Author: Sam Visnic

Is Fascia Really Relevant To Chronic Pain Relief?

Written by Sam Visnic on November 22, 2019. Posted in Massage Therapy.

From myofascial release, to fascial stretching therapy and fascial release tools, everyone seems to be focusing on this specific body tissue.

In this article, we’re going to take a look at fascia, as it’s been a rising hot topic in the alternative therapy realm, and whether or not it therapies targeted at fascia have value for the chronic pain sufferer.

What IS fascia?

In gross anatomy, fascia is simply connective tissue that wraps around muscles and other anatomical structures. If is flexible and capable of stretching in response to muscle contractions and body movements, and it covers almost every organ, not only muscle groups.

So it IS flexible enough to move along with muscle so that it won’t obstruct its normal contraction.

The growing interest in fascia started by the idea that musculoskeletal pain is triggered by deformation of this connective tissue wrapping. This model of pain has been named the “Fascial Distortion Model”, and was introduced in 1991 by Stephen Typaldos, but other therapists have talked about fascia in relationship to pain and musculoskeletal dysfunction over the years. Therapists such as John Barnes have been teaching myofascial release for decades.

According to the Fascial Distortion Model, it is possible to fix fascial distortion by a series of techniques involving handwork and specialized tools.

Even though it is mentioned by the American Fascial Distortion Model Association that this model has proven useful in treating acute and chronic injuries, there is no scientific validation that such distortions actually exist or that manual therapy specifically can do anything about it.

Facts about fascia you need to know

Misconceptions about fascia and how it is related to muscle pain are EVERYWHERE now, and even skilled physical therapists, chiropractors, fitness trainers, and massage therapists are lured into fascination by its assumed implications.

Somehow we are led to believe that fascial restrictions can be identified through chains or patterns throughout the body, and targeted with either stretching, hands-on techniques, or using metal tools designed to work directly with fascia.

The problem is these claims are simply not well supported by science, and most research appears to show we can’t do much about fascia directly, especially not in the short-term.

This appears even more evident when we learn about the actual strength of fascia. It’s pretty hard to believe any changes in extremely dense and tough tissue can be accomplished within the context of a therapy session, or even a few for that matter.

Consider the following facts:

It is NOT possible to change or deform fascia using manual therapy

A study published in the Journal of the American Osteopathic Association evaluated the ability to deform or change fascia via massage therapy. This is relevant to the claim that fascial release improves pain because according to this model, therapists should be able to stretch or fix “fascial deformations” in the first place.

However, the evidence pointed out by this paper shows that mechanical deformation and stretching of fascia is only possible by using high forces (on the plantar fascia and IT band), while certain types of fascia (in the nose for example), may be influenced by less.

To put this in perspective, in order to deform the fascia on the bottom of the foot (plantar fascia) by 1%, you would need to apply more than 8,000N of force. The force of a lion’s jaw can produce a bit more than 4,000N of force!

This is because this thin layer of connective tissue is too tough to lengthen by simple common clinical therapeutic techniques. The amount of pressure needed to do so would be extremely stressful (if even possible) by the therapist, and certainly be extremely painful to the recipient.

Thus, it’s not likely at all that these alleged fascial distortions can be fixed by massage, or stretching techniques.

Fascial contraction and pain

Some studies show that similar to the muscles they cover, fascia can undergo a weak and slow type of contraction. This is undoubtedly exciting information and destroy the thought that fascia is form of inert connective tissue.

However, it should be stressed that contractions found in fascia are extremely subtle and difficult to register, especially when you compare them to that of muscles.

The question is whether or not there is any real significance to these contractions, especially in the context of therapeutic techniques. (Actual practice, not just in a test tube!)

Is it possible that such a weak contraction can influence the correct functioning of muscle groups?

That’s a tough sell to assume that these weak contractions generated in-vitro would act by themselves in the body causing deformations to the fascia and triggering pain.

Another entertaining thought is that any manual therapy practitioner can actually assess or feel the release of fascial tissues, and be able to distinguish them from both the muscles contained, as well as all of the tissues that lay on top of them! Virtually impossible.

We haven’t even touched on the issue that pain itself is not purely a structural issue. We know that tissue damage and pain are not fully associated, so even if damage to fascia is found through deformations, etc., it doesn’t mean it has ANYTHING to do with pain!

The primary mechanism for pain relief lies in changes to your nervous system

I’ve already mentioned how tough the fascial covering of a muscle is and that is very unlikely to mold or fix fascia with manual therapy.

Doing so would require excessive pressure that is inconceivable in massage or stretch therapy.

However, there is definitely something that feels different after these heavy-pressured massage or stretching sessions, and of course many people report feeling pain relief.

Does this prove that fascia needs to be released? Does it validate the narrative often espoused by these fascia-focused therapies?

No, it doesn’t prove that at all. There are a great many potential reasons why people feel better after hands-on therapy sessions.

Endorphins improve pain, novel sensory input can alter perception of pain, activating the parasympathetic aspect of the nervous system, and even the placebo effect are all potential explanations and common effects from manual therapy.

The take home point here is that we can emphasize the end result of feeling better through movement and manual therapy techniques, and get rid of the likely false story of WHY those techniques are working.

One of those false stories is that you feel better because of changes to your fascia, and how it could have been altered as an effect of the therapy.

References:

Thalhamer, C. (2018). A fundamental critique of the fascial distortion model and its application in clinical practice. Journal of bodywork and movement therapies, 22(1), 112-117.

Chaudhry, H., Schleip, R., Ji, Z., Bukiet, B., Maney, M., & Findley, T. (2008). Three-dimensional mathematical model for deformation of human fasciae in manual therapy. The Journal of the American Osteopathic Association, 108(8), 379-390.

Schleip, R. (2003). Fascial plasticity–a new neurobiological explanation: Part 1. Journal of Bodywork and movement therapies, 7(1), 11-19.

Meltzer, K. R., Cao, T. V., Schad, J. F., King, H., Stoll, S. T., & Standley, P. R. (2010). In vitro modeling of repetitive motion injury and myofascial release. Journal of bodywork and movement therapies, 14(2), 162-171.

Schleip, R., Klingler, W., & Lehmann-Horn, F. (2006). Fascia is able to contract in a smooth muscle-like manner and thereby influence musculoskeletal mechanics. Journal of Biomechanics, 39(1), S488.

https://www.nationalgeographic.com/news/2012/3/120315-crocodiles-bite-force-erickson-science-plos-one-strongest/

Massage Myths: Can You Really Break Up Scar Tissue, Knots, And Adhesions?

Written by Sam Visnic on November 16, 2019. Posted in Massage Therapy.

Massage therapy has been around for a VERY long time, and recent science has backed up many arguments that were formerly enveloped in mystery regarding its practice. However, there are still myths and misconceptions to address, especially since many of them are still being perpetuated by health professionals as part of their social media marketing efforts.

The concept of breaking up “knots”, “adhesions”, and scar tissue is one in particular. One of the most popular questions people seek answers for is how to massage scar tissue to break it down.

Marketing vs. Reality

Since there is no way to monitor every single event and physiological change during an actual massage session, scientists need to take facts and draw conclusions accordingly. This makes massage therapy more susceptible than many other health practices to myths and misconceptions based on subjective and personal experiences.

Thus, it is pretty common to see professional therapists continue to recommend debunked practices like drinking more water after a massage session to clear “toxins” away or using vague terminology like “freeing up scar tissue and adhesions”, “releasing fascia“, or “digging out knots”.

According to some bodyworkers, adhesions are formed by dysfunctional fibrous tissue that attaches to the muscle, prevents it from stretching, restricts the range of motion of the body, and causes muscle pain. I specifically recall being taught these things when I first became a massage therapist.

In school we were taught that these knots were mis-aligned muscle fibers that rearrange in bunches that become hypersensitive and tense. It’s not uncommon to see topics like these all over the internet from massage therapists:

How to break up scar tissue
How to break up fascia
How to break up fascial adhesions at home
Massage for adhesions
Scar tissue massage therapy

These concepts have become so widespread in people that even massage therapists who do not believe in them (I’m one of them!), are forced to use the language as part of the discussion with the person in order to assess their situation and convey the outcome of their therapeutic program!

There is, however, a long distance between this widely used marketing babble and what science has really found out about the musculoskeletal system.

What are knots, adhesions, and scar tissue really?

If you look up the term “adhesion” in a medical-type textbook, the only reference you will find is to a type of scar tissue that is commonly associated with inflammation, and is capable of sticking neighboring tissues together.

These adhesions are a common outcome of surgery, and the only way to release them is by cutting through with a scalpel. You won’t find any other usage of the word “adhesion” associated to muscles or surrounding tissues spontaneously gluing together, as is often implied by many bodyworkers, and there’re no scientific literature on the best practices to release them by using touch therapies.

Thus, scar tissue is not likely to create adhesions without having had surgery. They are mostly post-interventional problems, except in some instances. For example, females with a prolonged history of pelvic pain may create scar tissue and adhesions around the uterus. Definitely not associated to muscle issues, and certainly can’t be resolved with massage!

What about muscle “knots”? There’s at least SOME truth to defend this concept because muscle tension feels different than a relaxed muscle, and it is not something that untrained individuals may realize. Even considering, this doesn’t mean that the muscle fibers have somehow become distorted, or its collagen fibers become mis-aligned. Due to this, there is nothing to “re-align” with massage!

The trigger point debate continues to rage on…

When researching about muscle knots, it is highly likely you will come across terms such as trigger points and myofascial pain. If you look at the concept of trigger points, in essence it’s the same as what has been described as a muscle knot.

A trigger point is said to be a hypersensitive muscle area that is tense and usually feels like a bump or palpable nodule. In some cases, pressing this area would elicit pain local to the area, or radiate to another location.

Whether or not trigger points are real is a cause of ongoing debate. What people FEEL during or after a massage isn’t on trial, but the explanations for pain and discomfort are.

Trigger point supporters say muscle stress affects blood circulation and promotes the accumulation of metabolic waste in this painful area. The area becomes acidic, stimulates nerve endings, and this contributes to tightening up muscle tissue even more in a vicious cycle.

While this explanation sounds reasonable, critics highlight that there’s no scientific proof to back up these arguments, and it is no more than pure speculation.

Moreover, therapy based on the idea of trigger points have the same results as placebo therapy, contributing to the argument that the concept of trigger points is no more than a wild guess.

So, CAN massage break up adhesions, scar tissue, and muscle knots?

Whether or not muscle knots actually exit, massage therapy contributes to improving pain associated with this type of ache. However, it is not because of a chemical or mechanical dysregulation of the muscle tissue. It’s a result of changes in the nervous system and skillful touch by a massage therapist that contributes to soothing muscle tension in these areas.

But, what about using more force and performing a super deep tissue, painful massage in order to break up adhesions, scar tissue, and release muscle knots?

This concept is very similar to what is known as tissue provocation therapy, a type of healing technique that is based on how tissues become able to adapt to stress. According to this type of treatment, we can force adaptation in the affected tissue by applying stress.

For example, a Chinese massage technique called Gua sha uses hard tools to apply pressure and achieve maximum penetration to break up scar tissue, muscle adhesions, fascial restrictions, and other alleged musculoskeletal problems.

According to safety studies, this technique is associated with severe skin burns, dermatitis, and other nasty side effects.

Unfortunately, there is also no magical massager to break up scar tissue, no matter how fancy the tool looks.

So what do we make of the “muscle knots popping sound” that is heard when experiencing massage?

Muscle tendons can flip over bones as they move when massaged, and joints cavitate (pop) as when getting a chiropractic adjustment. While it isn’t always clear to answer the why do muscles pop during massage question, it’s certainly not something like “toxins being released”, as commonly stated by many massage therapists.

Provocation therapy is unnecessarily painful and has the same effects as a placebo therapy. This only shows how people look for exotic treatments with impressive claims to raise expectations, even more if they are painful and someone with authority claims it’s a necessary step for recovery.

Nope. Inducing pain is not required to achieve what really matters, which is a change in your nervous system that will contribute to relaxing your muscles, improving neuronal chemistry, and alleviating pain!

References:

Hall, H. (2010). The Graston Technique–Inducing Microtrauma with Instruments. sciencebasedmedicine. org. Retrieved, 01-09.

Cheatham, S. W., Lee, M., Cain, M., & Baker, R. (2016). The efficacy of instrument assisted soft tissue mobilization: a systematic review. The Journal of the Canadian Chiropractic Association, 60(3), 200.

Vashi, N. A., Patzelt, N., Wirya, S., Maymone, M. B., Zancanaro, P., & Kundu, R. V. (2018). Dermatoses caused by cultural practices: Therapeutic cultural practices. Journal of the American Academy of Dermatology, 79(1), 1-16.

Schleip, R. (2003). Fascial plasticity–a new neurobiological explanation: Part 1. Journal of Bodywork and movement therapies, 7(1), 11-19.

Hutson, M., & Ward, A. (Eds.). (2015). Oxford textbook of musculoskeletal medicine. Oxford University Press.

Is Aerobic Exercise Helpful For Chronic Pain?

Written by Sam Visnic on November 13, 2019. Posted in Movement and Exercise.

Exercise is often recommended for many different health conditions, especially those related to the cardiovascular system, but it’s certainly not the only area where it may be extremely valuable.

Living a sedentary lifestyle is a fairly significant risk factor for health issues, and it not only limited to stroke and heart disease.

Chronic pain is included in the list of reasons to recommend physical activity, and even though many people are apprehensive of being more active when they have pain, studies show that it works and improves symptoms both in the short and long-term.

There are two main forms of physical activity (aerobic and anaerobic), and each of them is associated with an improvement in chronic pain.

We’re going to focus on aerobic exercise (often referred to as “cardio”), and how pain mechanisms can be inhibited by this simple form of movement.

What happens when you do aerobic exercise?

During aerobic exercise, the most significant changes involve the respiration and cardiovascular systems. Your muscles play an essential part, and the stroke volume of your heart increases to make up for the increased requirement of oxygen and nutrients.

Thus, the function of your capillaries is enhanced, and the part of your cells that produces energy, called mitochondria, increases in both number and efficiency.

Additionally, there are many nervous system and hormonal adaptations that occur after aerobic exercise. These changes improve both strength and stamina, and have the ability to reduce insulin resistance and other metabolic problems.

Aerobic exercise can also play a role in improving flexibility, balance, coordination, and also positively impact muscle/postural asymmetry.

All of these improvements can be associated to various pain inhibitory mechanisms we’ll discuss below.

How does aerobic exercise inhibit pain?

The exact mechanism by which physical activity improves chronic pain symptoms is not entirely understood. Unfortunately the vast majority of clinical trials do not make a clear distinction between aerobic and anaerobic physical activity when examining the effects of exercise on pain perception.

Most of these studies are a combination of interventions, therapeutic recommendations, and patient education, which makes it even more difficult to set aside and evaluate the differences between aerobic and anaerobic exercise separately.

That said, it is still possible to make a distinction based on what we do know by looking at the short and long-term effects of aerobic exercise.

Short-term pain inhibition from aerobic exercise

Reduction of pain perception, called hypoalgesia, has been reported after physical activity in healthy individuals, people with chronic pain, and experimentally-induced pain.

There are two mechanisms involved in this short-term numbing effect: one of them is the release of endorphins, and the other is a modulation in the pain pathways in the central nervous system.

According to studies, after high-intensity aerobic exercise, there’s a hypoalgesic (numbing) effect lasting approximately 30 minutes. This effect is longer compared to resistance training exercise (anaerobic exercise), which lasts only a few minutes.

Studies seem to show that more exercise or a higher intensity is related to more hyperalgesia. The suggestion is that to generate a considerable effect we should engage in high-intensity physical activity for more than 10 minutes or moderate to high physical activity for 30 minutes or more.

Now of course you can imagine this wouldn’t work in a number of scenarios. For example some clinical trials have reported an INCREASED pain response instead of pain inhibition in cases of individuals with severe chronic pain.

People with fibromyalgia, for example, do not have immediate pain inhibition after physical activity, but of course they can still benefit from exercise in the long run.

Long-term pain inhibition from aerobic exercise

The long-term pain inhibitory effects of aerobic exercise are only reported in individuals that maintained a regular program of activity.

Long-term activity is known to modulate the endocannabinoid system (natural cannabis-like molecules produced by the human body), reduce the inflammation by improving circulation, and normalize transmission of glutamate in the brain and pyruvate in the muscle tissue.

By altering the release of inflammatory substances and improving circulation, it is possible to reduce swelling and other symptoms that may be associated with some chronic pain issues.

The endocannabinoid system in particular has a strong inhibitory effect that’s commonly targeted by pain medications. This system is also modulated by aerobic activity after releasing endorphins.

Additionally, glutamate and pyruvate are essential for sensory perception in the muscle tissue and its transmission in the central nervous system. Thus, by reducing these substances, physical activity may modulate pain perception in the long-run.

Psychological effect of exercise

We can’t talk about pain perception without including the psychological function. It is well established that depression, anxiety, and similar mental health problems have a negative impact on pain perception.

Individuals that engage in aerobic exercise usually report a significant improvement in mood and psychological symptoms, which may have a positive effect on the chronic pain experience. There are not, however, enough studies to evaluate these changes in a large amount of people suffering from chronic pain.

So, does aerobic exercise help?

In a nutshell, aerobic exercise is known to reduce pain perception immediately after exercise and in the long-run. However, for long-lasting results, it is necessary to engage in sustained activity, and most cases of chronic pain would also benefit from combining some aerobic exercise with anaerobic exercise.

By joining the strengthening nature of anaerobic exercise and the physiological changes mentioned in this article, it is possible to reduce pain symptoms and improve quality of life for chronic pain sufferers.

References:

Kawi, J., Lukkahatai, N., Inouye, J., Thomason, D., & Connelly, K. (2016). Effects of exercise on select biomarkers and associated outcomes in chronic pain conditions: systematic review. Biological research for nursing, 18(2), 147-159.

Naugle, K. M., Fillingim, R. B., & Riley III, J. L. (2012). A meta-analytic review of the hypoalgesic effects of exercise. The Journal of pain, 13(12), 1139-1150.

Nijs, J., Kosek, E., Van Oosterwijck, J., & Meeus, M. (2012). Dysfunctional endogenous analgesia during exercise in patients with chronic pain: to exercise or not to exercise?. Pain physician, 15(3S), ES205-ES213.

Bender, T., Nagy, G., Barna, I., Tefner, I., Kádas, É., & Géher, P. (2007). The effect of physical therapy on beta-endorphin levels. European journal of applied physiology, 100(4), 371-382.

Koltyn, K. F. (2002). Exercise-induced hypoalgesia and intensity of exercise. Sports medicine, 32(8), 477-487.

Sajedi, H., & Bas, M. (2016). The evaluation of the aerobic exercise effects on pain tolerance. Sport Science, 9, 7-11.

Naugle, K. M., & RILEY 3rd, J. L. (2014). Self-reported physical activity predicts pain inhibitory and facilitatory function. Medicine and science in sports and exercise, 46(3), 622.

Gerdle, B., Ernberg, M., Mannerkorpi, K., Larsson, B., Kosek, E., Christidis, N., & Ghafouri, B. (2016). Increased interstitial concentrations of glutamate and pyruvate in vastus lateralis of women with fibromyalgia syndrome are normalized after an exercise intervention–a case-control study. PloS one, 11(10), e0162010.

Ghafouri, N., Ghafouri, B., Fowler, C. J., Larsson, B., Turkina, M. V., Karlsson, L., & Gerdle, B. (2014). Effects of two different specific neck exercise interventions on palmitoylethanolamide and stearoylethanolamide concentrations in the interstitium of the trapezius muscle in women with chronic neck shoulder pain. Pain Medicine, 15(8), 1379-1389.

Your Sleep Issues May Be Making You Hurt

Written by Sam Visnic on November 10, 2019. Posted in Lifestyle.

Sleep is essential for life, and every organism with a nervous system requires this type of resting phase. Moreover, it is noted that other types of organisms without a brain do have a circadian rhythm as well.

This only highlights the importance of sleep in the physiology of living beings. It is further noticed that sleep deprivation is associated with a number of diseases, including mental health problems, an impairment in the immune system, and metabolic dysfunction including obesity and type 2 diabetes.

But what about chronic pain?

Is there any connection between sleep deprivation and chronic pain?

What relevant scientific findings can you apply in your day-to-day life to improve your symptoms of chronic pain?

Is there a link between pain and sleep deprivation?

The connection between chronic pain and sleep deprivation has been established for a long time. For instance, back in 1979, it was noted in a scientific study that rats who were subject to sleep deprivation had a significantly lower pain threshold, which means they are more susceptible to pain.

More recent studies in humans have confirmed the validity of these findings, and it has been found to be a risk factor to suffer recurrent migraine attacks. Similarly, the current evidence on the matter describes a higher pain perception in various settings, including fibromyalgia, joint dysfunction, and muscle soreness.

The majority of studies agree that not having enough sleep at night predisposes people to chronic pain, increases the severity of the symptoms, and the recurrence of the attacks because it is associated with hyperalgesic changes.

In other words, when you don’t sleep properly, your body starts feeling pain differently. This might be proven in different patients with different sources of pain, as discussed in the following section.

How sleep modulates pain in various settings

Besides clinical trials on migraine, there is plenty of supporting evidence to show a definite link between sleep fragmentation or deprivation and chronic pain. We can see the scientific evidence in various medical settings:

Arthritis and joint pain: According to a clinical trial published in 2016, sleep fragmentation induces an increased sensitization to joint pain. The study compared patients with knee arthritis with a healthy sleep pattern with others who did not sleep properly. After this comparison, the authors concluded that treating sleep is fundamental to improve chronic pain in patients with arthritis.
Fibromyalgia: This is a condition that features chronic pain, and it is often difficult to trace and diagnose. According to a survey performed in patients with this type of pain, insomnia was strongly associated with pain (not as a result of pain but as an aggravating factor).
Low back pain: It is a common problem, and most people have at least one episode throughout their lifetime. However, it was found that 53% of people with chronic symptoms of low back pain have sleep problems as compared to 3% of pain-free patients who reported insomnia.
Other musculoskeletal problems: One of the first associations between sleep deprivation and pain was around the issue of musculoskeletal symptoms. Sleep-deprived patients report an increase in muscle tenderness and more frequent musculoskeletal symptoms. Moreover, recent findings pointed out that the perception of musculoskeletal pain in these patients is increased by 24%.

All of this evidence points out that people who do not sleep properly have a higher sensitivity to pain. However, a learned individual may wonder if there’s a real organic change or is it only a subjective sensation.

In other words, is pain more severe or is the patient emotionally biased to feel more pain? According to the evidence published in the journal Psychosomatic Medicine, pain sensitivity is increased, it is possible to measure this organic change, and there’s no additional alteration in perceptions that may contribute to bias.

The most recent discoveries about pain and sleep deprivation

Even though there are many studies on the human brain, and the connection between sleep and chronic pain has been defined for so long, there were no studies on brain perception of pain during periods of sleep deprivation until recently.

In January 2019 it was discovered that healthy young people who do not sleep properly have higher activity in brain areas that trigger pain (the primary somatosensory cortex) and reduced activity in brain areas that coordinate movement and modulate our perception of pain (the insular cortex and the striatum).

After this study, we can trace the exact reason why sleep deprivation modulates pain. For some reason still to be explained by subsequent studies, not having proper or sufficient sleep increases the sensitivity of the sensory network, primarily focusing on neurons that trigger pain.

At the same time, the body becomes unable to modulate or mute pain sensation and perceives more sharply these sensory impulses. Moreover, the study found that even mild sleep deprivation affects pain perception.

These studies and medical knowledge have a suitable therapeutic potential in a hospital setting and highlights how important it is for patients suffering from chronic pain to have proper sleep at night.

Similarly, it should be a wakeup call for anyone who is continuously disrupting their sleep pattern and feeling any type of pain symptom the day after. Insomnia hurts, and there’s much we can do about it.

One of the most severe chronic pain diseases is fibromyalgia, and according to a clinical trial, applying a few sleep hygiene tips has been found to improve the symptoms in these patients.

Recommendations include sleeping every day at the same hour, not using the same room to sleep, eating and studying, turning off screens before going to sleep and avoiding coffee, alcohol, tobacco and heavy, greasy foods.

There are many ways to improve our quality of sleep and reduce our perception of chronic pain. What we have to do is raise our awareness of the importance of sleep and follow easy recommendations.

References:

Hicks, R. A., Coleman, D. D., Ferrante, F., Sahatjian, M., & Hawkins, J. (1979). Pain thresholds in rats during recovery from REM sleep deprivation. Perceptual and motor skills, 48(3), 687-690.

Alstadhaug, K., Salvesen, R., & Bekkelund, S. (2007). Insomnia and circadian variation of attacks in episodic migraine. Headache: The Journal of Head and Face Pain, 47(8), 1184-1188.

Orlandi, A. C., Ventura, C., Gallinaro, A. L., Costa, R. A., & Lage, L. V. (2012). Improvement in pain, fatigue, and subjective sleep quality through sleep hygiene tips in patients with fibromyalgia. Revista brasileira de reumatologia, 52(5), 672-678.

Burton, E., Campbell, C., Robinson, M., Bounds, S., Buenaver, L., & Smith, M. (2016). Sleep mediates the relationship between central sensitization and clinical pain. The Journal of Pain, 17(4), S56.Tang, N. K., Wright, K. J., & Salkovskis, P. M. (2007). Prevalence and correlates of clinical insomnia co‐occurring with chronic back pain. Journal of sleep research, 16(1), 85-95.

Jansson, C., Mittendorfer-Rutz, E., & Alexanderson, K. (2012). Sickness absence because of musculoskeletal diagnoses and risk of all-cause and cause-specific mortality: a nationwide Swedish cohort study. PAIN®, 153(5), 998-1005.

Moldofsky, H., & Scarisbrick, P. (1976). Induction of neurasthenic musculoskeletal pain syndrome by selective sleep stage deprivation. Psychosomatic medicine.

Lentz, M. J., Landis, C. A., Rothermel, J. S. H. A. V. E. R. J. L., & Shaver, J. L. (1999). Effects of selective slow wave sleep disruption on musculoskeletal pain and fatigue in middle aged women. The Journal of rheumatology, 26(7), 1586-1592.

Caffeine and Chronic Pain: Are They Linked?

Written by Sam Visnic on November 7, 2019. Posted in Nutrition.

Caffeine has been a staple in the human diet for generations, and its social and cultural significance far exceeds that of most other psychoactive substances.

Avid consumers of caffeine report that it keeps them alert, active, and improves their outlook. This, and the fact that caffeine is legal and widely available, makes it into the world’s most widely used drug.

For many individuals, caffeine is part of the daily diet, and in some cases, its consumption may become excessive. For this reason, we need to be aware of the effects of caffeine, and how it may impact people with chronic pain.

How do you take your caffeine?

Caffeine is included in a variety of beverages and foods, but by far the most commonly consumed is coffee, followed closely by sodas, teas, and energy drinks.

What does caffeine DO to the body?

Caffeine exerts various effects on the human body, primarily enhancing alertness and prolonging attention, and it does this through direct stimulation of the central nervous system. This is why a cup of coffee can make it much easier to focus on tasks that are often boring!

The stimulant action of caffeine occurs due to its action as an adenosine antagonist and adenosine receptor agonist. Through this action, it plays a role in the regulation of brain activity as well as the states of wakefulness and sleep.

This has caused many scientists to become interested in the many ways in which caffeine consumption may affect human health. The subject is highly controversial, especially with regard to the relationship that exists between caffeine and chronic pain.

Caffeine is added to pain medications?

Because of all its reported health benefits, caffeine has been added to a variety of drugs over the years.

The primary formulations being aspirin, acetaminophen, and other non-steroidal anti-inflammatory drugs (ibuprofen). Caffeine was likely originally added in order to offset the latent sedative effects of some of these drugs.

However, many now view caffeine as a substance that accelerates, prolongs, or enhances the analgesic effects of these pain relief medications.

How much caffeine is too much?

Before we get into the murky waters of discussing caffeine’s interaction with pain, we need to address the issue of how much caffeine is considered normal vs. excessive.

Due to the rapid and demanding pace of modern life, caffeine consumption is increasing around the world. People of all ages are studying or working more and sleeping less, and caffeine presents an effective alternative to combat the effects of fatigue and exhaustion. Many individuals are actually unaware of the amount of caffeine they consume on a daily basis and often fall into overconsumption.

Given that the Wold Health Organization recognizes caffeine dependence as a clinical disorder, it’s an important question to ask, how much is too much?

For the most part, caffeine’s characteristics make it a substance whose use has a high safety margin. Caffeine absorption after oral administration is rapid and thorough. It is distributed in most body tissues and crosses the blood-brain barrier very easily, which explains its potent stimulant effects.

Most of the world’s health agencies recognize that low to moderate doses of caffeine present with no complications on health.

It is important to note that if consumption of caffeine is done in a self-administered manner (without medical prescription), it is recommended to not exceed a daily dose of 400 mg. To put that into perspective, consider that a 16 oz. cup of Starbucks Blonde roast packs about 360 mg!

Considering how widely available coffee shops are and the social aspects of consuming coffee with co-workers, friends, and family, it’s easy to see how consuming over the recommended daily ceiling of 400 mg is possible.

Excessive caffeine intake and chronic pain

The relationship between caffeine and pain lies a bit on the complicated side and deserves more scrutiny.

Case in point, habitual excessive caffeine consumption has been repeatedly associated with the appearance of headaches. It may also interfere with the analgesic action of some pain-blocking agents, according to recent studies.

Excessive caffeine intake can have the following effects:

It may decrease the pain threshold and increase susceptibility to pain by activating the stress response.
It may cause muscle spasms, muscle twitching, and muscle tension, all of which are clinically significant components in individuals with chronic pain.
It can generate physical dependence, which can manifest as a withdrawal syndrome if intake is abruptly stopped.
Additionally, there is a psychological component that needs to be addressed. Caffeine in excess can increase anxiety in even healthy individuals. Since people dealing with chronic pain are often already experiencing increased levels of anxiety, stress, and anger, caffeine may very well increase pain by increasing the person’s susceptibility and awareness of it.

The chronic effects of caffeine intake are based on an up-regulation of certain types of receptors (adenosine) as well as their hypersensitivity. Thus, caffeine has the ability to make chronic pain worse. For some individuals, too much caffeine (or any at all for some people) may be a recipe for disaster.

The caffeine and headache connection

Of particular note is the relationship between caffeine intake and the development of medication overuse headaches.

Headaches caused by the excessive use of pain relievers is a type of chronic headache, which occurs in susceptible individuals. It’s considered a serious condition and now stands as the third most common type of chronic headaches around the world.

Therefore, when caffeine is consumed excessively for ongoing periods of time, it may very well induce distinct neurological changes that increase cortical hyperexcitability and promote the rapid release of certain neuropeptides, which can trigger or exacerbate the chronicity of pain.

Caffeine, sleep and chronic pain

The majority of studies agree that not having enough sleep or having poor quality of sleep predisposes people to chronic pain, increases the severity of the symptoms, and the recurrence of the attacks because it is associated with hyperalgesic changes. In other words, when you don’t sleep properly, your body starts feeling pain differently.

It’s well known that excess caffeine intake, or consuming it too late in the day can negatively impact one’s ability to get to sleep. This reduces total sleep time, thus increasing the likelihood of creating more problems with pain sensitivity.

The verdict:

Caffeine has both pluses and minuses, and as with most things, it’s not absolutely good or bad, but needs to be evaluated in the case of the individual.

When caffeine is consumed in the form of coffee in particular, there are many additional potential benefits which need to be considered as well. Maybe some decaf instead of full strength!

References:

Sawynok, J. (2011). Caffeine and pain. Pain, 152(4), 726-729.

McPartland, J. M., & Mitchell, J. A. (1997). Caffeine and chronic back pain. Archives of physical medicine and rehabilitation, 78(1), 61-63.

Pectoral Muscle Strength Technique: Top 6 Pec Stretch Release Techniques

Written by Sam Visnic on March 5, 2019. Posted in Massage Therapy, Muscles, Pectorals, Stretching.

Power and flexibility often go hand in hand.

To maximize pectoral muscle strength techniques, it’s important to have the right level of mobility. Not only will this help you perfect new techniques, but it’s also going to help stave off injuries.

When it comes to strengthening the pectorals, these six pec stretch release techniques can unlock even more potential.

What Is Pectoral Muscle Release?

The pectoral muscle group consists of 2 muscles: the pec major and the pec minor.

These muscles can often become tight, leading to excessively rounded shoulders, shoulder or neck pain, and breathing imbalance. Pec stretch release techniques can help alleviate these pains, restoring greater mobility and allowing the patient to focus on their pectoral muscle strength technique.

As well as helping with shoulder and neck problems, the pec stretch release techniques shown below can be effective for improving many issues.

When Might You Need Pectoral Muscle Release (Pec Major and Pec Minor):

Your pecs are important muscles in your body, so it’s important to maintain flexibility in this area, particularly if you’re working on pectoral muscle strength techniques.

However, there are some tell-tale signs that you might need pectoral muscle release:

Shoulder pain
Rounded shoulders
Neck pain
Referred pain down the arms
Imbalanced breathing or rib cage patterns

Movement is an important part of recovery, and in these cases, the right pec stretches can help alleviate pain and return mobility to the affected area.

Pec Muscle Release – Massage Therapy

The pectoralis major is the most superficial and easy to access chest muscle. It starts at the sternum and inserts into the upper arm. There are a variety of glides that can be used as demonstrated in the video, and even simple compression of the muscle can be used to assist with reducing tender areas.

The pectoralis minor, however, is a bit more challenging to access because it lies underneath the larger pec fibers. It needs to be treated from the side, or side-lying position.

With treatment from an experienced professional and the right stretching routine, it is possible to release the pectorals, allowing people to get back to the workouts they love.

6 Pec Stretch Release Techniques

Stretching out the pecs is an important part of working on your pectoral muscle strength technique. The more mobility you have in this area, the better quality workouts you can do, leading to more effective and healthy muscle growth.

Pec Major Stretch – Standing Wall Stretch

One of the easiest and most familiar ways to get a pectoralis major stretch is with a doorway stretch. Place your arm so that your elbow is slightly higher than your shoulder and step forward a bit while simultaneously turning your body away from the arm.

One thing to note, if the anterior shoulder capsule is sensitive for any number of reasons (underlying shoulder pathology) you may feel discomfort instead of the intended effect which is to stretch pectoralis major. In this case you may need to opt for a self-massage style technique, or seek additional help to address the shoulder issue prior to doing these stretches.

Pec Stretch – Swiss Ball Stretch

The swiss ball pectoral stretch is a good alternative to the doorway stretch, especially if you have a hard time getting a good stretch.

Make sure you use a ball that is large enough, and that you allow your shoulder blades to move toward each other to simulate stepping forward through the doorway as discussed in the previous stretch.

Pec Muscle Release – Post Isometric Relaxation

Post-isometric relaxation works well for the pectoral muscles.

This is accomplished by moving toward the end of a massage table (or bench) and allow your arm to hang as if you were doing a stretch with gravity assistance. If you are doing this by yourself, lift up your arm (using your chest muscles) just enough to activate the muscle.

Hold for 8-10 seconds, take a deep breathe in, and exhale as you attempt to relax further into the stretch. Hold for 10 seconds, then repeat 2-3 more times or until no additional range of motion is achieved.

Pec Minor Release – Massage Therapy

Massage therapy works very well for the pec minor muscle.

Correct positioning as well and low-moderate pressure is ideal for addressing this muscle. You don’t need to push too hard! In addition, it’s important to be cautious of nerves in the area of the pec minor.

Pec Major/Minor Muscle Release – Self Massage w Ball

Self-massage for the pectoral muscles is possible with the use of a tennis or lacrosse ball. Place the ball into the desired area and lean into a wall or doorway.

You may wish to move your arm slightly back behind your body to lengthen the pectorals as you compress the tissues with the ball. You can move your body to scroll through the tissues, and isolate any areas that are particularly tender. It is fairly common to find pectoralis major trigger points that refer to the shoulder and often down the arm. 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.

Conclusion

Stretching should be an essential part of your pectoral muscle strength technique. If you’re suffering from pain in your neck and shoulders, then it’s going to hold back your workout, and it could be due to your pectorals.

With the right treatment, and some pec release techniques, you can alleviate pain and make your workouts even more effective.

Mobility is key and pectoral muscle release could be exactly what you need.

Is A Short-Leg Contributing To Your Sacroiliac Joint Pain?

Written by Sam Visnic on September 28, 2018. Posted in Mobility, SI Joint.

A very important factor to rule out in chronic SI joint pain is that of a leg length discrepancy.

When the legs are not equal length, it can make the sacral base un-level, thus contributing to stress and strain at the sacroiliac joints and lower lumbar spine.

There are 2 different types of leg length issues that you should know about:

Leg Length Discrepancy Erik Dalton

1. Anatomical Leg Length Discrepancy

This refers to when one leg is actually shorter than the other. This can be a result of injury to the joints/bones, or what you were just born with. The truth is that this type of leg length issue is very rare!

RMT-Weight-Shift

2. Functional Leg Length Discrepancy

This type is usually caused by muscle and joint imbalances, which upon correction, the leg length is restored. This is the MOST common type of leg length issue seen.

How To Test For The Two Types Of Leg Length Discrepancies

In this video, John Gibbons explains a simple test that can be used to assess leg length variation.

If a true anatomical leg length discrepancy is suspected, a full length X-ray may need to be performed to confirm.

How To Fix Functional Leg Length Discrepancy

Since functional leg length findings are associated to muscle and joint issues, they must be addressed by resolving these imbalances.

For instance, excess anterior pelvic tilt is a VERY common finding in SI joint-based imbalances and leg length discrepancy.

In the video above, I talk about the most common causes for excess anterior pelvic tilt, which include short/tight hip flexor and lower back muscles, and long/weak hip extensors and abdominals.

5 Special Tests To Uncover SI Joint Dysfunction

Written by Sam Visnic on September 26, 2018. Posted in Mobility, SI Joint.

As you can imagine, much controversy surrounds manual testing for dysfunction of small joints that move as little as 2 mm. Many clinicians believe the following manual tests produce non reliable evidence of SI joint involvement in pain, but presently there are few other options.

Medically, the customary procedure for SI joint diagnosis is joint blocks via injection, but these as well have difficulty standing up to criticisms. Clearly more research needs to be devoted to the accurate diagnosis of SI joint pain.

The above, however, does not necessarily mean these tests are not clinically useful. They can provide valuable information, particularly when they are able to reproduce symptoms, and of course be used to follow up and assess changes after therapeutic interventions. Since these tests are relatively safe and easy to perform, they can be used to gather clues.

The following tests are the most customary ones, and I will not delve into more complex testing in this post, as that is better suited to a clinician’s textbook, but you should also be sure to check out my other blog post: Is A Short Leg Contributing To Your Sacroiliac Joint Pain

#1 Gaeslen’s Sign

#2 FABER Test

#3 ASIS Distraction

#4 Side-Lying Sacral Compression

#5 Femoral Shear Test

In Summary:

It is suggested by some therapists that at least 3 out of the 5 tests above must be positive to indicate SI joint involvement, and that if all 5 tests are negative, move on to testing other areas as possible pain generators.

Physical therapist Stuart Fife, reports dismal numbers with regard to reliability and accuracy of manual testing methods, and Richard DonTigny asserts that often the correction validates the diagnosis.

Based on this information, it appears that all tests may give clues, and instead of any one given test, multiple tests should be performed to accurately test for SI joint involvement in pain, and which corrective measures should be carried out for resolution.

Sacroiliac Joint Belts – Do They Work?

Written by Sam Visnic on September 25, 2018. Posted in Mobility, SI Joint.

Sacroiliac joint belts can be a helpful tool in the process of pain relief and restoration of function. Belts have been found in studies to reduce laxity of the sacroiliac joints and improve stability.

The SI belt essentially serves a sort of artificial locking function to compress the surfaces of the joints together, which increases friction and reduces shearing forces.

Do These Belts REALLY Work?

In short, YES! In the video I state that the biggest issue is whether you actually HAVE pain coming from the sacroiliac joints or not. Attaining an accurate diagnosis of pain from the SI joints isn’t that easy, simply because there isn’t an established “gold-standard” test.

Some people get significant and immediate reduction in pain once the sacroiliac joint belt is properly used, while others only have a minor reduction in pain, but often times there is some improvement in mobility or strength in the pelvic muscles. These are positive signs that you may benefit from the belt.

Is there a simple test to find out if the belt COULD work for YOU?

Yep! In the video above, I show a test that can be performed while lying on your back. Since the belt’s job is to compress the pelvis, we can mimic this action with a set of hands. Definitely ask someone to do this for you, which will be a much better test than attempting it on yourself.

Lay with your legs straight out. Lift your leg up from the floor in a controlled speed while assessing how it feels, both in terms of muscle strength, coordination, and pain levels. Test the other side as well.

Next, ask someone to gently compress your pelvic bones inward, toward your midline, and hold while you repeat lifting your legs. If there is improvement, then you will likely benefit from wearing the si belt.

Does it matter if you put the belt on standing vs. sitting vs. lying down?

Yes. I recommend only putting on sacroiliac joint belts while lying on your back, AFTER doing your corrective mobilizations. This way it functions as an SI brace to “lock in your work”.

SI Belt – How To Wear

There are a few things to know when wearing an SI belt. The video I created for Youtube has received tens of thousands of views and the comments clearly show that most people were not applying the belt correctly.

If you follow the steps I outline, you’ll get the most out of the belt and get results if indeed the belt is what you really need.

How tight does the belt need to be?

Its important to understand that the emphasis should be placed on the position of the belt, NOT how tight it is. One study in particular showed that a belt with a tension of 100 N did not significantly differ from one at 50 N in terms of reducing sacroiliac motion.

More is NOT better in this case!

Which belt is the best?

Sacroiliac joint belts all do the same thing so its really a matter of comfort, since most people who benefit from it will wear it often. Nothing is worse than having to deal with a poorly designed belt that is constantly riding upward when you sit or move.

I personally like Serola. Now, I don’t have SI joint pain, so I can’t comment, but many of my clients like this belt.

Does relying on an SI belt make your own muscles weak?

No. Using a sacroiliac joint belt is not the same type of thing as a lumbar spine brace. SI joint instability is a ligamentous/joint problem. Since there are no muscles that directly move those joints, wearing the belt will not weaken anything. You can wear it 24/7 if you want.

That said, it does NOT mean you shouldn’t address the muscles that support the pelvis. In fact, this is the CRITICAL element. Without adequate muscle balance, strength, endurance, and coordination of the core muscles, you are very likely to have ongoing setbacks in your corrective process.

How long should you wear a sacroiliac belt?

There are two aspects of this question. First, you “can” wear a SI joint stabilization belt pretty much throughout the day.

The factors that should be considered include the stress on skin (chafing), and altering your ability to move freely due to any misplacement of the belt. If you wear it properly and not too tight, you should be able to wear it comfortably for longer stretches of time.

The second aspect is how long over time should you commit to using a SI joint belt? This is going to depend on the primary reasoning for wearing it (damage to sacroiliac ligaments, short term pregnancy or post pregnancy, etc).

Generally speaking, the goal ultimately is to not needing the belt and relying on your on musculoskeletal stability improved functioning. So, you should work closely with your therapist for a plan for easing away from it.

This could take as little as a week, to months, again, all depending on the initial reasoning why you’re wearing it.

SI joint pain belts are really a relatively short-term crutch. They aren’t the “main show”!

How To Know If Your SI Joints Are Causing Your Pain

Written by Sam Visnic on September 12, 2018. Posted in Mobility, SI Joint.

Not too long ago, the sacroiliac joints (SIJ) were considered a primary source of lower back pain, and in particular, sciatica, however, once it was found there was no “canal that held the nerves against the joint”, the emphasis was shifted to disc herniations.

While the debate rages on, much like with spinal discs, can the sacroiliac joints be a cause of lower back pain? Well, as of recently, research is showing much more about how the SI joints can be a part of the overall pain picture.

Lets start by getting acquainted with the SI joints and how they may be cause of pain, and of course, how to address it.

What ARE The Sacroiliac Joints?

The SI joints are a part of what is referred to as the “pelvic girdle”. The main function of the pelvic girdle is to link the upper body and the lower body for movement. The pelvic girdle is made up of 3 bones and 3 joints (2 of which are the SI joints).

The bony plate at the bottom of the spine is called the sacrum, and the 2 large hip bones that are found on the left and right sides of the sacrum are called the ilia (ilium is singular). The joints at which the hip bones attach to the sacrum are the sacro-iliac joints. In the front of the pelvis, the 2 ilia are joined together by what we call the pubic joint.

The pubic joint is connected by very strong ligaments, and have opposing surfaces that keep it quite limited with regard to range of motion, but can be effected by the influence of the muscles that attach in the area, as well as hormonal changes.

The sacroiliac joints are unique in that cartilage on the sacral side is hyaline cartilage and the cartilage on the ilial side is fibrocartilage. The SI joints are L-shaped with regards to their contour, and its interesting to note that the shape of these joints vary quite dramatically from person to person, and according to Philip Greenman, DO, from side to side in the SAME person!

These joints appear to have the greatest amount of motion from age 25 to 45 (Greenman), which is very interesting, especially considering this is the age range in which back pain appears the highest, and additionally, when disc pathology is greatest.

Additionally, as both genders age, gradual changes such as fibrous adhesions and even ossification often occur, which obliterate these joints. (Grays Anatomy, Pg. 675, 1995).

2 Types of SI Joint Stability: Form and Force Closure

Generally, it is agreed there are two major stabilization systems for the SI joints, called force and form closure.

Form closure refers to the stability of the SI joints via the shape of the surfaces of the ilia on the sacrum. These surfaces are a combination of concave and convex. Force closure refers to the functioning of “slings” of muscles as well as the ligamentous support.

One such sling involves the glute maximus and opposite side latissmus dorsi as they merge into a super thick diamond-shaped area of connective tissue in the lower back called the thoraco-lumbar fascia.

How Do The SI Joints Cause Pain?

Frequently, SI joint dysfunction is overlooked and misdiagnosed, mostly due to the multiple effects that are seen as a result that make the overall situation appear to be multi-factorial and complicated. SI joint expert, physical therapist Richard DonTigny, has identified the following:

1. The glute medius is inhibited when held in anterior rotation
2. The ilial orgin of the gluteus maximus is separated from its sacral origin
3. The iliolumbar ligaments are loosened as the ilia approximate the vertebra
4. The long posterior ligaments will be stretched and may avulse from the PSIS
5. The ilial origin of the piriformis is separated from its sacral origin 6. If the sciatic nerve exits through the piriformis it may become painful

Yes, this is quite the complicated list! At first when the SI joint dysfunction appears, these may not all be present, but as the problem becomes chronic, some or all of them may appear and make it very difficult for the average doctor or therapist to see through to the root cause of the pain.

Depending on who the pain sufferer is seeing, and their specialty, normally accounts for what they will focus on correcting. This usually leads to failure, because only the symptoms are being addressed. At the root cause of course, is the mechanical dysfunction of the small SI joints!

How Does Sacroiliac Joint Pain Usually Show Up?

As you can see from the image, the most obvious and common area of pain related to SI joint problems is right next to the small bones that can be felt just to the sides of the lower spinal vertebrae called the posterior superior iliac spines. (PSIS for short).

Although the picture shows a relatively small region of common pain, pain patterns associated to SI joint dysfunction are highly variable due to the complex nature of nerve innervation to the joint.

The SI joints do not commonly refer pain to the lumbar spine, but that does not mean they are not frequently involved with problems in the lumbar region. It is important to keep in mind the relationship of sacroiliac joint dysfunction to disc pathology.

Disc pathology may be exacerbated by side bending and/or rotation, therefore, when the SI joints are not balanced, they will contribute to stress on vulnerable discs. It is also possible that SI joint dysfunction may actually be a factor in causing disc bulging.