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Author: Sam Visnic

Pec Minor Release Techniques

Best 4 Pec Minor Release Techniques – Pain Free And Safe Movements

Written by Sam Visnic on . Posted in Massage Therapy, Muscles, Pectorals, Stretching.

Best 4 Pec Minor Release Techniques

Most people are quite familiar with the larger, more superficial chest muscles, called the pectoralis major, however, underneath this muscle is another, called the pec minor.  The pec minor release techniques later in this article will be specific to this muscle.

This muscle is very important to address, since it’s responsible for pulling the shoulder blade forward and down onto the ribs. (contributing to the rounded shoulders appearance).

If during an evaluation there is an upper cross syndrome with rounded shoulders and excessive forward head positioning, this muscle should be addressed.

For the most part, in any upper body impairment the pec minor is likely to be strongly involved.

Pec-Minor-Release

How to know if you may need to address the Pec Minor Muscle:

  • Hunched or slouched forward shoulders
  • Rotator cuff or other shoulder injuries
  • Neck pain
  • Thoracic outlet syndrome
  • Breathing imbalances

Pec Minor Release w Tennis Ball

The pectoralis minor can be addressed with a tennis ball.  This is one of my favorite self pec minor releases.  Now, one thing to mention here is that you will NOT be making contact directly with the muscle.

Since the pectoralis major lays over the top, you’ll be influencing the pec minor indirectly with this technique.  You will need to play with ball positioning to find the most tender spots.

Pec Minor Release Massage

Addressing the pec minor with massage release techniques can be very powerful and useful.  My favorite position for this is side lying, as it allows for gravity assistance in moving the pec major out of the way.

However, some therapists prefer to do this supine (client laying on their back).  The preference will ultimately depend on the anatomy of the individual, and the therapist’s ability to feel the muscle.

Pec Minor Stretch
The pec minor can be challenging to stretch due to how deep the muscle is and it’s function.

It’s not uncommon to feel either a stretch OR some discomfort on the front of the shoulder when attempting to stretch the pec minor. Therefore, take your time when setting up this stretch and avoid being too aggressive.

Pec Minor Release – Post Isometric Relaxation
Post-isometric relaxation is very effective for the pec minor muscles, in particular for resolving pec minor trigger points.

A therapist is needed for this technique.

Lay on your back with arms down at sides. The therapist will guide the shoulder slightly up away from the nipple as well as down toward the table. You do NOT need to go far with this stretch.

Hold for 8-10 seconds, take a deep breathe in, and exhale as you attempt to relax further into the stretch. Next, while maintaining a light stretch, gently push the shoulder into the hand of the therapist with about a 10-15% percent effort.

Hold for 10 seconds, then take a deep breath and relax fully, allowing the therapist to take up the slack and see if the stretch can be taken a bit further. Repeat 2-3 more times or until no additional range of motion is achieved.

Thanks for checking out my recommended best pec minor release techniques.

As always, no muscle should be seen as the sole contributor to any given problem.  No muscle works in isolation.

It’s always best to approach muscular imbalances with a systemic approach to get the best results.  That is why I developed my Posture Hacking System.

How To Sit with SI Joint Pain

How To Sit With SI Joint Pain

Written by Sam Visnic on . Posted in Mobility, Pain, SI Joint.

How-to-Sit-With-SI-Joint-Pain

Sitting with SI joint pain for any length of time can make you miserable.  Unfortunately there isn’t just “one fix” that will work for everyone all the time.

Instead, there are a number of things that can help reduce SI joint discomfort.  They need to be tested to find out which works best.

However, the key reason why most people feel pain when sitting is because of a lack of movement.  Tissues, and especially nerves, need blood flow and oxygen to reduce increased sensitivity.

This is especially important to remember because at the end of the day, you need to MOVE as a human being, and not doing so simply cannot be worked around by using an expensive ergonomic chair, creams, pills, etc.

The sacroiliac joints and surrounding joints need to be addressed not only with positional changes, but also with specific exercise protocols, which can be found in my other posts.

That said, let’s get to our how to sit with SI joint pain list.

How To Sit With SI Joint Pain – Seated Hip Shift Mobilization w Ball

Since we are all asymmetrical (not balanced front/back/left/right), we tend to have favorite sides to sit on, muscles to use more, etc.

These asymmetries can be exacerbated in our daily activities, so we need to be conscious of using both sides of our body.  This movement in particular will help accomplish this task while sitting.

SI joint dysfunction is often associated to relative anterior/posterior tilting of the iliac crest on the sacrum. While this is hard to validate, especially visually on a standing movement or posture test, we can replicate this alternating shifting movement with this mobilization.

Here is how to do it:

  1.  Sit upright with your feet flat on the floor and with your hips slightly higher than knee level.
  2. Place a small ball or yoga block between your knees. (even a rolled up towel or pillow will work)
  3. While keeping your feet flat on the the ground, shift your weight to one side and pull your hip back while simultaneously pushing the opposite hip forward.
  4. Hold this position for 1-2 seconds, then repeat on the other side.
  5. Shift from side to side until you start to feel some fatigue, you start to lose good form, or feel any discomfort.

When you perform this hip shifting maneuver, it’s essentially “pumping” the hips and lower back.  You need to make sure this movement is done with low intensity.  It’s not about forcing the range of motion or building strength or anything else.

Just introducing movement, getting blood flowing, and relaxing overly sensitive nerves.

How To Sit With SI Joint Pain – Seated Hip Shift Mobilization w Band

This option is almost identical to the previous one, but in this version you will place a light mini-band around your knees.

The first version emphasizes the groin muscles to pull the hip back, and this version emphasizes the glutes to slide the opposite knee forward, but also to decelerate the same side hip as it goes back.

Yeah, that can sound a bit confusing, but the point is those muscles need to do both. In addition, adding a bit of resistance to the glutes further helps you to feel them and also get a bit of a muscle pump for blood flow.

Here is how to do it:

  1.  Sit upright with your feet flat on the floor and with your hips slightly higher than knee level.
  2. Place a light-moderate mini-band above your knees. (don’t go too heavy on this as it will distort the movement!)
  3. While keeping your feet flat on the the ground, shift your weight to one side and pull your hip back while simultaneously pushing the opposite hip forward.  Maintain the tension outward against the band with your knees.
  4. Hold this position for 1-2 seconds, then repeat on the other side.
  5. Shift from side to side until you start to feel some fatigue, you start to lose good form, or feel any discomfort.

You may find that one of these versions appears to help reduce discomfort better, OR doing both of them provides the best effect.

The one that works better for pain relief is the one you should repeat often throughout the day.

That said, IF you are going to do an exercise movement frequently, my rule is to make sure it’s done with LOW intensity.  Getting excess muscle soreness or fatigue is not the goal, and in fact it may slow down progress because you have to wait until it goes away to proceed.

 Should You Use A Standing Desk?

A standing desk is always a good option to rotate with sitting, especially if you’re dealing with sacroiliac joint pain. The loading on the SI joints is different in the standing position due to differences in muscle activity.

The standing desk is a great option to allow you to take frequent breaks from sitting and reduce the pressure on your spine .

Seat Cushions For SI Joint Pain

Seat cushions can often be helpful for low back pain and SI joint relief. The surface of many office chairs aren’t comfortable and may generate a source of noxious input into the lower back.

There are many different seat cushion options, but I have frequently recommended the Auvon version, which you can check out here.

Sometimes just adding a novel source of stimulation from a new sitting surface is enough to reduce sacroiliac joint pain.

 

Related Blog Posts:

5 Special Tests To Uncover SI Joint Dysfunction

How To Know If Your SI Joints Are Causing Your Pain

Sacroiliac Joint Belts – Do They Work?

Is Cycling Good For SI Joint Pain?

Best Mattresses For SI Joint Pain

Is Walking Good For SI Joint Pain

Yoga For SI Joint Pain – Here Are The Best Poses

Best Chair For SI Joint Pain

How To Release Voodoo Floss Elbow

Voodoo Floss Elbow: How To Release

Written by Sam Visnic on . Posted in Mobility, Muscles.

Mobility wrap (also known as “Voodoo Floss”) techniques can be extremely helpful as “catch all” therapy to address various issues. I find it extremely helpful for nagging issues such as elbow tweaks and also tendinitis relief.

In this article I’ll show you how to apply the voodoo floss to the elbow. This technique is different from how to wrap an elbow with traditional athletic tape or kinesiotape, and the results are different, so be sure to ask your healthcare provider if it is appropriate for you before trying it!

Step 1: How to start the wrap

Getting the wrap started is often the toughest part. You want to make sure the first wrap around is tight so that it doesn’t unravel as you get it going.

Place the wrap around your upper forearm, then pin your arm to your stomach to hold it in place as you pull tension in the wrap to cover the loose end.

Step 2: Hold the wrap on your knee to reposition

Hold the wrap down on your knee by pressing down with your elbow. Then, you can reposition your hand without the wrap unravelling. (You will do this every time you perform a wrap around in order to maintain the tension).

The goal tension of the tape should be around a 5-6 on a 10 scale in terms of max tension. You should easily be able to keep it on for 90 seconds to 2 minutes max with very little discomfort.

WARNING: Do NOT put too much tension on the band! This does not in any way make it more effective, and may cause injury!

Step 3: Continue wrapping with 50% overlap

Continue wrapping the tape around the arm moving toward the elbow and over the top with approximately a 50% overlap every round.

Avoid bending the elbow too much when wrapping directly over the elbow, or you’ll lose the quality of the placement.

When you reach the end of the tape, tuck the end into the last 1-3 layers of tape so that it stays put.

Step 4: Move elbow and arm in a variety of positions for 90 seconds

Once the tape is firmly in place, begin moving the elbow and arm around in various positions (remember your biceps and triceps attach to your shoulder so move everything!).

Perform this varied movements for roughly 90 seconds to up to 2 minutes max (depending on how much tension you have on the tape) or if you feel discomfort, take it off sooner.

Step 5: After 90 seconds to 2 minutes, unravel the band and test

After 90 seconds to 2 minutes, unravel the band and move your arm around. Test any previously restricted movements and/or painful ranges of motion.

You should notice improvement ranging from minor to often dramatic!

Voodoo Floss Elbow: How To Release – Demonstration Video

 

Back Extensor Release Techniques

Back Extensor Release Techniques

Written by Sam Visnic on . Posted in Massage Therapy, Muscles, Stretching.

The back extensor muscle group contains the Longissimus, Iliocostalis, and Spinalis.

If during an assessment excessive anterior pelvic tilt, excessive lumbar spine lordosis, back or sacroiliac joint pain is found, these muscles should be addressed.

Back Extensors Release

How to know if you need to address the Back Extensor Muscles:

Back Extensors – Massage Therapy

The back extensor muscles are easily accessed because they are superficial muscles.  They run from the sacrum all the way up to the back of the skull.

Due to the length of the muscles, its easiest to treat them in smaller chunks.  Elbow glides are most commonly used by massage therapists, but after the warm up, thumb-based techniques can address the spinal extensor muscles with more precision.

VIDEO

Back Extensors Release – Knees to Chest Stretch

Since most people do not feel a stretch in thoracic region of the extensors (due to excess rounding of the back called kyphosis), we focus on lengthening the erectors of the lumbar spine.

The knees to chest stretch is a simple way to accomplish this goal, but don’t worry if you do not feel a stretch.  Not everyone does!

VIDEO

Back Extensor Release – Cat Stretch

The Cat stretch works very well for lengthening the spinal extensors, but the emphasis needs to be on pelvic tilting to affect the lower aspect of the muscles.

Its important to note that the lumbar spine doesn’t flex very far, so only a little pelvic tilting is necessary.  Its not uncommon for some people to feel slight discomfort at the L-5/S-1 level, so only go as far as comfortable.

VIDEO

Back Extensor Release – Post Isometric Relaxation

Post-isometric relaxation works very well for the back extensor muscles.

Correct positioning over the end of the table is essential during this one, and if any discomfort is felt in the lower lumbar spine, reduce intensity and/or consult with your physician for guidance.

Be sure to contract at a low intensity for 8-10 seconds prior to relaxing fully into the new stretch position for another 8-10 seconds.

VIDEO

 

Back Extensor Release – Side Bend Stretch Over Ball

The side bend stretch over a swiss ball, when correctly positioned, is a great way to lengthen the spinal extensors.

VIDEO

Back Extensor Strengthening

Prone Extension

  • Start lying face down with your arms at your sids, palms facing the floor, and feet together.
  • Squeeze glutes, lift your chest up as high as comfortable while keeping your chin tucked and head retracted.
  • Lift and externally rotate your arms for a full shoulder blade squeeze.
  • Hold for the desired amount of time, then lower back to the starting position.
Prone-Extension-Back-Extensor-Strengthening

Opposite Arm – Leg Raise

  • Start on your hands and knees.  Wrists under shoulders and knees under hips.
  • Find neutral pelvic position, lift chest, and tuck chin.
  • Lift your hand and opposite knee just high enough to slide a magazine under while maintaining your alignment.
  • Maintain normal breathing.
  • Hold for the desired amount of time, then return to the starting position.
Opposite-Arm-Leg-Raise-Back-Extensor-Strengthening

Kneeling Hip Extension

  • Start in a kneeling position on a soft pad or mat.
  • Place your hands across your chest and arch your lower back slightly.
  • Shift your weight back as you tip from your hips until you reach a comfortable depth or until you start to lose ability to hold your lower back arch.
  • Pause for the recommended duration, then reverse the motion back to the starting position.
  • Repeat for the desired number of repetitions.
Kneeling-Back-Extension-Strengthening
Hypnosis and Chronic Pain The Future of Relief

Hypnosis And Chronic Pain: The Future Of Relief?

Written by Sam Visnic on . Posted in Lifestyle, Pain.

Hypnosis and chronic pain is a controversial topic to talk about, and some people immediately dismiss it because of the commonly seen exaggerated or ridiculous claims normally associated with the practice.

However, hypnotherapy, mindful meditation, and similar techniques have been tested in various settings with excellent results.

Unlike the pharmaceutical approach, hypnosis has few or no side effects, and versions such as self-hypnosis can be assigned via personal instruction, or audio recordings, thus making this an inexpensive technique to implement for the chronic pain sufferer.

Even as hypnosis is surrounded by skepticism mostly due to its reputation in the entertainment industry, recent research has identified some significant effects in the human brain after its use.

So, is hypnosis really effective?

Can we just categorize the results as being related to the placebo effect?

Lets take a deeper look at this.

Chronic pain and mindfulness

Addressing chronic pain with mind-body interventions is an interesting approach, especially in chronic disease conditions such as cancer.  These interventions are non-invasive, are inexpensive, and do not have side effects, so they can often times be easily implemented with minimal hassle.

The majority of these interventions have something in common: They promote mindfulness and help pain sufferers to manage their emotions, thoughts, and behaviors.

There are some pretty impressive studies that show how mindfulness and practicing meditation is associated with a higher pain threshold, and lower activation of areas in the brain that assign an emotional response to pain.

There is definitely a link between emotions and perception of pain, and chronic pain sufferers found in these techniques a way to use the connection between mind and body to relieve symptoms.

Even if 5-10 minutes of practice can start reducing pain, longer interventions (up to 8 weeks) are required for more effective pain management. Clearly the more you practice the better the result.

Application of hypnosis for different pain scenarios

The extent to which hypnosis has been tested in the medical field is pretty impressive.  For example, it has been used as the sole form of anesthesia for delivering babies, and it has been documented to manage normally painful dental procedures.

In cases of acute pain, hypnosis has been applied in chemotherapy, to manage burn wounds, and as anesthetic to take needle biopsies and certain forms of plastic surgery.  In fact, some of these individuals have been shown to have an 89% improvement in their medical and psychological condition compared to those who did not receive hypnosis.

Additionally, in individuals suffering from chronic pain, there are many randomized-controlled studies for issues like chronic back pain, fibromyalgia, cancer-related pain, and gut directed hypnotherapy for irritable bowel syndrome (IBS) and even small intestine bacterial overgrowth (SIBO).

In the majority of cases, hypnosis was found to be similar to standard care, which includes things like medication, group support, relaxation, and other techniques.

It has been found to be useful not only to improve pain, but also to promote self-sufficiency in individuals with those chronic ailments.

Meta-analysis of hypnosis for pain relief

There are a ton of studies of hypnosis, but they do not always have the best quality of evidence.  For this reason, there are reviews and meta-analyses, which is a special type of research that analyzes the evidence after gathering ALL of the studies available to date.

Meta-analyses not only include data from many different sources but also they investigate the possibility of bias and methodologic problems and how they would potentially affect the results.

In the most recent review and meta-analysis about hypnosis for pain relief, the authors included data of a total of 3632 participants from 85 controlled experimental trials.  After carefully assessing the data, they concluded that hypnosis produces a moderate to large analgesia in all types of pain.

Another key finding is that hypnotic suggestibility (the ability of a person to induced into a hypnotic state, which varies from person to person is important in determining whether or not the intervention will be effective.

Individuals with a higher susceptibility to hypnosis had 42% reduction in pain intensity while those with a medium hypnotic susceptibility reduced their pain symptoms by 29%.

Since the majority of people (close to 90% of us) fit in the medium to high susceptibility to hypnosis profile, these findings suggest that hypnosis is much more useful than placebo, and we can have a real and measurable improvement in pain perception after just a single visit.

What we know about hypnosis and chronic pain

Many things about hypnosis are currently unknown, including the exact mechanisms for how it works.  However, there are imaging studies about the brain in hypnosis.

Hypnotic suggestions for analgesia cause an altered activity in the prefrontal area of the brain, the insular, and the anterior cingulate cortex.  These brain areas are associated with the state of relaxation and awareness of external stimuli, and are important in pain modulation, which is essential to achieve hypnotic analgesia.

Studies have also found that people with lower hypnotic suggestibility have a different response in their anterior cingulate cortex and prefrontal region, and this is probably one of the reason why they won’t experience any meaningful change in their symptoms post-hypnosis.

There’s also a psychological explanation that may contribute to our understanding of the role of hypnosis in pain relief.

Models suggest that hypnotic suggestion creates an attentional shift from pain sensation that is responsible for reducing the monitoring and perception of pain.  This would also explain why patients with lower suggestibility have less pronounced effects after hypnosis.  They are just less responsive or willing to engage in the intervention.  Clearly this would reduce its therapeutic effect.

To sum it up, hypnosis for chronic pain is ultimately a fairly effective therapeutic intervention that is safe and economical.  It can be added to most if not all types of standard therapeutic protocols to assist with pain relief and empowerment of the individual to be able to modulate their own pain perceptions, emotions, and behaviors.

 

References:

Eaton, L. H., & Hulett, J. M. (2019, April). Mind-Body Interventions in the Management of Chronic Cancer Pain. In Seminars in oncology nursing. WB Saunders.

Thompson, T., Terhune, D. B., Oram, C., Sharangparni, J., Rouf, R., Solmi, M., … & Stubbs, B. (2019). The effectiveness of hypnosis for pain relief: A systematic review and meta-analysis of 85 controlled experimental trials. Neuroscience & Biobehavioral Reviews.

Moss, D., & Willmarth, E. (2019). Hypnosis, anesthesia, pain management, and preparation for medical procedures. Annals of palliative medicine.

Rizzo, R. R., Medeiros, F. C., Pires, L. G., Pimenta, R. M., McAuley, J. H., Jensen, M. P., & Costa, L. O. (2018). Hypnosis enhances the effects of pain education in patients with chronic nonspecific low back pain: a randomized controlled trial. The Journal of Pain, 19(10), 1103-e1.

Dillworth, T., Mendoza, M. E., & Jensen, M. P. (2011). Neurophysiology of pain and hypnosis for chronic pain. Translational behavioral medicine, 2(1), 65-72.

Jensen, M. P., & Patterson, D. R. (2014). Hypnotic approaches for chronic pain management: Clinical implications of recent research findings. American psychologist, 69(2), 167.

Rizzo, R. R., Medeiros, F. C., Pires, L. G., Pimenta, R. M., McAuley, J. H., Jensen, M. P., & Costa, L. O. (2018). Hypnosis enhances the effects of pain education in patients with chronic nonspecific low back pain: a randomized controlled trial. The Journal of Pain, 19(10), 1103-e1.

Sensitization In Chronic Pain: Knowing This Changes Everything

Sensitization In Chronic Pain: Knowing This Changes Everything

Written by Sam Visnic on . Posted in Pain.

Over the past decade, more scientific data has been made available to explain challenging cases of chronic pain that appear resistant to any generally accepted and appropriate therapeutic approach.

A new theory that is gaining acceptance is central and peripheral sensitization.  It’s a process that contributes to various types of pain syndromes, including things like fibromyalgia and osteoarthritis.

As you will see in this article, central and peripheral sensitization has been found to be responsible for unexplained changes in pain caused by both biomechanical and other triggers.

Knowing about these phenomena can be an absolute game-changer for people with chronic pain that no one can seem to figure out or help them with.

The role of central and peripheral sensitization

Different from many other organs, the brain undergoes continuous changes, known as neuroplasticity.  These changes are responsible for learning, but they also modulate excitability and neuronal activity.

Central sensitization is a modulatory process in the brain that results in a persistent state of high reactivity.  In this state, the pain threshold is lower, and individuals may still feel pain after an injury has already healed.

On the other hand, peripheral sensitization is often a cause of central sensitization, and it is modulation or change in the peripheral nervous system that disrupts pain perception, and is perceived by the brain as a constant source of pain.

This is a common finding in cases of nerve injury, both mechanical and chemical.  Thus, central and peripheral sensitization may be responsible for various forms of pain that cannot be explained by a biomechanical model, as in ghost limb pain and fibromyalgia.

The type of pain triggered by central and peripheral sensitization has two main characteristics, known as hyperalgesia and allodynia.

Hyperalgesia is an exaggerated perception of pain after a stimulus that is mildly painful, such as slight pinpricks.

Allodynia refers to experiencing pain with stimulus that is not normally painful, as in simple touch or gentle pressure.

Individuals experiencing unexpected or random shifts in pain sensation are not crazy or making up their symptoms.  That same goes for those who sometimes experience improvements after taking medications, doing movement, or getting a massage, but at other times are extremely irritable as a result of these same things.

Still, we cannot generalize and say that ALL types of pain come from central and peripheral sensitization.  In most cases, they are no more than pain modulators that contribute to noxious stimuli and sometimes explain the maintenance of pain symptoms in otherwise healthy people.

Mechanisms of central sensitization in chronic pain

The changes and modulation of pain pathways in cases of central and peripheral sensitization are very subtle and difficult to detect.  In most cases, they will be changes in the receptors at the molecular level inside whats called neuronal cells.

These changes occur after repetitive activation of pain receptors.  These changes in brain connectivity are coupled with changes in neurochemistry, in particular an increase in the release of chemicals that are associated with pain perception.

Thus, we will have abnormal levels of GABA, choline, and glutamate, which have been correlated with a bad mood and increased perception of  pain.

There are a few potential causes of central sensitization:

  • Stroke:  It causes chemical and structural modifications in brain tissue, leading to altered pain perception in some individuals.
  • Spinal cord injuries:  This leads to structural modulation of pain pathways, and it is responsible for unexplained causes of pain after trauma.
  • Genetic factors:  There appears to be a genetic prevalence as a predisposing factor for central sensitization.  None has been found yet, but it appears to be the case according to the scientific data.
  • Stress and anxiety:  Negative emotions have a profound effect on the neurochemistry of the brain, and can promote a state of alert that triggers excitability and favors the perception of pain.
  • Prior history of psychologic or psychiatric ailments:  Anxiety, traumatic memories, depression, psychosis, and similar ailments maintained for long enough can create dysregulation in the neurochemistry of the central nervous system that may trigger central sensitization.
  • Poor sleep:  It is a cause and consequence of pain, and acts as a vicious cycle, increasing sensitivity to pain at the same time.

As noted, pain perception is much more than biomechanical impulses.  It has a strong biopsychosocial aspect that we should be aware of.

The most logical approach to dealing with chronic pain

Even though the understanding of central and peripheral sensitization is available for everyone, and has a pretty solid foundation, many healthcare practitioners don’t appear to be well-informed of these mechanisms and may not take them into consideration when working with an individual suffering from chronic pain.

The focus is often almost exclusively on biomechanical causes of pain, rather than realizing the value of the biopsychosocial aspects of health as they relate to the PERSON that has the pain.

Several therapeutic recommendations have been synthesized to improve chronic pain in individuals with central and peripheral sensitization.

  • Exercise:  Aerobic based physical activity, such as walking, light strength training, swimming, and even yoga can be helpful.  They improve psychological symptoms such as depression and anxiety, and contribute to strengthening muscles.  This is important for addressing any potential biomechanical sources of stress in the body.  Interestingly, even individuals with irritable bowel syndrome can improve their symptoms and quality of life after following a 12-week exercise intervention!
  • Cognitive-behavioral therapy:  It is extremely important to educate people about pain (pain science education!), and techniques to cope with it.  Cognitive-behavioral therapy can help relieve emotional responses to pain episodes, and help control the severity and frequency of symptoms.  Even individuals with biologic causes of chronic pain, such as pelvic pain due to endometriosis, have reported improvements in quality of life after using cognitive-behavioral therapy in combination with alternative health therapies.
  • Massage:  Relaxation massage and/or bodywork which emphasizes reducing excess muscle tension can have profound effects on the chronic pain sufferer, even if only for the short-term.  Research shows the effectiveness of massage therapy on symptoms such as anxiety and depression.
  • Nutrition:  The value of anti-inflammatory nutritional guidelines, eating for optimal blood sugar regulation, and attaining recommended daily intakes of certain vitamins and minerals is often under-emphasized.  Food allergies, sensitivities, and nutritional deficiencies should be evaluated and addressed in the chronic pain sufferer in order to reduce overall physiological stress load.

So, in conclusion, recognizing central and peripheral sensitization in the chronic pain sufferer can immensely change the focus of the therapeutic approach health practitioners take to help the individual improve not only pain levels, but also quality of life.  It’s clear that focusing purely on the biomechanical model is insufficient and will fail to address the primary underlying issues involved.  As always, a multi-disciplinary, biopsychosocial-based, TEAM-approach is best when it comes to working with chronic pain!

 

References:

Eller-Smith, O. C., Nicol, A. L., & Christianson, J. A. (2018). Potential mechanisms underlying centralized pain and emerging therapeutic interventions. Frontiers in cellular neuroscience, 12, 35.

Fleming, K. C., & Volcheck, M. M. (2015). Central sensitization syndrome and the initial evaluation of a patient with fibromyalgia: a review. Rambam Maimonides medical journal, 6(2).

M Adams, L., & C Turk, D. (2015). Psychosocial factors and central sensitivity syndromes. Current rheumatology reviews, 11(2), 96-108.

Ji, R. R., Nackley, A., Huh, Y., Terrando, N., & Maixner, W. (2018). Neuroinflammation and central sensitization in chronic and widespread pain. Anesthesiology: The Journal of the American Society of Anesthesiologists, 129(2), 343-366.

Lumley, M. A., Cohen, J. L., Borszcz, G. S., Cano, A., Radcliffe, A. M., Porter, L. S., … & Keefe, F. J. (2011). Pain and emotion: a biopsychosocial review of recent research. Journal of clinical psychology, 67(9), 942-968.

Nijs, J., Van Wilgen, C. P., Van Oosterwijck, J., van Ittersum, M., & Meeus, M. (2011). How to explain central sensitization to patients with ‘unexplained’chronic musculoskeletal pain: practice guidelines. Manual therapy, 16(5), 413-418.

Woolf, C. J. (2011). Central sensitization: implications for the diagnosis and treatment of pain. Pain, 152(3), S2-S15.

Top Six Calves Release Techniques

Top 6 Calf Release Techniques

Written by Sam Visnic on . Posted in Massage Therapy, Muscles, Stretching.

 

The calf muscle group involves 2 primary muscles: the gastrocnemius and the soleus.  Both of these muscle merge into the achilles tendon.

The most common reasons for working on the calves include plantar fasciitis pain, and the inability to achieve optimal depth in the squat.

Gastrocnemius
Soleus

How to know if you may need the following calves release techniques:

  • Anterior pelvic tilt
  • Challenges squatting deeply
  • Calf strain
  • Ankle or knee pain
  • Plantar fasciitis

Are Your Calves REALLY Tight?

How do you know if your calves are actually tight?

They can be tested with a goniometer passively (with a therapist), or actively with a knee reach test.  Both of these tests can also include testing ankle mobility.

Watch the video below to learn more about calf flexibility testing.

Calf Release – Massage Therapy
The calves are generally very responsive to massage therapy work, but can often be very tender. They appear to respond well to medium pressure and many repetitions. Over time, as tolerance improves, the pressure can be progressively increased.

Calf Stretching – Standing – Gastrocnemius Version

The standing calf stretch is the most common way to improve calf flexibility.  In particular, this standing version emphasizes the more superficial calf muscle, called the gastrocnemius, because the knee is straight.

It’s a common error for the heel to rise during this stretch, which can make it difficult to access the muscle, so always make sure to follow the steps to maximize the stretch.

VIDEO

Calf Stretching – Standing – Soleus Version

The standing calf stretch can not only target the larger gastrocnemius, but also the deeper soleus muscle.

The difference between these stretches is simple:  In order to access the soleus, the knee must be bent.  Many people find it difficult to really feel the soleus muscle stretching, usually feeling more ankle restriction than stretch.

If this is the case, you may find the kneeling ankle mobilization to be more useful.

Calf Release With Percussion Therapy Tool

Percussion tools can be helpful for freeing up tight calf muscles.  The easiest position in which to apply this technique is the half-kneeling.

This is additionally a good way to improve ankle mobility and squat depth.

VIDEO

Graston-IASTM Therapy Tool For Calves

Graston-type IASTM (instrument assisted soft tissue mobilization) tools can be helpful for improving calf flexibility and improving recovery.

These tools are mostly used by professional therapists, but the techniques can be safely implemented at home.

Foam Rolling Calves For Self-Massage

Self-massage for the calves is easily do-able with a standard foam roller.  The goal is to roll with a light-moderate level of discomfort that allows you to comfortably work on the tissues.

When you find areas that are particularly tender, hold those points for 10-15 seconds, then move to another area.

Continue this process until you treat the areas that you can access effectively.

VIDEO

 

Can Orthotics Help With Pain

Can Orthotics Help With Pain?

Written by Sam Visnic on . Posted in Plantar Fasciitis.

Biomechanics of the lower body are not as simple as they might appear.  There’s quite a bit of pressure involved in every step we take, and even if we take it for granted, our feet and knees are always subject to a lot of stress.

The good news is, we are built to handle this kind of stress.  There are some specific circumstances, however, that can cause us to need some extra help.  This is where orthotics may be helpful.

Orthotics is a speciality that focuses on creating devices called orthoses.  There are shaped according to the contours of your limbs or to stabilize, alter or reduce range of motion, depending on what they are being used for.

In foot orthoses, special inserts like arch supports, or even special shoes can be designed with the intent on changing how we walk or run.

All of this sounds very powerful in its potential to affect the body, and many people presume all sorts of physical issues may be improved by the use of orthotics for the feet, but does it really work this way?

How effective are orthotics really?

Do you really need orthotics?

The orthotics field is complex, and if we want to consider the relationship between orthotics and pain, we have to narrow down the focus to two different types of pain that are pretty common:  foot pain and lower back pain.

One of the most reliable sources of scientific info comes from Cochrane reviews, and one of them analyzed whether or not custom-made foot orthoses are helpful to address foot pain.

The authors concluded that there is very good evidence that they improve pain in SPECIFIC pathologies, such as pen cavus, plantar fasciitis, hallux valgus, and various types of arthritis.

If any of these aren’t present, according to their review, there is limited evidence for assigning custom-made foot orthotics (1).

What about back pain?  Since there is not that much evidence, this is where the controversy shows up.  If we look through the literature, some studies show that id does work to alleviate back pain.

However, after taking a looking further into the research, there appears to be a lack of real scientific arguments, while others report that orthotics for back pain have the same effect as placebo.

Despite the apparently reasonable-sounding claims by people who want to make the sale, there are 4 main issues that appear to benefit from orthotics, and a few others that might as well:

  • Plantar fasciitis:  This is essentially inflammation in the sole of the foot, around the heel and arch.  It’s quite painful in the morning, and is thought to be often caused by increased pressure over your plantar fascia ligaments (2,3).
  • Arthritis:  When arthritis affects the joints of the foot, orthotics might come in handy.  This is especially true in the case of things like deformative arthritis like rheumatoid arthritis (4).  Still, according to the literature, arthritis by itself is not an indication for orthotics, and they are often used when it’s not really necessary (5).
  • Metatarsalgia: In this case, an evaluation of the gait cycle and abnormalities of the foot may be needed to find the potential source of pain.  In some cases, it is associated with overloading abnormalities, and orthotics may come in handy and improve symptoms in both the short and long term (6,7).
  • Diabetes and other foot-related pathologies:  Pathologies that compromise circulation of the foot may require orthotics in order to reduce pressure on the planter foot and in the incidence of some complications, such as in the case of diabetes (8).

So, what if you do NOT have any of these issues?  Can orthotics help?

Well, it’s possible, but there isn’t much research to support the use of them in such cases.

What about orthotics to improve postural pain?

You may have noticed that back pain is not listed as a problem that requires the use of orthotics…

That’s because there’s no clear evidence that they can directly improve back pain issues!

You might be wondering, ok…but what about improving posture?  Doesn’t improved posture mean less pain?

Of course one of the most common arguments is that orthotics will improve posture as a result of changing gait, and as a result, back pain is resolved.

This depends greatly on WHY the postural issue exists.  (well beyond the scope of this blog post). In short, most back pain is classified as “non-specific”, and it’s often resistant to most forms of standard therapy.

This is because there’s most often many sources of input that contribute to the pain (speaking especially toward chronic back pain) and trying to address it with a pair of orthotics isn’t going to work (9).

So, even though poor posture, work ergonomics, etc. can contribute to pain, it’s often given way more importance than it deserves.

One area to look at is leg length differences.  It’s often thought that if you have a “short leg”, your gait will become irregular and you will end up with some type of physical pain, whether it be knees, hips, lower back, etc.

Studies show that assessments of leg length differences are likely to be biased, even in chiropractors with over 30 years of experience (10)!

Even if you do have a significant difference, it is clear that people with this problem do not have more back pain issues relative to everyone else (11).

Orthotics for lower back pain: Yay or Nay?

A recent systematic review and meta-analysis of several clinical trials on shoe insoles and its relationship with low back pain state that there is not enough evidence to support the use of insoles to treat or prevent low back pain (12).

Even though some studies claim that there’s a significant improvement after using orthotics (13), the truth is that after analyzing the methodology of their studies, there’s a statistical but not a clinical significance. In other words, even though their statistics might seem to indicate that there’s an improvement, it is not translated into real value in the clinical practice (14).

So to sum it up, orthotics appear to be most helpful when they are used for specific types of pain, mainly located in the foot and associated with overloading and pressure problems.

Since orthotics, especially when custom-made, can get pretty pricy, they clearly aren’t the go-to when it comes to other types of chronic aches and pains.

They certainly don’t have more direct value than hands-on massage techniques, exercises, stretches, and self-mobility drills.

Graded Exposure: The Key To Movement Success

Graded Exposure: The Key To Movement Success

Written by Sam Visnic on . Posted in Movement and Exercise.

Most health professionals recommend resting the area affected by an acute injury in order to recover.  In many cases, due to the extent of the injury, this may absolutely be necessary.  However, it appears that recently the tide is turning in terms of how soon movement is recommended in order to speed recovery from certain types of injury or even surgical procedures.

In fact, getting things moving again may reduce the risk of developing chronic pain.

Movement has different effects in the acute vs. chronic pain sufferer, but the process we are going to discuss in assigning it is focused on the chronic pain sufferer.  This concept is called graded exposure.

Pain itself can be warning sign that protects us from re-injury, but sometimes people adopt an undesired pain-avoidance behavior that does more harm than good.  The concept of graded exposure has been designed with these individuals in mind.

Fear of movement and re-injury

Pain and common disabilities associated with it are influenced by many different things, and some of them do not appear to respond to a structural-biomechanical approach.  Psychological and psychosocial factors play an important part, and individuals with fearful thoughts related to movement often experience more pain and disability in the long run.

It’s also known that longstanding avoidance of movement and compensatory strategies (altered movement due to previous injury or fear of movement) may lead to a progressive impairment of movement skill.

Thus, we need to differentiate pain disability and the disability that results from something like a musculoskeletal problem.  Sometimes, musculoskeletal problems are gone, injuries are healed, but the disability remains due to fear of movement and avoidance behavior.

It appears that often health professionals that work with individuals that suffer from chronic pain tend to forget is that perhaps the primary obstacle that is being experienced isn’t the tissue itself, but the fear of performing certain activities or movements because the individual believes they are re-injuring the painful area.

What is graded exposure?

Graded exposure is that concept that is based on progressively exposing individuals to increasing levels of stress in order to stimulate adaptation in the central nervous system.

It can significantly reduce sensitivity to movement and avoidance behaviors that contribute to chronic pain.

What needs to be considering in graded exposure is applying just the right amount of stress that will not cause any setbacks in progress, but instead stimulate adaptation.

This principle is easily applied to areas such as muscle building, for example.  Every workout session, the stress increases just a bit more, either through more repetitions or added weight.  Doing too much hampers progress, and may lead to injury.

We can easily apply this concept to virtually all therapeutic modalities, including exercise, stretching, massage therapy, neuromuscular techniques (such as muscle energy techniques), and much more.

Is there a difference between graded exposure and graded exercise?

There are many applications of graded exposure, and we should differentiate this to graded exercise.  Graded exposure is a concept of progressively increasing stress to overcome the fear of movement and modulate the nervous system, but as mentioned, can be applied to many different types of therapeutic modalities.

Graded exercise is a common meth0d that is meant to teach an individual that they can do certain movements and reach certain ranges of motion via a progressive approach.  This is especially helpful for individuals that suffer from chronic pain and are afraid to perform certain movements or activities.

As it is, graded exposure is part of graded exercise, and it’s certainly possible to apply the principles of both at the same time.

 

Graded exposure and adaptation of the nervous system

Several studies have identified a strong link between pain perception and mood.  Anger and negative emotions lower the pain threshold, making us more sensitive to pain, and giving us extra reasons to feel irritable.

Thus, it is widely accepted that our psychological and social circumstances modulate our interpretation of pain, and our reactivity and levels of vigilance.  Our perception of safety is also important, and this is what progressively changes during graded exposure.

Achieving a dosage of stress that triggers very low-intensity pain with a controlled movement is away to send a signal to your nervous system that this move or particular range of motion is safe to perform.

In time, it will feel more comfortable and less pain will occur with this movement because you will have adapted to this stressor.  More stress can be applied to create further adaptation, and reduce the pain “alarm” further as your nervous system becomes de-sensitized to the stimulus.

This technique is generally based on mainly observational and anecdotal evidence, but there is also scientific literature that establishes the foundations and the role of graded exposure in cases of pain.

Still, there is no final guideline or definitive recommendation to guide the application of graded exercise in particular.  This is where the art of the work and experience comes into play.

There are some principles that are helpful to follow:

  • Assessing fear of movement:  There are many potential ways to assess fear of movement.  From graded tests to simple client interview and demonstration.
  • Implementation of movements and stress loads:  Sometimes there are multiple movements that are problematic, and/or activities that don’t produce discomfort until load is applied.  These can be divided up and dealt with one at a time.  Improvements in some movements may directly improve others without specifically addressing them!
  • Re-evaluation and modifications:  After a given time that depends on the individual’s situation (often times within the same visit), the problematic movements or tests can be repeated, and adjustments made to further improve the response.

The bottom line is that graded exposure and exercise can be an extremely valuable component of any chronic pain sufferer’s movement and/or massage therapy program.

The power lies in identifying activities, movements, ranges of motion, and other factors which trigger fear, or avoidance, and creating a plan to systematically reduce or eliminate that fear by starting with education, then selecting an appropriate low-threatening way to begin, and progressing over time as results are attained.

 

References:

Vlaeyen, J. W., Kole-Snijders, A. M., Rotteveel, A. M., Ruesink, R., & Heuts, P. H. (1995). The role of fear of movement/(re) injury in pain disability. Journal of occupational rehabilitation, 5(4), 235-252.

Tuna, Z., & Oskay, D. (2018). Fear of movement and its effects on hand function after tendon repair. Hand surgery and rehabilitation, 37(4), 247-251.

George, S. Z., & Zeppieri Jr, G. (2009). Physical therapy utilization of graded exposure for patients with low back pain. journal of orthopaedic & sports physical therapy, 39(7), 496-505.

Can Lifting Weights Give You Relief From Pain?

Can Lifting Weights Give You Relief From Pain?

Written by Sam Visnic on . Posted in Movement and Exercise.

There are few things in the health field as versatile as exercise.  It is commonly recommended and sometimes prescribed a s part of the therapy for various health conditions.

Even though we assume this type of recommendation for people with excess weight and even cardiovascular issues, it is also very helpful for people that suffer from chronic pain.

First, before diving into this topic, we need to separate exercise into two main types:  aerobic and anaerobic.  Aerobic exercise is also known as cardiovascular (cardio), and anaerobic exercise is  known as resistance training, weight training, or strength training.

Below, we’ll evaluate what the research shows when it comes to the effective use of anaerobic training to relieve chronic pain.

Do pain symptoms improve with resistance training?

While many studies show that resistance training improves pain symptoms, other show it might not be all that useful.  This can definitely seem confusing, but this discrepancy can exist for a few potential reasons, including the type of pain that is being experienced, and of course the WAY the training is being performed.

If you have a properly designed program and you’re doing everything correctly, you’ll likely to get improvement from some types of chronic pain (1).

A recent review and meta-analysis of resistance training and chronic lower back pain show that aerobic exercise and resistance training were both associated with a significant reduction in pain intensity. However, resistance exercise displayed an added benefit to the psychological well-being of the individual, which is essential to modulate the perception of pain. (2).

It’s also interesting to note that there are many variants of resistance training, and each of them has proven to reduce pain in a different way.  For instance, we can divide resistance training into static and dynamic muscle contractions.

Static muscle contraction, which includes isometric exercise (muscle contraction with no movement), is associated with a moderate-to-large modulation of pain, and certain studies have found that maintaining contraction at a low weight for a longer time recruits and exhausts more muscle fibers, leading to a more significant exercise-induced-hypoalgesia.

On the other hand, dynamic resistance, which is performed essentially by shortening and lengthening the muscles, has been found to have similar effects, but usually in the short-term (3).

When and how is strength training appropriate for chronic pain?

Resistance training can be utilized for various types of chronic pain, including fibromyalgia, which is known to be a fairly challenging condition.

Fibromyalgia is a pain condition that is highly variable between people that have it, and it’s associated ultimately with a dysfunction of the nervous system and increased susceptibility to pain experience.

Most of the information out there shows that controlling pain in fibromyalgia is an extremely challenging venture.  Even so, “old-school” resistance training is still an effective way to reduce the sensation of pain and tenderness, and maintain or increase muscle strength in these individuals.

According to a Cochrane review, aerobic exercise is superior to moderate intensity resistance training in some cases, so it appears to be a good idea to combine them to some degree (4).

One of the more common applications of resistance training in chronic pain is associated with things like repetitive strain injuries.  For example, a randomized control trial focused on strength training to treat working populations that had repetitive strain injuries, some of which had a work disability.

They underwent 10 weeks of strength training against the usual ergonomic care that is recommended to address this kind of pain. Strength training showed significant improvements in hand/wrist pain and reduced time to fatigue by an impressive 97% (5).

Achieving these improvements in chronic pain with resistance exercise is not so difficult. All we need is to choose key exercises per muscle group, include one or two sets for each exercise, choose the appropriate weight to perform a correct technique without a problem, and resting between sets a few minutes.

Each repetition should be performed at medium-speed, and doing this twice every week for each muscle group is usually enough for good results. This is in accordance with the current recommendations of physical activity for health by the World Health Organization, which includes 150 minutes of moderate physical activity (aerobic exercise) a week combined with muscle-strengthening activities 2 days a week or more (6).

Common obstacles and risks of resistance training

Generally in order to be effective, resistance training needs to be done 2-3 times per week.  This sounds easy, but there are some obstacles to be aware of.

  • You may not feel immediate improvements:  Even though there’s a connection between resistance training and pain sensitivity, it does not produce rapid shifts in pain perception like modalities such as massage or relaxation training.  Real improvements in this area take time, as much as 12 weeks to see the true benefits.
  • It’s about changing your mindset and lifestyle:  Resistance training will require time commitment and persistence.  If you’re not committed or lack the ability to stick to it, you aren’t likely to get the outcome you are seeking.

Resistance training may not be the thing that everyone needs for their type of chronic pain, or it may not fit into their needs at a particular time.

Here are a few more things to be aware of:

  •  Strength-training injuries:  Hitting the weights without any professional help, and no mastery of exercise technique may not only reduce the benefits, but also get you injured.  Getting injured in the process of trying to relieve pain is a common issue, and this is why you should seek help from a professional!
  • Imprecise exercise protocols for the type of pain:  Certain types of chronic pain won’t respond well to aggressive resistance training.  Some, like fibromyalgia, need to be very closely monitored because the training program may constantly need to be adjusted based on how the person is feeling.  Frozen shoulder is another issue that may not respond well to strength training at all, and in fact may make it much worse.

Summary

Resistance training (anaerobic exercise) certainly has its place in the therapeutic regime of the chronic pain sufferer and has been shown to be highly effective, but it must be applied to the right kind of pain issue, in the right way, and progressed over time as the person adapts to the program.