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.

Acupuncture for hot flushes/flashes

Have you ever thought about acupuncture for hot flushes/flashes. Acupuncture may help with the intensity and frequency of such events. Watch the video for a brief insight into how acupuncture might help you

Grade 2 calf strain

This time of year I often see many runner coming into clinic complaining of calf strains. With many people running on the downs failure to warm up or stretch after running often leads to overloading of the calf muscles leading to tearing of the muscle. A Calf muscle injury is common in sports. Calf injuries are sometimes known as a ‘pulled Calf'. The term 'pulled muscle' comes from the description of how the injury takes place. Usually the Calf muscle is forcibly stretched beyond its limits and the muscle tissue becomes torn. A tear in the Calf muscle is referred to as a Calf strain and depending on its severity it is classified as a first, second or third degree strain: A first degree strain is damage to a few muscle fibres. A second degree strain is damage to a more extensive number of muscle fibres. A third degree strain is a complete rupture of the muscle itself.

 Calf Muscle Strain Signs & Symptoms

With a grade one Calf strain the signs may not be present until after the activity is over. There may be a sensation of cramp or tightness and a slight feeling of pain when the muscles are stretched or contracted. With a grade two Calf strain there is immediate pain which is more severe than the pain of a grade one injury. It is confirmed by pain on stretch and contraction of the muscle. A grade two Calf strain is usually sore to touch. A grade three Calf strain is a very serious injury. There is an immediate burning or stabbing pain and the athlete is unable to walk without pain. The muscle is completely torn and there may be a large lump of muscle tissue above a depression where the tear is. After a few days with grade two and three injuries a large bruise will appear below the injury site caused by the bleeding within the tissues.

 Calf Muscle Strain Treatment

Resting may be the common sense approach, but it is one that is often ignored. This is unwise, since it does not take much to turn a grade one Calf muscle strain into a grade two, or a grade two Calf strain into a grade three. As a general rule, grade one Calf strains should be rested from sporting activity for about 3 weeks and grade two injuries for about 4 to 6 weeks. In the case of a complete rupture, the Calf muscle will have to be repaired surgically and the rehabilitation afterwards will take about 3 months. I treat calf strains with a combination of massage, acupuncture, kinseotaping and advice on when to return to running.

Diet as Medicine

This is a long video so make yourself a cup of tea but what follows is an interesting lecture on the benefits of proper diet. An often overlooked subject.

Acupuncture outperforms migraine drug

Acupuncture has been shown to outperform the drug valproic acid in reducing the pain intensity of migraine headaches, without any of the adverse effects associated with drug therapy. A prospective, controlled study involving 100 migraine patients was carried out by Italian clinicians. Patients were randomly divided into two groups; Group A (acupuncture) received 20 acupuncture sessions, while Group V (valproate) received 600 mg/day of valproic acid, over a period of six months. Rescue analgesia (10 mg rizatriptan) was allowed as needed to treat migraine attacks. Both groups showed improvement in scores on the Migraine Disability Assessment (MIDAS) questionnaire after three and six months of treatment. Pain intensity was shown to be better in Group V at three months, but after six months of treatment, pain intensity, pain relief scores and rizatriptan intake were all significantly better in Group A. The rate of adverse events was 47.8% in Group V, compared with 0% in Group A. (Acupuncture Versus Valproic Acid In The Prophylaxis Of Migraine Without Aura: A Prospective Controlled Study. Minerva Anestesiol. 2013 Mar 19. [Epub ahead of print]).

Acupuncture top therapy for relief of arthritis

Acupuncture is the most effective complementary therapy for treating osteoarthritis, and also scores highly for other chronic musculoskeletal pain conditions, according to a report by the charity Arthritis Research UK. The report summarises current evidence for practitioner-based complementary therapies that are commonly used to treat rheumatoid and osteoarthritis, fibromyalgia and low back pain. The report found a lack of scientific evidence to support the use of most of the twenty-five therapies considered. Each therapy was scored according to its effectiveness on a scale of one to five, based on published data from clinical trials. Effectiveness was measured in terms of improvements in pain, disability or quality of life. In addition the safety of each therapy was graded as green, amber or red. The therapies that were shown to be the most effective were: acupuncture for osteoarthritis (scored 5), low back pain (4) and fibromyalgia (4); massage for fibromyalgia (5) and low back pain (5); tai chi for osteoarthritis (4); and yoga for back pain (4). (http://www.arthritisresearchuk.org/news/press-releases/2013/january/new-report-on-complementary-therapies-for-arthritis-reveals-lack-of-scientific-evidence.aspx).

Exercise for Hip and Knee Replacement

One of the most important areas to consider for hip and knee surgery pre and post operation is the importance of exercise. Prehab is just as important as rehab post operation as the stronger and fitter you are prior to operation the better outcome your operation will be. Watch the video above to find out why.

Acupuncture for Cancer related fatigue

Toyah Willcox on coping with insomnia using acupuncture

New Years Resolutions in 2013

Many people make New Years resolutions but do they actually stick to them. Watch this interesting video to find out....

Acupuncture benefits IVF

Results from a meta-analysis by Chinese authors indicate that acupuncture, especially around the time of controlled ovarian hyperstimulation, can improve pregnancy outcomes in women undergoing IVF. The paper also suggests that more positive IVF outcomes can be expected if treatment is individualised to each patient. Twenty-three trials (a total of 5598 participants) were included in the analysis, including nine studies that had not been included in previous systematic reviews of acupuncture for IVF. The pooled clinical pregnancy rate (CPR) from all acupuncture groups was found to be significantly higher than that from all control groups, whereas the live birth rate (LBR) was not significantly different between the two groups. However, the results were quite distinct when the effect of the type of control procedure used and/or the timing of acupuncture treatment were examined in a sensitivity analysis. (The role of acupuncture in assisted reproductive technology. Evid Based Complement Alternat Med. 2012;2012:543924. Epub 2012 Jul 2).

Acupuncture, fatigue and breast cancer

A large-scale clinical trial has shown for the first time that acupuncture is effective in treating fatigue in former breast cancer patients.

England cricket star, Stuart Bond has acupuncture

Acupuncture benefits IVF

Many women turn to acupuncture when trying to conceive and will often use acupuncture as a means to enhance fertility. The research below suggests that acupuncture when used alongside IVF may be beneficial

Results from a meta-analysis by Chinese authors indicate that acupuncture, especially around the time of controlled ovarian hyper stimulation, can improve pregnancy outcomes in women undergoing IVF. The paper also suggests that more positive IVF outcomes can be expected if treatment is individualised to each patient. Twenty-three trials (a total of 5598 participants) were included in the analysis, including nine studies that had not been included in previous systematic reviews of acupuncture for IVF. The pooled clinical pregnancy rate (CPR) from all acupuncture groups was found to be significantly higher than that from all control groups, whereas the live birth rate (LBR) was not significantly different between the two groups. However, the results were quite distinct when the effect of the type of control procedure used and/or the timing of acupuncture treatment were examined in a sensitivity analysis. (The role of acupuncture in assisted reproductive technology. Evid Based Complement Alternat Med. 2012;2012:543924. Epub 2012 Jul 2).