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If you have taken a break from running for six weeks or more, it’s important to identify and address any muscle imbalances you might have before you return to running. Muscle imbalances contribute to unstable posture, poor biomechanical alignment, and compensation mechanisms – all of which can contribute to a running injury. Getting your muscles in balance simply lets you work your legs properly for running.
Muscle imbalances are usually caused by the tightening of a mobilizing muscle and the weakening of a stabilizing muscle. Mobilizing muscles are generally big muscle groups that produce movement and high power. Stabilizing muscles are smaller and control movement or joint position, working against gravity. Muscles work together with your nervous system in a neuromuscular control system that helps you keep your balance. Any dysfunction in this neuromuscular system results in poor postural control, delayed muscle reaction time, and muscle imbalances.
When it comes to good running form (posture, balance, control, and symmetry), there are four basic form requirements that you should evaluate:
- Maintain stability and balance while standing on one leg with your foot pointed straight forward.
- Use the dynamics of your armswings to stabilize and balance your body.
- Keep your body straight and balanced while pushing off through the big toe.
- Keep your body straight and balanced while kicking straight back.
How do you know if your form is correct? You can use Basic Closed-Chain Exercises as an evaluation tool to locate any region that isn’t working right or is out of balance. There are eight Basic Closed-Chain Exercises (see table below) that break your running style down into these four different form elements, and help you find any stiffness, weakness, or asymmetry. Using these exercises, you can detect a muscle imbalance if you feel any difference in strength or range of motion on the left and right sides of your body.
You can also use these exercises to specifically attack any deficit in strength, symmetry, or running pattern that you find and bring your body back into balance. Closed-chain exercises duplicate the biomechanics of running and strengthen your body for running. You should striving for symmetry in form, pace and duration of each exercise. For example, as you practice one-leg armswings, it’s important to concentrate specifically on what you are trying to accomplish. You are trying to put certain angles very specifically where they need to be, and trying to maintain that symmetry and balance from the beginning of each exercise to the end. This requires mental focus, body awareness, and a dedicated follow-through.
The importance of mental focus while doing closed-chain exercises cannot be overemphasized. The instructions for each exercise include a specific mental focus statement that addresses one of the four basic form requirements for balance. As you perform each exercise you can repeat this statement to yourself like a mantra to help you keep your attention focused on what you are trying to accomplish. If you are not focusing on your form, you are probably doing it wrong.
Another important lesson when learning closed-chain exercises is to practice keeping your balance, not to practice losing it. You are working on areas of weakness and neuromuscular dysfunction, so you can expect to start out a bit wobbly or to become easily fatigued. If that happens, stop before you lose your balance, not afterwards. Take a break and try again. You don’t want to practice doing an exercise the wrong way.
Clearance: When you can easily complete all eight Basic Closed-Chain Exercises with no break in form, you have passed your balance and control checkup and you are ready to move on with building up your running base.
Basic Closed-Chain Exercises for the 4 Basics of Form and Balance
Evaluate your balance and muscular control with a series of 8 Basic Closed-Chain Exercises. (See Chapter 14 of The Running Injury Recovery Program for instructions.) Each of these exercises focuses on one of the four basic principles of good running form and balance:
|Form Requirement||Basic Closed-Chain Exercises|
|1. Maintain stability over the aligned foot||14-1 Square Hops|
|14-2 Side Step-Down|
|2. Control armswings to achieve a balanced body||14-3 One-Leg Armswings, Barefoot|
|14-4 One-Leg Armswings with Single Pillow (Shod)|
|3. Control your weightbearing through the big toe||14-5 Barefoot Push-Up|
|14-6 Quick Steps|
|4. Maintain stable posture with straight kickback||14-7 Weighted Kickback|
|14-8 Box Step Up and Over|
If you have taken a break from running for 6 weeks or more, for whatever reason, you can strengthen your body to return to running with my 12-Week Running Fitness program.
As a Miami runner, each year I long for an end to the stifling heat and humidity of summer and look forward to running in the cool, crisp mornings of fall. You might think you can just take a break from running and pick up wherever you left off, but in my professional experience, runners lose their runner’s body after 6 weeks of little or no running. That means your muscles, ligaments, and even bones are more susceptible to stress, and you increase your risk of injury.
To avoid this problem, you should get back into running carefully and gradually while strengthening your body for running. I recommend a progressive, 12-week running fitness program broken into six 2-week intervals. This program is based on the 2-week-interval Walk/Glide plan described in The Running Injury Recovery Program, where you can find detailed instructions and illustrations for all of the techniques mentioned below.
In this program, you’ll use progressive Walk/Glide sets (see the table) as a training tool. We start at Level 0 with 60 minutes of Fitness Walking – a very strenuous and balanced form of walking – and 0 minutes of running. At Level 1, you’ll begin 5-minute Walk/Glide sets with 1 minute of Glides (a smooth and upright form of running). Each two weeks you will increase your Glide time until you can glide continuously for at least 50 minutes while maintaining correct form.
During each 2-week interval, your goal is to practice these Walk/Glide sets until you can complete them correctly, with no break in form. Before moving on, you must be able to complete each 60-minute training session continuously and with good form, for at least one week. This is a checkpoint that lets you know when you have reached your strength goals and are ready to step up to the next training level.
The Training Plan
- Wear well-fitted and supportive training shoes.
- Set a training schedule for your Walk/Glide Program: 1 hour per day, 3 to 5 days per week. In this case, more or less is not better. Choose the number of days that is closest to the number of days you plan to run consistently this season.
- Focus on form: In the Walk/Glide Program you will alternate Fitness Walking and Glides. Your posture should be straight and balanced, using a smooth, full-footed, heel-to-toe stride.
- Warm up and cool down: Each 60-minute training session includes 10 minute of Fitness Walking as a warmup, then 50 minutes of Walk/Glide sets. After your sets, cool down with a few more minutes of Fitness Walking.
- Wait for “clearance;” Do not progress to the next higher training level until you have completed your training schedule for 2 full weeks. If you have not completed your Walk/Glide sets continuously and with good form for at least 1 week, then keep on working at it, even if you take more than 2 weeks at that level.
- Stick with it! A little patience now will improve your running skills and reduce your risk of injury.
|Training Schedule for 12-Week Running Fitness Walk/Glide Program|
|Warmup/ Fitness Walking||5 Minute Walk/Glide SetsRepeat 10 times = 50 minutes|
|Level 0(Weeks 1 and 2)||60 minutes||No running|
|Level 1(Weeks 3 and 4)||10 minutes||1 min. Glide + 4 min. Fitness Walk (x10)|
|Level 2(Weeks 5 and 6)||10 minutes||2 min. Glide + 3 min. Fitness Walk (x10)|
|Level 3(Weeks 7 and 8)||10 minutes||3 min. Glide + 2 min. Fitness Walk (x10)|
|Level 4(Weeks 9 and 10)||10 minutes||4 min. Glide + 1 min. Fitness Walk (x10)|
|Level 5(Weeks 11 and 12)||10 minutes||50 min. Glide|
Most people know when they are injured. It hurts. Runners who live with chronic arthritis pain face a larger challenge. If they take pain medication to manage their chronic pain, then they might not notice the pain of a running injury and that injury can get progressively worse. If they do notice the running injury, then their pain medication can interfere with the recovery process.
If you take pain medication for arthritis, and have a running injury and keep on running, it can only move you faster toward a severe, crippling running injury and eventually a need for hip or knee surgery. I have known runners who pushed on through Red Flag symptoms and ended up at Injury Stage 5, crippled, which ended their running careers when they were unable to fully recover.
Since pain is a primary indication of a running injury, runners with chronic arthritis pain must be particularly vigilant. Taking pain medication in order to run is a Red Flag warning symptom, meaning that you should not run. However, if you must taking anti-inflammatories to control your arthritis pain, then you still may be able to run, as long as you follow a plan that is approved and monitored by a qualified healthcare professional. You still should not take pain medication in order to run – that’s still a Red Flag situation.
Whether you try to manage your arthritis pain without any pharmacological help, as I do, or you are on a prescribed regimen of anti-inflammatories, your arthritis pain can flare up when you run. So how can you tell whether your pain is from the arthritis or from a running injury? One of the conditions that define a running injury is that the pain you are experiencing must be unusual and disconcerting. If you are following a running plan that has been approved by your healthcare professional, you will soon get to know your own limits and how much running triggers your arthritis pain. Once you recognize that kind of pain, it is still pain, but it will no longer be unusual or disconcerting. Any pain that is different should be unusual and disconcerting; in that case you should stop running and consult your healthcare professional.
If you are running with chronic arthritis pain, remember that triggers and Red Flags still count, even though the pain is no longer unusual or disconcerting:
- Follow a modified training plan approved by your healthcare professional.
- Know your pain triggers and avoid them as much as possible.
- Do not take pain medication in order to run.
- Watch for other Red Flag symptoms such as altered stride.
- Get qualified professional help to monitor both your chronic condition and your running injuries.
The following is a list of video taped demonstrations of all the exercise in The Running Injury Recovery Program.
The exercises are demonstrated, video taped and edited to the best of my abilities therefor are imperfect. Remember the goal of all this exercises is not do them perfectly but to identify impairments to running and strengthen your body to run healthy again.
|Exercise Number||Name||Run Time||Link|
|Self-Mob 10-1||Toe #1||1:09||http://youtu.be/4oZzpduGGPA|
|Self-Mob 10-2||Toe #2||1:09||http://youtu.be/jkpev2JW9Ic|
|Self-Mob 10-3||Arch #1||1:09||http://youtu.be/QGfBCBFaNLg|
|Self-Mob 10-4||Arch #2||1:09||http://youtu.be/vFdoDTC1gcg|
|Self-Mob 10-5||Heel #1||1:09||http://youtu.be/8rzDz-JMdp4|
|Self-Mob 10-6||Heel #2||1:09||http://youtu.be/sCNv-x0cwJg|
|Self-Mob 10-7||Shin #1||1:09||http://youtu.be/nIBD1KppbDc|
|Self-Mob 10-8||Shin #2||1:09||http://youtu.be/vm-0OAuSv2s|
|Self-Mob 10-9||Calf #1||1:09||http://youtu.be/X3DEEHuxjwY|
|Self-Mob 10-10||Calf #2||1:09||http://youtu.be/Lw8v2_zIL5o|
|Self-Mob 10-12||Band #1||1:09||http://youtu.be/RpaEjVh7Ng4|
|Self-Mob 10-13||Band #2||1:09||http://youtu.be/bQgk1Cp566c|
|Self-Mob 10-14||Band #3||1:09||http://youtu.be/AF0TloHyKMc|
|Self-Mob 10-15||Hamstring #1||1:09||http://youtu.be/-Jvcv47tqVE|
|Self-Mob 10-16||Hamstring #2||1:09||http://youtu.be/L8TO0LQXlNE|
|Self-Mob 10-18||Buttock #1||1:09||http://youtu.be/LnFsi28awoA|
|Self-Mob 10-19||Buttock #2||1:06||http://youtu.be/6r8jYO6udhk|
|Exercise Number||Name||Run Time||Link|
|Stretch 11-1||Wall Toe Rope||01:22||http://youtu.be/T5F7uj3kjxQ|
|Stretch 11-2||Wall Calf Rope||01:21||http://youtu.be/gBr2r8226Io|
|Stretch 11-3||Wall Hamstring||01:39||http://youtu.be/_vI-zKRyV3c|
|Stretch 11-4||Ankle-Knee Wall||01:39||http://youtu.be/whsbLtuKjqk|
|Stretch 11-5||Toes to Nose||01:24||http://youtu.be/YKyiu4dmtcI|
|Stretch 11-6||Toes Nose Belt||01:39||http://youtu.be/KpIZtN1z3Yw|
|Stretch 11-7||SLR Belt||01:39||http://youtu.be/USqt8lFbW6s|
|Stretch 11-8||SLR Belt Side||01:39||http://youtu.be/R9GZaPfHABY|
|Stretch 11-9||Cross Leg Side Bend||01:25||http://youtu.be/_w1yq0Vk-zI|
|Stretch 11-10||Side Quadriceps||01:24||http://youtu.be/UpxIZGBElXs|
|Stretch 11-11||Ankle Knee Diagonal||01:14||http://youtu.be/uXDC4bkQIlw|
|Stretch 11-13||Back Incline||01:19||http://youtu.be/EAzDrLavXQM|
|Exercise Number||Name||Run Time||Link|
|Closed-Chain 14-1||Square Hops||0:59||http://youtu.be/8l0AI5g4ykE|
|Closed-Chain 14-2||Side Step Down||0:56||http://youtu.be/mqE0r9-YR8o|
|Closed-Chain 14-3||1 Leg Armswings, barefoot||0:51||http://youtu.be/W_A05uGDoZM|
|Closed-Chain 14-4||1 Leg Armswings single pillow||1:06||http://youtu.be/4R_4Pgw6NCU|
|Closed-Chain 14-5||Barefoot push up||0:54||http://youtu.be/L66fT_sCIxI|
|Closed-Chain 14-6||Quick Steps||0:56||http://youtu.be/ThvzIwDmMYo|
|Closed-Chain 14-7||Weighted Kickback||1:25||http://youtu.be/KkdjFyKAukM|
|Closed-Chain 14-8||Box Step Up and Over||1:39||http://youtu.be/uOJCEtqqwrY|
|Closed-Chain 14-9||Hip Abduction, Theraband||1:22||http://youtu.be/vn4t_7k_NQ8|
|Closed-Chain 14-10||Lateral SLR, Theraband||1:09||http://youtu.be/T5PaQKLXFW0|
|Closed-Chain 14-11||SLR with Theraband||1:21||http://youtu.be/t9FzXXx9ywA|
|Closed-Chain 14-12||1 Leg Armswings double pillow||1:17||http://youtu.be/5uxWo0U9imE|
|Closed-Chain 14-13||1 Leg Armswings. Side incline||1:13||http://youtu.be/l7llIxmxpgE|
|Closed-Chain 14-14||1 Leg Armswings, double weights||1:13||http://youtu.be/oCUyJ9zXpLo|
|Closed-Chain 14-15||High Knees with Theraband||1:39||http://youtu.be/LRm-HPfh87Y|
|Closed-Chain 14-16||Barefoot Push Through||1:46||http://youtu.be/pVVCufr7ZYY|
|Closed-Chain 14-17||Shod Pushup, ankle weights||1:58||http://youtu.be/P2aB1GEZkCk|
|Closed-Chain 14-18||Shod Pushthrough, ankle weights||1:09||http://youtu.be/Quah0LVUMt8|
|Closed-Chain 14-19||Box Step Up||1:46||http://youtu.be/TcJm8ZciYRI|
|Closed-Chain 14-20||Theraband Kickback||1:18||http://youtu.be/rKONFKbp5K8|
|Closed-Chain 16-2||Hills: Uphill||1:09||http://youtu.be/rEQX0u4upO0|
|Closed-Chain 16-3||Hills: Downhill||1:12||http://youtu.be/o6buyV5QLKc|
|Exercise Number||Name||Run Time||Link|
|Base 15-2||Fitness Walking||1:40||http://youtu.be/GL9mxRR2mho|
|Base 15-4A||Arms In||1:23||http://youtu.be/6SpymesIles|
|Base 15-4B||Arms Out||1:39||http://youtu.be/KLY12K0u-xU|
|Base 15-4C||Feet In||1:32||http://youtu.be/BHR5rsUfWY8|
|Base 15-4D||Feet Out||1:22||http://youtu.be/SL194Kq0uhU|
|Base 15-4E||Hands on Head||1:17||http://youtu.be/SfGsVZWaF0s|
|Base 16-X||Hills -ALL||3:58||http://youtu.be/gnKS6Ii0NR8|
|Base 16-X-1||NEW Uphill||2:09||http://youtu.be/k7yuhsYB7gA|
|Base 16-X-2||NEW Downhill||2:10||http://youtu.be/K30bj_25a1w|
|Base 17-1A||High Kickbacks||0:54||http://youtu.be/zSC0d8caALw|
|Base 17-1B||High Knees||0:57||http://youtu.be/LwBePiHwwOY|
Dr. Kyle Ridgeway, PT, DPT recently published a great article about “Trigger Point Dry Needling” that raises a number of concerns about the increasing use of this invasive procedure by physical therapists. During my own PT training in Manhattan, I studied with the founder of trigger point theory of pain relief, orthopedic surgeon Dr. Hans Kraus, and observed many trigger point injections. Later, in my work at a chronic pain clinic in Miami, I successfully used non-invasive manual therapy trigger-point techniques instead of needles to alleviate pain (although I prefer to use the term “soft tissue restrictions” instead of “trigger points”). In my experience, non-invasive manual therapy effectively alleviates pain in about 90% of my patients, without the negative side effects of invasive drug injections or “dry” needling. For 9 more reasons to avoid this increasingly popular technique, read Dr. Ridgeway’s article: “What are the Issues with Therapeutic or Trigger Point Dry Needling? 9 Considerations to Ponder” at:
What are the Issues with Therapeutic or Trigger Point Dry Needling? 9 Considerations to Ponder
Dry needling continues to garner increasing popularity within physical therapy. And, the focus is not just clinical, a pubmed search for “physical therapy” and “dry needling” illustrates an 8 fold increase of manuscripts from 2010 to 2015 (66) compared to 2000 to 2005 (8).1,2
The number of continuing education courses, certifications, and companies offering dry needling continues to rapidly expand. Further, there appears to be no shortage of anecdotal reports of the remarkable “power” of this intervention and clinical experiences suggesting it’s “the next big thing.” But, I have some questions, and justified concerns regarding the outpatient orthopaedic physical therapist’s most invasive intervention. Larry Benz has commented “trigger point dry needling is not #physicaltherapy.”3
Yes, while there is a paucity of evidence, TDN probably works in some instances-likely more to “meaning effect” and placebo than anything else (which of course is fine but in states with informed consent forms it probably works as a nocebo). My concern is the nocebo effect of TDN on our profession.
The irrational exuberance around TDN within the #physicaltherapy profession is ironic if not downright damaging. We fight and defend for direct access, expanded scopes of practice, evidence as the core basis of our interventions, and being recognized in the healthcare chain as force multipliers within the musculoskeletal world yet state legislators in many states are hearing PT’s fight for the right to stick needles into patients. TDN is hardly a transformative intervention and regardless it does not define #physicaltherapy.
Like Larry, I am concerned and request that we as a profession take a moment to appraise this intervention, in terms of applicable clinical evidence and appropriate critical reasoning, before enthusiastically implementing dry needling, let alone recommending it to patients in professional publications.4 Further, the issues and assessments are not limited to dry needling specifically, as the approach can be applied to other interventions and concepts such as cupping.
Clinicians utilizing dry needling will exclaim “dry needling is not acupuncture!”, but the paradox is proponents continue to use acupuncture“evidence” (of both traditional Chinese medicine and biomedical flavors) to supposedly support their practice. Obviously, dry needling is not actually acupuncture. I’m not sure it even bears repeating that rarely is dry needling the sole intervention provided by a physical therapist. But, given the invasive nature and significant learning cost, in terms of both time and money, the addition of dry needling to a treatment plan as either an additive intervention or in replacement of other interventions, seems suspect without research supporting significant improvement in outcomes.5 And, this improvement should be specific to needling itself, not the byproduct of other non-specific mechanisms. Or, alternatively, needling must illustrate some measurable, or even highly plausible, physiologic effect known to improve a patient’s condition, main complaint, or medical diagnosis.
What issues with dry needling should be considered?
1) Acupuncture Literature Applies
2) Dry Needling Research is Underwhelming and Misrepresented
3) Poor Terminology Surrounding Needling, Trigger Points, and Myofascial Pain
4) Lessons from the Evolution of Manual Therapy: Manipulation
5) Treatment Targets and Proposed Mechanisms
6) Insights from the Study of Pain
7) Risk vs. Benefit and Invasiveness
8) Cost and Time
9) Bias in Research Interpretation and Conflicts of Interest
The Acupuncture Literature Applies
I contend that the acupuncture literature can provide us with some insights on the specific effects of inserting a needle into human flesh, be they physiologic, psychologic, perceptual, or otherwise.6 Of course, this is dependent on the assumption that any specific meaningful effects exist beyond transient, clinically irrelevant short term improvements in symptoms and subjective reports likely mediated by meaning response, expectation, context, non-specific effects, and placebo.7
In short, it is unambiguously clear from high quality investigations, systematic reviews, and meta analyses that acupuncture is nothing more than a “theatrical placebo.“8 The research illustrates:
- Poorly designed smaller studies with high risk for bias showing promising results
- Larger, well controlled studies show no meaningful clinical benefit
- Needling location doesn’t matter
- Needle depth doesn’t matter
- Skin penetration doesn’t matter18
- The needle doesn’t even matter, toothpicks work just as well
Interestingly, similar to potential mechanisms in manual therapy what does appear to modulate, or predict, small observed outcomes in select patients is expectation, patient beliefs, and individual practitioner factors among others.7,9-14 Specifically,
The individual practitioner and the patient’s belief had a significant effect on outcome. The 2 placebos were equally as effective and credible as acupuncture. Needle and non-needle placebos are equivalent. An unknown characteristic of the treating practitioner predicts outcome, as does the patient’s belief (independently). Beliefs about treatment veracity shape how patients self-report outcome, complicating and confounding study interpretation.
Whether studied as a means to move qi along meridians or under a more western and biomedical informed lens, acupuncture has consistently failed to show that is an effective treatment.15 Such results should not only give us pause regarding the recommendation of acupuncture to patients for the treatment of various painful problems, but should also raise serious questions regarding the enthusiastic implementation of dry needling into physical therapist practice, clinical research agendas, and post professional education.
If needle insertion, needle location, needle depth, or even using a toothpick do not seem to affect outcomes in acupuncture, I’m perplexed by those who propose dry needling is somehow, in some way profoundly physiologically different.16-18 And furthermore, how anyone can subsequently claim dry needling location, depth of penetration, and other specific factors relating to application technique can robustly impart some important physiologic effect or meaningfully impact on clinical outcomes. Physical therapists should likely temper claims of mechanistic specificity, or effect, and be cautious in citing acupuncture literature to support the practice of dry needling.
Dry Needling Research is Underwhelming and Misrepresented
Many will claim the research around dry needling is growing, and promising results suggest broad applicability. Oddly, some will state that dry needling is not acupuncture and in the next breath cite flawed, or misinterpreted, acupuncture literature as a seemingly evidence base plea for the usefulness of dry needling. While the volume of manuscripts relating to dry needling continues to rise, the actual trial data is underwhelming at best, if not outright negative. Yet, articles in professional magazines, clinical perspectives, and (flawed) systematic reviews positively frame the intervention as effective.19-21 These assertions may mislead casual readers to conclude the data supporting dry needling is quite strong. This is not the case. Harvie, O’Connell, and Moseley at Body in Mind conclude:22
We contend that a far more parsimonious interpretation…is that dry needling is not convincingly superior to sham/control conditions and possibly worse than comparative interventions. At best, the effectiveness of dry needling remains uncertain but, perhaps more likely, dry needling may be ineffective. To base a clinical recommendation for dry needling on such fragile evidence seems rash and risks exposing patients to an unnecessary invasive procedure.
A more recent systematic review effectiveness of trigger point dry needling for multiple body regions concluded “The majority of high-quality studies included in this review show measured benefit from trigger point dry needling for MTrPs in multiple body areas, suggesting broad applicability of trigger point dry needling treatment for multiple muscle groups.”23 Unfortunately, that is not what the trials included indicated as only:
- 47% showed a statistically significant decrease in pain when compared to sham or alternative treatments
- 26% displayed a statistically significant decrease in disability
- 42% did not include a sham or control intervention group
- 32% investigated only the immediate effects (ranging from immediately post-intervention to 72 hours) of TDN which is a research design with remarkable limitations24
- 3 assessed the quality of the blinding in the sham group
- 1 was retracted at request of the journal editor
Specifically, one randomized trial effectiveness of trigger point dry needling for plantar heel pain found a number needed to harm (NNH) of 3 and a number needed to treat (NNT) of 4. So, for every 3 patients treated with needling 1 is likely to develop an adverse event while for every 4 patients treated only 1 is likely achieve a beneficial outcome. Or, in other words, patients in the treatment arm were more likely to experience an adverse event than a beneficial outcome. One of the most commonly reported adverse events, in addition to bruising, was an exacerbation of symptoms, which I will argue is only acceptable if intermediate and long term outcomes of dry needling are somehow superior. An invasive intervention that results in more adverse events, lacks long term benefit, or fails to measurably change an underlying physiologic derangement should likely not be employed. Subsequently, available interventions that are effective, less invasive, and less likely to result in symptom exacerbation such as graded exercise/activity/exposure, cardiopulmonary exercise, pain education/therapeutic neuroscience education, and non-invasive manual therapy should be preferentially implemented.
These are significant and specific concerns that require careful consideration.
Poor Terminology: Trigger Points, Myofascial Pain, and Needles
Unfortunately, dry needling is riddled with poor terminology and vague language. Admittedly, such an issue is not unique to dry needling, and thus this entire post is applicable to many interventions and trends within physical therapy: cupping, scraping the skin with instruments (instrumented assisted soft tissue mobilization), and trendy tools in the proverbial tool box.25,26 But, never the less language is a significant issue as researchers attempt to investigate and understand the intervention in greater depth and clinicians continue to broadly implement it into practice. It’s not just semantics, precision in language is an absolute necessity.28
What are the actual differences between trigger point dry needling, dry needling, therapeutic dry needling, intramuscular manual therapy, functional dry needling, systemic dry needling, integrative dry needling, or any other form of physical therapists poking patients with needles?
Regardless of the clinical trial data (which is actually weak), those utilizing a myofascial trigger point approach to dry needling need to acknowledge the current issues with regards to a lack of consistent criteria defining a trigger point, the questionable clinical importance (if any) of the proposed trigger point construct, and the poor reliability in trigger point identification. There are many foundational issues at the core of the trigger point theory including an absolute lack of established validity. John Quintner upon evaluating trigger points:29,30
The existence of such bands had never been demonstrated and it was therefore highly speculative and erroneous to attribute nerve entrapment to such a mechanism. Other weaknesses in their theory included the somewhat metaphysical concepts of “latent trigger points,” “secondary trigger points,” “satellite trigger points” and even “metastasising trigger points”. To further confuse matters, it was later shown that “experts” in MPS diagnosis could not agree as to the location of or even the presence of individual MTrPs in a given patient. The mind-boggling list of possible causative and perpetuating factors for MTrPs was completely devoid of scientific evidence and therefore lacked credibility…Finally, those who became “dry needlers” appeared to be unaware that when justifying their assault on MTrPs they were following the “like cures like” tenet of homeopathy. In their parlance, physical therapists (including physicians) were obliged to create a lesion in muscle tissue in order to cure (“desensitise”) a lesion (for which there was no pathological evidence)…
…subsequent literature was also notable for its failure to acknowledge that the underlying hypothesis was flawed – no one has ever succeeded in demonstrating nociceptive input from putative myofascial trigger points. All subsequent “research” simply assumed the truth of what started out – and remains – as conjecture.
Also, worth mentioning are the significant issues such as tautological reasoning inherent in not just trigger point theories and hypotheses, but also myofascial pain syndromes and fibromyalgia.30-33 I do agree with the term “Therapeutic Dry Needling.” I contend this language and nomenclature separates the technique from theoretical and mechanistic principles, thereby allowing continued growth and open discussion as the science evolves. In addition, the current terms, and many of the accompanying theories, are not fully encompassing of the state of the literature in regards to trigger points, myofascial pain, pain treatment, and possible treatment mechanisms. Lastly, some further perpetuate specific targets and theories of intervention that are quite frankly unreliable, and worse, invalid. Not to mention, understanding will inevitably change over time. Specifically, precise operational definitions are required for scientific inquiry. Vague language leads to vague reasoning and muddies research results. Geoffrey Maitland is credited with the insight “to speak or write in wrong terms means to think in wrong terms.”
In aggregate there is sufficient reason to not only doubt, but discard, the foundational premises of trigger points, myofasical pain, and potential “needleable lesions” as clinically meaningful entities and necessary treatment targets.34-35
The Evolution of Manual Therapy: Manipulation
History, some may say, is our greatest teacher. A rearward glance into the evolution of manual therapy practice and mechanisms, specifically manipulation, appears eerily applicable to the current discussion. Specific derangements such as sacral nutations, ESRL, FSRL, sacral flares, leg length discrepancies, static posture position, and subtle biomechanical “faults” supposedly necessitated specifically matched techniques for proper symptom resolution. The minute differences between techniques such as angle, spinal level, specific joint mechanics, and other application factors such as speed were presented as highly important to garnering the proper effect. The tissues were hypothesized to be the primary dysfunction and treatment target. Concepts such as the “manipulatable lesion” were developed.
The paradigm of assessment and treatment attempted to mirror diagnostics in other segments of medicine, a laudable effort to be sure. Clusters of information, in the case of manual therapy the patient’s symptoms, palpable dysfunctions, and malalignments, were supposed to be aggregated into a specific diagnosis. Specific diagnoses warranted specific treatment at a specific dosage or speed or spinal level. Unfortunately, the fatal flaw with this diagnostic approach in manual and physical therapy is the overall lack of essential diagnoses, commonplace in medicine, and the high prevalence of nominal diagnoses.36 Outpatient orthopaedics is primarily characterized by pain complaints, often times absent of significant trauma, tissue injury, or diagnosable physiologic derangements. In a failed attempt to solve such a conundrum, nominal diagnosis or clinical syndromes such as patellafemoral pain syndrome or “pain on the front of the knee mostly when squatting or bending the knee with the foot on the ground” and shoulder impingement syndrome or “pain on the front of the shoulder mostly when raising the arm overhead that sometimes feels like a pinch” were created with the goal of improving the specificity of treatment and our ability to match interventions to patient presentation.
Proposed mechanisms included changing tissue length, loosening joint capsule, breaking adhesions, unsticking stuck joints, and improving tissue related joint mobility. Minute, subtle, questionably detectable, but in actuality irrelevant, biomechanical faults were pitched as the cause of patient symptoms. But, years of research now state otherwise.37
Matching a specific manual therapy technique to a specific, theoretical, but quite frankly imaginary, fault proved not only to be futile, but unnecessary.38 The amount of force provided through the hands lacks the speed, acceleration, and load to meaningful change tissue length and other material properties. Manual therapy techniques were shown to result in movement at many levels of the spine. And, the specific technique utilized didn’t seem to matter much. Overall, technique type, long lever vs. short lever, speed, and exact level of the spine didn’t seem to matter much either. Predictors of response to treatment did not include classical palpation and hands on motion testing. Fear avoidance beliefs and length of symptoms did however. The neurophysiologic mechanisms of manual therapy appeared similar to placebo mechanisms.9 Patient expectation of success was important as was therapeutic alliance.11,39,40 Clinician expectation was correlated with outcome. Framing of the intervention’s potential effects seemed to affect degree of analgesia.41
Manual therapy can now be conceptualized as a neurological input and patient interaction whose overall effect, in both direction and magnitude, appear to be related to host of a complicated interacting factors, most of which have little to do with the specific technique.10
Yet, those teaching and researching dry needling appear to be clearing an old trail. Peripheral derangements, specific techniques, and minute, likely minimally important dysfunctions as a root cause of a patient’s symptoms. Assumptions, in my opinion incorrect ones, are leading us down a long road, which if manual therapy and manipulation research is any indication, will require an even longer journey to reverse.
Treatment Targets & Proposed Mechanisms
In addition to vague language, the currently proposed treatment targets and purported mechanisms of dry needling fail to integrate understanding from the acupuncture literature and compose an incomplete consideration of potential mechanistic factors.
Trigger points, latent trigger points, twitch response, trigger point referral patterns, facilitated segments, neuro-trigger points, micro-tissue trauma, chronic local inflammation healed by needle induced inflammation, and the list goes on. The fact that a dense array of sensory receptors of various types, including nociceptors, exist in nearly every layer of tissue including the cutis and subcutis, suggests it is not only possible, but quite likely that stimulation of these receptors is sufficient to produce the proposed therapeutic benefits. This is anatomically and neurologically true regardless of needle depth. The clinical studies of acupuncture support such a claim as neither needle location nor depth nor skin penetration nor the needle itself appear to specifically contribute to outcomes. The skin contains dense array of free nerve endings, and other receptors. Those who present possible dry needling constructs should acknowledge the current, multi-factorial mechanisms of manual therapy and the various factors contributing to overall treatment responses.
- Can we ascertain specifically which structures are needled?
- Is it not likely we are needling a host of structures?
- Can we ascertain the receptors that are stimulated during needling?
- Is it not likely we are needling various receptors?
- Can we actually target specific tissues or receptors?
- Is targeting specific tissue necessary, or even sufficient, for symptom resolution or a positive clinical outcome?
- Does specificity in anyway affect outcome?
There are many inherent issues with assuming, let alone presenting, specificity of a treatment target and subsequently proposed mechanism based on test/re-test assessments and clinical observations of benefit. Such an explanatory model assumes the underlying theoretical construct is accurate but also that:
1) The test is specific to that tissue, structure, or defined dysfunction (validity)
2) A positive, or negative, test (or test cluster) is accurately identifying the tissue, structure, or defined dysfunction (reliability, sensitivity and specificity)
3) The subsequent treatment intervention is specific to the identified dysfunctional structure and thus
4) The mechanism of effect specifically relies on treatment target, application, and location
5) Resolution of the symptom and clinical outcome is dependent on the preceding
A test/re-test approach, while clinically appropriate for assessing response to treatment, is inappropriate reasoning as a mechanistic explanatory model. So, we must further explore:
- What is the premise of this intervention?
- Is it more efficacious, effective, or efficient than other interventions?
- Are the models of assessment and treatment plausible? Valid? Reliable?
- Are there other explanations that may explain the observed effects, and thereby question the necessity of needling?
- Is this intervention as specific to certain tissues or explanatory models as it is presented?
- Is needling necessary, or even sufficient, for symptom resolution? Or, a positive outcome?
All approaches to and explanations of dry needling need to incorporate current, multi-factorial mechanisms of manual therapy and various factors contributing to overall treatment responses in pain. Such research would suggest that targets and mechanisms of many of our interventions for pain are not nearly as specific as previously assumed and currently presented. With this this in mind, one should be cautious in making claims of specificity. How can all the other potentially stimulated neuro-vascular structures, contextual factors, patient-practitioner interactions, and various other treatment effects be ruled out, or at least addressed as not only potential contributors to outcomes, but confounders to study results?
Pain Science and Complexity
Pain is now understood as a multifactorial, individualized, lived sensory and emotional experience much more profound than mere peripheral nociceptive signaling. The neurophysiologic, psychologic, environmental, contextual, as well as social factors present in the concept of pain are exceedingly complex. And, that is not inclusive of the profound philosophical and linguistic challenges of defining, studying, understanding, educating, and ultimately interacting with someone in pain. Attempting to accurately reconceptualize pain illustrates:42
…the biology of pain is never really straightforward, even when it appears to be. It is proposed that understanding what is currently known about the biology of pain requires a reconceptualisation of what pain actually is, and how it serves our livelihood. There are four key points:
(i) that pain does not provide a measure of the state of the tissues;
(ii) that pain is modulated by many factors from across somatic, psychological and social domains;
(iii) that the relationship between pain and the state of the tissues becomes less predictable as pain persists; and
(iv) that pain can be conceptualised as a conscious correlate of the implicit perception that tissue is in danger.
These issues raise conceptual and clinical implications
And thus, it is worth mentioning not only a few of the myriad of factors that contribute to symptom severity, symptom report, and seeking medical treatment, but also the the swarm of interacting constructs that contribute to effect.43
Treatment Mechanisms in Pain
> Non-specific effects
> Patient Expectation
> Provider Expectation
> Previous Experience
> Believability of the Intervention
> Psychologic State
> Framing and Language Surrounding the Intervention
> Regression to the Mean
> Naturally History
> and others
Obviously, such factors are not unique to dry needling. They are present in all treatments, especially those for pain. But, given the current understanding of pain stemming from a multitude of varied scientific disciplines, how can we assume, let alone propose, that sticking a human in pain with a fine needle contains sufficient and significant effect to be a primary contributor to relief and positive outcomes in both the short and long term? And, more importantly, why should we? It appears we’ve learned little from decades of research into the nature of pain, the mechanisms of treatment, passive vs. active approaches to care, acupuncture, “wet needling,” and manual therapy. Physical therapists, will rightly so I might add, critique the overuse of “wet needling” (and other interventions) by physicians, yet barely raise but a whimper of protest at the proliferation of dry needling. It may be time to refine our internal, smaller picture to facilitate crossing the chasm.44,45
Risk vs. Benefit and Invasiveness
The invasiveness of dry needling within the scope of physical therapist practice presents a unique and complicated challenge when attempting to assess risk vs. benefit in isolation, risk vs. benefit in comparison to other medical procedures, as well as risk vs. benefit in comparison to other physical therapist delivered interventions. It seems we over simplify, and potentially misunderstand risk versus benefit analysis as it applies specifically to physical therapy interventions. Sure, comparing dry needling adverse event types and rates to other medical interventions is tempting. It is an interesting health services inquiry. And, such an approach does hold some value for comparing intervention risks, benefits, and efficacy within the spectrum of the many possible health care interventions. Arguably, and quite plausibly, dry needling within the confines of a physical therapy treatment plan is safer than early imaging, prolonged NSAID use, delayed physical therapy referral, opiates, and of course spinal surgery. But, it seems to me this particular argument, even if compelling, even if true, is a weak and incomplete justification for needling. Although, please note even acupuncture may not be as safe as assumed.46-48
Comparisons regarding the risk, invasiveness, efficacy, and effectiveness of specific physical therapist delivered interventions are necessary.49 These comparisons are required in general, but also specifically within various conditions, complaints, diagnoses, and patient populations. Given the invasiveness, regardless of risk profile, to justify widespread utilization dry needling must illustrate robust effectiveness (or even significantly more efficacy) in relation to other physical therapist delivered interventions. And, any potential effectiveness must be assessed in the context of possible negative effects such as an exacerbation of symptoms and other more significant adverse events.
On the grounds of efficacy, effectiveness, risk, invasiveness, and potential benefit when compared to our other interventions for pain, I can’t understand an argument that currently justifies dry needling. Physical therapists must not merely claim superiority, or justify interventions, on the tenuous foundation that we are less invasive and less risky than other medical interventions. It’s not quite that simple. Physical therapists must provide the same internal scrutiny to comparing our own interventions in addition to comparing physical therapy interventions to physician practice patterns.44 Further, when taking into account the training cost and time it does not make sense to advocate for this intervention.
Training Cost & Time
An often undiscussed problem with dry needling is both the cost and time required to learn the technique. Currently, all states that allow physical therapists to practice dry needling require further training or even certification. So now, unfortunately, physical therapists are burdened not only with assessing the potential applicability, safety, risk and benefit of the intervention, but also the cost (time and money) required to even be granted permission to practice dry needling. Such a situation is quite acceptable for an intervention with robust effectiveness and broad applicability. But, for a single, questionably effective, invasive intervention this seems unnecessary if not wrong. For clinicians, what knowledge could be gained or other skills developed? For professional organizations, what other legislative challenges could be addressed? Who stands to benefit from such a scenario? Well, most obviously those who sell dry needling courses.
Bias in Research Interpretation and Conflicts of Interest
Similar to manual therapy, an alarming number of studies investigate immediate effects only which regardless of results is likely “much ado about nothing.”24 Many of the manuscripts pertaining to dry needling also contain overstated conclusions or even a misrepresentation of results.
In this regard, it is worth noting that many of those publishing positive systematic reviews, providing anecdotes and patient stories of success, and presenting on the potential favorable impact of dry needling teach or directly financially benefit from the teaching of dry needling.19, 20 For example, Kenny Venere and I observed that the authors of a highly positive viewpoint on acupuncture for knee osteoarthritis that was published in PT in Motion not only teach dry needling continuing education courses, but also offer a certification in dry needling.15,50 Oddly, this section and the subsequent statements were edited out of the final printed version of our letter. In any case, one of the authors is the “President of the Spinal Manipulation Institute and Dry Needling Institute of the American Academy of Manipulative Therapy” which offers a postgraduate diploma (which I’ve been openly critical regarding the name).51 The diploma is described as such:
an evidence-based post-graduate training program in the use of high-velocity low-amplitude thrust manipulation and dry needling for the diagnosis and treatment of neuromusculoskeletal conditions of the spine and extremities.
Now, other individuals and companies in the dry needling post-professional education business are all also at risk of being significantly influenced by financial incentives. For example, a program director for another dry needling continuing education company, continues to publish manuscripts defending the construct of myofascial trigger points which are, unsurprisingly, the foundation of their approach to dry needling.51 I’m sure many will contend I’ve unfairly singled out these individuals. But, I am by no means insinuating those financially vested in the dry needling continuing education business are insincere or intentionally misrepresenting trial data.
I do however wish to highlight the potential for interpretation bias of research evidence when significant (or even potential) conflicts of interest and financial incentives are present. Chad Cook, PT, PhD referring to manual therapy research poignantly states don’t always believe what you read:53
…there have been a number of manual therapy studies that were designed by clinicians who have a personal interest in the success of one intervention over another. These clinicians have either a vested interest in the applications that are part of the interventional model because they provide instruction of these techniques in continuing education courses in which they profit from (although it may seem minimal, it is not); or because the tools are part of a philosophical approach or a decision tool that was designed from their efforts or efforts from those they were affiliated with. In nearly all cases, the bias is not intentional and certainly not malicious…
I am concerned that new clinicians, passionate followers of selected manual therapy approaches, and in some occasions, seasoned clinicians, will be mislead because they lack expansive/formal research training with respect to study methodology. Certainly, once information is advocated within the clinical population, it takes years to diffuse its use, even after acknowledgement of its erroneous findings.
Dr. Cook’s concerns, which I urge you to consider, relate intimately to the surge in dry needling literature and clinical application. In physical therapy research the impact of potential conflict of interest and resulting bias of researchers also highly involved in continuing education companies is in a word: unknown. But, it is quite obvious that there is a potential conflict of interest and subconscious bias present for individuals who directly financially benefit from teaching a specific technique, or approach. And, this issue transcends dry needling. Regardless of intent, there is an incentive for positive conclusions surrounding that particular technique or school of thought. What and where are the incentives? I understand, and openly support, those who identify and ask difficult questions surrounding the possible unidentified conflicts of interest which have historically been neither discussed nor disclosed. It absolutely requires consideration. More disclosure within academia and the research literature regarding business relationships and continuing education ties is warranted.
In designing, or interpreting research conscientious checks and balances, for example blinding and proper study methods, must be executed. My sense is that it would be profoundly difficult to conclude an intervention is minimally effective, or even unnecessary, after designing, teaching, and selling courses founded upon the apparent diagnostic power and treatment effectiveness of a single intervention or specific treatment paradigm.
Summary & Conclusion
Unfortunately, I sense that dry needling is the new manipulation, which to be clear is not a compliment nor an endorsement. The intervention is not going away, and precious research dollars, cognitive space, and professional resources will undoubtedly be devoted in attempts to “prove it works” (or even “how does it work?”) which is in direct contrast to the true scientific method which is founded upon falsifiability, or “prove yourself wrong” (or even “does it even work?).
But, in getting to the point, the terminology is poor, the constructs questionable, and the current research underwhelming. Acupuncture literature suggests effects are small and non-specific to needling, and the current dry needling data demonstrates the same pitfalls in both design and interpretation. Note this is our most invasive intervention for pain, and it is technically quite passive. Additionally, many of the theoretical constructs and clinical explanations are myopic, vague, and appear invalid. Assessing risk vs. benefit of the intervention in isolation, and in comparison to other physical therapist delivered interventions, is an important, under discussed complexity of implementing needling into practice. Significant potential conflicts of interest and bias are present in the literature. As if that wasn’t enough, the time and cost to learn this intervention are astounding.
Yet, positive clinician experiences, professional publications, and overly optimistic reviews continue to escalate. Jason Silvernail, DPT, DSc, FAAOMPT asserts:
We should all – every one of us – be nothing but disturbed by our colleagues’ use of emotional anecdotes. I look forward to the day when mentioning an anecdote automatically makes our students shake their heads and turn away…Highly recommend people look into MJ Simmonds’ work on intolerance of uncertainty in our profession and how that anchors practitioners beliefs into concrete and wrong explanatory models loaded with nocebo and external loci of control.
Given the discussed issues, and likely others, the current unbridled enthusiasm and growing popularity of dry needling seems unwarranted, if not a mistake. I urge physical therapists, educators, clinicians, researchers, students, and professional leaders to re-consider.
History, it appears, has taught us little in this regard.
References & Resources
1. Pub Med Search. "Physical Therapy AND "Dry Needling" 2010-2015. Performed August 3, 2015 2. Pub Med Search. "Physical Therapy" AND "Dry Needling" 2000-2005. Performed August 3, 2015 3. Benz L. Trigger Point Dry Needling is Not #PhysicalTherapy. Evidence in Motion Blog. March 2014 4. JOSPT perspectives for patients. Painful and Tender Muscles: Dry Needling Can Reduce Myofascial Pain Related to Trigger Points. J Orthop Sports Phys Ther. 2013;43(9):635 5. Ridgeway K. Measuring Outcomes, Outcome Measures, and Treatment Effects. Physical Therapy Think Tank. December 13, 2014 6. O'Connell N, Moseley GL. Acupuncture research – the path least scientific? The Conversation. October 30, 2012 7. White P, Bishop FL, Prescott P, Scott C, Little P, Lewith G. Practice, practitioner, or placebo? A multifactorial, mixed-methods randomized controlled trial of acupuncture. Pain. 2012 Feb;153(2):455-62 8. Novella S. Acupuncture Doesn't Work. Science Based Medicine. June 19, 2013 8. Colquhoun D, Novella SP. Acupuncture is theatrical placebo. Anesth Analg. 2013 Jun;116(6):1360-3 9. Bialosky JE, Bishop MD, George SZ, Robinson ME. Placebo response to manual therapy: something out of nothing? J Man Manip Ther. 2011 Feb;19(1):11-9 10. Bialosky JE, Bishop MD, Price DD, Robinson ME, George SZ. The mechanisms of manual therapy in the treatment of musculoskeletal pain: a comprehensive model. Man Ther. 2009 Oct;14(5):531-8 11. Bialosky JE, Bishop MD, Cleland JA. Individual expectation: an overlooked, but pertinent, factor in the treatment of individuals experiencing musculoskeletal pain. Phys Ther. 2010 Sep;90(9):1345-55 12. Linde K, Witt CM, Streng A, et al. The impact of patient expectations on outcomes in four randomized controlled trials of acupuncture in patients with chronic pain. Pain. 2007 Apr;128(3):264-71 13. Kong J1, Kaptchuk TJ, Polich G, et al. An fMRI study on the interaction and dissociation between expectation of pain relief and acupuncture treatment. Neuroimage. 2009 Sep;47(3):1066-76 14. Bishop FL, Lewith GT. A Review of Psychosocial Predictors of Treatment Outcomes: What Factors Might Determine the Clinical Success of Acupuncture for Pain? J Acupunct Meridian Stud. 2008 Sep;1(1):1-12 15. Venere K, Ridgeway KJ. Acupuncture Effect Not Clinically Meaningful. PT in Motion. 2015 Aug;7(7):6-7 16. Chae Y, Lee IS, Jung WM et al. Psychophysical and neurophysiological responses to acupuncture stimulation to incorporated rubber hand. Neurosci Lett. 2015 Mar 30;591:48-52 17. Bulley A, Thacker M, Moseley L. Against all reason- effects of acupuncture and TENS delivered to an artificial hand. Physiotherapy . 97 Supplement S1 18. Cherkin DC, Sherman KJ, Avins AL et al. A randomized trial comparing acupuncture, simulated acupuncture, and usual care for chronic low back pain. Arch Intern Med. 2009 May 11;169(9):858-66 19. Ries E. Dry Needling: Getting to the Point. PT in Motion. 2015;5 20. Dunning J, Butts R, Mourad F et al. Dry needling: a literature review with implications for clinical practice guidelines. Phys Ther Rev. 2014 Aug; 19(4): 252–265 21. Kietrys DM, Palombaro KM, Azzaretto E et al. Effectiveness of dry needling for upper-quarter myofascial pain: a systematic review and meta-analysis. J Orthop Sports Phys Ther. 2013 Sep;43(9):620-34 22. Harvie DS, O'Connell N, Moseley L. Dry needling for myofascial pain. Does the evidence make the grade? Body in Mind. July 4, 2014 23. Boyles R, Fowler R, Ramsey D, Burrows E. Effectiveness of trigger point dry needling for multiple body regions: a systematic review. J Man Manip Ther. 2015. DOI: http://dx.doi.org/10.1179/2042618615Y.0000000014 24. Cook C. Immediate effects from manual therapy: much ado about nothing? J Man Manip Ther. 2011 Feb; 19(1): 3–4 25. Cotchett MP, Munteanu SE, Landorf KB. Effectiveness of trigger point dry needling for plantar heel pain: a randomized controlled trial. Phys Ther. 2014 Aug;94(8):1083-94 26. Brence J. The Tools We Use. Forward Thinking PT. July 29, 2013 27. Silvernail J. Why I don't like the 'toolbox' concept. SomaSimple. Discussion Lists. February 8, 2015 28. Ridgeway KJ. Precision in Language. Physical Therapy Think Tank. May 7, 2014 29. PubMed Search for Author "Quintner JL[Author]." 30. Quintner J. The trigger point strikes … out!. Body in Mind. January 20, 2015 31. Quintner JL, Cohen ML. Fibromyalgia falls foul of a fallacy. Lancet. 1999 Mar 27;353(9158):1092-4 32. Cohen M, Quintner J. The horse is dead: let myofascial pain syndrome rest in peace. Pain Med. 2008 May-Jun;9(4):464-5 33. Cohen ML, Quintner JL. Fibromyalgia syndrome, a problem of tautology. Lancet. 1993 Oct 9;342(8876):906-9 34. Quintner JL, Bove GM, Cohen ML. Response to Dommerholt and Gerwin: Did we miss the point? J Bodywork & Move Ther. July 2015;19(3):394–95 35. Quintner JL, Bove GM, Cohen ML. A critical evaluation of the trigger point phenomenon. Rheumatology (Oxford). 2015 Mar;54(3):392-9 36. Dorko B. Incantation. The Clinicians Manual. 37. Rupiper M. Over at LinkedIn: Reply to The Drama of Manipulation; is it necessary? SomaSimple. Discussion List. April 7, 2013 38. Ridgeway KJ, Silvernail J. SI Joint Mechanics in Manual Therapy: Relevance, Please? Physical Therapy Think Tank. March 18, 2012 39. Ferreira PH, Ferreira ML, Maher CG et al. The therapeutic alliance between clinicians and patients predicts outcome in chronic low back pain. Phys Ther. 2013 Apr;93(4):470-8 40. Fuentes J, Armijo-Olivo S, Funabashi M et al. Enhanced therapeutic alliance modulates pain intensity and muscle pain sensitivity in patients with chronic low back pain: an experimental controlled study. Phys Ther. 2014 Apr;94(4):477-89 41. Bialosky JE, Bishop MD, Robinson ME, Barabas JA, George SZ. The influence of expectation on spinal manipulation induced hypoalgesia: an experimental study in normal subjects. BMC Musculoskelet Disord. 2008 Feb 11;9-19 42. Moseley GL. Reconceptualising Pain According to Modern Pain Science. Physical Therapy Reviews. 2007; 12: 169–178. Accessed via Body in Mind 43. Taylor AG, Goehler LE, Galper DI et al. Top-Down and Bottom-Up Mechanisms in Mind-Body Medicine: Development of an Integrative Framework for Psychophysiological Research. Explore (NY). 2010 Jan; 6(1): 29 44. Venere K. The Bigger Picture. Physiological. May 30, 2015 45. Silvernail J. Crossing the Chasm - Meso to Ecto. SomaSimple. Discussion List. January 19, 2009 46. Hall H. Acupuncturist’s Unconvincing Attempt at Damage Control. Science Based Medicine. June 21, 2011 47. Ernst E. New evidence on the risks of acupuncture. Edzard Ernst. October 13, 2014 48. Ernst E, Lee MS, Choi TY. Acupuncture: does it alleviate pain and are there serious risks? A review of reviews. Pain. 2011 Apr;152(4):755-64 49. Venere K. Let’s Talk About Efficacy and Effectiveness. Physiological. September 9, 2014 50. Dunning J, Butts R, Perreault T. The Evidence of Acupuncture. Viewpoints. PT in Motion. April 20105(4) 51. Ridgeway KJ. Osteopractor™ Not now, not ever. Physical Therapy Think Tank. May 17, 2012 52. Fernández-de-las-Peñas C, Dommerholt J. Myofascial trigger points: peripheral or central phenomenon? Curr Rheumatol Rep. 2014 Jan;16(1):395 53. Cook C. Don't always believe what you read. Forward Thinking PT. February 27, 2012 54. Silvernail J. Enough is Enough. SomaSimple. Discussion List. December 11, 2010
Many people suffer with some kind of chronic pain from conditions such as osteoarthritis or chronic nerve pain. The problem with chronic pain is that you can’t just wait a while and hope it will go away. It might get better or worse, but you know it’s always going to be there. The management of chronic pain requires a therapeutic program that can be sustained for long periods of time. For some of us, that can mean a lifetime.
The first instinct of most chronic pain patients and their doctors is to reach for the medicine bottle. The pharmacological universe is full of pain killers ranging from opiates to NSAIDS. The question is, do you really want to be taking any of these drugs for long periods of time, or maybe forever?
Here are a few things to consider: (1) All drugs have side effects, and the longer you take them, the worse the side effects can get. (2) You can become habituated or even addicted to pain killers. Then you start increasing your dosage but stop getting the benefits. Or you move to a stronger pain killer. (3) Using pain killers to mask your perception of pain can lead to injury. Pain killers dull your sense of pain throughout your body and can allow you to do damage without realizing the extent of your injury.
For myself, I choose to manage my arthritis pain without drugs, using a modified walk/run exercise program. Note that I say manage, not eliminate. I also advise all of my patients who suffer from chronic pain to keep moving. If they can walk, I prescribe a therapeutic walking plan. Those who are runners can usually keep on running, as long as they monitor themselves carefully to avoid red flag pain triggers.
Running has several benefits for runners who have chronic pain. Of course everyone knows that running produces endorphins and other brain chemicals that make you feel better while you are running; but running can also increase your tolerance to chronic pain by raising your pain threshold – meaning that your chronic pain will cause you less discomfort and be less debilitating. Finally, all pain has a muscular component. When you feel pain, your muscles get tense, then rigid, and your pain increases. The physical exercise of running (including self-mobilizations and stretches) helps control that muscular component.
Non-pharmacological management of chronic pain is a 24/7 occupation. If you are a runner, running can be an important part of that job!
See the article in Runners World: Running as Pain Relief
Bruce R. Wilk, P.T., O.C.S. is author of the “The Post Injury Running Recovery Program” and Director of Orthopedic Rehabilitation Specialists.
“Tom” is a big man in his early 60s who runs for fun and fitness. It helps him control his weight and his diabetes. A lifelong runner who periodically runs half marathons, Tom has had bouts of acute and chronic foot pain throughout his adult life, and was prescribed orthotics years ago. Recently, when his pain started getting progressively worse, he consulted a podiatrist – but the pain did not get better.
When Tom finally came to see me, he was crippled. His left foot was swollen like a cyst. I spotted his shoes and took out the orthotics. The left orthotic was cracked through the middle where a rubber wedge had been glued to the bottom of the orthotic. Tom told me the wedge had been added by his podiatrist, but he didn’t know the orthotic had broken.
In my physical examination, I found pinpoint pain in Tom’s left metatarsals, positioned precisely above the wedge and break in the orthotic. I manually drained the swelling in Tom’s left foot and gave him compression socks to wear, but he still couldn’t walk. I suspected a metatarsal stress fracture.
I put Tom on the Running Injury Recovery Program, starting with protection and rest/recovery. He was on a cane for 3 weeks, and it took 6 weeks more for him to walk without pain. Twelve weeks after his first symptoms, I was able to palpate a bony callus at the original site of pain (at the orthotic wedge and break) which supported my diagnosis of stress fracture.
Tom successfully completed the Running Injury Recovery Program and is now walking and running normally, without orthotics! If you use orthotics, this is a reminder to check them frequently and have your need re-evaluated regularly by your prescriber or other qualified healthcare provider. If you are an orthotic user and develop acute foot pain immediately check if any part of the orthotic is damaged. If so, take immediate action to correct this.
Several weeks before patient went to the podiatrist with acute to moderate left sided foot pain and his left orthotic was posted with a wedge on his left orthotic but not one on his right.
With the growing obesity epidemic and increasing onset of childhood diabetes and cardiovascular disease, many fathers ask me if it’s healthy and safe for their children to run. The answer is yes, when properly performed and supervised. Both of my daughters were introduced to running at an early age and now, as adults, both are still running.
As fathers, it’s our responsibility to promote a positive attitude and safe training habits for our children. Safety begins with adequate nutrition and hydration. When kids become runners, they can start thinking of themselves as athletes and begin eating healthy for running. Balanced meals with nutrient dense foods and those rich in calcium and protein are particularly important for young runners. Being an athlete can even motivate kids to avoid unhealthy foods such as sodas, candies, sweets, and fried foods, and save the high-calorie treats for special occasions. Runners do need extra calories, but not as many as you might think. Encourage your kids eat enough healthy foods to satisfy their appetites, but don’t let them overeat.
Like adults, children should drink water before, during, and after every run. Don’t let your kids wait until they are thirsty to drink water, by then fluid loss has already taken its toll. Learn the symptoms and watch out for signs of dehydration, heat exhaustion, and heat stroke. Pay attention to weather conditions; on extremely hot or humid days be sure they take in extra fluid and, if possible, avoid running during the warmest hours of the day.
Proper equipment is also important for running safety. Make sure your kids wear proper shoes that are well-fitted by a knowledgeable running-shoe professional, and clothing that is comfortable and appropriate for each individual child’s body, running habits, and weather conditions. Watch out for any signs of chafing, limping, or blisters due to shoes or clothing, and regularly check shoes for signs of deterioration or uneven wear on the soles.
Kids should follow the same good training habits as adults. When properly trained and supervised, they can slowly increase weekly mileage and run any distance. However, even though kids may seem to have unlimited energy, running too far or too fast without building up a proper foundation is harmful. Be sure that your kids are increasing their running speed and distance slowly, and take off 1 to 2 days per week from running. This will help prevent burnout, allow their body to recover, and give them time to enjoy other activities.
Even when we do all we can to keep our children safe, any physical activity always presents some risk of injury. With running injuries, the good news is that, if you catch the signs early, the cause usually can be easily identified and corrected. Keep an eye on your kids and communicate with them. Ask questions and really listen to the answers. Is your child in pain? What hurts? When does it hurt? Does it hurt after you stop running? How long has this been going on? Does it hurt when you walk?
Often, kids will deny that they are in pain because they don’t want to be fussed over, or from fear of being pulled from participation. It’s important to observe your child before, during, and after their run for any signs of a running injury. Ask yourself these questions:
- Does your child limp during their run?
- Are they complaining of significant or unusual pain after they run, or at rest?
- Are they limping or compensating when they walk, when they go up or down stairs, or when they stand up?
- Are they taking any pain medication to run, or to sleep well?
- Are they avoiding or unable to perform any of their normal activities?
Minor discomfort and soreness during and after activity is normal, but persistent pain that interferes with running or everyday activities raises a red flag. If you have concerns that your child may be suffering from a running injury, consult a health care provider who has experience working with runners. It’s never wrong to get a professional opinion.
Running is a wonderful family activity and a great opportunity for sharing and bonding. As fathers, the best gift we can give our children is a lifetime of healthful activity. Supervise and participate in your child’s running and you’ll have a safe, fun running experience!
One of the problems with professional evaluation and treatment of running injuries is the lack of standardized protocols that are founded on a proper research database using standardized definitions and procedures. It is sad but true that, in 2015, the healthcare community still has not successfully defined what a running injury is, which shows how far away we still are from a universally accepted set of protocols for the treatment of running injuries (which is why I was compelled to publish my own definition and treatment protocols in The Running Injury Recovery Program).
In an article published in the May 2015 issue of the Journal of Orthopaedic & Sports Physical Therapy titled “A Consensus Definition of Running-Related Injury in Recreational Runners: A Modified Delphi Approach” (http://www.jospt.org/doi/abs/10.2519/jospt.2015.5741#.VUeYde-BGUk) the authors try to establish a formal definition of a running-related injury in recreational runners because “The lack of standard concepts in research is perhaps the most significant difficulty in the comparison of results between studies” and “a consensus has not yet been reached.”
The authors came up with the following definition for a “running-related injury”: “Running related (training or competition) musculoskeletal pain in the lower limbs that causes a restriction on or stoppage of running (distance, speed, duration, or training) for at least 7 days or 3 consecutive scheduled training sessions, or that requires the runner to consult a physician or other health care professional.”
This definition was based on a consensus survey of 26 published researchers. Participants in the survey were selected from a list of published researchers who had previously published a definition of running-related injury, and from reference lists of researchers who had conducted other studies related to running (based on a previous study titled “Descriptors used to define running-related musculoskeletal injury: a systematic review” (http://www.jospt.org/doi/abs/10.2519/jospt.2015.5750#.VUeuOO-BGUk).
Apparently, actually being a runner, or being a professional who deals with injured runners, was not a primary criterion. I think best practices for this study might suggest a slightly different methodology. To me, it would have been more interesting to hear a definition derived from runners, coaches, physical therapists, and other primary, specialist, or emergency healthcare practitioners who have experience in dealing directly with injured runners.
Let’s examine some individual parts of this proposed definition. The first part is “Running related (training or competition) musculoskeletal pain in the lower limbs that causes a restriction on or stoppage of running (distance, speed, duration, or training).” In The Running Injury Recovery Program, I loosely define a running injury as an unusual or disconcerting pain that is associated with running (i.e. that appears either during running or in some consistent pattern after running) and that stops (or gets progressively better) when the runner stops running. The words “unusual or disconcerting” are used specifically to differentiate injury pain from the “normal” pain that typically results from exertion, particularly after a maximum effort for a competition or personal record (PR). That kind of effort invariably results in musculoskeletal pain that requires some recovery time. By definition, recovery time might be described the same way, as “Running related (training or competition) musculoskeletal pain in the lower limbs that causes a restriction on or stoppage of running (distance, speed, duration, or training).” My point is that, unless that pain is also unusual or disconcerting, the proposed definition might easily describe part of “normal” recovery rather than a unique characteristic of a running injury.
The next part of the proposed definition specifies a time period of “at least 7 days or 3 consecutive scheduled training sessions” during which training, distance, speed, or duration may be restricted. The problem with that is, all strenuous physical exertion requires some recovery time, but the exact amount of time it takes to recover cannot be quantified in such general terms because any recovery period must vary with the degree and duration of exertion, as well as the individual athlete’s conditioning. In my experience as a running coach, I’ve often seen runners complain of severe muscle pain that affected their training level for some time after a maximum effort race. However, as a PT, I knew they did not have a true “running injury”— they were just in that normal recovery period. For example, a sprinter who wins a race with a submaximal effort may have a recovery time of minutes, but a marathon racer who exerts himself to a personal record may need a month or more to return to normal training distance, speed, or duration. Again, that can be considered a part of normal recovery, not a definitive quality of a running injury. On the other hand, it might not take a runner even 7 days to identify a real (unusual or disconcerting) running injury. Clearly a period so tightly defined as 7 days or 3 training sessions is too restrictive and in my opinion detracts from the proposed definition.
I do agree with the final part of the proposed definition: that a definition of running injury should include any pain “that requires the runner to consult a physician or other health care professional.” In the real world, a running injury may or may not involve consultation with an actual health care professional, but a runner might consult a coach or trainer, or even try self-assessment through The Running Injury Recovery Program. Again, the important point here is that the runner perceives a particular pain as being “unusual or disconcerting” enough to suspect a possible injury and seek help.
I applaud the authors of this study for recognizing that the lack of standardized definitions is a huge problem in the field of running injury research, and for taking the first step toward a solution. In their conclusion, the authors clearly state that “The existence of this consensus definition does not necessarily mean that we have found the correct or best definition of running-related injuries,” but they are certainly on the right track and I hope they will continue until we have a complete set of good working definitions to help standardize running injury research.