Pain and Movement
I wanted to create a quick post about an article entitled, Pain Series: A look at the role of movement in relation to pain (Click for link). The article was written for the American Academy of Orthopaedic Manual Physical Therapists (AAOMPT) student special interest group (a physical therapy tour de force in the orthapedic world).
Here is an excerpt
Pain does not give us a measure on the current state of the tissue.
This has been shown through numerous studies on both animal and human subjects. These data have shown that pain, nociceptor activity and the state of the tissue are not isomorphically related at all but are modulated by a variety of factors.Nociception is neither sufficient or even necessary for the experience of pain even though it is the most common driver of the pain experience.
Pain is modulated by a number of different factors including those from the somatic, psychological, and social domains.
The influences on pain are varied and seem to be heavily dependent on the context that the noxious input is evaluated under. Some areas that have been shown to modulate pain include:
- Inflammatory mediators.
- Tissue temperature.
- Blood flow.
- Attention (results are mixed)
- Anxiety.
- Expectation.
- Belief.
- Social context.
- Etc…
As pain persists the relationship between the perception of pain and the state of the tissue becomes even more imprecise.
The number of changes that occur in response to activity of the system are large and the list of those identified is growing at a rapid rate. As nociception persists the neurons transmitting nociception and the pain networks in the brain become sensitized. Clinically these changes manifest as hyperalgesia and allodynia not only in relation to tactile stimuli but also movement. This is a key concept in understanding the role of movement in pain. Persistent pain can result in changes in the proprioceptive representation of the painful body part in the primary sensory cortex. This can have implications for motor control since it is known that experimental disruption of these maps results in disrupted motor planning. There is a mounting body of evidence that these changes can become part of the overall issue.
Pain can be ‘conceptualized as a conscious correlate of the implicit perception that tissue is in danger.’
The neuromatrix theory fits our current knowledge of biology and neuroscience and is flexible enough to grow with the research. Two very important components to the theory. Pain is just one of various outputs from the CNS in response to perceived threat and it is this threat perception that drives the outputs – not the actual threat.
In summary, pain changes the way we move and the way our brain interprets the information going to it as a result of our movements. Sometimes (many times), to fix movement patterns, we have to help reduce the level of threat detected by your brain so that your output of pain decreases. That’s all for today!
Yours in Health,Tim Irving DC, MS, LMTOptimum Function: 819 SE Morrison St. ste. 215, Portland, OR, 97215Optimum Function = Optimum Health
10 Things to Demand When Seeking Pain Relief
Here are 10 things that any patient in pain should expect, and possibly demand, when they visit a health care provider of any kind for pain relief. This post has also been adapted from another post by, Byron Selorme – Science Based Yoga Educator, on Soma Simple.
- Prognosis; AKA a reasonable timeframe for resolution:
- Providers should help you experience some pain relief within 10 visits. Treating pain should not be like renting an apartment you’re not signing up for a 1 to 5 year lease with options for renewal. Unless you’re recovering from a recent injury or major trauma, there should be some positive gains so you an evaluate whether or not the providers’ treatment(s) is/are working. NOTE: your provider should also verbalize this timeframe when they explain to you what their proposed course of care will be.
- Education:
- The field of pain science has evolved so much in the last 10 years. Every provider needs to learn the updated explanations for what is going on when you are in pain. It has been said that, “Knowledge is power”; well, in this case, knowledge is medicine. Learning why you experience pain will go a long way towards the resolution of your pain experience.
- Attention:
- If you are being treated by a provider who claims they can help you with your pain, expect them to be paying careful attention to you. You will be presenting expert evidence of your current experience and situation. It is important to note that this has nothing to do necessarily with the long story that you’ve developed to explain your pain to the many people who are not really interested in listening. This has to do with someone who is directing their caring attention towards you and noticing cues that you might not even realize that you’re demonstrating. Pain is a very emotional experience. And for this you need help sometimes from another person but they can’t help you if they don’t understand you or pay attention to you and your story.
- Atmosphere:
- Because your experience of pain is very much dependent on context (where you are, how you feel, if you’re scared, etc.), the atmosphere you are being treated in also matters. A clean organized treatment space that allows you to remain separate from others, the absence of distractions and clutter are very important. The context of the room is an input to your nervous system, there does not need to be specific decor but the focus should be on reducing the disruptive input to your nervous system (I.e. calming).
- Empowerment:
- Your inner locus of control is fundamental to reducing pain (AKA your nervous system’s detection of a threat). At the end of each encounter you should feel more in control and have a greater understanding of your role in the elimination of your pain and how important this control is.
- Honesty; comfort with uncertainty:
- Sometimes, exactly what happens physiologically is beyond a provider’s current knowledge level; in fact, regarding pain, it is often beyond everyone’s knowledge level. What you should require from them is that they are honest about this. Too often, providers create a narrative about what their particular therapies are doing or causing to happen in your body; this is often results from being uncomfortable with stating that they don’t know what is occurring. Consider that your provider does not need to have all the answers to be effective. Instead invite them to be someone with great technical knowledge and skill, willing to team up with you and your pain experience. Together you can problem solve, troubleshoot, and work with each other to reduce your painful experience. Also, be wary when providers quickly blame muscles, joints, fascia or other tissue for the sole reason you are experiencing pain; especially if there was no recent (less than 8 weeks) trauma.
- Encouragement to find movement and move more:
- There is a saying that is getting rather stale, but is still true, “motion is lotion”. The problem can be that sometimes a provider will get locked into a prescriptive set of movements that they think are the cure-all for everything. Movement is good, exercise is good, but we’re not entirely sure why they work. Also, there are NO magic exercises out there for ANY pain experience. If you’ve read some of my recent (2012 and newer) posts, you know that I am a proponent of novel movements and often have patients use novel movements to help reduce pain. Novel movements (those that you don’t normally do throughout the day), pain education and a very basic knowledge of your nervous system, helps to feed your brain new information so that it can create a new model that is pain-free.
- A strong aversion to pseudoscience:
- Many pseudoscientific treatments had their time; and often, people derived benefit from them, this doesn’t mean people should still be using them with patients. Back in their day, science was murky and many who utilized these methods thought they were practicing cutting edge medicine. A good rule of thumb is, if a treatment has little scientific evidence supporting its use with patients, it should be questioned. If there is NO risk involved, it may be utilized, but still be questioned, and probably not the only treatment offered. If there is ANY risk involved, it should not be performed unless it is the only treatment the provider has found to be clinically-effective. Even then, they should be honest with you about the risk and the lack of evidence so you may make an informed decision as to whether or not you want to utilize this type of treatment. If a provider’s primary concern is helping patients get better, it should be totally OK if they discover that what they once learned, is no longer useful or riskier than is warranted.
- A passion for learning:
- It is not unreasonable to discuss with your provider about what they have learned recently, regarding pain and pain relief treatments. Ask them about their sources of learning; do they read from a variety of sources? Do they cling to one particular “guru” who they’ve learned all their masterful techniques from. No one person that understands it all. There are many people today doing very amazing research and many clinicians helping many patients with pain relief. Providers should be interested in improving their understanding in some way, this requires that their sources are varied, journal articles, colleagues, continuing education and their own ability to integrate all this are all very important in this process.
- A willingness to treat pain:
- In the various physical medicine classes I teach, I have told my students that pain is often one of the major complaints that people present with; in this regard, pain relief should be a primary concern. If you visit a provider because of pain in your shoulder and they spend all of their time trying to increase your range of motion, core strength, or something silly, like balancing a perceived difference in the length of your legs, run away; especially if they mention something like “…I don’t treat pain, I treat dysfunction.” Pain is a reasonable thing to treat first and if any exercise, treatment or movement activity is prescribed, the focus should be in reducing the pain experience. In my opinion, pain is not treated well and soon enough. Do not tolerate a provider who ignores it, If they do not address your painful experience, get out of there.
Pain, Pain Relief, Movement and Body Mechanics: Turn Back, We Got it Wrong
Movement, or more specifically, novel movements can be quite useful for pain relief. They are an opportunity to create a new impression in your nervous system.
There is no guarantee that this new impression will be a favorable one; if you’re not careful the impression may cause an output of pain from your brain. If you’re careful, the impression may help to “convince” your brain and nervous system that movement should not be interpreted as dangerous and therefore, offer some pain relief.
If the impression causes yet another output of pain, there will most likely be some protection, and therefore limited or limiting movement. In order to change things for the better and create a pain-free impression you need to nudge your painless range of motion in the right direction. One way to stack the deck in your favor is to pair the new or novel movements with something that already has produced a favorable impression by your brain and nervous system.
This is creating context to obtain pain-free movement. Context is important when talking about pain and can be used in your favor.
Do you need to perform specific movements or movement patterns for this to occur? People often worry that imperfect movements create patterns of strain that can cause pain at any moment. In fact there are those in the functional movement camps that insist this will happen (I know, I used to be one of those people). Is this based on fact? Will “improper” movement cause us to break down, will this result in pain?
Consider these questions and points:
- Why don’t people with cerebral palsy hurt constantly at every joint even though movement is often difficult to control and where movement and postural asymmetry are very common.?
- How do you explain why so many people display these imperfect and asymmetrical movement patterns but have no pain?
- Why are so many of us walking around with herniated discs, meniscus tears, rotator cuff tears, and/or arthritis without knowing it? There is actual tissue damage in these people and yet they don’t hurt. The research documenting all of these findings exists….. in large quantities.
- How can we explain phantom limb pain; even in individuals who were born without a limb?
What about the countless stories of how people (maybe you) have had pain relief by changing movement patterns and/or posture?
Body mechanics and movement are important and useful to consider clinically, but my argument is that I would not be helping my patients by convincing them that their body mechanics and movement patterns are going to lead to them falling apart, injuring themselves and/or leading to degeneration or arthritis. Not only would this be harmful to my patients, but this is clearly not the case in any way.
Now this is flies in the face of what many in my profession as well as the physical therapy, athletic training and personal training profession, as gospel. Am I denouncing my own profession as well as many others? Well, in this case….. yes!
Body mechanics clearly play a role in the treatment of my patients and I use movement every day to help people with pain. When pain is present, movement and body mechanics can change drastically, but movement patterns and body mechanics are not useful as a pain predictor even though they can be a useful in pain relief.
Regardless of how you move you will all hurt at times during your life and pain may correspond to certain movements.
Neuroscientist, V.S. Ramachandran said that “pain is an opinion.” Painful movement means that our body is acting on the opinion that we are under threat and should therefore be protected. So, how can we change this “opinion”?
Movement patterns and postures should be thought of as tendencies or movement habits. They develop over time and therefore can give me a glimpse at your movement history. If you do something new, something outside of your normal movement regiment (I will call this novel movement), you give your nervous system something to form a new opinion about. If you perform this novel movement in a non-threatening context, a context of safety, a context of expansion, your nervous system is not likely to come to an opinion hat this is threatening and therefor not output pain.
Pain relief that occurs with postural changes, specific exercises or prescribed movements likely helps to reduce pain because they are all novel movements and is another example of the power of novelty. It likely has nothing to do with attaining perfect posture or perfect movements patterns or reducing musculoskeletal strain reduction, but has everything to do with non-threatening movement variability.
Yours in Health,Tim Irving DC, MS, LMTOptimum Function: 819 SE Morrison St. ste. 215, Portland, OR, 97215Optimum Function = Optimum Health9 Things About Pain EVERYONE Should Know
This post has been adapted from information posted by, Byron Selorme – Science Based Yoga Educator, on Soma Simple. People need to read this, this information is what each and every person needs to understand about pain.
- Despite all the impact demolition derby drivers sustain, they have ultra low incidence of chronic whiplash/ crash. It has nothing to do with the forces (they get blind sided too) but everything to do with the meaning and context of what happens. http://www.ncbi.nlm.nih.gov/m/pubmed/15827919/
- If you treat your body like it is fragile and damaged, it will become more so.
- Being afraid of the pain getting worse makes you fearful of movement.
- Working through pain and ignoring flare ups will negatively impact your nervous system. You are more likely to develop chronic pain when your nervous system is not “happy”.
- You can’t stretch out your pain; strengthening only indirectly affects the pain. So forget about weak muscles and asymmetry as being the cause of your pain.
- Treatments that are painful are more likely to perpetuate an environment in which your brain outputs pain; meaning, predominantly painful treatments can amplify your pain.
- Getting imaging like MRIs and X-rays should be an absolutely last resort. Unless there is evidence of serious red flags, chances are any findings on MRI’s, X-rays etc will just cause you to worry about something unnecessarily. Many people have no pain and would have plenty of abnormal findings n X-rays and MRIs.
- Your brain is in complete control of the pain experience. Pain is produced as a pain experience just like hunger and thirst. Only with pain, it is similar to a smoke alarm. Sometimes the alarm may go off because you took a shower or burnt some toast. With pain, there doesn’t have to be anything wrong for the experience to occur. This one is the most vexing because it feels so real. And it often has a distinct location. You would swear that something is wrong “right there”.
- Your brain extends throughout your entire body; there is almost 45 miles of nerves in your body. All nervous tissues have their own blood supply and they can get very cranky if they are not well fed. This is where you may need the help of a competent health care provider, and the earlier the better.
Pain and Performance
I have been putting together some resources on pain education; here’s a link to the page on my website Pain Relief. On this page, you will find handouts used to help those in pain as well as a pain presentation I gave at NCNM.
This morning, I find Todd Hargrove’s blog about a pain and performance presentation he gave at a Parkour gym in Seattle, here’s a link Todd Hargrove’s Talk on Threat and Performance
Todd does an excellent job talking about updated information about pain and how it can guide (and negatively affect) your athletic performance. Reducing the threat, or, rather, convincing your nervous system that there is not threat when performing athletic tasks like Parkour, is often the goal with any therapy that touts pain relief; even if the person performing the therapy is unaware of this.
Enjoy Todd’s video and blog post and stay tuned for more recorded talks from me on this subject. If anyone is interested in having me talk about this subject in person feel free to contact me.
Yours in Health,Tim Irving DC, MS, LMTOptimum Function: 819 SE Morrison St. ste. 215, Portland, OR, 97215Optimum Function = Optimum HealthPain Education Can Help to Make You Pain Free and Reduce Disability
Pain education can help reduce pain and disability; often, good pain education reduces your nervous system’s identification of various signals as “threatening”. If you’ve been following my recent blog posts, our brains can perceive many things as threatening and therefore, output pain as a result. These things may be nociception, emotions, ideas, memories and more. In addition, I have written about how some health care providers, unknowingly, pass on messages that can be threatening. This is particularly true when well meaning health care providers ascribe too much importance to some alleged injury to your muscles, ligaments, tendons and joints as the cause of the pain. For example, many massage therapists, chiropractors, physical therapists and trainers talk about muscle knots; there really are no such things, well….. they’re not knots.
How many times has your chiropractor or massage therapist told you that you had extensive muscle knots and scar tissue, and that was the cause of your pain? This idea may have caused you to think you had caused some damage to your body. In turn, even sub-consciously, this may have caused you to lose confidence in your ability to heal.
And what was “prescribed” for these “knots”? Probably, lots of massage, chiropractic adjustments, stretching, foam rolling, joint mobilizations and more. Why?
No one knows the answer, it certainly isn’t because all of these things have been proven to help with tender spots in our bodies. Please, read that again…… This last sentence may be a shock to some of you as most providers pass their recommendations off as scientific facts. Try this as an experiment, see what happens when you perform, fun, novel movements within and pain free range without foam rolling, rolling on lacrosse balls, using trigger point sticks, knobs, without getting adjusted and without constant stretching. Chances are, you’ll feel pretty good.
Often, as a health care provider myself, I find that some of my recommendations to patients become obsessions; so I need to be certain that my recommendations are rooted in science. Doctors and therapists can cause patients a lot of anxiety by making them feel like they defects in their body when there is no evidence of them. Many of my patients have been told that their back is “out”, that they have the “neck of a seventy year old”, or that their knee is “bone on bone.” These statements can increase the perception of threat, cause disability and pain, and lead to treatments that are unnecessary or even harmful. Yes, these statements can be interpreted as threatening by our brains and actually cause pain and disability.
I have to share a video that has been circulating recently showing physical therapist Peter O’Sullivan, working with a former client, Jack, about his dramatic recovery from debilitating back pain. The successful therapy involved dealing with Jack’s fears that forward bending was unsafe, which stemmed in part from hearing previous therapists tell him that he had the “back of a seventy year old”, that his back was “in pieces” and that “he couldn’t do nothing.” But O’Sullivan showed him otherwise, and the results were amazing to say the least. This guy went from not being able to ride in a car to digging ditches pain free in short order. I have been showing this to my students lately and hope you too will find it a bit mind-blowing:
The results Jack experienced are pretty amazing and I can tell you, from my clinical experience, his were pretty extreme. I have seen patients leave my office in quite a bit less pain and some, pain free, after a good “dose” of pain education. For more information on this topic and to se some of the pain education tools I use in practice, go here, Pain relief Portland, Oregon
Yours in Health,Tim Irving DC, MS, LMTOptimum Function: 819 SE Morrison St. ste. 215, Portland, OR, 97215Optimum Function = Optimum HealthLow Back Pain – A Biopsychosocial Approach
I know it’s been but one day since my last blog post but the approach I took in the video I link to at the end of this post is similar to the approach I took with my own bout of acute jaw pain (TMJD), as illustrated in my last post; Pain Relief – This Summer’s Pain Education and Jaw Pain Experiment
The approach is based on new ideas related to pain sciences and in general, is as follows:
- Educate the patient about their pain to reduce fear
- Encourage them to move in novel and pain free ways
- Give them a strategy to continue moving in graded ways until their pain is decreased and movement is back to normal.
- Teach them that a flare up may happen and what to do about it
- Have them come back in only to reassess things or if they have trouble tonight the above.
Here’s the link to the other blog post where a Physical Therapist uses pain sciences to deal with what the patient would call “muscle pain”. You’ll see that the main form of treatment was to educate the patient about his pain and get him moving in pain-free ways. Once he did this, his pain and dysfunction was relieved. All this without any passive treatments. By passive, I mean someone else (the PT) does something to the patient, without any input from the patient. A Biopsychosocial Approach To Low Back Pain
Yours in Health,Tim Irving DC, MS, LMTOptimum Function: 819 SE Morrison St. ste. 215, Portland, OR, 97215Optimum Function = Optimum HealthPostural Rehabilitation: Let’s Sit-Up Straight and Look at the Evidence
The idea that poor posture contributes to neuromusculoskeletal pain, and that important, or even possible to properly rehabilitate posture, has been around for a long time and continues to be very popular. We have still been unable produce any good evidence to support this model. There is a ton of mis-information on this topic; a provider could choose any weekend during the year and probably find a seminar somewhere that is on postural treatments.
Here’s my take on posture:
It’s not an issue of posture, it’s an issue of the quality of your body position from which you move. This means, your posture can be crappy, as long as when you move from a biomechanically-sound position. Does you sacral curve need to be “x degrees”….. no! Does your head need to be exaclty over your shoulders…..no!
For every “guru” that’s out there selling this ignorant and potentially harmful (monetarily at the very least) idea, there are hundreds of examples of individuals who have what most clinicians would call “bad posture” and are completely, functionally ad biomechanically fine, in every way.
Existing evidence supports rehabilitation using a biopsychosocial model over a traditional biomedical (i.e., posture and body mechanics) model, but a biopsychosocial model has been very slow in adoption for various pain states. This model looks at the individual’s relationship, thoughts, ideas, and fears with regard to pain and the clinician helps to dispel myths about pain, teach the patient about why the pain exists and helps them resolve whatever issue is causing the pain. Posture is not usually one of them.
Postural-based approaches to pain have been found ineffective and no longer recommended by clinicians who are “in the know”. This shift has occurred in part because these biomechanical messages are not backed by very good evidence, they can often impede the resolution of a patient’s pain and can convey negative messages to patients about the cause of their pain.
The idea that we can change our posture via exercise, manipulation, soft-tissue work and the like is simplistic, attractive and makes sense to a lot of people. Unfortunately, this idea contradicts current evidence. Many ideas that were once thought to be “common sense” and logical have been proven wrong. Disease was once thought to be caused by evil spirits, the world was once thought to be flat and the earth was once thought to be the center of the universe, are you picking up what I’m putting down? The relationship between posture and pain is complex and there is no consensus on a valid definition of “good posture” or a reliable way to measure it. Postural evaluation procedures show poor reliability validity.
The correlation between posture and pain is tenuous at best, with most studies suggest there is no relationship. Therefore, the therapeutic investment in correcting postural and biomechanical factors is irrational, since it is unlikely to influence the course of a patient’s pain.
References:
- Linsmeyer A. “The Effect of Flexibility and Posture on Neck Pain and Common Treatments in Physical Therapy.” Aurora Baycare Annual Spine Conference, Nov. 8, 2011.
- Cote P, van der Velde G, Cassidy JD, et al. The burden and determinants of neck pain in workers: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. JMPT, 2009 Feb;32(2 Suppl):S70-86.
- Linton SJ, van Tulder M. Preventive interventions for back and neck pain problems: what is the evidence? Spine, 2001;26(7):778-87.
- Weiniger S. Strengthening Posture for Rehab, Performance, and Active Aging. Seminar sponsored by Northwestern Health Sciences University., Dec. 10, 2011.
- Waddell G. The Back Pain Revolution, 2nd Edition. Churchill-Livingston, 2004.
- Toward optimized clinical practice. Guideline for evidence-informed primary care management of low back pain. Edmonton (AB): Toward optimized practice; 2009 Mar 2.
- Lederman E. The fall of the postural-structural-biomechanical model in manual and physical therapies: exemplified by lower back pain. J Bodyw Mov Ther, 2011 Apr;15(2):131-8.
- Dagenais S, Haldeman S. Evidence-Based Management of Low Back Pain. St. Louis: Elsevier Mosby, 2012.
- Cecchi F, Molino-Lova R, Chiti M, Pasquini G, Paperini A, Conti AA, Macchi C. Spinal manipulation compared with back school and with individually delivered physiotherapy for the treatment of chronic low back pain: a randomized trial with one-year follow-up. Clin Rehabil, 2010;24:26-36.
- Hrysomallis C, Goodman C. A review of resistance exercise and posture realignment. J Strength Cond Res, 2001 Aug;15(3):385-90.
- “Good Posture Defies Easy Definition.” The BackLetter, 2003;18(11)124.
- Dunk NM, Chung YY, Sullivan D, Callaghan JP. The reliability of quantifying upright standing posture as a baseline diagnostic clinical tool. JMPT, 2004 Feb;27(2):91-6.
- Fernandez-de-Las-Penas C, Alonso-Blanco C, Cuadrado M, Pareja J. Neck mobility and forward head posture are not related to headache parameters in chronic tension-type headache. Cephalalgia, 2007;27:158-64.
- Van Nieuwenhuyse A, Crombez G, Burdorf A, et al. Physical characteristics of the back are not predictive of low back pain in healthy workers: a prospective study. BMC Musculoskel Disord, 2009;10:2.
Portland Chiropractor | Pain Part 2; Pain and Stretching
Intro:
In the first part of my blog entries about pain, I wrote about pain and how much is too much versus how much is to be expected. Basically, laying out the guidelines to figure out if the pain you are experiencing is “normal” or if it requires treatment.
This part is about myofascial pain and stretching.
Stretching does Not Help Prevent Injuries:
The best way to avoid myofascial and/or musculoskeletal pain is to no injure yourself. At my Portland Brazilian jiu jitsu gym, Straight Blast Gym, I find many people stretching for various reasons and in various ways. Static stretching, dynamic stretching and even stretching with a buddy occurs in gyms everywhere. Why?
Often, when asked, people respond by stating that it keeps them from getting injured. Well, there is little to know research evidence that suggests this is the case; in fact, there is quite a bit of evidence suggesting that stretching (depending on the type of stretching), can actually pre-dispose you to GETTING INJURED.
Rather than writing a very opinionated post about stretching, I decided to grab some convincing research evidence to back my claims:
Effect of stretching on sport injury risk: a review: This review paper surveyed research from 1966 to 2002 and found no statistically-significant link between stretching and a reduction of injury risk.
Stretching before exercise does not reduce the risk of local muscle injury: a critical review of the clinical and basic science literature: This study (another literature review) did a more comprehensive search and still found no link between stretching and decreased injury risk.
A randomized trial of preexercise stretching for prevention of lower-limb injury: This was a very well-designed study that found no reduction of injury in study participants who performed a pre-exercise stretching routine.
There are so many research papers on this topic, none seem to clearly link stretching to decreased injury.
Stretching to Reduce Pain:
Another reason people often cite when asked why they stretch is because it reduces pain for them before and after exercise or activity. Well, this may be true is they are performing active “stretches” or what I like to call self-mobilizations (more on this in a bit, it has to do with joint motion, not muscle length), it probably has no real effect on pain at all.
Again, the evidence for this is overwhelming, I have picked out a few studies to illustrate my point:
Effects of stretching before and after exercising on muscle soreness and risk of injury: systematic review; this study showed no significant decrease in soreness with stretching before or after exercise.
The effect of passive stretching on delayed onset muscle soreness, and other detrimental effects following eccentric exercise: This study also showed stretching has no effect on pain when performed before an activity.
Stretching to prevent or reduce muscle soreness after exercise: And yet another one that showed no reduction in soreness in those who stretched before and/or after activity.
Warm-up, Not Stretching:
OK, so many people stretch as part of a warm-up. The evidence is clear about stretching; skip it, but DO perform a warm up. Here is some evidence showing that warming up can help prevent injury although it probably still does not prevent soreness or pain.
Comprehensive warm-up programme to prevent injuries in young female footballers: cluster randomised controlled trial: Although the original premise that warming up would prevent lower extremity injuries was not proven; warming up does seem to reduce the risk of severe injuries and overall injuries.
Compliance with a comprehensive warm-up programme to prevent injuries in youth football: Here’s another study that showed a reduced risk of injury when young athletes perform a warm-up.
Again, skip the stretching but perform a warm-up; I’ll touch on my warm-up recommendation at the end.
Stretching and Trigger Points:
I have even heard that massage therapists, trainers and other health care providers are telling their clients/patients that stretching reduces the risk of developing myofascial trigger points. There really is no evidence for this idea; I think the idea came from (erroneously) the Travell and Simons trigger point books. I further believe it came from this part of the books; Simons et al. Myofascial Pain and Dysfunction, pp127–135.
Travell and Simons’ well-documented “spray and stretch” method seems to be promoting stretching for the treatment and eradication of myofascial trigger points. The point of the vapocoolant spray is to “distract” the nervous system from the pain of stretching a muscle that is both dysfunctional and painful because it is riddled with trigger points. These book go on to further suggest (possibly true) that myofascial trigger points have both small patches of hypercontracted muscle fibers (trigger points) and long stretches of fibers that are overextended. Without the spray, muscles in this predicament may contract defensively if stretched. Interestingly, Travell and Simons do not recommend stretching trigger points without the spray.
Stretching and Pain (Soreness):
So, does stretching help to reduce soreness from activity and exercise? No.
I have seen many patients with myofascial pain, trigger points and other musculoskeletal pain syndromes; stretching is rarely something I recommend. Here is some evidence supporting my stance on the matter; at the end of this post, I will write about my recommendations for warming up and self mobilizations:
Delayed onset muscle soreness : treatment strategies and performance factors
Stretching to prevent or reduce muscle soreness after exercise: Stretching does not reduce muscle soreness after exercise…. sorry.
Warm-up and Self-Mobilizations:
The common thread here is that static stretching does not decrease activity-related pain. What does? Well, a good warm up and some mobility exercises. Here are areas of your body that really need optimal movement and mobility:
- Ankles
- Hips
- Thoracic spine
- Shoulders
If you tend to have joints that are mobile or hypermobile…. you don’t need to worry about mobilizations and PLEASE DON’T STRETCH. How do you know which of these areas you need to focus on? Well, if you have a history of low back or knee pain; you should focus on your thoracic spine (upper back), hips and ankles. If you’ve had a lot of shoulder injuries or neck pain, focus on your thoracic spine, shoulder and hips. Stay tuned to my new website:
Optimum Health Education: Online Classes on Health, Nutrition and Functional Movement
In the months to come, I will be posting both free and paid lessons on this topic and more.
Yours in Health,Tim Irving DC, MS, LMTOptimum Function: 819 SE Morrison St. ste. 215, Portland, OR, 97215Optimum Function = Optimum Health