Stretching the good, the bad and the ugly

Many practitioners (myself included once upon a time) still give out static stretches to all patients without considering the impacts of different types of stretching. Static stretching is best described as holding a specific position with the muscle on tension to a point of a stretching sensation and repeated. Typically static stretching exercises have traditionally formed an integral part of the warm-up  and it has been suggested that static stretching before activity promotes improvements in performance ), and increases range of motion. This was and still is considered to be true. However, studies are now challenging the value of the conventional static stretching warm-up and its ability to improve physical performance. In fact some studies suggest the opposite that static stretching reduces performance ! Oh dear not great advice then !

In fact static stretching may inhibit performance by reducing force production, balance, reaction time, sprint times, and power output.

Another gem often said is that static stretching reduces injuries. Current research implies that that stretching before exercise does not reduce the risk of injury (here is the article) http://www.ncbi.nlm.nih.gov/pubmed/10593217

Another common belief is that static stretching elongates the muscles again studies suggest that rather, the subject may simply have an increased tolerance to stretching (ability to withstand more stretching force).

As a result from this evidence an alternative to static stretching is that dynamic stretching be performed in a warm-up prior to activities.

The benefit of dynamic stretching incorporates whole body movements and involves actively and rhythmically contracting a muscle group

through part of its functional ROM . This acts to elevate core body temperature, enhance motor unit excitability, improve kinaesthetic awareness, and maximize active ROMs . Dynamic stretching may include skipping, hopping, jumping, and rotation motions of the extremities, such as arm and leg swings (10,11,22). A proposed physiological rationale for replacing static stretching with dynamic stretching in a preperformance warm-up lies in mechanical (viscoelastic) and neuromuscular tissues changes.

In contrast to static stretching, dynamic stretching is not associated with strength

or performance deficits, and actually has been shown to improve dynamometer-measured power.

So before activity dynamic stretches

After activity static stretches held for between 15 to 30 seconds

Why is my pain so bad ?

Clifford J Woolf  us considered to be one of the most respected experts on pain hypersensitivity and below is some of his current research and conclusion. Its an important topic for both practitioners and patients to understand as the amount of pain someone may be in may not be relative to tissue damage. This was again highlighted to be where by a colleague was treating a patient in their early 20 suffering from pain in their low back. He was convinced that something was wrong and went for MRI scan of the lumbar spine. The test results from the scan were normal leaving the patient confused as to what was wrong. Sometimes explaining the pain hypersensitivity model is useful to explain to patients as it helps explains the mechanisms underlying their suffering which can be reassuring for patients.

Pain systems need to be sensitive enough to detect potentially harmful stimuli. But often they become too sensitive, causing us pain that provides no benefit. This hypersensitivity arises because our pain pathways actually increase in sensitivity when they relay pain messages, and the mechanisms of this sensitization are beginning to be revealed.

Normally, pain is produced only by intense stimuli that are potentially or actually damaging to tissue (technically known as noxious stimuli, although commonly referred to as pain stimuli). This pain is mediated by a specific system of high-threshold peripheral and central neurons designed to respond only to such noxious stimuli (the nociceptive system, also see Sensing damage), which is responsible for the 'ouch' pain we experience in response to a needle prick or on touching a hot surface.

Nociceptive pain is an essential early warning device that helps protect us from the dangerous environment we find ourselves in. To do this the sensation of pain needs to be so unpleasant that we cannot ignore it.

Clinical pain, by contrast, occurs in response to tissue injury and inflammation (inflammatory pain), damage to the nervous system (neuropathic pain) and alterations in the normal function of the nervous system (functional pain). It features both spontaneous pain that arises without any apparent peripheral stimulus and hypersensitivity to peripheral stimuli.

Pain hypersensitivity takes two forms:

    thresholds are lowered so that stimuli that would normally not produce pain now begin to (allodynia).

    responsiveness is increased, so that noxious stimuli produce an exaggerated and prolonged pain (hyperalgesia).

Pain hypersensitivity after an injury helps healing by ensuring that contact with the injured tissue is minimized until repair is complete – an adaptive response. However, pain hypersensitivity may persist long after an injury has healed or occur in the absence of any injury. In this case, pain provides us with no benefits, and is a manifestation of pathological change in the nervous system.





One way of reversing this is to use electroacupuncture which by sending small currents across the overstimulated area helps to restore the normal pain response.

Can Acupuncture help De Quervain's tenosynovitis

 De Quervain's tenosynovitis is a painful condition affecting the tendons on the thumb side of your wrist. If you have de Quervain's tenosynovitis, it will probably hurt every time you turn your wrist, grasp anything or make a fist.

Although the exact cause of de Quervain's tenosynovitis isn't known, any activity that relies on repetitive hand or wrist movement can make it worse. Its usually worse in females and quite often I see females who have just had a baby. Maybe its the repitive action of holding the baby combined with some ligament laxity that creates instability within the tendons. Other susceptible groups are musicians, assembly workers, golfers, machinists and more recently, video game players and people who overuse smartphones.

The test to help you decide if you quervains is the catchy name of the Finkelstein test. In a Finkelstein test, you bend your thumb across the palm of your hand and bend your fingers down over your thumb. Then you bend your wrist toward your little finger. If this causes pain on the thumb side of your wrist, you likely have de Quervain's tenosynovitis.

• Immobilizing your thumb and wrist, keeping them straight with a splint or brace to help rest your tendons
• Avoiding repetitive thumb movements whenever possible
• Avoiding pinching with your thumb when moving your wrist from side to side
• Applying ice to the affected area

In addition to the above acupuncture works as a useful adjunct.

Acupuncture may reduce muscle shortening which is causing tension in the tendons and their terminal insertions. Acupuncture may facilitate blood flow to the tendon locally and at a distance, through the release of several neuropeptides. My own experience is that by using acupuncture along with the advice above that the condition improves with a reduction in pain. Thus is of course only my experience and needs to subjected to a large clinical trail to confirm my experience.

Dr Stuart McGill reveals all about low back pain

What is the right way to strengthen your core?
Who gets low back pain ?
Whats the correct way to do pilates?

Dr Stuart McGill tells it how it is

Dr Mike Evans explaining low back pain - could acupuncture help ?

Here is another great video from Dr Mike Evans on the diagnosis and cause of low back pain. Currently, the National Institute for Health and Clinical Excellence (NICE) recommends acupuncture as a treatment option for lower back pain. NICE makes this recommendation on the basis of scientific evidence.

Acupuncture for back and pelvic pain during pregnancy

A Cochrane Database systematic review has concluded that current evidence supports acupuncture as a treatment for pelvic and back pain in pregnancy. The authors included 26 randomised trials examining 4093 pregnant women in their review. Moderate-quality evidence suggested that both acupuncture and exercise tailored to the stage of pregnancy can significantly reduce evening pelvic pain and lumbo-pelvic pain compared to usual care alone. In addition acupuncture was found to be significantly more effective than exercise for reducing evening pelvic pain, and was also more effective than physiotherapy at relieving evening lumbo-pelvic pain and disability and improving pain and function, although the effects were small. (Interventions for preventing and treating pelvic and back pain in pregnancy. Cochrane Database Syst Rev. 2013 Aug 1;8:CD001139).

Muscle energy techniques for Whiplash, neck pain and forward head posture

Neck pain is a common problem within our society. Upper trapezius and the levator scapulae are the most common postural muscles that tend to shorten leading to restricted neck mobility. Muscle energy techniques are believed to be particularly helpful in lengthening postural muscles, which are prone to shortening. Muscle energy techniques aim to

• To strengthen muscles
• To relax muscles, especially useful for treating cramping muscles
• To help regain correct muscle function
• To reduce localized oedema

Below is a video of John Gibbons treating a short neck muscle (the sternocleidomastoid) whom I have trained with and learnt this technique. Muscle energy techniques are a safe, effective and gentle way of reducing pain and restoring mobility to anyone suffering from neck pain.