What’s the Scoop on Cupping?

My first exposure to cupping was seeing the perfectly circular bruises on Michel Phelp’s during the 2016 Summer Olympics. Since then, I have come across it many times in the University of Delaware athletic training room seeing athletes performing exercises with cups suctioned to their back. I have even tried it myself a couple of times to see what the hype was about and if I felt a difference using this type of recovery method. 

Figure 1. Michael Phelps swimming with visible cupping markers (bruises) on his shoulders. 

Now if you haven’t heard about cupping you may be wondering: what is cupping? Cupping is the application of plastic, glass, bamboo, or ceramics cups [1] to the skin via suction. The suction can either be created naturally by heating up the inside of the cup using a flame and allowing it to cool on the skin creating negative pressure and lifting/stretching the skin up. The other way to get this pressure is to use a suction device.[1] There are also two types of cupping, similar to needling; there are both wet and dry methods. Dry cupping is exactly the procedure I described above while wet cupping is when small cuts are made on the skin before the cup is applied and blood is drawn out. [1] The original idea behind this technique was that it was regulating Qi in the body. More recently, people claim that it promotes blood flow and therefore has a positive effect on the healing process, reducing soreness and pain. There are still many who find cupping bizarre and disgusting due to the often dark bruising and the odd look of the skin suctioned into cups. In particular, a Forbes article by Steven Salzberg goes as describes it as “someone giving you a massive hickey, and then doing another dozen or so all over your back, or legs, or wherever ” [2]. So by now, you should have a pretty clear image that while there are many advocates and cupping has been gaining interest (especially if professional athletes on the world stage have used it), there are still many skeptics and people who say it is harmful. Let’s see exactly what the research says about cupping. Is it beneficial? Harmful?

 

An article published in The Journal of Alternative and Complementary Medicine by a group of Australian and German researchers performed a systematic meta-analysis of clinical trials evaluating the effects of cupping on athletes. [3] They found 11 valid (according to their criteria) trials with a combined total of 498 participants from China, the United States, Greece, Iran, and the United Arab Emirates. Participants received cupping 1 to 20 times in daily or weekly intervals either alone or in combination with another procedure, like acupuncture.[3] The study found no conclusive results however. Even though there were improvements to the participant’s perception of pain, an increased range of motion, and lower levels of creatine kinase, there were large variations between symptom intensity and recovery measures, and other metrics.[3] There are also some limitations to this study. One of the main concerns is the reliability of the data. The researchers report an unclear or high risk of bias in many of the trials and they also mention that none of the trials reported safety. 

 

Another study published in 2016 in the Journal of Novel Physiotherapies evaluated the effects of various soft tissue mobilization techniques, including cupping, on active myofascial trigger-points in 20 amateur soccer players.[4] Athletes received cupping once a week for three weeks. They found that all techniques used, including cupping, improved pain pressure threshold and pain sensitivity significantly. [4] The researchers concluded that more research must be done to fully be able to draw a conclusion. Some limitations of the study were the small sample size (n = 20) and that the study was limited to only amateur soccer players. Other studies, including the previously mentioned study viewed multiple different sports instead of one. This also provided a much larger sample size compared to this study.  

 

Overall, there appears to be no definite answer, at least at this time, on if cupping helps promote healing and reduce pain and muscle soreness. For some, it appears to be beneficial in relieving pain but due to a limited number of studies and the questionable accuracy of others, there is no conclusive data for or against cupping. As the first-mentioned study by Bridgett et. al stated, “ No explicit recommendation for or against the use of cupping for athletes can be made. More studies are necessary for conclusive judgment on the efficacy and safety of cupping in athletes.” [3].

 

 

References:

[1] NCCIH. “Cupping.” November 2018. Retrieved from: https://www.nccih.nih.gov/health/cupping

[2] Steven Salzberg. “ The Ridiculous and Possibly Harmful Practice of Cupping”.  May 2019. Retrieved from: https://www.forbes.com/sites/stevensalzberg/2019/05/13/the-ridiculous-and-possibly-harmful-practice-of-cupping/#57ce2d2331f3

[3] Rhianna Bridgett, Petra Klose, Rob Duffield, Suni Mydock, and Romy Lauche.The Journal of Alternative and Complementary Medicine.Mar 2018. 208-219.http://doi.org/10.1089/acm.2017.0191

[4] Fousekis, Konstantinos et al. “The Effectiveness of Instrument-assisted Soft Tissue Mobilization Technique(Ergoné Technique), Cupping and Ischaemic Pressure Techniques in the Treatment of Amateur AthletesàMyofascial Trigger Points.” (2016).

 

Questions to Consider:

  1. Have you ever gotten cupping done? If yes, what are your thoughts? Did you find it beneficial? If no, was there a reason why?
  2. How do you think studies looking at cupping should compare its effects for the most accurate evaluation? Should they compare across different sports because the benefits should not be sport dependent or within one sport to get a better comparison?

To Stretch or Not To Stretch

Stretching is regularly included in exercise regimes by athletic trainers and coaches and is often recommended to novice athletes. The chronic effects of stretching result from consistent practice and are thought to be a preventative measure to reduce risk of injury by increasing flexibility to increase overall range of motion. [1] This increased range of motion is thought to increase overall performance. However, those against stretching argue the long-term effects could lower performance by decreasing muscle strength.

Types of Stretching

Three common types of stretching include static, dynamic, and proprioceptive neuromuscular facilitation (PNF). [2] Static stretching involves lengthening a specific muscle group for a period of time without movement. This method is arguably the safest form of stretching, especially for beginners, as it minimizes the risk of tearing or straining the muscle by overstretching. [3] PNF incorporates static stretching in addition to isometric contraction and relaxation of the muscle. Unlike static and PNF methods, dynamic stretching involves active movements to increase the range of motion while raising the heart rate before an exercise.

Mechanisms to Increasing Flexibility

Several mechanisms describe how stretching can increase flexibility over time including increasing compliance and increasing stretch tolerance. Compliance relates to the elasticity of the muscle-tendon unit and is useful in generating forces as elastic energy is stored by eccentric contractions during the stretch-shortening cycle (SSC). [4] Stretching can increase the compliance of the muscle-tendon, increasing the energy potential. Increasing the stretch tolerance of a muscle is a second mechanism to increase flexibility. Long-term stretching can alter how the central nervous system receives signals from structures aiding in proprioception and regulation of muscle stiffness including nociceptors, Golgi tendon organs, and muscle spindles. [5] Altering these signals may result in greater ranges of motion with decreased resistance by the nervous system.

Stretching Reduces Injury in Some Sports

Research has shown that stretching can reduce injury by increasing flexibility, but only in some sports. For sports requiring jumping motions that involve high intensity SSCs, like soccer and football, stretching has been shown to reduce injury. [4] In these sports, the muscle-tendon system works as an elastic spring. With a compliant unit, potential injury is reduced as greater energy can be absorbed by the tendon, sparing the muscle fibers potential damage. However, if the tendon has low compliance greater forces can be transferred to the muscle, resulting in injury if the muscle is unable to support high amounts of energy.

A prospective study published in 2003 from Ghent University measured initial muscle flexibility for 146 male professional soccer players and analyzed how flexibility related to the development of muscle injuries throughout the season. Goniometers were used to measure the flexibility of the hamstring, quadriceps, adductor, and gastrocnemius muscles on both sides of the athletes. The study reported no statistical significance between players height and weight, but did not analyze other factors like age. Throughout the season, 67 players were diagnosed with a lower extremity injury. For the hamstring and quadriceps muscle, the injured group had a significantly lower initial mean flexibility. No significant difference for flexibility was found for injuries involving the adductor or gastrocnemius muscles which could be due to the low power of this analysis. Thus, this study recommends implementing a stretching program to prevent muscle injuries, although there are many limitations. This study only analyzed intrinsic muscle flexibility when muscle injury can be caused by many intrinsic and extrinsic risk factors. Also, the specific circumstances of the injuries were not incorporated in analysis. [6]

Unlike sports involving high intensity SSCs, there is insufficient evidence that stretching is effective in preventing injury in sports with lower intensity SSCs, including cycling and swimming, as well as jogging (which utilizes high intensity SSCs, but not at maximum exertion). [4,7] Rather than utilizing the ability to absorb energy, these sports utilize the conversion of metabolic energy into mechanical work by concentric contractions. [4]

Can Stretching Increase Performance?

Although long-term stretching can increase range of motion, this does not always mean an increase in performance.  A 2007 study investigated the long-term effects of PNF and static stretching on range of motion and jump performance. Twenty-three healthy male volunteers were randomly divided into 3 groups to follow a static stretching program, PNF stretching program, or a control group with no stretching. Range of motion was recorded by a goniometer. Jump performance was measured by timing a subject dropping from a box onto a contact mat and jumping as high as possible to then calculate jump height. Measurements were recorded at the beginning and end of the study. While no group had any significant change in jump performance, both stretching groups had a significant increase in joint range of motion. The authors believe measuring muscle hypertrophy could have been a better measure of performance. [8]

Does Stretching Decrease Performance?

Stretching is not always recommended for sports involving lower intensity SSCs because a muscle-tendon system that is too compliant could reduce performance. For these sports, decreased flexibility with greater stiffness can contribute to more rapid tension changes for faster responses. [4] A 2001 study investigated the effects of stretching on 16 male and 16 female college aged runners. At the beginning and end of the study VO2peak, running economy, and flexibility, measured by a sit and reach test, was evaluated. Running economy is used to evaluate running performance as a measure of VO2 and the respiratory exchange ratio. [9] The participants were randomly assigned to a stretching or non-stretching group and followed these programs for 10 weeks. The stretching group performed 15 static stretches in a 40 minute session for 3 days a week for the 10 weeks of the study. This study found an increase in flexibility in the stretching group, but no significant change in running economy for both the stretching or the non-stretching group. Stretching does not appear to increase or decrease running performance, and thus may not be harmful to incorporate in these sports. However, limitations to this study include the limited measurements of flexibility provided by the sit and reach test, as well as potential confounding factors that can affect running economy. [10]

Although acute stretching often results in decreased muscle strength, longer-term effects of stretching may actually promote muscle hypertrophy. A 2013 study analyzed the effect of stretching before a strength training workout and found that strength levels increased for both the stretching and non-stretching groups, although the group without stretching had a greater increase. [11]

To Stretch or Not To Stretch?

Overall, the long-term effects of stretching include increased flexibility which can reduce injury in sports with high intensity SSCs. Although stretching has not been found to decrease the risk of injury in sports with low intensity SSCs, it does not lower performance. The studies discussed did not find that stretching enhanced or reduced performance, but this may be due to influences to muscle hypertrophy that were not included in these studies. As long as stretching is performed utilizing proper techniques to prevent overstretching, incorporating stretching into your workout can be beneficial and help increase flexibility overtime.

Questions to Consider

  1. Do you regularly stretch? If so, do you prefer stretching before, after, or before and after your workout? In your own experiences have you noticed any effects from stretching versus not stretching?
  2. What do you think about the different methods to measure flexibility (goniometry, sit and reach test)? How might the limitations of each of these methods influence results and conclusions made by studies? If you are unfamiliar with sit and reach tests, check out this video. Is there a better way to measure flexibility?
  3. Do you think the duration of stretching for the stretching protocols in these studies is important to consider? Do you think these protocols should be standardized across studies (such as types of stretches performed or muscles that are targeted by stretching for certain sports)?

References

[1] Stone M, Ramsey MW, Kinser AM, O’Bryant HS, Ayers C, Sands WA. Stretching: acute and chronic? the potential consequences. Strength and conditioning journal. 2006;28(6):66-66. doi:10.1519/1533-4295(2006)28[66:SAACTP]2.0.CO;2.

[2] Mann D, Whedon C. Functional stretching: implementing a dynamic stretching program. Athletic therapy today. 2001;6(3):10-13. doi:10.1123/att.6.3.10

[3] Muniz Medeiros D, Martini T. Does Stretching Have Long-Term Effects on Muscle Performance? A Clinical Commentary. J Yoga Phys Ther. 2017;7(2). doi:10.4172/2157-7595.1000269

[4] Witvrouw E, Mahieu N, Danneels L, McNair P. Stretching and injury prevention : an obscure relationship. Sports Med. 2004;34(7):443-449. doi:10.2165/00007256-200434070-00003

[5] LaRoche D, Connolly D. Effects of stretching on passive muscle tension and response to eccentric exercise. The American Journal of Sports Medicine. 2006;34(6):1000-1007. doi:10.1177/0363546505284238

[6] Witvrouw E, Danneels L, Asselman P, D’Have T, Cambier D. Muscle flexibility as a risk factor for developing muscle injuries in male professional soccer players. a prospective study. The American Journal of Sports Medicine. 2003;31(1):41-46. doi:10.1177/03635465030310011801

[7] Yeung EW, Yeung SS. A systematic review of interventions to prevent lower limb soft tissue running injuries. Br J Sports Med. 2001; 25: 383-9. doi:10.1136/bjsm.35.6.383

[8] Yuktasir B, Kaya F. Investigation into the long-term effects of static and pnf stretching exercises on range of motion and jump performance. Journal of Bodywork & Movement Therapies. 2009;13(1):11-21. doi:10.1016/j.jbmt.2007.10.001

[9]Nelson AG, Kokkonen J, Eldredge C, Cornwell A, Glickman-Weiss E. Chronic stretching and running economy. Scandinavian Journal of Medicine & Science in Sports. 2001;11(5):260-265. doi:10.1034/j.1600-0838.2001.110502.x

[10] Saunders PU, Pyne DB, Telford RD, Hawley JA. Factors affecting running economy in trained distance runners. Sports Med. 2004;34(7):465–485. doi:10.2165/00007256-200434070-00005

[11] Borges Bastos CL, Miranda H, Vale RG, et al. Chronic effect of static stretching on strength performance and basal serum igf-1 levels. Journal of Strength and Conditioning Research. 2013;27(9):2465-2472. doi:10.1519/JSC.0b013e31828054b7

Myofascia-nating, does myofacial release work?

Many people envision an evening under the hands of a masseuse as the perfect example of a relaxing experience, even as those hands dig deep into the “hurts so good” territory. This is often justified with the long term effects promised as the gain to the pain, such as relief of chronic pain, reduced soreness, and feeling looser. These claims are primarily backed by anecdotal evidence rooted in experiences of clients ranging from casual massage goers to professional athletes, as well as from those of practitioners.

Ubiquitously coined by masseuses, physical therapists, and athletic trainers, myofascial release is one of those deep soft tissue massage techniques that gets people excited to let them above their personal pain thresholds. But does myofascial release have any scientific evidence behind it’s effectiveness?

But what really is myofascial release?

The theory is that a primary factor in muscle tightness and pain is the condition of the sticky, gooey web that holds our muscle fibers together and to other parts of our body.

Fig 1: Fascia around and between layers of muscle

Originally posed by physician Stephen Typaldos came the idea that virtually all musculoskeletal injuries were due to distortions of connective tissue, particularly when sticky masses of fascia clump in between muscular fibers. Myofascial release is the practice of, in theory, releasing these fascial clumps to relieve tension on the musculoskeletal system. Dr. Typaldos found a lot of success in his career by using rubbing, friction, sliding, and pulling on acute pain- success that has inspired practitioners to adopt his strategies and aim for the best results.  However, while clumps of fascia melting away is easy to visualize, there is no scientific proof that distortions actually exists, nor that they can be removed by manual work. Some argue that fascia doesn’t even matter while others swear by it and pose theories to back their claims, but currently the mechanism, if any, behind myofascial release is unknown.

There is also no common consensus over how myofascial release is really used. For example, some professionals apply myofascial release to trigger points, which don’t seem to be related to fascia at all as per the video below:

Of course, for anyone looking for relief from pain and soreness myofascial release sounds like a good idea, but the costs of repetitively visiting therapists and masseuses is a deterrent. Thus enters the market of self myofascial release including products such as rollers and massage tools, where one can supposedly achieve myofascial release at home without the need of a practitioner. However, things get a little murky here as well – some argue that these techniques can’t actually achieve myofascial release, and there is no proof in either direction:

Ultimately, these grievances are rooted in the lack of understanding over the mechanism behind myofascial release. Even as these techniques aren’t tightly defined, we’re still left wondering the question: “But does it work?”

Does the massage work?

This one is tricky to answer, using scientific evidence, as there is a lack of high quality, highly controlled studies I myofascial release massage. A 2013 review on the effect of myofascial release on adults with orthopedic conditions found only 10 peer reviewed articles on the topic. Of these, 6 were case studies of which 5 had degrees of improvement ranging from slight to full recovery, and one on which the treatment failed. Of course, there is no way of knowing if massage really had any effect on those results. Of the studies, it was found that in treating plantar fasciitis, hamstring tightness, and misaligned pelvis myofascial release was useful (especially in plantar fasciitis, with on average 60% better pain reduction than the group without three months down the line!. However, the study with the largest subject was on low back pain, in which it was found that myofascial release did improve back pain, but no better than other manipulation techniques. There was no control in this study, however, so again it’s hard to tell if time alone healed all the subjects. With only one randomized control study (plantar fasciitis), I concurred with the authors here that there was a greater need for stronger studies on the subject.

A 2017 review looked only at randomized controlled trials where individuals and personnel were blinded to which treatment group they belonged in. Only 8 were found, all of which indicated myofascial release was beneficial. The conditions studied were tennis elbow and low back pain. Among these, two of them found that myofascial release on top of physical therapy was more useful than just physical therapy.

As we can see here, there really aren’t many conclusive studies on the matter, without a big enough sample of studies to draw a consensus from. I’ll agree it looks like from what we’ve seen myofascial release therapy seems to help, but only two of the above studies actually compare it to fake massage or other massage techniques. While those two studies found myofascial release was better than faking a massage, two are hardly enough to conclude that myofascial release is responsible for reduced pain and not just any massage. Looking at a third study, we see that there is no significant difference between myofascial release and Swedish massage in pain symptoms.

Okay…but what about foam rollers?

An example of a foam roller

Many people use foam rollers as a cheaper alternative to hands on massage to achieve myofascial release. It doesn’t look like we’re sure if myofascial release is even a real thing, but let’s not just go throwing our rollers out feeling dejected and lied to all along. Even if we aren’t sure how foam rollers work, they may still help.

One study looked at 20 gym-going males and how foam rolling affected them while doing a resistance squat and jump height protocol. They were evenly and randomly split into a foam rolling group and non foam rolling group. The study found that throughout their training which consistent of five consecutive days of exercise, the group that foam rolled had consistently lowered muscle soreness and improved range of motion at each time point. The participants that foam rolled did not have better gains in their squat one rep max, but did have better jump height improvement in comparison to the control. One limitation of this study is that the control group had no replacement to foam rolling, such as just laying down on foam, after their workouts, so there could have been another factor involved in the difference between the two groups.

Another study looked at the effect of foam rolling in delayed onset muscle soreness (DOMS), in which a squat regiment was used to induce the pain in both the no foam rolling and foam rolling group, who foam rolled immediately afterward the workout and then 24 hours later and 48 hours later for 20 minutes each time. The foam roller group had significantly reduced muscle soreness and increased tenderness of the quadriceps. The athletes had recorded performance measures such as sprint time and squat reps before the DOMS protocol, and the group the foam rolled had less reduction of performance 24, 48, and 72 hours after. Again, we can say the lack of a more robust control condition applies here, but again the results are promising.

So lets roll it all together

Even though it looks like overall we’re really not too sure what myofascial release massage is, how it works, or if its effective, we can still draw some conclusions from the research. The first is that myofascial release isn’t harmful. With neither the foam rollers or the manual massage did pain increase for subjects or performance decrease. Its true that myofascial release could be no different than any other massage in it’s effects, but they trend to show that whether or not a release of clumps of fascia occurs, the massage does help with pain for certain cases. The same thing goes for foam rolling the legs. Maybe no form of release is occurring at all, but spending the time to foam roll is showing to increase flexibility and reduce soreness at least over the span of time that DOMS is a factor. Importantly, there is no case here to say that if you feel like myofascial release helps you that there is any reason to give it up.


Questions to Consider:

Is it important to know how myofascial release works or just that it does work? If you had limited resources and to support one of those two types of studies, which would it be?

Are randomized controlled trials important to understanding how effective myofascial release is? Or is that being too strict, and looking at case studies and less controlled studies is sufficient enough? Why?

References:

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. doi: 10.1016/j.jbmt.2010.01.002

Whitehead, M., Jeffrey, E., khurana, A., Gail, Oster, D., Wilson, S., … Miller, C. (2018, March 8). Self Myofascial Release- What is MFR and how does it work? Retrieved from https://deeprecovery.com/is-myofascial-release-real/

Ingraham, P. (n.d.). Fascia Science Review. Retrieved from https://www.painscience.com/articles/does-fascia-matter.php#sec_origins

Problems MFR Helps. (n.d.). Retrieved from https://www.myofascialrelease.com/about/problems-mfr-helps.aspx

American Fascial Distortion Model Association. (n.d.). Retrieved from https://afdma.com/

Mckenney, K., Elder, A. S., Elder, C., & Hutchins, A. (2013). Myofascial Release as a Treatment for Orthopaedic Conditions: A Systematic Review. Journal of Athletic Training, 48(4), 522–527. doi: 10.4085/1062-6050-48.3.17

Laimi, K., Mäkilä, A., Bärlund, E., Katajapuu, N., Oksanen, A., Seikkula, V., … Saltychev, M. (2017). Effectiveness of myofascial release in treatment of chronic musculoskeletal pain: a systematic review. Clinical Rehabilitation, 32(4), 440–450. doi: 10.1177/0269215517732820

Liptan, G., Mist, S., Wright, C., Arzt, A., & Jones, K. D. (2013). A pilot study of myofascial release therapy compared to Swedish massage in Fibromyalgia. Journal of Bodywork and Movement Therapies, 17(3), 365–370. doi: 10.1016/j.jbmt.2012.11.010

Macdonald, G. Z., Button, D. C., Drinkwater, E. J., & Behm, D. G. (2014). Foam Rolling as a Recovery Tool after an Intense Bout of Physical Activity. Medicine & Science in Sports & Exercise, 46(1), 131–142. doi: 10.1249/mss.0b013e3182a123db

Pearcey, G. E. P., Bradbury-Squires, D. J., Kawamoto, J.-E., Drinkwater, E. J., Behm, D. G., & Button, D. C. (2015). Foam Rolling for Delayed-Onset Muscle Soreness and Recovery of Dynamic Performance Measures. Journal of Athletic Training, 50(1), 5–13. doi: 10.4085/1062-6050-50.1.01

Enough (N)SAID about Ibuprofen & Soreness

If I’m being honest here, it’s been a while since I’ve had a solid gym routine. But this semester I’ve been going pretty regularly, and let me tell you, I’ve felt the burn. My muscles have felt pretty sore in the 2-3 days following my workouts, so I’ve had to turn to ibuprofen a few times to relieve the pain. But even after taking ibuprofen in the morning, I’ve felt sore again by the end of the day. This got me thinking: how effective is ibuprofen at reducing muscle soreness?

Non-steroidal anti-inflammatory drugs (NSAIDs) are commonly served over-the-counter at pharmacies. Some common forms you may recognize include aspirin and ibuprofen (Motrin, Advil). NSAIDs are taken for many reasons; they reduce pain and inflammation, lower fevers, and reduce clotting action.[1,2] The typical dosage for adults who are looking to reduce mild-moderate pain is 400 mg every 4-6 hours. For adults who have pain caused by osteoarthritis, the typical prescribed dose is 1200 mg.[3] However, despite their pain reducing use, NSAIDs could yield negative side effects such as increased risk in developing nausea, stomach pains, or an ulcer.[1]

The mechanism of NSAIDs when it comes to reducing pain and inflammation is known and understood. After intense workouts, prostaglandins are produced by muscle cells. They aid in the healing process of muscle, but this often leads to inflammation, pain, and fever. Enzymes called cyclooxygenases (COX-1, COX-2) produce the prostaglandins that promote inflammation, pain, and fever. The goal of NSAIDs is to inhibit COX-1 and COX-2 from producing prostaglandins, thus decreasing the pain. However, the COX-1 enzyme is responsible for creating prostaglandins that protect the stomach lining and support platelet aggregation, so the inhibition of the enzyme is what could lead to stomach ulcers and the promotion of bleeding.[1,2,4] The science behind NSAIDs seems promising, but clinical research may prove otherwise.

Athletes commonly take NSAIDs after performing physical activity because they claim the drugs reduce pain and decrease recovery time. But here is the issue: only very few studies have been able to support this claim. Some studies have reported results that do indicate a beneficial effect, by stating NSAIDs used prophylactically mitigate exercise-induced inflammation, circulating creatine kinase levels, and muscle soreness.[5] On the other hand, these claims made by athletes lack scientific support. NSAIDs are known to treat inflammation, but many histological studies have proven that most overuse injuries are caused by tissue degeneration and not inflammation. Also, NSAIDs temporarily “mask” the pain caused by tissue degeneration or soreness. This does not ensure that muscles or tissues are actively getting healthier; it only hides the pain from the athlete. [5] Clearly, there are many different opinions about the use of NSAIDs, specifically ibuprofen, in the sports medicine field. Let’s take a look at what the “research says” about it. 

A study at the University of Saskatchewan was conducted to determine the effects of ibuprofen on muscle hypertrophy, strength, and soreness during resistance training. Participants (12 males, 6 females) trained their left and right biceps for six weeks, alternating arms on each day. The training program called for concentric curls at 70% of RM and eccentric curls at 100% of 1 RM. Every day after their training, they either received a 400 mg dose of ibuprofen or a placebo. On training days, each participant was asked to rate their soreness on a scale from 0-9. For both the placebo and ibuprofen, the participants reported soreness during the first week and that soreness decreased throughout the program to the point where participants felt no soreness in either arm during the final week. The researchers concluded that ibuprofen was not effective in reducing perceived soreness during the training. However, the researchers do not reflect on the limitations of their own study.  They had a small and uneven sample size when it came to gender and there could have been discrepancies and residual effects that came along with taking ibuprofen inconsistently. Additionally, they seemed pretty convinced by their findings, but maybe the dose they chose was not strong enough to show any reduction in soreness in a long term study.[6]

On the other hand, another study drew opposite conclusions. Researchers in Greece conducted a study to determine the effects of ibuprofen on delayed onset muscle soreness (DOMS) and muscular performance. Participants (14 men, 5 women) who have not done strength training in the last 6 months performed eccentric leg curls at 100% RM. Nine (9) subjects were given a 400 mg dose of ibuprofen every 8 hours for 48 hours after exercise, while the remaining 10 subjects received a placebo. The subjects rated their amount of soreness on a scale of 1-10 prior to exercising, 24 hours after exercising and 48 hours after exercising.  The results showed that muscle soreness was significantly lower for the ibuprofen group at both 24 hours and 48 hours after exercising. Similar to the previous study, the researchers did not evaluate the limitations of their study. The number of participants and number of each gender were low and uneven, respectively. Also, the soreness results were not discussed much in the conclusion of the paper. The researchers did not support why the soreness decreased with scientific evidence, which is what they did for the other the parameters they were testing for.[7]

Clearly, both studies came to different conclusions. However, both studies were conducted for different amounts of time, contained different exercises, and with subjects of different athletic abilities. There have been plenty of studies conducted to determine how effective ibuprofen is at reducing soreness, but each study contradicts the next. 

Overall, many studies show that ibuprofen is a short term solution to hiding muscle soreness, but it may not be effective long term. Though, I’m still going to keep on using it to treat my soreness.

Questions to consider:

  • Do you take NSAIDs to reduce your soreness after working out? How effective do you find them to be?
  • Do you think there’s a better way to measure soreness and how ibuprofen affects our muscles?
  • Do you think the length of the study has any correlation with the effectiveness of ibuprofen?

Sources: 

  1. (n.d.) Nonsteroidal Anti-inflammatory Drugs (NSAIDs). Retrieved from  https://www.medicinenet.com/nonsteroidal_antiinflammatory_drugs/article.htm#what_are_nsaids_and_how_do_they_work
  2. Tscholl, M., et al (2016). A sensible approach to the use of NSAIDs in sports medicine . Swiss Sports & Exercise Medicine , 65(2), 15–20.
  3. (n.d.) Ibuprofen (Oral Route). Retrieved from https://www.mayoclinic.org/drugs-supplements/ibuprofen-oral-route/proper-use/drg-20070602 
  4. (n.d.) What Are NSAIDs? Retrieve from https://orthoinfo.aaos.org/en/treatment/what-are-nsaids/
  5. Stuart J. Warden (2010) Prophylactic Use of NSAIDs by Athletes: A Risk/Benefit Assessment, The Physician and Sportsmedicine, 38:1, 132-138, DOI: 10.3810/ psm.2010.04.1770
  6. Krentz , J. (2008). The effects of ibuprofen on muscle hypertrophy, strength, and soreness during resistance training. Applied Physiology Nutrition and Metabolism , 33(3), 470–475. doi: 10.1139/H08-019

The Cold Facts on Icing

If you’re an athlete, there is a good chance that you have been told to ice your muscles after exercising. Icing is commonly thought to alleviate inflammation and soreness, as well as help to heal injuries caused by muscle overuse more quickly.1 There are different types of icing techniques popular in the world of athletics, ranging from a simple ice pack or frozen gel to cryotherapy and cold therapy chambers.2 Despite its wide use, there is some controversy regarding whether cold therapies are beneficial to the muscles or causing more harm than good.

Inflammation is an acute physiological response that is needed for tissues in the body to heal after exercising. Those opposing ice therapies claim that icing a sore muscle reduces its blood flow and slows the natural process of alleviating inflammation. While there is evidence that icing can help to reduce soreness in the short term after a workout, this reduction in the immune response can prevent the muscles from healing as quickly as they otherwise would.3 Many researchers have studied these countering views on the subject.

 

Figure 1. Cryotherapy machine [6]

 

One study aimed to see if topical cooling could improve recovery in eccentric contraction-induced muscle damage.4 They used a sample of 11 college male baseball players and put them into two groups; a control group and a group receiving topical cooling. The subjects used a barbell to complete 6 sets of 5 eccentric arm contractions. Those individuals in the cooling group received the ice 0, 3, 24,48, and 72 hours after the exercise for 15 minutes each. This was then repeated four weeks later. The researchers then analyzed the muscle hemodynamic changes, muscle damage markers, inflammatory cytokines, subject pain levels, and isometric muscle strength. The results showed that the subjects pain was similar between the two groups in the short term, but was greater in the later periods after the workout. The measured creatin kinase and myoglobin were significantly greater in the cooling group in the 48 and 72 hour periods than the control group. The cooling also resulted in higher hemoglobin concentration.4

Another study was conducted using 42 moderately active college aged males.5 The researchers had the subjects do 5 sets of 20 drop jumps, followed by lower body immersion in cold water. Three groups were used; one having a water temperature of 5 degrees Celsius, one with 15 degrees Celsius, and one control group. Measurements were taken on isometric knee extensor torque, countermovement jump, muscle soreness, and creatin kinase directly following exercise and 24, 48, 72, 96, and 168 hours after. The results for the countermovement jump showed that the warmer water group recovered more quickly than the colder water group. Creatin kinase remained elevated in all group except the warmer group, which returned to baseline at 72 hours. The subjects reported lower muscle soreness in the warmer water group as well.5

The research shows that icing sore muscles can be beneficial shortly after working out, but that people will possibly experience the same soreness later in time compared to people who don’t ice. It also makes it seem like using only slightly cold ice packs and water is more effective than using extreme cold. Athletes who ice should consider the amount of time they ice and the temperature they use when choosing cold therapies after a workout to avoid possible long term soreness and to improve with training.

 

Questions to Consider:

  • Do you think that using experienced athletes or people who only exercise occasionally was a more effective method of research?
  • Have your experiences with ice therapies been positive or negative?
  • What could a future study do differently to see the effects of icing on exercise?

 

References

  1. Cluett, J. (2019, September 25). How to Properly Ice an Injury. Retrieved from https://www.verywellhealth.com/how-to-ice-an-injury-2548842

 

  1. Gotter, A. (2017, February 2). Treating Pain with Heat and Cold. Retrieved from https://www.healthline.com/health/chronic-pain/treating-pain-with-heat-and-cold

 

  1. Aschwanden, C. (2019, February 5). Athletes love icing sore muscles, but that cold therapy might make things worse. Retrieved from https://www.washingtonpost.com/national/health-science/athletes-love-icing-sore-muscles-but-that-cold-therapy-might-make-things-worse/2019/01/31/a465dd84-1f25-11e9-8e21-59a09ff1e2a1_story.html

 

  1. Tseng, C.-Y. (2013). Topical Cooling (Icing) Delays Recovery From Eccentric Exercise–Induced Muscle Damage. Journal of Strength and Conditioning Research27(5), 1354–1361.

 

  1. Vieira, A. (2016). The Effect of Water Temperature during Cold-Water Immersion on Recovery from Exercise-Induced Muscle Damage. International Journal of Sports Medicine37(12), 937–943.

 

  1. (n.d.). 5 Cryotherapy Side Effects Therapists Should Watch For. Retrieved from https://www.homeceuconnection.com/blog/cryotherapy-side-effects-therapists/

 

 

 

 

 

 

Elevation Masks for Endurance Training: Stamina or Scam?

Endurance athletes across the globe are always looking for a way to gain an edge on their opponents. Some methods that have been adopted by elite and amateur athletes alike are altitude and respiratory muscle training. Altitude training involves training at high altitudes where oxygen is more limited than at sea level. Respiratory muscle training involves strengthening the muscles that are required for breathing. Both types of training involve creating a hypoxic condition for the body, meaning that the tissues are not receiving an adequate supply of oxygen. Exposure to hypoxic conditions stimulates the production of erythropoietin in the kidneys, which increases production of red blood cells. This creates an increase in the oxygen carrying capacity of the blood and has been correlated to an increase in endurance performance [1].These training techniques are said to increase aerobic capacity (VO2max), endurance, lung function, and overall performance in athletes [2]. 

Respiratory muscle training can be done using an elevation mask, which is designed to simulate the conditions of training at altitude while training at sea level (figure 1). Elevation masks cover the nose and mouth, restricting air flow and making respiration more difficult for the athlete. They often have values that allow for adjustments to the amount of oxygen that enters the mask. The Elevation Mask 2.0 by Training Mask LLC is one type of mask that uses values and can simulate altitudes ranging from 914 m to 5486 m [2]. But the question is – do these masks really cause physiological changes in the body to improve stamina and endurance?

 

Figure 1. The Elevation Mask 2.0 (Training Mask LLC, Cadillac Michigan) that can be used by athletes during training in hopes of improving performance [2]. It consists of a silicone mask and neoprene head strap, with adjustable resistance caps to change the amount of air flow.

 

Many studies have attempted to test these masks and determine if respiratory muscle training is actually beneficial to endurance athletes. Acclimating to high altitude occurs as the body increases the amount of red blood cells, which has been shown to improve sea-level running performance [1]. However, this hematological effect has not been consistently shown in studies that used elevation training masks. In addition to the volume of red blood cells, significant changes have not been observed in blood lactate concentration in people wearing the mask during training. These trends indicate that elevation masks may work as respiratory muscle training devices but do not accurately simulate the physiological changes that occur in the body at high altitudes [2]. 

Increased aerobic capacity, or ability to pump oxygenated blood to the muscles during exercise, is one of the main goals of endurance training. By participating in any sort of endurance training program, VO2max can be improved as the body adapts to the demands being placed on it. However, the goal of altitude and respiratory muscle training is to further enhance this ability to reach peak performance levels. Studies have shown that increases in VO2max for groups wearing a mask compared to increases in control groups are not significant [2]. In contrast, ventilatory threshold, which refers to the point during exercise where the rate of ventilation increases faster than the rate of oxygen uptake, and power output show a significant increase in experimental groups wearing a mask compared to control groups [3]. These findings indicate that wearing the elevation mask may help improve the function of the cardiovascular system during exercise.

Ventilatory threshold (VT) has been shown to correlate to the amount of work the muscles can maintain without fatigue. When the VT is surpassed, the muscles do not receive the necessary amount of oxygen and fatigue begins to set in. Therefore, increasing the VT for an endurance athlete should result in better performance [4]. In addition to endurance based metrics, respiratory muscle training has been shown to improve deep breathing and increase ventilatory efficiency throughout exercise[3,5]. 

Although there seems to be trends present in studies involving elevation masks and endurance training, there are limitations to what can be concluded. Most of the studies evaluated had limited sample sizes and the duration and intensity of the exercise regimes varied between studies. However, the studies do seem to imply that elevation masks may be beneficial to endurance performance through respiratory muscle training. By making it more difficult for the athlete to inhale and exhale, the body does appear to undergo physiological changes to adapt to the lower levels of oxygen. This adaptation may result in increased VO2max, VT, and power output over time. It seems that using an elevation mask does not cause any of the hematological changes in the body that occur when a person actually reaches a higher altitude. So although endurance performance may increase as a result of using the mask, it does not directly mimic the conditions of elevation training.

 

Questions to Consider:

  • Prior to reading this article, had you heard of professional athletes using altitude training or elevation masks to improve their performance? And if so, what sport did these athletes participate in?
  • Do you think amateur athletes and non-athletes could benefit from using an elevation mask in daily life?
  • Have you ever experienced altitude sickness? If so, what symptoms did you have?

 

References:

  1. de Paula, P., Niebauer, J. (2012). Effects of high altitude training on exercise capacity: fact or myth. Sleep Breath 16, 233–239. https://doi.org/10.1007/s11325-010-0445-1
  2. Porcari, J. P., Probst, L., Forrester, K., Doberstein, S., Foster, C., Cress, M. L., & Schmidt, K. (2016). Effect of Wearing the Elevation Training Mask on Aerobic Capacity, Lung Function, and Hematological Variables. Journal of sports science & medicine, 15(2), 379–386.
  3. Kido, S., Nakajima, Y., Miyasaka, T., Maeda, Y., Tanaka, T., Yu, W., Maruoka, H., & Takayanagi, K. (2013). Effects of combined training with breathing resistance and sustained physical exertion to improve endurance capacity and respiratory muscle function in healthy young adults. Journal of physical therapy science 25(5), 605–610. https://doi.org/10.1589/jpts.25.605
  4. Graef, J.L., Smith, A.E., Kendall, K.L. et al. (2008). The relationships among endurance performance measures as estimated from VO2PEAK, ventilatory threshold, and electromyographic fatigue threshold: a relationship design. Dyn Med 7(15). https://doi.org/10.1186/1476-5918-7-15
  5. Granados, J., Gillum, T., Castillo, W., Christmas, K., Kuennen, M. (2016). “Functional” Respiratory Muscle Training During Endurance Exercise Causes Modest Hypoxemia but Overall is Well Tolerated. Journal of Strength & Conditioning Research 30(3), 755-762.

Achey Breaky Muscles

Athletic expertise is not required for one to feel the aching and lasting effects of delayed-onset muscle soreness (DOMS). The aftermath of these effects can often exist along a spectrum ranging from significant muscle tenderness to debilitating pain.¹ In addition, the duration of these effects can exist along a spectrum ranging from 24 to 72 hours.¹ A common misconception correlates a good workout with the subsequent symptoms of DOMS, however, that is just not the case. With that being said, DOMS will often occur in accord with performing new exercises or increasing the intensity and/or duration of a current exercise.¹

 

The lingering soreness and stiffness as a result of DOMS can often cause individuals to seek methods that will ultimately reduce these symptoms and accelerate their return to the gym. Unfortunately, many of the treatment options on the market have mixed outcomes due to the individualized nature of exercise. Some may obtain adequate results through methods, such as massage or ibuprofen, while others may not; whereas, some methods prove to be completely ineffective, such as cryotherapy and stretching.¹ Furthermore, let’s give a look at a newly proposed treatment for DOMS and whether its results are promising.

 

Blood-flow restriction (BFR) training is often used at physical therapy as a passive way to regain strength without adding heavy weight. The venous blood supply is terminated at the area of injury, which in turn reduces the amount of oxygen at the site, activates anaerobic metabolism, and encourages muscle hypertrophy.² This proves to be an effective technique for restrengthening the muscle of patients who strictly lift lighter loads.² But, where is the crossover between BFR and DOMS?

Figure 1. BFR machine.[8]

BFR is thought to provide an alternative training method that will achieve similar muscle gains to resistance training with heavy loads while also minimizing the effects of DOMS. It has been postulated that BFR training may attenuate DOMS by preventing calcium-mediated proteolysis³ and by recruiting fast-twitch motor units.⁴ However, it has also been hypothesized that BFR training may induce muscle damage through ischemia-reperfusion (lack of oxygen in the tissues) or through the reduction of neutrophils that aid in inflammatory response.⁵

 

A 2019 study wished to examine the effects of BFR training on DOMS by using 25 untrained females and submitting them to isokinetic forearm flexion training, where half performed a bicep curl with a BFR cuff at a load reflecting a 30% eccentric-peak torque and the other half at a load reflecting a 30% concentric-peak torque.⁶ The findings revealed neither eccentric or concentric movements with a BFR cuff resulted in DOMS after the 7 days of training.⁶ These results were inconsistent with other studies that showed an increase in DOMS with concentric exercises.⁶ Is this inconsistency due to the low number of participants, the lack of diversity, or the duration of the experiment being only 7 days?

 

In contrast, a 2017 study compared the effects of BFR training and resistance training on DOMS by using 17 male participants and assessing their elbow-flexor muscle strength for 7 days in one of four training techniques: heavy load, light load, intermittent high-pressure BFR, and continuous low-pressure BFR.⁷ From this, the researchers found DOMS was significantly greater in BFR training (both intermittent high-pressure and continuous low-pressure) than in resistance training (both in heavy and light load).⁷

 

Much like the other methods of muscle recovery, BFR training may not be the most effective way to minimize DOMS. Exercise can be highly variable and strongly impacted by genetics, which may be the reason a consistent and reliable technique for treating DOMS has yet to be discovered.

 

Watch this youtube video to learn more about DOMS.⁸

Questions to consider

  • Based on the study mentioned in this article, do you think their findings are an accurate representation of the effects of BFR training on DOMS?
  • How have your opinions regarding DOMS changed with this post?
  • Did the video help you understand DOMS in an easily digestible way?

 

References

  1. Cheung K, Hume P, Maxwell L. Delayed onset muscle soreness: treatment strategies and performance factors. Sports Med. 2003; 33(2):145-164. DOI: 10.2165/00007256-200333020-00005
  2. Blood-Flow Restriction Training. American Physical Therapy Association. Website.http://www.apta.org/PatientCare/BloodFlowRestrictionTraining/. Updated May 24, 2019. Accessed February 20, 2020.
  3. Sudo M, Ando S, Poole DC, Kano Y. Blood flow restriction prevents muscle damage but not protein synthesis signaling following eccentric contractions. Physiol Rep. 2015;3(7):e12449.
  4. Loenneke JP, Fahs CA, Wilson JM, Bemben MG. Blood flow restriction: the metabolite/volume threshold theory. Med Hypotheses. 2011;77(5):748-752.
  5. Curty VM, et al. Blood flow restriction attenuates eccentric exercise-induced muscle damage without perceptual and cardiovascular overload. Clin Physiol Funct Imaging. 2017;38(3):468-476.
  6. Hill EC, Housh TJ, Smith CM, Keller JL, Schmidt RJ, Johnson GO. Eccentric and concentric blood flow restriction resistance training on indices of delayed onset muscle soreness in untrained women. Eur J Appl Physiol. 2019;119(10):2363-2373.
  7. Brandner CR, Warmington SA. Delayed onset muscle soreness and perceived exertion after blood flow restriction exercise. Journal of strength and conditioning research. 2017;31(11):3101-3108. doi:10.1519/JSC.0000000000001779
  8. Should You Still Train Sore? Youtube. Website. https://www.youtube.com/watch?v=Ut_4C_5CNbg. Published November 18, 2018. Accessed February 20, 2020.

Personalized Blood Flow Restriction. Owens Recovery Science. ORS. 2020c.

Dry Needling: Is it Worth the Pain?

Arriving at a physical therapy appointment to have a needle stuck deep into the body’s muscles only to leave hobbling and sorer than before doesn’t seem like an effective method for rehabilitation. However, the post-treatment benefits have made dry needling one of the many techniques individuals are using to treat and prevent injury from exercise.

What is Dry Needling?

While wet needling uses hollow needles to inject corticosteroids into muscle [7], dry needling (DN) consists of inserting a fine needle, similar to those used in acupuncture, deep into the muscle without injections. The needle is then twisted and moved around the area without being fully removed from the skin. The needling itself can be uncomfortable, feeling like a pinch, cramp, or deep prick, and can result in local soreness post-treatment. Physical therapists seek to insert the needle into a myofascial trigger point (MTrP) to relieve myofascial pain syndrome (MPS), the most common muscle pain disorder seen in clinical practice [1]. In exercise science, MTrPs are defined as “hyperirritable local point(s) located in taut bands of skeletal muscle or fascia which when compressed causes local tenderness and referred pain” [10]. Potentially caused by muscle overuse [2], this pain is commonly described as having a knot in a muscle and creates localized tenderness, pain to deep touch, and restricted movement [1].

The video above shows a physical therapist performing the dry needling technique on various muscles. Created by Dynamic Physical Therapy, Covington, LA (2013).

Dry needling is used as a rehabilitation technique to decrease the pain MTrPs can cause. The “fast-in and fast-out needle technique” applies high pressure stimulation to the MTrP, often causing a twitch response. These twitch responses are the result of a spinal reflex generated by the activation of nociceptors and mechanoreceptors. These receptors respond to the painful mechanical irritation and stretch the needle causes within the muscle [1]. When this occurs, a single motor unit fires and a visible, isolated contraction – the “twitch” – can be seen. These twitch responses can occur local to the needle or within muscles on the opposite side of the body. This phenomenon has led researchers to believe that the pain associated with MTrPs is due to central nervous system (CNS) changes [1]. 

How is Dry Needling Portrayed in Healthcare?

Healthcare providers, such as MedStar National Rehabilitation Network and ChristianaCare, have been advocates for dry needling. They mention DN is “an effective physical therapy modality…in the treatment of orthopedic injuries” [5] and that it can even be used for preventing pain and injury [4]. There have been many personal accounts of the wonders of dry needling in recovery from nagging injuries. AshleyJane Kneeland, who struggles with muscular pain due to lupus, fibromyalgia, and postural orthostatic tachycardia syndrome, cites DN treatment as relief for her painful spasms and headaches, as well as providing general relaxation [6]. But how effective is dry needling, really? Is there science to back up these claims?

What Does the Science Say?

Elizabeth A. Tough and co-authors performed a meta-analysis in 2009 of seven studies assessing the effectiveness of DN in managing MTrP pain. This study provides an update for the systematic review by Cummings and White, which found no evidence suggesting injections through wet needling generate a better response than dry needling [3]. One study found by Tough et al. suggests DN is more effective in treating MTrP pain than undergoing no treatment, two studies produced contradictory results when comparing DN in MTrPs to DN elsewhere, and four studies showed DN is more effective than other non-penetrating forms of treatment (placebo controls). However, when combining these studies for a sample size of n=134, no statistical significance was found between DN and placebo treatments. 

While the authors conclude the overall direction of past studies trend towards showing that DN is effective in treating MTrP and MPS [10], there is no significant evidence yet. The lack of statistical significance could be due to low consistency in study design for studies included in the meta-analysis, as each employed varying mechanisms for needle placement, depth, and treatment frequencies, along with there being an overall small sample size. Therefore, further studies are required to significantly conclude that DN is effective in MTrP rehabilitation.

Ortega-Cebrian et al. recognized the limitations in previous studies and thus sought to create a significant evaluation of the ability of DN to decrease pain and improve functional movements. The authors use a myometer (MyotonPro, [8]) and surface electromyography (sEMG) to assess the mechanical properties of muscle in subjects (n=20 M) with quadricep muscle tension and pain [9]. 

The MyotonPro allows researchers to quantify muscle tone and stiffness. While no standards exist for describing these parameters with respect to changes after rehabilitation techniques, researchers found the device to be reliable through inter-rater reliability (comparing values of the MyotonPro to another rater). Pain was assessed by subjects using the Visual Analogue Scale (VAS) and a goniometer was used to measure small range of motion (ROM) improvements. DN was performed by one of two experienced therapists until twitch responses ceased [9].

Authors report that DN resulted in statistically significant pain reduction and an increase in flexion ROM. However, the ROM was very small and could be within the range of measurement error of the goniometer. Also, the p-values reported in-text for these parameters do not match the corresponding table which presents a question of the reliability of author reporting. All sEMG parameters, except for decreased vastus lateralis activity, were not significantly changed by DN, as well as all MyotonPro parameters, besides a decrease in vastus medialis decrement (muscle elasticity) and resistance. In a power analysis performed after the study, authors report needing 198 subjects for statistically significant results – much higher than the 20 subjects used [9]. Therefore this study continues the uncertainty in the benefits of DN, but does present significant subject-reported pain reduction.

Is it Worth the Pain?

So is dry needling worth the pain? After being put to the test through experimental studies, there is no clear evidence that dry needling is more beneficial than alternative rehabilitation methods such as wet needling, placebo needling, or acupuncture [9]. However, while the mechanisms of changes in muscles with trigger points due to dry needling are unknown, subjects do report pain reduction. Dry needling should be taken on a case-by-case basis since current knowledge of widespread benefits is limited. Essentially, if dry needling treatment alleviates pain more than other rehabilitation methods and the pain of the procedure is bearable, why not give it a try?

 

Questions to Consider:

  • Would you be willing to try dry needling regardless of uncertainties in the literature?
  • Do you believe it is a problem that healthcare providers claim dry needling is effective despite a lack of conclusive evidence?
  • What should future studies do to ensure significant results?

 

References:

[1] Audette, J. F., Wang, F., & Smith, H. (2004). Bilateral Activation of Motor Unit Potentials with Unilateral Needle Stimulation of Active Myofascial Trigger Points. American Journal of Physical Medicine & Rehabilitation, 83(5), 368–374. doi: 10.1097/01.phm.0000118037.61143.7c. 

[2] Bron, C., & Dommerholt, J. D. (2012). Etiology of Myofascial Trigger Points. Current Pain and Headache Reports, 16(5), 439–444. doi: 10.1007/s11916-012-0289-4. 

[3] Cummings, T., & White, A. R. (2001). Needling therapies in the management of myofascial trigger point pain: A systematic review. Archives of Physical Medicine and Rehabilitation, 82(7), 986–992. doi: 10.1053/apmr.2001.24023. 

[4] Dry Needling®. (n.d.). Retrieved from https://christianacare.org/services/rehabilitation/physicaltherapy/dryneedling/

[5] Dry Needling. (n.d.). Retrieved from https://www.medstarnrh.org/our-services/specialty-services/services/dry-needling/

 [6] Dry Needling: The Most Painful Thing I’ve Ever Loved. (2015, March 25). Retrieved from https://www.everydayhealth.com/columns/my-health-story/dry-needling-most-painful-thing-ever-loved/

[7] Dunning, J., Butts, R., Mourad, F., Young, I., Flannagan, S., & Perreault, T. (2014). Dry needling: a literature review with implications for clinical practice guidelines. Physical Therapy Reviews, 19(4), 252–265. doi: 10.1179/108331913×13844245102034. 

[8] Muscle Tone, Stiffness, Elasticity measurement device. (n.d.). Retrieved from 

 [9] Ortega-Cebrian, S., Luchini, N., & Whiteley, R. (2016). Dry needling: Effects on activation and passive mechanical properties of the quadriceps, pain and range during late stage rehabilitation of ACL reconstructed patients. Physical Therapy in Sport, 21, 57–62. doi: 10.1016/j.ptsp.2016.02.001. 

[10] Tough, E. A., White, A. R., Cummings, T. M., Richards, S. H., & Campbell, J. L. (2009). Acupuncture and dry needling in the management of myofascial trigger point pain: A systematic review and meta-analysis of randomised controlled trials. European Journal of Pain, 13(1), 3–10. doi: 10.1016/j.ejpain.2008.02.006.

Kinesio Tape : Does it Really Work?

Most individuals, athletes or not, have experienced a musculoskeletal injury due to the overuse of a specific tissue or muscle. These overuse injuries can slow down an individual either in the workout routines or daily life. While not all injuries react the same way, many overuse injury areas are known to build up lymphatic fluid causing swelling and pain. The swelling and pain come from the accumulated lymphatic fluid putting increased pressure on the injured muscle or tissue.

 

Taping using Kinesio Tape (KT) has become a very popular proposed treatment and recovery aid over the past couple of years. KT became popular after the 2008 Beijing Olympic games, where beach volleyball player Kerri Walsh Jennings caught the attention of many spectators for wearing multi colored tape strips on her shoulder. KT is believed to lift the skin from the underlying layers of fascia, or bands or connective tissue. The lifting of the skin from the fascia results in a greater movement of lymphatic fluid, which transports white blood cells throughout the body and removes bacteria, waste products, and cellular debris. When the tape is correctly used it may also be able to provide support to the surrounding muscles and help to ensure that the muscle does not over extend or over contract [1].

                                                           

Figure 1. Athlete wearing Kinesio Tape.

 

Research suggests show that the tape will allow increased oxygen to the injured muscle and decreased inflammation. A 2012 study tested the effects of KT on blood flow in the gastrocnemius muscle and whether or not the way KT is applied changes the outcome on the muscle performance. In this study 61 healthy active individuals with no recent leg injuries were assigned to either treatment KT, sham KT, or a control group. Before taping a blood flow, circumference, and water displacement was taken for the gastrocnemius muscle. The individuals were then taped, and each measurement was taken again 24 hours and 72 hours after being taped. The results of this study showed no significant differences in the blood flow to the muscle using KT. There was also no change in the muscle’s performance based on the application technique of the tape [1].

 

From five previous systematic reviews, a new systematic review had been created to evaluate whether or not KT was more effective than no treatment or a placebo treatment, for people with musculoskeletal conditions, on pain levels, disability, and quality of life. Several different studies had been performed that looked at the pain levels on a scale from (0-10) for performing different activities while wearing either KT or another form of tape. These studies are prone too potential bias from the users and small sample sizes. Many of the referenced studies only shared certain of the results or were considered significant but of low quality [2].

 

Within a study done on subjects who had been diagnosed with rotator cuff tendonitis/impingement similar results were found as in the studies before. The only difference in this study was that they took self-reported measurement for range of motion along with pain. While the taping was ineffective compared to sham tape in long term, the KT provide immediate in pain free abduction range of motion. Once again, this study was limited to a. young population and it lacked a control group for comparison [3].

 

Although studies show that KT is ineffective in aiding injury rehabilitation, it is. Still used often by many groups of people. Since KT is relatively safe there is no reason why it cannot be used. Whether or not KT acts as a placebo or works I ways that are yet to be understood, it has worked for a large population of people for many years in helping to get past injuries for exercise and daily life.

 

Questions to Consider

 

Have you ever used Kinesio Tape? If so, did it help alleviate pain or support movements?

 

KT placebo effect or valid injury rehabilitation aid?

 

Do you think KT will last as an injury aid?

 

References

 

[1] Hannah L. Stedge, Ryan M. Kroskie, and Carrie L. Docherty. (2012). Kinesio Taping and the Circulation and Endurance Ratio of the. Gastrocnemius Muscle. Journal of Athletic Training, 47(6), 635-642.

 

[2] Patricia do Carmo Silva Parreira, Luciola da Cunha Menezes Costa, etc. (2014). Current evidence does not support the use of Kinesio Taping in clinical practice: a systematic review. Journal of Physiotherapy, 60(1), 31-39.

 

[3] Mark D. Thelen, James A. Dauber,  Paul D. Stonemen. (2008).Journal of Orthopaedic & Sports Physical Therapy,38(7), 389-395.

 

[4] “WHAT’S THE DEAL WITH THE TAPE? Benefits of Kinesiology Theraputic (KT)Tape-Small Tool Delivers Big Impact.” Fischer Institute, 16 Oct. 2017, fischerinstitute.com/benefits-kinesiology-therapeutic-tape/.

 

Acute/short-term effects of stretching

 

Stretching is a critical component of many regimens seen in clinical and fitness settings. Whether you’re a person who prefers to stretch before/after your routine, many people will attest to the physiological benefits of stretching. Proponents of stretching believe that it improves performance during exercise and prevents injuries and soreness. Some would go so far as to say that an individual may not be stretching enough when they repeatedly experience pain or injury after their workouts with no signs of improvement. Despite these enduring beliefs, the science behind the benefits of stretching is questionable. For the purposes of this blog post, we will focus on the acute, short-term effects of stretching on performance during exercise.

Three forms of stretching  used in exercise and rehabilitation settings include dynamic stretching, ballistic stretching, and static stretching. Dynamic stretching is a type of stretching which involve fluid-exaggerated movements. Ballistic stretching utilizes fast countermovements. Static stretching involves extending target muscles to a limit point, and maintaining that position for an interval between 10 and 30 seconds. In order to minimize injuries, static stretching is encouraged for non-athletes.

Numerous scientific studies have shown that have shown that static stretching results in an improved joint range of motion  (ROM) and greater flexibility in the muscles targeted by this technique. Conversely, research has also shown that stretching before exercises can result in a lower force output generated in the muscles that are targeted. Compliance is the lengthening of muscle fibers in response to an applied force. According to an article cited by the the National Institute of Health (Anderson, 2005), increased compliance (which occurs a result of stretching) has been linked to a decreased ability to absorb force at rest, whereas decreased compliance results in a muscle being able to withstand higher tension. This is significant because, when sarcomeres are stretched to the point that the actin and myosin filaments do not overlap, the force absorbed is transmitted to the muscle fiber cytoskeleton; resulting in fiber damage (regardless of a muscle’s joint ROM). Thus, compliance may result in decreased performance depending on the type of exercise performed. Another issue that arises related to the use of stretching before exercise is the type of stretching utilized. Science has shown that muscle fibers can experience tension when stretched as little as 20% of their total length1. Thus, it is difficult to establish a universal standard describing correct stretching techniques. In addition, improved joint ROM can be attributable to extraneous factors (such as increased pain tolerance); making the strength of its relationship to stretching highly questionable.

There are a plethora of studies conducted that attempt to quantify the effect of stretching on performance. One study, conducted by researchers at Sahmyook University in 20182 examined the effects of stretching on muscle strength, endurance, and endurance in a non-athletic sample of 13 active collegiate male students. These subjects were separated into three groups: those who did not perform any warm ups before exercise  (NWU), those who performed aerobic warm ups in the form of power walking for ten minutes (AWU) before exercise, and those who performed aerobic warm ups with static stretching for ten minutes (ASU). All three groups performed isokinetic muscle testing. The stretching used in the study consisted of straddling, seated calf stretching, and standing quadriceps stretching for the lower body. Two repetitions of each stretching motion were performed for 20 sec each and the entire stretching program took 5 min to perform. All subjects rested for 1 min after warming up and then underwent isokinetic muscle testing of the knee joints. The sequence of performance of each warm-up exercise was individually randomized. In the successive weeks, each group was tested according to the type of warm-up performed. The testing was conducted for 3 weeks, and all groups were allowed a week to rest in between tests.

In order to quantify the results in each group, a knee extension/flexion isokinetic  dynamometer was used. Participants were asked to extend and flex the knee by exerting their maximum strength as fast as possible while keeping their trunk up against the backrest during the test and to hold onto the handles. The subjects performed the maximal test of four repetitions. Each maximal test was conducted with an angular speed of 60°/sec to measure isokinetic muscle strength and an angular speed of 180°/sec to measure isokinetic muscle power. In addition, the muscle endurance test was conducted with an angular speed of 240°/sec. The exercise was conducted twice prior to testing to familiarize the subjects with the test, thereby achieving optimal results. The subjects were verbally encouraged and allowed to view their torque graphs during testing as a form of visual feedback to increase motivation.  To analyze muscle strength, power and endurance, measurements of the left and right knee joints were divided into each independent variable before data processing was performed. In addition, psychological evaluations in the form of questionnaires were administered to subjects before and after workouts for individuals in all three groups. These assessments utilized a 5-point Likert scale (1, very bad; 2, bad; 3, average; 4, good; 5, very good). The Kruskal–Wallis rank test were used to examine the differences of variables among groups and the Wilcoxon test was used to investigate psychological conditions before and after warm-ups within times in each group. A Mann–Whitney post hoc test was implemented to detect any significant differences in the Kruskal–Wallis test. The significance of all data was established at p ≤0.05. The results from the table have been included in figures attached to this post. The data is shown in the bottom of this point via a hyperlink. 

Based on the results of this experiment, the researchers concluded that there was no significant effect of the type of warm-up activity on performance in any of the tests performed in this study. Shown in Table 2, at 60°/sec (which is an angular speed for rating muscle strength), the NWU showed higher rates for both the extensor and flexor. However, the researchers determined that the difference was not statistically significant Shown in Table 3, at 180°/sec (an angular speed associated with rating muscle power), AWU and ASW groups attained higher rates for the flexor and extensor, respectively, although the difference was not statistically significant. The total work at 240°/sec (which reflects muscle endurance) was higher in ASW for both the flexor and extensor than NWU and AWU, though not statistically significantly. These results are shown in Table 4. In a similar manner to the trends seen when evaluating athletic performance, the individuals in the ASW group marked higher scores on their psychological assessments than the AWU and NWU groups. The results are shown in Table 5. However, the researchers determined that the result were not statistically significant.

Overall, while there appears to be some merit to the psychological benefits of stretching before exercising, its effect on athletic performance remains inconclusive. However, if you find that stretching helps improve your outlook/state-of-mind during the course of your workout, I would highly encourage you to continue your routine.

 

Questions to Consider

  1. Based on the experiment, do you believe that stretching before a workout provides any benefits/advantages towards performance?
  2. Does this post affect your views towards stretching?
  3. Would you encourage someone seeking to exercise more frequently to stretch before/after their exercises?

 

References

  1. Andersen JC. Stretching before and after exercise: effect on muscle soreness and injury risk. J Athl Train. 2005;40(3):218–220.
  2. Park HK, Jung MK, Park E, et al. The effect of warm-ups with stretching on the isokinetic moments of collegiate men. J Exerc Rehabil. 2018;14(1):78–82. Published 2018 Feb 26. doi:10.12965/jer.1835210.605

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