilt/Tight Abductors (Stretches for Appropriate muscles sequence):

Lengthen (stretch)

1)     Hamstrings: Semitendinosis, Biceps Femoris, Semimembranosis

        a.      Knee Pain**

        b.     Hip Pain

2)     Quadriceps: Vastas Lateralis, Vastus Intermedius

        a.      IT Band Pain

        b.     Hip Pain  

        c.      Knee Pain

3)     Adductors: Adductor Magnus/Longus, Sartorious, Gracilis

II. Reduce tension/adhesions (compression on foam roller/trigger point ball)

4)     Adductors: Adductor Magnus/Longus, Sartorious, Gracilis    

5)     Abductors: Gluteus Maximus, Gluteus Minimus, Gluteus Medius

6)     Hip Flexors: Piriformis, TFL, Quadratus Femoris (high hamstring), Pectineus (adductor)

Strengthen:

1)     Abdominals: Rectus abdominus, Obliques, interus/externus, Quadratus Lumborum, Iliopsoas

Series of stretches to target back and thighs

Series of stretches to target back and thighs

Muscle Movements and the Stretch, Pt 1

The Physiology of a Muscle Stretch

The biomechanics of a musculoskeletal stretch is under conscious control. When we straighten our knees (think getting from from a chair), the brain signals the quadriceps to contract and the knee ‘joint’ straightens out from a 90 degree bend into a 180 degree plane. We will look at the complex movement of this joint in three posts - one for the physiology discussion and impact of stretching (pt 1); One for the opposition forces like reciprocal inhibition and supporting movements of other muscles (pt 2); and the actual response of the structure of the knee through the involvement of the tendons, ligaments and other soft tissue - which have separate receptors that 'regulate' the action though Golgi Tendon organs (pt 3). Since the movement of the quads, activevates the movement of stretch, or lengthening the hamstrings, then we can add the ‘support’ movement of the adductors of the thigh and the abductors of the hip flexors and gluteal muscles. So there is a lot going on, just to help you stand. You may not be ‘aware’ of all this movement, which is how the action ‘triggers’ a chain of physiologic responses that take place without conscious awareness of the brain. But the muscles are aware, because of the receptors in the muscles and the joint.

In order to maintain your posture (even bad posture - so stop slouching) your muscles are constantly monitoring their shape. A change in shape of a muscle (the stimulus) causes the muscle to readjust its shape (the response) and maintain your posture. The receptors within the joint and the muscles work together to detect movement and changes in muscle tension and length. These receptors signal the central nervous system (CNS) to respond by regulating the contracting state of the muscles. This in turn affects the range of motion of a joint or muscle group. 

This is the way that conscious biomechanic actions influence the unconscious physiological response - so we don’t move ‘too far,’ or remain stable in our positions that we hold throughout the activity. Moving the body initiates a sequence of biomechanic and physiologic events that involves the Spinal Cord (CNS) individual muscles (PNS) and structures like joints, which makes a lot more sense when you compare these actions to a “system” of pulley-lever and internal controls (rough metaphor - I know)!

The spinal cord initiates movement through a 'reflex arc,' in order to regulate the tension and length of skeletal muscle movement. This 'reflex' affects operates between the CNS and the muscle belly anywhere in the body - so let's just stick with the example of the knee. A motor neuron carries the message from the central nervous system to the effector in the quadriceps (since they are the prime movers in the movement of the knee). In a 'knee-jerk' reflex arc the sensory neuron directly connects to the motor neuron in the spinal cord. This is called a simple reflex arc. from the spindle (receptor) to where it connects with the motor neuron in the spinal cord. The regulation and monitoring of the movement occurs automatically, in response to the neural messaging - to create the biomechanical actions (and therefore the movement). When a muscle contracts or stretches, receptors within the structure alert the CNS to this movement event. The CNS signals the muscles to respond appropriately, either by relaxing or contracting the appropriate muscles. Different muscles respond by creating, supporting or allowing the movement - so there are many muscles reacting to create a single chain.

All of this takes place without our being aware of it, an it's within milliseconds or the thought leaving the brain. The arc of nerves between the muscles and spinal cord allows this messaging and feedback to produce balance and fine-tune movement. There is a complex array or receptors and corresponding reflex arcs connecting the musculoskeletal system to the CNS.  To provide a brief example, I am only discussing the three major reflexes:  the muscle spindle, reciprocal inhibition and Golgi tendon organs as they will give the control response for the end of the muscle movement.

There are three types of stretching that we generally discuss: Ballistic stretching - uses jumping movements to activate the target muscles (more propulsive - fast twitch focus); Passive stretching - uses the body weight, gravity, and synergist/agonist muscle group relationship to create a stretch. The person is having the muscle acted upon, so that no muscles are "active" in the process of creating the stretch; Facilitated stretching - also known as PNF or proprioceptive neuromuscular facilitation - it involves briefly contracting the target muscle for a stretch, and then taking a longer stretch to take additional stretch through the 'slack' created by the response to the CNS.

Muscles that are shortened will benefit from the extra effort of lengthening them, so that they remember the correct and full Range of Motion regardless of their level of use. So Stretching is designed to lengthen muscles shorted under constant use, or warm muscles that have been static for long period of time. PNF or proprioceptive changes are necessary, to make muscles more efficient in between workouts, or when the nervous system isn't responding in the way that you expect - to support your movements.

Principles of Efficient Stretching   - Active Isolated Stretching
 

Principle #1: Prolonged or forceful stretching is counterproductive. After about 2 seconds, a muscle contracts defensively in response to a stretch that is forceful enough to injure it. (This action is known as the myotatic or stretch reflex.) .  
 
Principle #2: Active movement facilitates stretching. Sherrington’s Law of reciprocal inhibition in muscular contraction states that when a muscle on one side of a joint is contracted, the muscle on the opposite side of the joint is sent a neurological signal to relax or release.  
 
Principle #3: Muscles are more efficiently stretched when they are at rest or relaxed Momentary rest between stretches is as important as the stretch itself. It reduces fatigue and enhances blood flow to resupply oxygen and nutrition and eliminate waste products.  
 
Principle #4: Regular breathing increases oxygenation Increased oxygenation of the blood helps deliver nutrition to the muscles and improves waste removal. When oxygen is lacking anaerobic metabolism occurs, converting glucose to lactic acid, which promotes fatigue. I
 
 
Principle #5: Flexibility is specific Flexibility is most efficiently maximized by identifying and then isolating which part of which muscle is inflexible. AIS stretches are designed to stretch the distal and proximal ends of a muscle separately. In addition, they use 10-15 and 45º rotations in both directions to maximize the stretching of all the different muscle fibers. 
 
Principle #6: Specific movement establishes specific neuromuscular pathways Repetition of specific movements creates new neuromuscular patterns, essentially rewiring the neuromuscular system. The development of new neurons — through appropriate stretching improves the functioning of existing neurons.  
 
Principle #7: A gentle assist facilitates increased flexibility  Another factor that stimulates neurogenesis is actively going beyond a person’s normal capacity. Gentle assists challenge the tissue, facilitating neurological development and enabling a gradual increase in flexibility. People who have degenerative neuromuscular conditions such as multiple sclerosis or polio are generally not encouraged to move beyond their comfort level — which means there’s no opportunity for them to restore lost functioning.
 
Principle #8: A muscle’s ability to withstand a stretch and tensile force is important for injury prevention. To injure a normal muscle, the muscle must either be stretched beyond its capacity or subjected to a load that is too great for it to bear. A strong muscle can absorb greater amounts of force and a fully flexible muscle can lengthen and absorb force before failure or injury occurs. 

Principle #9: Flexibility and strength are interdependent.  Flexibility without strength and strength without flexibility are both inefficient and increase the vulnerability to injury and dysfunction. Typically people are weakest at the end of their range of motion. AIS develops strength within the optimal range of motion.  
 
Principle #10: Muscle extensibility increases with body temperature. (from DeLee research 2003) The basic, ground substance of connective tissue is hyaluronic acid — a highly viscous substance that binds and lubricates the collagen, elastin, and muscle fibers. It has the consistency of Vaseline at room temperature when the muscles are “cold,” and as the temperature of the muscle increases it becomes more malleable and fluid. This is why are warming up is important in order to maximize flexibility. 
 
Principle #11: To prevent injury, minimal force should be used during stretching. Laboratory studies show that most muscle injuries occur when more than 70% of maximal sustainable force is used. The same research showed that 50% or less of maximal force should be used to prevent injury. 
 
Principle #12: Placing tension throughout ligaments and tendons increases their strength The way to strengthen tendons and ligaments is to put tension through them. Brief, repeated stretches put a tensile force through these structures and increase their strength. (In contrast, prolonged stretching can lead to injury; tendons and ligaments are not elastic, and therefore when you stretch them, you damage their integrity and structure.) 
Knee_StretchReflx.JPG

Delayed Onset Muscle Soreness...and Massage in Recovery

What is DOMS?

We’ve all experienced that agonizing muscle ache, where there is pain of trying to get out of your car, wobble up the stairs, or move normally after a hard day at work or workouts. This soreness is called delayed onset muscle soreness (DOMS). If you’ve been exercising long enough, you’ve probably felt it. If you've been sitting all day after exercising - you definitely felt it. Some athletes relish this pain as an indicator of success, but is that really the accurate?

I frequently see DOMS occur after a daunting day of activity - with little mental or physical break from one activity. Think six hours in dance class for professional ballerinas, think ANY Iron-man Triathlon. Think of going to the gym before class or work, or bootcamp - and not getting home until 12 hours later. That's a long day... It can also occur in experienced athletes after taking a few weeks off from workouts as part of a recovery.  

A number of treatment strategies have been introduced to help alleviate the severity of DOMS and to restore the maximal function of the muscles as rapidly as possible. Here what aids in the recovery process:

  1. Nonsteroidal anti-inflammatory drugs have demonstrated positive effects based on the dosage. They may also be influenced by the time of use.
  2. Massage has also shown varying results that may be attributed to the time of massage application and the type of massage technique used.

Here is what hasn't worked:

  1. Cryotherapy, stretching, homeopathy, ultrasound and electrical current modalities have demonstrated no effect on the alleviation of muscle soreness or other DOMS symptoms.

Exercise is the most effective means of alleviating pain during DOMS, however the effect if 'active recovery' use as an analgesic is also temporary. Athletes who must train on a daily basis should be encouraged to reduce the intensity and duration of exercise for 1–2 days following intense DOMS-inducing exercise. Alternatively, exercises targeting less affected body parts (think alternate sequence of workouts - upper body, lower body or legs, arms and back or chest,  should be encouraged in order to allow the most affected muscle groups to recover. Eccentric exercises (lengthening under tension and/or weight) or novel activities should be introduced progressively over a period of 1 or 2 weeks at the beginning of, or during, the season in order to reduce the level of physical impairment and/or training disruption. This introduction to activity (10-15% increase) should also be applied when restarting an exercise program. There are still many unanswered questions relating to DOMS, and many potential recovery.

DOMS is Not Fiber Damage

Studies show (1) that DOMs is not restricted to any particular muscle group, but some people tend to experience it more in certain muscles. Technically speaking, DOMS is (primarily) caused by a type 1 muscle strain – some degree of fiber damage, but nothing too serious – predominantly as a result of unaccustomed exercise (either different levels or activities) or long periods of forced inactivity. As you may have experienced, it can range from slight muscle discomfort to severe pain that limits range of motion. Generally, muscle soreness becomes noticeable ~8 hours post-workout and peaks 48-72 hours later, although the exact time course can vary.

There is little doubt that DOMS is correlated with exercise-induced muscle damage to some degree; however, measurement of muscle damage at a microscopic level are poorly correlated with reports of soreness. Basically, if you’re really sore, it doesn’t mean you completely “shredded” the muscles you are feeling soreness in. This is supported by MRI images showing little damage to some muscles post-exercise. Not only do the time cycle, or course of changes that markers of muscle damage indicate, differ from one another, but they also don’t match the time course of muscle soreness (Newham, 1988). It is possible for severe DOMS to develop with little or no indication of muscle damage, and for severe damage to occur without DOMS.

Certain types of exercise can cause significant muscle damage. The image below is taken after an extensive eccentric exercise protocol. As you can see, the muscle fiber just looks messed up. The majority of studies examining exercise-induced muscle injury and DOMS use untrained subjects undertaking large amounts of unfamiliar eccentric exercise. This model is unlikely to closely reflect the circumstances of most people who workout. However, it does give us some insight into what happens in the muscle. (See Image No. 1 below - Image of muscle from an electron microscope after eccentric exercise. Notice the disruption in the muscle pattern).

Another DOMS-inducing stimulus that occurs during exercise is metabolic stress (this does not refer to the buildup of lactic acid, because lactic acid and collagen buildup do not cause DOMS.)  Thinking that lactic acid causes muscle soreness is as inaccurate and dogmatic idea, as the idea that massage gets rid of body toxins.  Viewing by-products of exercise as toxins is outdated and flat-out wrong, after high-intensity exercise, rest alone will return blood lactate to baseline levels well within the normal time period (think 24 hours) between training sessions. However, there is some evidence that hydrogen ions and reactive oxygen species – both of which increase in concentration during exercise – may contribute to DOMS (2). Metabolic stress during exercise can cause changes on a structural level at the cell membrane (sarcolemma). The damage allows fluids and other factors to enter the cell, which promotes inflammation (3).

Cell swelling occurs during exercise-induced muscle damage when fluid and plasma proteins can exceed the capacity of the drainage. The result is edema in the muscle, with significant swelling lasting ~48 hours post-exercise.

Does DOMS mean more muscle growth?

Some studies show the presence of DOMS after long-distance running, which indicates it doesn’t just occur during resistance training. This should be an anecdotal sign that DOMS isn’t a good gauge of muscle growth, because running causes minimal hypertrophy - and there may indeed be DOMS after long distance endurance races.

People who are new to working out often have the most pronounced DOMS. They also happen to grow the most, so you can see how the two may be intertwined. This is due to the new stimulus that exercise provides. Again, they get sore because they aren’t accustomed to exercising – not because they are growing like monsters. Interestingly, there is no difference in DOMS between sexes even for beginners.

There is some evidence to show DOMS may negatively affect workouts by altering motor patterns in subsequent workouts. This could cause reduced activation of the desired muscle. Hence, DOMS could actually hinder your next workout. In addition, severe DOMS can decrease force capacity by up to 50% (6). This causes functional deficits that may impair training at a certain level, which could hinder muscle growth in the long term.

Exercising while having DOMS does not seem to make muscle damage worse (7), but it may interfere with the recovery process. In extreme cases, exercise-induced muscle damage can cause rhabdomyolysis, a serious condition that can lead to renal failure. So be careful when throwing a newbie into an advanced program – especially if they’ve never exercised. You could do some serious damage.

”The “No pain, No gain” theory is wrong – at least for muscle growth.” 

How do I feel DOMS?

Nociceptor

So if you aren’t destroying your muscles or burning them up with lactic acid, then why do they hurt? I recently discussed this concept with a member of my lab.

Nociceptors are free nerve endings that respond to damaging stimuli by sending pain signals to the brain. In muscle tissue, these receptors can sense chemical stimuli such as inflammation or disturbances in microcirculation to blood vessels. These receptors are not inside the muscle because muscle cell death is not painful. In comparison, tearing a muscle can be extremely painful. The pain is due to the release of muscle substrates into the space where nociceptors are located. This also helps us appreciate that DOMS probably doesn’t occur due to something inside the muscle (i.e., in the contractile apparatus) (7).

How can I reduce DOMS?

One of the best ways to decrease the risk of DOMS is to slowly progress into a new exercise program. If you’ve ever had an advanced program, you’ll notice the first week or two may have reduced volume. The “prep” phase of programs has two purposes: 1) allowing the muscle time to acclimate to a new movement, and 2) leaving room for more adaptation.  

We all know we should warm-up properly. This is probably one of the only times you’ll hear it doesn’t help. While it may prepare you for exercise (I highly suggest it), neither warming up nor stretching before exercise has been shown to reduce or prevent DOMS.

Something a lot of people use to relieve DOMS is foam rolling. However, it has only been shown to improve DOMS in some studies. During foam rolling, you use your own body mass on a foam roller to exert pressure on an area of soft tissue. The motion places direct pressure on an area, which stretches it. It is considered self-induced massage because the pressure somewhat resembles the pressure exerted on muscles by a massage therapist. Again, there are only a few studies that have measured the effects of foam rolling on performance. These studies found foam rolling can enhance recovery after DOMS and alleviate muscle tenderness. Self-massage through foam rolling could benefit people wanting to recover in an affordable, easy, and time-efficient way.  

Another intervention commonly used is massage. Some researchers have shown decreases in pain associated with DOMS after a massage (8). However, massage has no effect on muscle metabolites such as glycogen or lactate. One study found massage decreased the production of the inflammatory cytokines by mitigating cellular stress resulting from muscle injury (8). Many people believe massage can provide increased blood flow to specific areas, reduced muscle tension, and mood enhancement. Massage produces direct pressure, which may increase ROM and stiffness. These benefits are expected to help athletes by enhancing performance and reducing injury risk.  The effects of timing of massage (pre- or post-exercise) on performance, injury recovery, or injury prevention are not clear because the mechanisms of each massage technique have not been widely studied.

Supplements to reduce DOMS

Caffeine has long been known to increase alertness and endurance, shown by the the average person’s morning grumpiness before drinking the black gold. Interestingly, a recent study by Hurley et al., reported caffeine has the ability to reduce DOMS. They mesured perceived soreness in males consuming caffeine one hour before a workout. They found a lower level of soreness in the biceps on day 2 and 3 compared to a placebo after subjects completed a bicep curl protocol.  Using a dosage of 5mg/kg bodyweight they found a beneficial effect of caffeine on soreness. For comparison, a 185lb (~84kg) male would take about 420mg of caffeine preworkout. That is a ton of caffeine! An 8oz Red Bull contains roughly 85mg. Does your preworkout supplement have that much caffeine? Probably not. If you’re wondering when caffeine peaks in the blood, it’s about one-hour post ingestion. Caffeine is an adenosine antagonist and affects the activity of central nervous system (CNS) by blocking adenosine receptors, thus resulting in decreased levels of soreness. This suggests that short-term caffeine ingestion before a strenuous workout may decrease overall soreness levels.  However, the subjects who took caffeine were able to perform more reps than the control group, which could be a confounder.

Taurine is found in muscle and has multiple biological functions. Remember that Red Bull I mentioned earlier? Well, it has about 1,000mg of taurine. For reference: Up to 3,000mg a day of supplemental taurine is considered safe. One double-blind study (10) of males completed over 21 days measured the effects of 50mg of taurine (20x less than the content in a Red Bull) after 7 days of eccentric exercise.  The researchers found a reduction in DOMS and oxidative stress markers after exercise; however, there was no effect on inflammatory markers. Could this be a way to battle the other side? If inflammation is one component to DOMS and oxidative stress is another component, we need a study to combine the two. That probably won’t happen soon, but it would be fun to see if they were synergistic.

Omega-3 fatty acid is found in fish and is becoming increasingly used tofortify foods. You can also find EPA/DHA in those lovely pills that make you burp fish all day. Several studies reported positive effect of omega-3 fatty acids on DOMS, presumably due to the decrease in pro-inflammatory factors such as IL-6 and TNF-alpha. There are a ton of studies to show taking an omega-3 supplement is good for you in many ways, and this seems to hold true for DOMS. If you’re interested in the results, the main table from Jouris et al 2013is below.

Manual Therapy to reduce DOMS

y, on the other hand, Cryotherapy probably doesn’t reduce DOMS.  This goes directly against the current trend of athletes jumping in a tube surrounded by liquid nitrogen to help recovery. Whole body cryotherapy exposes athletes to cold, dry air below -100C for between two and four minutes in a specialized chamber. A recent Cochrane Review by Costello et al., found that there was insufficient evidence to determine whether cryotherapy can reduce muscle DOMS or improve recovery.  

No guidelines currently exist for its clinical effectiveness or for safe usage. Cryotherapy is thought to work by reducing  temperature in the skin, muscle, and core. The theory is muscle soreness is relieved by reducing muscle metabolism, skin microcirculation, nerve conductivity and receptor sensitivity. In addition, it could have a placebo effect by reducing the subjective feeling of DOMS post-exercise. Using a meta-analysis based on four eligible studies, it seems cryotherapy does not reduce DOMS or improve recovery. Furthermore, insufficient evidence exists on whether this therapy could actually be harmful.  We do know, however, that cold water emersion post-exercise can decrease rate of muscle growth. For the time being, cryotherapy and cold water emersion are probably two things you should avoid – you probably won’t recover any faster, and you may not build as much muscle.

2) Neuromuscular Massage, is a consistent deep tissue treatment which aims to release muscle adhesion at the source - the neuromuscular endplate. It can be painful, it can be time consuming - and if you use it during training, you may have to plan it for the off days where you have nothing else going on. It actually changes the proprioception or spacial orientation of the muscles. Athletes report 'having more space, more flexibility and greater capacity.' Since a lot of this is in the mind, if you've been training within specific parameters for a big race, you know how your body functions - once you make these changes you have to dial it into your mind as well. Hurdler's are a very specific example - if you know exactly how much hip flexion it takes to get over a hurdle, and after an NMT appointment you have "way more stride," it's going to through you off.

3) Active Release Techniques, is another deep tissue technique which aims to release muscle adhesion, realign muscle fibers and can be uncomfortable. But it is a much quicker and less of a change to the proprioception wherever it is used. Made famous by chiropractors, this technique actually takes muscles through a stretch (both active and passive), where the body is guided back to length, strength and done with full knowledge of the brain (hence the active). The client is shown, talked through and is participating in the treatment - so that by the end of the time, they know how much change has taken place. Although there can be significant changes, the awareness around the movements doesn't progress from total relaxation to 'realignment' within 24 hours. The reset is immediate - and there is minimal change to the parasympathetic nervous system, and there is no catch-up time to the brain.

Conclusion

Soreness can provide some insight, but don’t use it as a marker for a good workout. High levels of soreness indicate the athlese has exceeded the capacity for the muscle to undergo repair. Indeed, soreness can impede the ability to train properly, and it may decrease motivation.

The consensus among researchers is that there is no single component that causes DOMS. Instead, there are a number of complex events that may explain this phenomenon. It is the main cause of reduced exercise performance including decreased muscle strength and range of motion for both athletes and non-athletes. A combination of all the post-workout recovery tools, is probably a good idea to see what works for you as an individual.

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Simple Explanation of Pain

This is a great, easy to follow video about chronic pain. It helps you understand what current research has been saying about chronic pain - thats its not a joint or muscle problem, rather a 're-wiring' of the brain perception of itself. In other words, the brain has become more sensitive than before.

During the past twenty years, research on chronic pain has significantly increased, with considerable advances in understanding its etiology, assessment, and treatment. These discoveries have important healthcare implications, when pain is one of the leading causes for why people seek out medical care. Pain is an even bigger influence for movement and manual therapies. Whether or not pain relief is your immediate goal, the fact remains that the majority of people who walk into your office experience some degree of pain and/or tension that they want help with.  This is why we must understand what pain is, and more importantly, what pain is not, when communicating with our clients.

For manual and movement therapists, knowledge of the anatomy and movement of the body becomes fundamental as well. This is a simple review of the most recent understanding of pain, providing a summary of some of the latest pain science research, and how both are relevant and applicable to you and your clients. It proposes explanations for phenomena where, with your treatment, your client’s pain may decrease, remain the same, or perhaps gets worse. Ultimately, understanding these phenomena will empowering to both you and your clients success in managing the pain in their lives.

Within roughly the last twenty years, neuroscience and pain science have discredited the belief that pain reflects the state of physical tissues (i.e. pain = tissue damage), a purely biomechanical explanation for pain (Gifford 1998, Lederman 2010). This is the major falsification reversed, in how we once believed and understood pain to manifest in the body. The International Association for the Study of Pain (IASP) defines pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.”

Simply put, pain is the brain’s perception of tissue damage (Butler and Moseley 2003). Perception is the key focal point, because pain is about how a person consciously and non-consciously creates meaning of his/her physical reality. This perception of tissue damage (i.e. pain) is modulated by a number of cognitive, emotional, and sensory inputs (Gifford 1998; Carlino et al. 2014).

When someone in pain walks into your office, they want answers to the following:

1.  What’s wrong with me?

2.  How long is this going to last?

3.  Is there anything I (the client) can do about it?

4.  Is there anything you (the practitioner) can do about it?

(Verbeek et al. 2004; Gifford 2014)

These questions are prompted by the underlying assumption that pain is the indicator for something “wrong” in the physical body. A number of hypotheses will be made (joint misalignment, degeneration, compression), so that a treatment regime can be identified designed to “fix” these physical morbidities. When experiencing pain health practitioners sensibly, but mistakenly, place all of our attention in the physical domain. Today, we see that this is a false conclusion that pain predictably represents tissue damage.

“Pain is an opinion on the organism’s state of health rather than a mere reflexive response to injury. The brain gathers evidence from many sources before triggering pain.”

-V.S. Ramachandran

One of the brain’s chief priorities is to keep the body safe and protected. Pain warns us of danger and compels us to take action to relieve and/or avoid that danger. This stimulus is known as ‘flight-or fight.’ Thus, the experience of pain is based on a prediction of danger that we are physically in, not how much we are actually going to experience. Even if there are no problems in the tissues, nerves, or immune system, you can still hurt if your brain concludes that you are in danger (Butler & Moseley 2003).

Historically, a class of sensory receptors called nociceptors were once, incorrectly, referred to as pain receptors. Nociceptors are receptors that require higher thresholds of stimuli to trigger an action potential, which in turn sends larger, more amplified signals to the central nervous system (CNS). These larger signals serve to get a person’s attention by acting as warning signals. The brain, though, can ignore input from the body, large or small, if the brain is either distracted enough or does not value the incoming messages. Because pain is context-dependent, the drama around pain, injury – whether real or perceived – will take priority in the brain’s attention. A notable example of this is seen with soldiers in the heat of battle who are shot but don’t feel pain until much later, once they are out of the dangerous environment.

The recovery from tissue damage includes the resolution of healing (particularly inflammation) and attenuation of nociception excitation. The process is not complete if the final stage of attenuation is not completed – and the system returns to homeostasis. The point is, that a time frame exists, and this is the expected cycle within which all tissues complete their healing phases. Pain serves an important role during healing to ensure the process is preserved, and to prevent further tissue damage in order to facilitate a full recovery (Lederman 2015; Figure 1).

 If pain persist past the healing window, it is considered chronic. It is important to reiterate, though, that an individual can experience acute pain even without tissue damage present. We can refer to this more accurately as a "pain event."

The neuromatrix theory of pain proposes that pain is an imprint, or “pain neurosignature,” of nerve impulse patterns. These patterns are generated by the body-self neuromatrix (Melzack 2001) and influence the structures, soft-tissue and functional activities. There are many inputs to the brain that can create or later trigger a pain neurosignature, including movements, thoughts, emotions, touch, memories, fears, smells, and visual stimuli, to name a few. Interestingly, the neuromatrix requires no actual sensory input for a person to experience pain, only the activation of a pain neurosignature or pattern that 'triggers' a response in the body; phantom limb pain is an example of this.

The most important takeaway from the neuromatrix theory of pain is recognizing that pain is an output of the brain rather than being dependent on or a response to sensory input like damaged tissue (Melzack 2001; Gatchel et al. 2007).

CONCLUSIONS

Our experience of pain is a top-down process—always. In fact, there is no such thing as myofascial pain, bone pain, organ pain, or even the existence of nerve pain. There’s just pain. This means damaged and pinched nerves do not have to hurt. Even in the presence of actual tissue damage—given pain is an output of the brain—it is our brain that concludes whether our tissues are in danger.

Pain is primarily a psychological experience (Craig and Hadjistavropoulos 2004). This is not to say that pain is all in your head, as in your discomfort is imaginary, but it is a construct of the brain projected onto the body. Modern pain science does NOT imply people imagine their pain.

Pain is real. Pain is always real. Pain literally changes our PNS and CNS physically and chemically. This is the dark side of neuroplasticity. Pain can be an output from our brain, that changes the input from the PNS and CNS. The resulting messages can then change the brain’s perception – a complicated ‘loop,’ with no end.

Myths about Massage that are 'Wrong.'

Massage Therapy has many wonderful and therapeutic benefits but the advice or cautions that wind up being shared are often inaccurate. What we hear can be a little misleading, so, I thought I'd take on the role of 'Masage ' today and discuss what's real and what's not.

Let me know if you have your own favorite Massage Therapy Myth, or illusions that have been shattered in the course of manual therapy. I love the good stuff.

Myth #1 - The sign of a really good massage is that you feel quite sore the day after

Everyone is different and some people are more sensitive than others but just because you don't feel sore the next day doesn't mean you had a bad massage.  Furthermore, there should be different things expected from different types of massage. Why? Because the techniques and the results or goals of the session are DIFFERENT. The sign of a good massage is that you feel better than you did before - it may take a while to feel the full benefits but you should experience some of the following:

  • Relaxation 
  • Renewed energy 
  • Increased mobility or flexibility of the area of the body 'worked' on
  • Difference in tension levels - do you 'feel better.'
  • Less pain 
  • Better sleep
  • Alertness 
  • Reduction in headaches

Myth #2 - You shouldn't have a massage if you're pregnant

Massage Therapy does not induce an early labor and is perfectly safe for both mother and baby during normal pregnancies. Most physicians (and yes, you need to let your doctor know before you go!) will support massage after the first trimester and right up until the due-date. High risk pregnancies are handled a little differently, but not much - if everything is communicated up front.  It can be extremely beneficial for the Mom-to-be and offer a way to relax and unwind during a physically and mentally tiring time.

Normal aches and pains from pregnancy, can be dealt with and if the therapist is trained, there is no danger to the mother or the baby. More complicated situations can also be handled - but that requires an advanced understanding and training around pregnancy and the impact on the female body.

Post-natal massage can be equally beneficial, and for those are are interested in 'naps' during the day it is ideal (generally six weeks after birth - with a doctor's note again)! Ask your Massage Therapist about Pre-natal massage and other forms of appropriate therapy to help both before and after your baby is born.  

Myth #3 - Massage will get rid of cellulite 

If Massage Therapists could really banish cellulite we'd never see a dimpled thigh ever again. And when I have clients that come in wanting to reduce water retention and ' discussing,' if I know how to help them get a 'thigh-gap,' to look more shapely...I stop listening, and you will never get an answer from me. This is NOT my area of expertise, or interest.

However, cellulite is persistent subcutaneous fat and it's appearance. It is found mainly in women, or they seem to care more, and the 'texture' is determined by hormonal factors, genetics, diet and lifestyle.  Eating a healthy, low fat diet rich in fruits, vegetables and fiber and taking regular exercise is the best option to prevent and reduce the appearance of cellulite.  Massage is an excellent addition to your healthy lifestyle and wellness routine, and good circulation is good for the SKIN, HEART and whatever else ails you.

Myth #4 - Toxins can be flushed out of the body via Massage

This is an interesting Myth, which while popular and interesting, is completely false. The body processes excess waste (by-products of food, drink, airborne pollutants etc.) in a variety of ways i.e. sweat, urine, faeces, or if you're ill by vomiting.  Your liver, kidneys and skin do a remarkable job of getting rid of these 'toxins' on a daily basis and keeping the skin, muscles and fascia of the body (including joints) free and balanced.  Massage does, however, increase blood supply to various parts of the body and can regenerate a lack-lustre circulation. This helps move things around and replaces 'things dislodged by massage' - collagen from adhesions, lactic acid from workouts, and lymph from injury sites. 

This may be what is actually being referred to when someone is talking about toxins - the by products and 'waste' not needed by the body. These things are actually replaced by the nutrients that the body needs - which circulation also brings in. So, it's a one-for-one exchange. Drinking water is a pleasant thing to do after a massage (we like ours with a slice of lime or cucumber) and is a great reminder to drink more fluids that aren't laced with sugar, colorings or other additives. Eating a healthy, again, focusing on a low fat diet rich in fruits, vegetables and fiber and taking regular exercise is the best option to prevent and reduce the toxins and inflammation (caused by diet imbalance).  Massage is an excellent addition to your healthy lifestyle and wellness routine, and good circulation is good for the SKIN, HEART and whatever else ails you.

Myth #5 - You shouldn't get a massage if you have cancer

Many Massage Therapists and cancer patients have often fallen foul of this myth.  Until recently, it was assumed that the action of massage could actively spread cancer cells throughout the body.  However, it DOES NOT. Therapist who receive training, and the general public should now realize that cancer cells are caused by the body's immune system malfunctioning, they cannot be spread or increased through manual contact. Cells that turn cancerous will do so regardless of massage therapy stimulus, and there is no way the contact between therapist and the client will cause cancer cells to move through the body then the same could be said of any form of exercise.

On the other hand, Massage Therapists need to be 'trained and knowledgeable' about the impact of Massage Techniques appropriate for work on tissues going through Chemotherapy, Radiation and other types of drugs associated with Oncology. This is an advanced technique that needs to have specific ways of working the patients in an appropriate manner - much like lymphatics and other types of techniques that actively work on areas that are injured.

Myth #6 - You shouldn't get a massage during 'workout' cycles

Many Massage Therapists and athletes have often run into issues with clients who have athletic trainers that tell their athletes - 'don't get a massage you'll be too relaxed or flexible.'  Until recently, it was assumed that the action of massage could impact the muscle fiber pliability, and lead to injury during heavy and continuous workout cycles. However,  most techniques DO NOT have a negative impact on the 'proprioception' of the brain, the biomechanics of sports movement and how the athlete performs. There will be a positive impact, and the return of full range of motion and movement capability may be different, but managed regularly as part of the work out cycle - the Athlete and the "Athlete's brain" will get used to the new normal without incident. They will also REMAIN INJURY FREE.

In fact if therapists have received 'sports' training, and understand the muscle recovery and cycle of activity there should be no functional impact,  on the athlete. This should encourage athletes and trainers alike to focus a small amount of their strategy on 'recovery,' instead of letting it happen without purpose or intent. Regardless of massage therapy stimulus, and techniques, recovery in the form of relaxation of muscles and reduction of stimulus or stress on the body on a regular basis will increase performance and prevent injury.  Relaxation and the 'optimization' of the body should be the goal of any form of massage.

What Massage Therapy Myths have you heard recently?  What misconceptions about Massage would you like to dispel?  Share them with us here in the comments section (below), our Facebook page, twitter account or Instagram account.

Beyond The Myth: Soft Tissue Release and Recovery

Beyond The Trigger Point Hype

This is a trigger point, but there is more to it than the medical definition: a hyper-irritable spot in fascia surrounding musculoskeletal tissue - muscle belly, attachments or the fascia itself

They can be identified by palpation, pain patterns or loss of strength and range of motion.

Because there is an impact to the soft tissue or is linked to musculoskeletal pain, They can be reset and released for pain reduction, increased range of motion and prevention of injury. The release feels like a small twitch in the muscle, but no contraction. unlike spasms, they do not involve the whole muscle.

They are NOT caused by trauma, inflammation, degeneration or infection – but they can develop as the body protects itself from these things.

There is a nervous system involvement – but they cannot be explained through a neurological examination.

Soft Tissue and Pain Treatments

How Understanding Pain Can Benefit Therapy

"Soft Tissue Release is only part of the equation, but if you don’t achieve it – full recovery may not be possible!"

Pain is usually the natural consequence of tissue injury resulting is one of the biggest reasons why manual therapy and therapeutic intervention can be critical to a successful recover. In general, as the healing process commences, the pain and tenderness associated with the injury will resolve. Unfortunately, some individuals experience pain without an obvious injury or suffer protracted pain that persists for months or years after the initial insult. This pain condition is usually neuropathic in nature and accounts for large numbers of patients presenting to pain clinics with chronic, non–malignant pain.

What they do not consider, in the attempts to control, improve or ‘get rid of it,’ Pain is the nervous system functioning properly to sound an alarm regarding tissue injury or potential injury which may be related to ongoing structural or imbalance in the body. The idea that neuropathic pain from the peripheral (PNS) or central nervous system (CNS) malfunctioning can become the single greatest gift in resolving the cause of the pain.

Acute pain and chronic pain differ in their etiology, pathophysiology, diagnosis and treatment. Acute pain is self–limiting and serves a protective biological function by acting as a warning of on–going tissue damage.

Chronic pain, on the other hand, serves no protective biological function. Rather than being the symptom of a disease process, chronic pain is itself a disease process. Nociceptive pain is mediated by receptors (messages are transferred to PNS) and fibers which are in skin, bone, connective tissue, muscle and viscera. It affects the sensitivity of any of these structures.

       Nociceptive pain can be somatic or visceral in nature. Somatic pain tends to be well localized, constant pain that is described as sharp, aching, throbbing, or gnawing. Visceral pain, on the other hand, tends to be vague in distribution, paroxysmal in nature and is usually described as deep, aching, squeezing and colicky in nature. It affects the ability of the muscle to ‘act,’ and in turn affect the physiology of the musculoskeletal structure (i.e. Knots, adhesions, contractures). This failure of the receptors in the body becomes the primary location for trigger points.

Neuropathic pain, in contrast to nociceptive pain, is described as "burning", "electric", "tingling", and "shooting" in nature. It can be continuous or paroxysmal. Whereas nociceptive pain is caused by the stimulation of peripheral receptors due to introduction of biochemical compounds produced by the body, neuropathic pain is produced by damage to, or pathological changes in the peripheral or central nervous systems.

Pathophysiology

The mechanisms involved in neuropathic pain are complex and involve both pathologic impact to peripheral and central nervous system phenomenon. The underlying dysfunction may involve deafferentation within the peripheral nervous system (e.g. neuropathy), deafferentation within the central nervous system (e.g. post–thalamic stroke) or an imbalance between the two (e.g. phantom limb pain).

Peripheral Mechanisms:

Following a peripheral nerve injury (e.g. crush, stretch, or axotomy) sensitization occurs which is characterized by spontaneous activity of the neuron, a lowered threshold for activation and increased response to a given stimulus – PAIN arrives. Following nerve injury nerve fiber can develop new receptors and sensitivity (slowly 1mm/month), which may help to explain the mechanism of sympathetically maintained pain and then subsequent decrease without treatment.

Following a peripheral nerve injury, anatomical and neuro–chemical changes can occur within the central nervous system (CNS) that can persist long after the injury has healed. The "CNS plasticity" may play an important role in the evolution of chronic, neuropathic pain. As is the case in the periphery, sensitization of neurons can occur following peripheral tissue damage and this is characterized by an increased spontaneous activity, a decreased threshold and an increased responsivity to afferent input, and cell death – MORE PAIN arrives.

So now you’re wondering what you can do – if anything – to reduce sensitivity, manage pain or reduce chronic conditions and live normally. Early recognition and aggressive management of neuropathic pain is critical to successful outcome. Often multiple treatment modalities are needed and should be provided by an interdisciplinary management team. Numerous treatment modalities available include systemic medication, physical modalities (e.g. physical rehabilitation), psychological modalities (e.g. behavior modification, relaxation training), and various surgical techniques (as a last resort). It should be noted that caution is warranted regarding the use of invasive techniques. Such approaches may produce deafferentation and exacerbate the underlying neuropathic mechanisms.

Manual Therapy Impact

Why therapeutic treatment of muscles works  

Neuromuscular Therapy (NMT) is an approach to soft tissue release and manual therapy that involves quasi-static pressure that is applied to soft tissue to stimulate skeletal striated issues (i.e. Adhesions, Trigger Points).

You cannot strengthen a muscle that has a trigger point, because the muscle is already physiologically contracted.  attempts to strengthen a muscle with trigger points will only cause the trigger point to worsen.

*Devin Starlaynt, MD author of Fibromyalgia and chronic myofascial Pain: A Survivor’s guide

  Through applied knowledge of Anatomy and Physiology, Kinesiology, Trigger Point physiology and trigger point development – i.e. Ergonomic or biopsychosocial influences, neuromuscular therapy treatments are designed to address postural distortion (i.e. Rolfing focuses on poor posture), Functional Muscle dysfunction (Corrective exercise re-trains biomechanical challenges), movement and psychological impairments to movement (i.e. Somatic retraining and PNF – Proprioceptive Neuromuscular Facilitation stretch). Both Nerve Compression syndrome or congestion and ischemia deal with the musculoskeletal impact on other areas of the body: nerves, veins and arteries. Remember, when normal distribution and circulation is impaired all systems become impacted.

Because Myotherapy incorporates trigger point therapy, manipulation of soft tissue through massage, dry needling, and joint mobilization it has become an allied health discipline throughout the world. Therapists with this expertise will also use stretching, nutritional support, exercise, posture, heat and cold therapy as well as ultrasound and TENS (Transcutaneous Electrical Nerve Stimulation) to achieve the return to normal balanced activity they seek. Pain reduction is an off-shoot of the successful procedures.

Why is Soft Tissue Ignored?

Muscles as a system in the body, is not ‘owned or claimed’ by any Medical Specialty. Soft tissue treatments are taught in medical school – because they are generally NOT life-threatening. Muscles tissue is the largest organ in the body. Tissue complexity is well documented, and there are multitudes of ‘dysfunction,’ beyond Trigger Points and Myofascial Pain Syndrome where the “primary target of these activities creates the wear and tear of daily activities.” These show up as Repetitive Stress Injuries (RSI) and Cumulative Trauma Disorders (CDT), but nevertheless it is the bones, joints, bursae and nerves on which the medical community focuses.

Where Physical Therapists and Chiropractors are involved with joint dysfunction, biomechanics, and exercise therapy, they often emphasize these things at the expense of soft-tissue or muscles. They simply over-simplify muscle pain as a “sensory disorder,” which can easily affect people with apparently perfect bodies, posture and fitness levels. There is a lot of wasted time ‘treating’ patients, through various methods when a little pressure on key muscles or lengthening of the muscle itself will provide relief. Muscles release in and of itself cannot be expected to occur in a single session – although occasionally it may feel like that.

Massage Therapists in generally know surprisingly little about myofascial pain syndrome, because the training varies for every practitioner. When they become pre-occupied with symmetry and structure, then the ability to give relief may be hard to find. Outside of Neuromuscular therapists, common skilled treatment of Trigger Points and Myofascial Pain is very rare, but look for these individuals who have spent time and effort to begin to understand treatment and management of pain and you’re going in the right direction.

Myofascial Pain vs. Fibromyalgia

   As a last point on the complexity of muscle pain, there is a common mistake in comparing Myofascial Pain and Fibromyalgia. Although unexplained FM might be a more clearly neurological disease, while MPS may be more of a problem of muscle tissue. They have related sets of unexplained symptoms, and they may be two sides of the same coin, with overlapping parts on an undefined spectrum of sensory malfunction, or different stages of the same process.

  Do NOT confuse “tender points” of fibromyalgia with ‘trigger points’ in muscles – they are not even close. Whatever the similarities of these two causes or labels, therapeutic approaches for MPS seem to be helpful for some FM patients as well. Although pure FM cases seem to be mostly immune to manual therapy.

Muscles, Trigger Points and Referred Pain

In addition to minor aches and pains, muscle pain is often the cause of unusual symptoms in strange locations. For example, people diagnosed with Carpal Tunnel syndrome are experiencing pain caused by congestion of the nerves in the Armpit or Neck (brachial plexus).

Sciatica: often described as shooting pain in the buttocks and legs, this is caused by muscular tension of the piriformis or other gluteal muscles – which in turn irritates the sciatic nerve. Many other ‘trigger point problems’ are mistaken for some “kind of nerve problem.”

Chronic Jaw Pain (TMJ), Toothaches, earaches, Sinus Headaches, Ringing in the Ears (tinnitus), Dizziness and Allergies: these may ALL be symptoms of trigger points in the muscles around the jaw, face, head and neck. There are several large nerves (i.e. Trigeminal Nerve in the cheek near the TMJ, Occipital Nerves at the base of the skull) which when impacted created these types of issues due to muscle tension and dysfunction caused by trigger points.

Migraines or Headaches in general: Since there are over 300 types of headaches, let us just say that some muscle, somewhere in the neck can contribute to headaches given enough tension. There are obvious headaches that affect the Sternocleidomastoid (SCM) around the eyes, ears and back of the head. Then there are less obvious muscles like the Occipitals that just simply block or congest the blood flow to the brain enough to cause tension. There is no way to predict the pattern of a headache from one trigger point, because they may cause secondary sights with the muscles that they touch. Isolating and treating the group of muscles involved in any trigger point situation may take several attempts – it all depends on the client.

Trigger points have many strange “features,” and behaviors. Some people deal with trigger point pain better (i.e. Less resistant to) than others. It helps to have a competent therapist, who understands the discomfort around the treatments – most people who have had trigger point treatment will NOT over do the impact to the nervous system (or overstress the clients comfort level). Some discomfort should be expected. Because of their medical obscurity and confusion with many other problems, the trigger point discussion or diagnosis is often the last thing to be considered. Despite their clinical importance and many distinctive characteristics, muscle pain is NEVER the first problem people look at.

A diagnosis of Trigger Points or Myofascial Pain means that the primary source of your symptoms is from trigger points. Often trigger points are present secondary to other sources of pain: like arthritis or bulging discs. Trigger points may cause the painful symptoms attributed to these conditions. Here is a list of diagnoses which may be Trigger Point origins:

-        Back Pain (lower, middle and upper)

-        Neck pain/stiffness

-        Rotator Cuff/shoulder pain

-        Jaw Pain (TMJD)

-        Tennis/Golfer’s Elbow

-        Carpal Tunnel Syndrome

-        Thoracic Outlet Syndrome

-        Frozen Shoulder/Adhesive Capsulitis

-        Repetitive Strain/Stress Injuries

-        Pelvic Pain

-        Hip Pain

-        Sciatic Pain

-        Knee Pain

-        Ankle Pain/weakness

-        Plantar Fasciitis

-        Achille Tendonitis

-        Bursitis

-        Arthritis

-        Disc Pain (bulge/rupture/herniation) or Radiculopathy

-        Tendinitis/Tendinopathy

“Many researchers agree that acute trauma or repetitive micro-trauma may lead to the development of a trigger point. Lack of exercise, prolonged poor posture, vitamin deficiencies, sleep disturbance and joint problems may all predispose to the development of micro-traumas.”  *David J. Alvarez, D.O. and Pamela G. Rockwell, D.O for American Family Physician

How Trigger Points are Formed

     Far from damage to muscle and connective tissue, trigger points can arise from every day use. Although it takes about 7-10 years to constantly place enough stress for them to form, it can happen because of:

1)     Repetitive overuse at home or work in activities like work at the computer, cell phone or gardening. These are using the same body parts hundreds of times daily without rest.

2)     Sustained loading or stress like heavy lifting, wearing body armor, sustained tension when extending muscles (like reaching to pull things down or moving patients in bed).

3)     Habitually poor posture or a sedentary lifestyle, that deconditions the body – or pushes people to overstrain their tired muscles after a week at work. Poorly designed furniture may also contribute.

4)     Muscle clenching and tension do to mental/emotional stress.

5)     Direct injuries from a blow, strain, break, twist or tear – car accidents and falls are critical situations to deal with immediately after they occur.

6)     Inactivity for long periods in exceptional positions, or prolonged rest (i.e. Couch surfing) may also compromise the way the muscles respond.

The only way to deal with trigger points is with a skilled practitioner. There are no commonly available lab tests or imaging studies that can confirm the diagnosis. Myofascial pain can be regionalized or general. Trigger points can be Active (causing pain to touch) or Latent (impacting movement and pre-disposing to injury) and are only noticeable when someone touches them. Treating Trigger Points individually can be simple – get a massage or manual therapy that identified and releases them. You just must get them all primary, secondary, and active – and then leave the latent ones for the next time.

Treating myofascial pain syndrome or the source of the trigger points and pain may be more complicated. Since trigger points are a contraction mechanism of the locked muscles, getting the release is only the first step. Once trigger points are released the muscles need to be moved throughout the full range of motion.

Soreness and ‘post-workout’ fatigue may be common after a trigger point session. However, with 24-48 hrs. rest the muscle will return to a normal one, if work-load balance remains abnormally high

trigger-point_action potential.jpg

Massage Treatments and Chronic Pain and Disease

     When someone asks me why I became a massage therapist, I just say - "I wanted to be passionate about my career." Then it became, "I want to help people manage pain. " Then I honestly wanted to share my joy and the usefulness I've found in manual therapy within anyone who would listen - at one point we were 'chastised to get a bullhorn and shout it from the street corners,' so this is my version of doing just that.

    Integrative Health and Medicine current offers a comprehensive prevention-based approach to effectively treat chronic disease and enhance health. This should include the use of soft tissue therapy and treatments to leverage CAM health care appointments. All appointments from health practitioners such as naturopathic doctors, chiropractors, physical therapists, acupuncturists, nurse practitioners, nurses, midwives, and nutritionists and orthopedic surgeons can benefit from pre- and post- healthcare appointments from a CMT/NMT. To fully embraces a multi-disciplinary team of licensed health care providers working at the highest level of their scope of practice, massage and neuromuscular therapy provide extensive preventative at pre-tax savings, as well as effective knowledge of soft tissue details .

These health care practitioners have been lumped into the term complementary and alternative medicine (CAM) providers, and if we use the term Integrative Health and Medicine professionals with distinct licensed professional certifications, CAM can be used in the traditional and there is no need to “discover” a new model of care.  Patients who work with Integrative Health and Medicine practitioners are already achieving basic wellness goals 1) are healthier, 2) have lower health care costs, and 3) report extremely high levels of patient satisfaction. Through a collaborative approach to health care, integrative health care solutions contribute improved health care every day.

How does the interrelated way in which the contributions of licensed Massage Therapy professionals can help reduce health care costs and fit into the existing Health Care system?

Without disruption, Massage therapy can be used prior to ALL appointments to soften, warm and prepare tissues in areas like the spine, or head and neck to leverage existing services  and make them more than previously identified.  Like corporate Wellness programs, Massage Therapy aims to help get people healthier to prevent big-ticket chronic diseases, like the seven preventable chronic diseases: cancer, diabetes, hypertension, stroke, heart disease, pulmonary conditions and mental illness. The cost of these chronic and life threatening heath issues, costs the U.S. economy $1.3 trillion annually, including the cost of lost productivity, treatment in the form of insurance reimbursement and medication. Combining the diversion of caregivers with the costs of absenteeism and ‘reduced workload’, the total impact of chronic disease already exceeds $1 trillion a year, including more than $100 billion in California alone.

While healthy lifestyle change requires investment from more than just the health care arena, health-oriented providers play a critical role. CAM users were 64% more likely to report that their health had improved over the last year.  Not only are prevention and health promotion fundamental cornerstones of CAM, integrative health and medicine practitioners including Massage Therapists can consistently provide additional resources and avenues into conventional providers. Because CAM creates better outcomes, contrary to the common critique that there is a lack of evidence, thousands of studies, including randomized controlled trials published in top medical journals which highlight research demonstrating the ways naturopathic medicine prevents cardiovascular disease and metabolic syndrome at a cost less than prescribing a pill!                                                                      

European countries, in which general practitioners are co-trained in integrative approaches, have incorporated CAM into national health care systems based on studies showing better outcomes and lower costs. Keeping costs low by keeping care simple and adhering to a common-sense therapeutic order, allows individuals to make a choice on healthy alternatives that have a longer lasting impact. With back pain alone, the cost to the health care system is 60% less with CAM treatments and largely due to expensive, often ineffective diagnostics and surgical procedures.

Massage therapists are experts in administering less invasive, low-cost treatments that support the body while it heals itself, and that serve as effective substitutes for riskier modalities such as prescription narcotics. An approach to treatment that begins with low-force, non-addictive, low-cost care options that feel good just makes sense. Reduce costs up front through complementary, alternative, and integrative therapies. Many people have the impression that the use of CAM creates substantial add-on costs for health care systems and individual payers. The myth that patients are draining their bank accounts on out-of-pocket costs associated with CAM looks like actual costs – $33 billion – which is pocket change compared to the $268 billion spent out-of-pocket on conventional care in the same year.  

In Washington state, where CAM health care providers of every discipline have been a mandated part of the health care system for nearly 20 years, data show that patients who see CAM providers have lower prescription drug costs, hospitalization costs, and total costs, despite starting out in poorer health and incurring the “additional” cost of the CAM provider’s services. Because CAM providers – including Massage Therapists offer therapies that are less expensive than those provided by other health care professionals, they not only reduce costs, but also may increase access through “first contact points of entry,” reaching people who are unwilling or unable to access the conventional health care system.

So, when you look at what we do, and why being a massage therapist is 'life changing,' not only for ourselves, fellow therapists and our clients...It can be for everyone in the health care system.

 

 

Posture and Impact on Pain

Your spine is strong and stable when you practice healthy posture. But when you slouch or stoop, your muscles and ligaments strain to keep you balanced — which can lead to back pain, headaches and other problems. In addition to physical pain, there is a physiologically efficient posture, and everyone knows that, right?  Okay, maybe you did not.

If most people understand what their posture does to there mind (as well as their body) then most people would also understand the value of Massage (all types no favorites). Here is how to use massage to prevent and maintain balance throughout the body in muscles, structural system and nervous system.

Natural Spine Curve

A healthy back has three natural curves:

  • An inward or forward curve at the neck (cervical curve)
  • An outward or backward curve at the upper back (thoracic curve)
  • An inward curve at the lower back (lumbar curve)

Good posture helps maintain these natural curves, while poor posture does the opposite — which can stress or pull muscles and cause pain.

Physiological Efficient Posture

Loss of an upright Physiological Efficient Posture makes the relationship between posture, psychology and pain more transparent.  'Bad' or inefficient posture can adversely affect all the systems of the body. I take for granted that I was used as bad example in class a lot (thank you to everyone who noticed), but I even I was unaware of ALL my postural faults: shoulder, hips, foot.

Think of the impact to cardiovascular, digestive, endocrine, energetic, excretory, fascial, immune, integumentary, lymphatic, muscular, nervous, respiratory, reproductive, skeletal and urinary systems when there is a constriction or reduced space within the structural system. This generally happens when you slouch over a desk, stay sedentary for 8-10 hours at work (my developer friends will appreciate this) and/or playing video games AFTER you get home from sitting in front of a desk all day your body does have the opportunity to 'move.'

Muscles were designed to move, by simply changing these habits and limiting sitting, walking regularly throughout the day and minimizing 'technology use' for 1-2 hours - then anyone can reduce the risk and long term negative affects of inefficient posture.

When you do have to work at a desk, "sitting up with good, tall posture and your shoulders dropped is a good habit to get into," says Rebecca Seguin, PhD, an exercise physiologist and nutritionist in Seattle.

This can take some getting used to; exercise disciplines that focus on body awareness, such as Pilates and yoga, can help you to stay sitting straight, Seguin says. Make sure your workstation is set up to promote proper posture.

Client’s mood and physical process in ALL the system above have all been shown to improve when an upright Physiological Efficient Posture is restored. Furthermore, bad posture and/or bad mood can be cyclical- they can improve and decline without effort or mindfullness. More importantly loss of the Physiological Efficient Posture moves people away from Homœostasis and further into Allostasis. These affects can be reversed through strengthening, massage/structural integration or psychological ‘restoration’ of movement. 

The Primary Alignment is the relationship between the body's Center of Gravity (Core) and its Counterweight. To understand more about the importance of a Physiological Efficient Posture and the Primary Alignment follow discussion on the philosophy of Somatics and Feldenkreis manual therapy (both related to the mind-body connection). 

Massage and Posture

In order to find out how Postural Alignment can be influenced by Massage Therapy practices, use assessments that focus on Orthopedic Testing and Bio mechanical assessments (HOPRS), Core Integration (Structural Integration -Rolfing) and Postural Alignment in corrective exercise to provide safe and gentle changes. These processes can help people with:

Many of these ailments ar a direct (and negative result) of posture that is not efficient and positive for the human body Alkylosing Spondylitis, Anxiety, Arthritis, Asthma, Back Pain, Balance Problems, Breathing Impairment, Depression, Digestive Problems, Fatigue, Foot Problems, Frozen Shoulders, Headaches, Insomnia, Jaw Problems, Joint Pain, Knee Problems, Kyphosis, Learning and Behavioral Difficulties, Lordosis, Low Energy, Menstrual Problems, Migraines, Multiple Sclerosis, Neck Pain, Pins and Needles, Poor Posture, Problems during and after Pregnancy, Recurrent Infections, Repetitive Strain Injuries, Scoliosis, Sciatica, Sinus Problems, Sports Injuries, Stress Management, Tension, Visual Disturbances, Wellness Care, Whiplash Injuries and more.

Postural Alignment does not treat or cure any disease or symptom. It is primarily concerned with creating a healthy, balanced state on all levels by helping people back towards homœostasis. Pilates and yoga are great ways to build up the strength of your "core"—the muscles of your abdomen and pelvic area. These muscles form the foundation of good posture, and a strong core can have many other benefits, from improving your athletic performance to preventing urinary incontinence. In addition to helping to increase body awareness and core strength, yoga is an excellent way to build and maintain flexibility and strengthen muscles throughout your body. Check in daily with your body's needs and listen to it's requirements.