Having just come back from Casper, Wyoming after taking the first of four Trigger Point Dry Needling Seminars taught by Jan Dommerholt, (who, in my opinion is one of the world’s foremost experts on trigger point dry needling), I have realized that I made a mistake in other posts.
Is dry needling acupuncture?
Yes, I believe it is…..
It is also chiropractic care and physical therapy; in fact, dry needling is ANY profession that diagnoses and treats myofascial trigger points. The needle is just a tool, many clinicians also use our hands, instruments, lasers and injectables to treat myofascial trigger points.
Dry needling is not exclusive to any one profession; let’s move on, patients need us! There is so much chronic pain out there that can be attributable (completely or in part) to myofascial trigger points that everyone who treats them and has the skills to do so with a needle SHOULD…. now!
I had a patient Wednesday of this week who has chronic TMJ pain that absolutely needs dry needling for myofascial trigger points in her lateral pterygoid. I did what I can with my hands but my hands cannot get to 90% of this muscle. What I did do knocked her pain back to the point where she is “hopeful” and does not feel like she has to live with her daily pain and headaches but because of the infighting between the chiropractic board and a few acupuncturists in Oregon, she cannot get this therapy. She had gone to orthodontists, TMJ specialists, massage therapists and yes, acupuncturists and has not had any appreciable gains with her chronic pain.
Shame on the powers that be for withholding this beneficial and valid therapy from patients who need it by not allowing providers who are qualified and trained to do it.
In a recent article published in the Journal of Manual and Manipulative Therapy by Jan Dommerholt entitled, Dry Needling: Peripheral and Central Considerations, Dr. Dommerholt discusses some updated theories and ideas as to the mechanism behind the benefits of dry needling (DN) and other related topics. Dr. Dommerholt has his doctorate in physical therapy and is one of the world-experts in the field of DN with regards to myofascial pain.
Over the last 10-20 years, DN has grown in popularity among chiropractors, physical therapists, naturopaths, acupuncturists and medical doctors. The indications for the use of DN vary by profession but most include some sort of myofascial disturbance. These myofascial disturbances or lesions often lead to aberrant biomechanical forces being transmitted through the neuromusculoskeletal system which can lead to further damage and injury. In addition to treating these structural lesions, DN also works on pain mechanisms mediated by the central and/or peripheral nervous systems.
In his paper, Dommerholt addresses the various models used to explain how myofascial lesions affect the entire neuromusculoskeletal system. One model, the pain-spasm-pain cycle, often referred to as “the vicious cycle” has not stood the test of time and research, as such, other models have since surpassed it. The pain-adaptation model is another model that suggests muscle pain from trigger points and other myofascial lesions lead to a cascade of antagonist activation which leads to an overall decrease in motor function. Neither of these models explains the role of myofascial lesions in neuromusculoskeletal pain and dysfunction. Later in the paper, Dommerholt discusses Hodges and Tucker recently proposed a new motor adaptation theory. This theory, although not specifically referring to myofascial trigger points or lesions, best represents what occurs when muscle pain causes a redistribution of activity within and between muscles leading to overall biomechanical dysfunction.
Dommerholt discusses the various schools of approach for DN, including, Yun Tao Ma’s approach, Gunn’s approach and Dommerholt and Huijbregts’ approach, this discussion is an interesting one and helps to explain why there may be some confusion as to exactly what Dry needling is and what it treats. The next couple of pages are devoted to an excellent and clinically-relevant discussion on the physiology behind active and latent trigger points. For a more comprehensive discussion on this topic, I suggest getting Dommerholt and Huijbregts’ book entitled, Myofascial Trigger Points: Pathophysiology and Evidence-Informed Diagnosis and Management (Contemporary Issues in Physical Therapy and Rehabilitation Medicine)
The section on muscle pain is quite interesting and what I would refer to as a concise summary of information pioneered by Mense and Gerwin in their books Muscle Pain: Understanding the Mechanisms and Muscle Pain: Diagnosis and Treatment . The section on central sensitization as a result of myofascial trigger points is another wonderful summary on this topic. The neurophysiology behind central sensitization, while complex, is clinically-relevant and a topic that all clinicians dealing with pain should understand. DN can disrupt this process, presumably through disrupting the neurochemical links developed during sensitization, effectively breaking the cycle.
The concept that Dommerholt seems to challenge is that trigger points are solely a peripheral problem. In this paper, he does an excellent job of presenting research to the contrary and how DN not only works to treat the peripheral neuromusculoskeletal system but acts on the central nervous system too. The implications of this evidence is broad and may explain why those with peripheral (local) myofascial lesions like trigger points receive both local and system wide benefits from the application of DN. This may help to explain why there is a good deal of variability in the DN approaches as discussed in the beginning of the paper.
In addition to all this great information, Dommerholt tackles the subject of Acupuncture and Dry Needling. This is a topic that is germane to current discussions and legal feuds here in Oregon. DN is a technique that should be in the scope of practice for physical therapists and chiropractors who diagnose and/or treat myofascial trigger point on a daily basis. The acupuncture community and chiropractic community are at odds right now in the Oregon legislature about this topic. Dommerholt tackles this task with ease and grace, presenting a cogent discussion that concludes with the idea that DN is yet another tool to treat myofascial trigger points and should be within the scope of practice for physical therapists, chiropractors and acupuncturists.
In the summary section, Dommerholt pulls it all together in a way that my writings would not do it justice; here are quotes from his summary:
“Dry needling or trigger point inactivation rarely is a stand-alone kind of intervention and is just one aspect of a comprehensive manual physical therapy approach.”
“Dry needling is not solely in the scope of any one particular discipline. Overlap in scope of practice is not only inevitable; it may even be desirable to best meet the needs of patients. Dry needling is an easy to learn technique in the hands of qualified health care providers.”
“In this review, we have postulated that dry needling is a potent therapeutic measure to remove a constant source of peripheral nociceptive input originating from myofascial trigger points. As such, dry needling does not replace other manual physical therapy technique, but may be useful in facilitating a rapid reduction of pain and a return to function. A thorough understanding of the role of trigger points in peripheral and central sensitization is important in manual physical therapy practice. Trigger points can be inactivated with manual techniques and joint manipulations, but dry needling may be a more efficient and quicker method.”
Reference: Dommerholt, Jan, PT, DPT, MPS, DAAPM; Dry Needling: Peripheral and Central Considerations; Journal of Manual and Manipulative Therapy 2011, Vol.19 No.4; pgs 223-237
I am VERY excited about this technique, please click on the following to go directly to the page I have devoted to Fascial Manipulation : Portland Fascial Manipulation
Well, the Oregon Dry Needling debate shuffles forward……
Of course, as a Portland Chiropractor who wants to use dry needling in my practice for the treatment of myofasacial trigger points, I am biased. I recently read an excellent blog by an Oregon acupuncturist (click for link) on the community acupuncture network. In this blog, the author states why she does not consider the dry needling issue here in Oregon to be one that the acupuncture community should be concerned with. In this blog post, the author dispels many of the myths about dry needling and refutes the arguments against physical therapists and chiropractors performing this technique. The only point I disagree with her on (and it’s a minor point) is her conviction that Dry needling IS acupuncture. To this, and to acupuncturists reading this post, I ask this:
How many hours have you spent learning trigger point theory? Can you explain the etiology behind trigger points? Can you state what the research has shown regarding the use of solid-filament, small-gauge needles and the eradication of trigger points? Have you been taught (in acupuncture school) how trigger points form, what biomechanical effects they have, how to rehab them and teach your patients what to do so they don’t come back? Have you been taught the fine details of locating them?
Trigger point therapy is not adequately taught in acupuncture school. Acupuncturists have mastered the use of solid-filament, small-gauge needles but have not mastered trigger point theory, assessment and treatment. Don’t get me wrong, I know a few acupuncturists who have gone through post-graduate training and are excellent clinicians regarding trigger points but Dry Needling is not acupuncture. Can acupuncturists perform Dry Needling…. yes, of course, they have already mastered the needling aspect of it, most would just need to pursue training on trigger point theory, assessment, rehab and treatment.
In contrast, a video on Vimeo from The Oregon College of Oriental Medicine posted this video (Click Here). In it, they really show their ignorance as to what we, as chiropractors in Oregon are trained to do. The panel consists of various teachers and acupuncturists in Oregon. They even have the nerve to claim that they are the Dry Needling experts in Oregon and they should teach PTs and chiropractors how to perform it….. really?
I wish I was at that meeting, I would have asked this question:
“Please, explain to me, the etiological, biochemical and neurochemical aspects of myofascial trigger points and how Dry Needling takes care of them. Compare and contrast this with other trigger point treatments and explain to me (us) how core acupuncture programs make their graduates experts in this treatment modality.”
I have emailed various individuals in the OCOM and NCNM acupuncture programs about where in the core curriculum is trigger point Dry Needling taught and have received one response that it is the same thing as “ashi points”. Nowhere do they learn the finer details of trigger point theory……. why would they consider themselves experts on this topic then? How insulting….
And so it goes, misinformed individuals guiding and teaching their profession to believe half-truths….
Lastly, there is a ton of great research, mostly coming from the PT profession on trigger points and Dry Needling, all you need to do is search for it on PubMed.
That’s all for today; I am reading a pre-published version of an article that Jan Dommerholt has written with a colleague on how trigger point Dry Needling affects the peripheral and central nervous systems to do more than disrupt the excess achetylcholine secretion and decreased acetylcholine esterase production often seen as one of the causes of trigger points….. stay tuned for my report on this article.
OK, since my last blog post, I have received several email regarding the chiropractic dry needling issue that is currently being discussed in Oregon.
In a nutshell: The insertion of a filament-gauged, solid needle into fascia and myofascial trigger points can produce many physical effects. Most are similar to what a skilled manual medicine practitioner can do (massage therapists, physical therapists, chiropractors etc.). It has been determined that chiropractors can utilize these types of needles as instruments to treat trigger points and myofascial lesions that we currently diagnose and treat. This apparently has some acupuncturists scared that their profession is in danger.
First, it’s not, look at one of the other 16 states where chiropractors are allowed to perform dry needling; if licensed, acupuncturists have continued to grow in number in these states.
Some of the other concerns that have been emailed to me:
Pneumothorax, AKA collapsed lung, this happens as a result of a needle piercing the chest wall and can occur pretty much anywhere in the thorax if the needle is not carefully placed. The only time I have heard of this happening has been in acupuncturists’ offices. In the 16 states where chiropractors are allowed to perform dry needling, I am sure at least a couple of them have produced pneumothorax but I doubt the number is higher (percentage-wise) than with the acupuncture population.
“Chiropractors are minimally trained…” OK, this is just downright offensive! We have over 4000 hours of training; our programs are clinical doctorates…. we are NOT minimally trained. We take classes in diagnosis (western diagnosis; meaning, we have within our scope, the ability to render a diagnosis of myofascial trigger points), physical examinations including, heart and lung, classes on phlebotomy and in Oregon, minor surgery.
“If chiropractors want to do acupuncture, they should become acupuncturists…”
I actually agree with this but is dry needling acupuncture? I am not an acupuncturist so I am not an expert as to what ans what is not acupuncture but I thought using a needle to treat myofascial trigger points and other myofascial lesions is not acupuncture per say…..according to some acupuncturists, I am wrong.
Here’s an analogy, is adjusting a vertebral motion segment the entirety of chiropractic? I hope not, I can’t see why laboratory diagnosis and phlebotomy classes prepared me to do that (tongue-in-cheek ). I know there are a few chiropractors out there who would vehemently disagree with me, that’s fine. I don’t think adjusting is all we do as chiropractors and as such, I have no problem with physical therapists mobilizing joint or even doing high velocity adjusting is they have been trained.
If I am wrong about dry needling not being the entirety of what acupuncturists do, then I am mistaken,; although I don’t think so. Why would the acupuncture community want to sully their art, their craft by distilling it down to be defined as the placement of a needle into a trigger point? Why would anyone spend all the time and money becoming an acupuncturist if that’s all is was?
Can acupuncturists do dry needling? Again, I am not the expert here but I think so….. here’s a question though? Can they diagnose myofascial trigger points (ICD-9 codes: 728.89, 729.1 etc)? If so, what is the standard of care for acupuncturists and trigger points? Can they diagnose joint adhesions and fibrosis to be treated with the insertion of a needle to promote fibroblast activity? If so, what ICD codes would they use?
My point is this, acupuncturists can perform dry needling just as naturopaths and physical therapists can perform high velocity adjusting, dry needling is to acupuncture what high velocity adjusting is to chiropractic….. a tool.
Another argument: “24 hours of training is not enough to perform dry needling…”. See the above retort, we have over 4000 hours of training on the human body; the extra 24 is to tie some of that information into the context of dry needling. Most of it is about safe needle selection and placement and adequate hands on time. This is plenty of time to teach doctors, who have an excellent working knowledge of the body, including precise placement of nerves, vessels, bones, muscles and depth of chest-wall cavity. In addition, we know when to use one of the other tools in our toolbox if an area is dangerous or prone to pneumothorax…. it’s really kind of simple. Answer this question, how long did it take until you (acupuncturists) were able to insert a needle into someone’s musculoskeletal system? Not long, huh? Most of the time you spent was on point location and other aspects of oriental medicine….. right?
In conclusion, let’s be fair and honest with what this is all about….. MONEY; and actually it’s only the perceived effects that chiropractors performing dry needling will have on the money in Oregonian acupuncturists’ pockets. I think we will all find out, it’s not going to have much of an effect, the rate of pneumothoraxs will not increase, patients will have access to another helpful, effective tool to treat myofascial lesions….. period.
What Oregon has the unique opportunity to do is makes sure the health care world knows that chiropractors cannot perform acupuncture without going through an approved acupuncture program but they CAN perform dry needling with some training on how to utilize needles in an effective and safe way. By doing this, the barrier to care perceived by the public regarding needling of any kind will be diminished and the acupuncture community in Oregon will actually benefit from this; the problem is, a few of them are just to short-sighted to see this
OK, many of you know that I have been involved in the efforts to allow chiropractors to perform dry needling (especially if you are a patient). This spring, the Oregon Board of Chiropractic Examiners (OBCE) ruled in our favor, allowing chiropractors to use this technique in the treatment of myofascial trigger points. What is dry needling? I’ll get to that in a bit….
Chiropractors in Oregon and the rest of the world, have been treating myofascial trigger points and myofascial pain since we became a profession. The big issue here is that many of us want as many tools to treat these issues as possible; this is where using small gauge, solid filament needles comes into play. Currently, there are a number of states that allow chiropractors to use this tool in the treatment of their patients with myofascial problems; I have chiropractic colleagues in Colorado who use dry needling to treat their patients and have communicated with chiropractors in other states that allow dry needling about how effective it is in treating myofascial trigger and tender points. I was first introduced to dry needling while I was working as a massage therapist in an osteopath’s office in Colorado. I observed hundreds of patients receive this treatment and the osteopath I worked with was great with regards to teaching me what and why he was performing it.
Dry needling involves placing a very thin, single use, disposable, sterile, solid filament needle (not hollow) with clean needle technique into a myofascial trigger point and/or tender point. The number of needles used during any individual visit and the number of visits you are given this treatment depends on many factors that differ from patient to patient. These points are detected an number of different ways. As chiropractors, we have been assessing myofascial dysfunction and treating it with various techniques, like:
Chiropractic adjusting
Manual trigger point therapy
Pin and stretch techniques
Physiotherapy modalities like electric stim and cold laser
Active rehab and myofascial release
Instrument-assisted soft tissue therapies
We fully understand why and how myofascial problems arise; aberrant biomechanical processes, joint dysfunction, injury and repetitive stress are all avenues to developing myofascial pathologies and chiropractors are aptly trained and qualified to both detect, diagnose and treat these pathologies. Using dry needling is yet another tool with which we treat these issues; in my experience observing, performing and having dry needling performed on me, I can say that it is often more efficient, just as effective and less painful than the other therapies listed. This is why I have been fighting for the inclusion of this technique into my scope of practice since I was still a chiropractic student.
What’s the problem? Well, the acupuncture community in Oregon have been duped into thinking that this ruling means chiropractors will be stealing patients from them and it would hurt the profession. This is just not the case, in most of the states where chiropractors are allowed to perform dry needling, acupuncture, as a profession, is doing just fine and has been growing at rates that are as good, if not better than in those states where chiropractors can’t perform dry needling. Having a chiropractic clinic in SE Portland and a teaching shift at the NCNM clinic in SW Portland, I refer patients for acupuncture all the time when it is appropriate; I have even referred my patients for acupuncture for myofascial issues. When I give these types of referrals, I have often been very disappointed in that the acupuncturist sometimes ignores needling the injured tissue and treats the patient more constitutionally, needling distant acupuncture points. This is the beauty of acupuncture, it is a healing modality at the foundation of Oriental medicine that works wonders with patients on many levels. Dry needling is an incredibly superficial technique compared to the broad scope of acupuncture and is only used to treat myofascial pathologies.
Last week, the OBCE approved me to utilize dry needling in my practice and I did, on many patient suffering from myofascial pathologies, the results were profound and now this week, because the Oregon Association of Acupuncture and Oriental Medicine filed an injunction, I cannot continue to use this technique to benefit my patients. Will I send these patients to an acupuncturist? No, there’s no need, I have other treatments that will work just as well as dry needling but may take longer and cause a bit more discomfort. Would these patient have gone to see an acupuncturist for their problem to begin with? No, they came to see me because it is more appropriate for them to do so, for this specific issue.
It’s really quite silly, as a chiropractor, I often perform high velocity, low amplitude thrusts to joints that need to have movement restored. The reason chiropractors do this is to help restore balance in the body so our innate healing properties can flourish. Does this mean chiropractors “own” this technique? No, there are other providers that use the same high velocity, low amplitude thrusts to joints; usually, these other providers are using this tool for slightly different reasons and what they are doing is not inherently chiropractic. Acupuncturists use solid filament needles to perform their craft; as a chiropractor, I would use the same needles to treat myofascial trigger and tender points; does this mean I would be performing acupuncture? Absolutely not, in fact, to imply this is a slap in the face to acupuncturists and Oriental medical practitioners just as saying a physical therapist who performs joint mobilizations is performing chiropractic. Both are using similar s tools for VERY different reasons!
What Oregon has is an opportunity to create dry needling verbiage in the Oregon rules and regulations that actually protects the scope and right of acupuncturists. there are states (I am not going to name them), who allow chiropractors to perform “chiropractic acupuncture” and “biomedical acupuncture”; these are unprofessional, inappropriate terms that disrespect the ancient art that is acupuncture. Oregon can be the first state to clearly define dry needling as completely separate from acupuncture just as joint mobilizations and manipulations performed by non-chiropractic providers are completely separate from the art of chiropractic.
I needed to replace the memory in a laptop computer today and getting to it with traditional tools seemed impossible without damaging the computer. I was able to use a couple of bicycle-specific tools to do the job effectively, efficiently, and without undue damage to the computer. Was I performing bicycle mechanics to my computer? No, that’s obvious, I was just using another tool for the job, a tool that performed better than the more traditional tools in my toolbox.
The acupuncture association in Oregon is now going to spend $30,000 to fight this and, in the end, chiropractors will likely be able to perform dry needling in Oregon; what a waste of money! In addition, I am also concerned that this move may create a false sense of extreme competition between chiropractor and acupuncturists and erode any collaborative efforts our two professions may put forth to bring more complementary medical treatments to Oregonians.
OK, rant over, I needed to get that off my chest. I hope this is over soon so I can use whatever tool necessary to
Well, while preparing to teach Nutrition III at National College of Natural Medicine (NCNM) in Portland, OR; I have been compiling information about blood sugar regulation and…. naturally, insulin. Insulin is a hormone that many of you have heard/read about in relation to diabetes and blood sugar regulation. Those who are in the body-building and/or weight lifting industry have heard about it because of some of insulin’s anabolic (muscle building) properties. What does insulin do?
Click on the following link for an article that addresses the function of insulin and relates those functions to body composition (body fat, lean muscle mas and more): Insulin and Body Composition
I’ve been working on a new project and came across an interesting research paper. Here’s another great reason to be lean (like you needed one); a 2009 article in the New England Journal of Medicine studied lean and obese men and the effects cold has on activating their brown adipose tissue. Brown adipose tissue, or brown fat, gets its color from the increased number of mitochondria compared to regular (yellow) adipose tissue. Mitochondria are the powerhouses inside our cells and can utilize fat for energy. With more of them, brown adipose cells can actually burn fat as it “spills” out of the adipose cells. Regular adipose cells need other cells’ mitochondria to burn fat that is liberated from them.
Classical thought was that brown adipose tissue serves an important role in infants but disappears in adults. Modern research is showing that adult men (especially non-obese adult men) still have brown fat and exposure to cold can activate it, allowing it to burn fat and produce heat. Interestingly, cold exposure can also activate the hypothalamic-pituitary-thyroid axis; this can help to bring a sluggish thyroid gland “back online”.
OK, lately, I have been obsessed with “The Dog Whisperer” on Animal Planet
Now, stay with me for the next paragraph, I will tie this all into the title of this post and a simple and effective way to set your body up for the efficient utilization of the calories you eat….
Early in 2010, we adopted a 5 week old lab/Shepard/pit bull mix. I have always been an animal lover and with both my dog and cat dying of cancer in the past 4 years, I have decided that we must investigate how best to keep our pets healthy; much in the same way I investigate ways to keep myself and my patients healthy. The first thing I did was to dive into the vast amounts of information on dog training. Huck (the lab/shepard/pit mix) is incredibly sweet, healthy and is fun to go off-road unicycling with; this is in part due to the principle laid out by Cesar Millan:
Exercise
Discipline
Affection
Providing these things in that order helps to set rules, limitations and boundaries for dogs but also helps to support them physiologically as this is how their body is meant to work. This is where my dog training research started to parallel my human health and wellness research. Regarding dogs, it has been amazingly helpful and healthful with our dogs to take them for a walk, play Frisbee with them, go unicycling with them or rough-house with them before they eat; it’s what they would do (or technically, their ancestors would do) in the wild, they chase their food down and eat it.
Well, for the better part of human history, this is what we would do too. Research is telling us that this is the way our physiology is set-up too; metabolic and lifestyle diseases have been on the rise for the better part of the last 60-100 years and food has become easier to get and eat every day. So, regarding food, we should consider food as the affection, it’s how our internal environment communicates with the external environment and how we nourish (READ: love) ourselves. I know; what about the discipline part?
Well, that could be built into our “how to eat equation” by stating this; we should eat until we are 75% full and have the discipline to choose a diet that is plant-based or mostly plant-based and not processed. OK, it’s a little bit of a stretch but it works well for my agenda
Here’s more, in fact, I’ll cut to the chase with my recommendation regarding exercise and meals:
Do some quick muscle contractions a few minutes before you eat to make sure you maintain a healthy relationship with sugar, insulin and fat deposition.
Now, I’ll get to the “how” and “what to do” in a little bit; first the “why”.
I’ll start off by saying this idea is not necessarily new ; it’s fairly well-established in research to one extent on another (see my references) and the idea has permeated a few resources for the every day individual; most notably, in a book called, 4 Hour Body by Timothy Ferriss (click for link to book). In this book the idea is discussed under the premise that this technique and other explained in the book will help you look and feel better. I want to expand upon this idea and state that it can help you regulate the sugar in your body.
Why would you want to do this?
It’s scientifically-solid and well understood that after an intense work out, food calories are less likely to be stored as unwanted fat. When our muscles perform work (especially intense work and even in VERY short bouts), they use sugar. Most of the sugar used is supplied by glycogen; this is a storage unit of sugar in muscles and the liver. As such, exercise depletes muscle glycogen and therefore many of the calories you take in after contracting muscles intensely serves to replenish this glycogen so it’s there the next time your muscles contract for more than a few seconds. In fact, it appears that this process occurs with as little as 60-90 secs of muscle contractions.
The appropriate exercise carried out a few minutes before eating may encourage glycogen restoration and not favor fat deposition, this is a GOOD thing.
In addition, this “habit” seems to be a good recipe to improve insulin sensitivity and improve your blood sugar regulation long term. Exercise before eating does this by increasing a substance in your body named GLUT-4 (glucose transporter type 4). By contracting muscles before insulin is secreted after a meal, it appears we can make sure that the calories we eat are used to replenish glycogen and not be stored inside our fat cells.
What type of exercises should you do? Here is a list of things you can do but the main principle is, 90 seconds of intense muscle contractions:
Go through each big muscle group and squeeze them as hard as you can for 10-30 seconds until you accumulate 90 seconds of muscle contractions. (the bigger the muscle group, the better
Do 90 seconds of kettlebell swings
Do 90 seconds of jumping jacks or jumping rope
Do 90 seconds of squatting up and down
The list goes on; NOTE: if the activity you choose causes pain, stop and talk to your chiropractor or trainer.
So, be good to yourself; regarding food, use this formula:
Exercise first (60-90 seconds),
Discipline next (make the right food choices; real, unprocessed foods, eat mostly vegetables)
Affection last (EAT )
I should also note that those of you who regularly workout should eat readily-available carbohydrates within 60-90 minutes after your workouts. This is the window of opportunity to maximally replenish your glycogen after a longer workout.
Questions? Ask away…..
References:
Terada S, Yokozeki T, Kawanaka K, Ogawa K, Higuchi M, Ezaki O, Tabata I.Effects of high-intensity swimming training on GLUT-4 and glucose transport activity in rat skeletal muscle.J Appl Physiol. 2001 Jun;90(6):2019-24.
Barnard RJ, Youngren JF. Regulation of glucose transport in skeletal muscle. FASEB J. 1992 Nov;6(14):3238-44.
Youngren JF, Barnard RJ.Effects of acute and chronic exercise on skeletal muscle glucose transport in aged rats.J Appl Physiol. 1995 May;78(5):1750-6.
Richter EA, Kristiansen S, Wojtaszewski J, Daugaard JR, Asp S, Hespel P, Kiens B.Training effects on muscle glucose transport during exercise.Adv Exp Med Biol. 1998;441:107-16.
Kawanaka K, Tabata I, Katsuta S, Higuchi M. Changes in insulin-stimulated glucose transport and GLUT-4 protein in rat skeletal muscle after training. J Appl Physiol. 1997 Dec;83(6):2043-7.
Terada S, Tabata I, Higuchi M. Effect of high-intensity intermittent swimming training on fatty acid oxidation enzyme activity in rat skeletal muscle. Jpn J Physiol. 2004 Feb;54(1):47-52.
Fujimoto E, Machida S, Higuchi M, Tabata I.Effects of nonexhaustive bouts of high-intensity intermittent swimming training on GLUT-4 expression in rat skeletal muscle. J Physiol Sci. 2010 Mar;60(2):95-101. Epub 2009 Dec 19.
Hiltunen JK, Qin Y.beta-oxidation – strategies for the metabolism of a wide variety of acyl-CoA esters. Biochim Biophys Acta. 2000 Apr 12;1484(2-3):117-28.
Yours in Health,Tim Irving DC, MS, LMTOptimum Function: 819 SE Morrison St. ste. 215, Portland, OR, 97215Optimum Function = Optimum Health 
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