Articles Of The Week May 9, 2021

Sometimes getting some focus is difficult, especially if you’ve been working on a project for an extended period. While these brain breaks are intended for kids, us adults could probably use one or two of them as well.

20 Energizing Brain Breaks For Kids – Lee Douglas

There are several courses out there professing how they can screen or predict injuries in athletes. So, what does the research say on predicting injuries in runners? Well, you’ll have to read this article to find out.

The Elusive Art of Predicting Running InjuriesAlex Hutchinson

Some really interesting stuff on helping people with pain. New research showing how interactions with a persons environment can influence a persons pain experience.

How Enactive Philosophy Can Transform the Treatment of Chronic Pain – Jenny Logan

We’re big fans of this podcast and big fans of Bronnie, so naturally we had to share this. They cover the clinical encounter and how it relates to a BPS framework.

The Massage Collective Podcast With – Bronnie Lennox Thompson

“As the body of knowledge to support the use of massage therapy continues to grow, understanding the basic science behind what we do and the guiding principles of adaptability enable us to apply this work to a number of pathologies.” Great to see this kind of information being developed.

Massage Therapy For The Postoperative Population; Shoulder, Hip, Knee, and Ankle – Richard Lebert

Trigger Points With Paul Ingraham


This week we have our second guest on the podcast the one and only Paul Ingraham.

Paul Ingraham is a Vancouver science journalist and publishing entrepreneur and a former Registered Massage Therapist.  He left that profession over concerns about pseudoscientific beliefs and practices, and went on to create, a website about the science of pain, injury, treatment, and rehab. He has written hundreds of articles and ten books on these themes (and about half of those are about repetitive strain injuries).  He’s also a reluctant runner and an avid ultimate player with a long list of his own sports injuries and pain problems. He is currently sheltering in place with his wife, still hiding from SARS-CoV-2, working on his next book and an endless supply of science updates to

Trigger point doubts article:

Trigger points book:

General article about massage science (an excellent place for MTs to start on


Paul Ingraham

Does Exercise ‘Work’ For Pain? – Scrutinizing The Question!

Exercise has become a popular treatment for many musculoskeletal issues over the past few years but surprisingly little is actually understood, even after tons of research, about how to use it in clinical practice and maybe even if it’s worth using?

In this blog, we will look at the actual question of “does exercise ‘work’ for pain” as ‘works’ tends to be a phrase that gets bandied about a lot without much clarity. Similar to “the research shows” when often the deeper you dive into the research the LESS clear it often becomes, especially around pain.

I will write a few more posts on the “everything works/nothing works” perspective, how it might work and how specific we may need to be in future posts.

Well Does It Work?


Well, it depends on what you mean by work? Which condition? What are you comparing it against? Do you mean pain? Do you mean disability? Did it have an effect on physical function or some biomotor variable? All of these things are quite different questions that often get lumped into the catch-all term ‘works’.

We need to think as well about WHY we might come to a conclusion on if it ‘works’ or does not. Is it because I have read widely in this area? Is it because who I follow on Twitter tells me it does or doesn’t or am I simply following my biases? A little bit of epistemology perhaps.

Like ANY intervention, exercise should be thoroughly scrutinized and the basic reality is we have to be prepared that exercise will not work for everybody, it is not a magic bullet or panacea and a lot of what we do is a bunch of informed trial and error really, but we will come back to that later in another post. We have to remember we are dealing with HUMANS who tend to be wonderfully variable in their responses as most biological organisms are.

We now discuss pain as being a complex, multifactorial experience (blah blah blah) so why do we expect one thing to come along and solve it all for everybody? For some it will be revelatory, for some, it will do very little and for others, even flair them up, so we need a bit of perspective but as a standalone treatment I think there is a lot to like here especially with the benefits for our health and well-being.

Just Hurry Up And Tell Me…..


The whole idea of “it works” could stem from how we have traditionally looked at the research. To show a difference between two interventions or ‘usual care’ it has been common to use a significance level of p = 0.05 to indicate something ‘works’, so the observed difference in effect between two groups is likely to be at least as big as reported and this then is used to reject or accept the hypothesis of a study. Generally, something like “treatment A WORKS better than treatment B” or something along those lines. Is exercise better than manual therapy? Is it better than usual care? You get the picture. I am no statistician or researcher, only a humble clinician so bear with me here.

So we might say exercise is better than usual care or whatever else, but the real question should be HOW MUCH better or the actual magnitude/size of the difference. The p-value is a statistical tool and not a measure of the actual average size of the effect. Something can be statistically significant without really making a difference to our patients and this is where minimal clinical important difference comes in (MCID).

A clinically meaningful change for pain has been discussed as being somewhere between 1-2 points on an 11 point VAS/NPRS dependent on what it is being tested against such as ‘usual care’ or another specific intervention. Other magnitudes of clinical significance have pointed a 20% or 30% change from the baseline and this makes sense as a 2 point change for a baseline of 4 is far more significant than a 2 point change on a baseline of 8 for example.

We have to be aware that these cut-off values such as 0.05 are also a bit arbitrary. If we critique the significance of p = 0.05 then we probably have to do the same for MCID too. The real value of any effect may only really be possible via subjective evaluation by the person experiencing them and their expectations of what that change should be.

We may also have to consider how we view the ‘mean effect’ as this may not actually reflect THE effect that MY patient gets (for a whole load of potential reasons). The mean represents the average response and is sensitive to those that respond very highly and also people who respond lowly or even negatively. In trials with small sample sizes, as much of exercise & pain-related research is these more extreme values can significantly alter the mean.

We should also take into account the standard deviation of the mean response and this is a measure of the variation within the group of participants being studied. This could mean (get it…) that the variation in response when applying the treatment in the clinic could also be pretty wide too. A confidence interval (CI) is another measure of uncertainty/variability around the potential treatment effect on a wider population. The CI reflects the inherent variability/error in the process of sampling taking into account the size and variation within the sample.

The last question here is does exercise research always reflect clinical practice? Personally, I tinker with the type of exercise, intensity, frequency, volume etc to ‘optimise’ for the person whether that’s in relation to their response or ability to achieve the program. If I am not getting the desired response then I feel quite at home playing with the variables. Is this right or wrong? I have no idea but standardized programs used to study exercise often don’t do this.

You Really Didn’t Answer The Question…


So what was the point of all this, well we can start to see that “it works” is a pretty nebulous term really. It’s the classic clinical conundrum of applying the world of research to our patients and how we should expect them to respond. Predicting the future is always tough and worlds of research and clinical practice is definitely not a game of certainties.

We have to consider the actual size of what ‘works’ and how likely is my patient to actually respond in this way and I see it as a bit of a “probability wrapped up in a probability”. This often makes clinicians feel uncomfortable as we tend to like certainties and sometimes research can be portrayed as more certain than it really is IMO.  But we really have to look at the trials, who they are studying, how many people, what exercise/dosage and what’s the spread of responses amongst other things to even get close to answering the question.

Next time we might actually answer the question ; )

How Can Massage Help Runners?

Some runners swear by it, others say it’s a waste of money. The fact that most elite runners have regular massage suggests there must be something in it, but how valuable a tool is it for recreational runners? Is there any evidence it reduces injury or increases performance? Let’s take a look…

What Does Massage Do?

The most commonly proposed benefits of massage are:

  • Massage helps flush away lactic acid
  • Massage improves circulation
  • Massage breaks down muscle/fascia adhesions.

It may therefore come as a surprise to hear that none of these are supported by research. In fact, the application of a little basic science suggests that such claims are either unlikely or simply not true.

What?” …I hear you shout. “So all that time & money I’ve invested has been for nothing?

No, hold on to your horses – I am a big fan of massage, I have after all taught it for several years. There is no doubt in my mind that it can help runners, just not in the way you think, and probably not as much as you may have been lead to believe.

Flushing Myths

Modern research has made it quite clear that muscle soreness is not caused by lactic acid build-up. Lactic acid (or more accurately ‘lactate’) actually clears from the bloodstream the moment you stop running, so the idea that massage helps ‘flush it out’ makes no sense.

How about flushing out toxins? Well, in all honesty, despite a lot of therapists using that as a reason, no one can actually say what these ‘toxins’ actually are. It’s an idea that sounds good but is certainly not scientifically based.

Linked with these flushing myths is the idea that massage ‘improves circulation’. Despite this being a very common claim, any increase in circulation would actually be minimal. Circulation increases when you raise metabolic demand; in other words, getting on and off the massage couch a few times will increase circulation far more than receiving a massage.

Breaking Down Knots

Ok, stay with me. Remember, I am a fan of massage and will get to the benefits soon. We just have to clear up the misconceptions first. Many runners put up with (and even expect) considerable discomfort during a sports massage in the belief that the therapist is applying the required force to break down ‘knots’ or ‘scar tissue’.

This idea is once again a myth; surgeons use scalpels to cut through scar tissue, so the belief that pressure from a thumb or elbow could break it down is obviously misplaced.

If your muscles feel more relaxed or lengthened after a sports massage, fantastic. But it’s not because the therapist has managed to force physical changes in your body’s tissues. It’s actually quite scary to think that a human being could do that with their bare hands.

How Does Massage Help Then?

So, what does massage do then? Studies show that massage after exercise can reduce the intensity of post-exercise soreness, so what is happening? Some of you may already be asking ‘why does it matter how it works, as long as it does?’

The answer to that question is as follows: if we know how something works, we can tweak it to make it work even better. If you (and your therapist) truly believe that the deep tissue massage is ‘breaking down scar tissue’, you will both be happy to put up with considerable pain, with shouts of “this hurts like hell but I know it’s necessary” and “no pain, no gain!”

Though there is a lot about pain that we do not yet understand, what we do know is that allowing a therapist to pummel you can actually lead to a delay in recovery. Pain is an output from a nervous system that is essentially trying to protect you from real or perceived damage. Trying to fight pain doesn’t make sense because all you’ll ultimately do is wind the nervous system up even more and cause it to output even more pain.

This is why stress, poor nutrition, lack of food, etc. can all increase pain. They all cause the nervous system to feel more vulnerable. And this is where we now reveal the most likely mechanism behind massage… it relaxes the nervous system

Relaxing The Nervous System

Studies show that massage can reduce both depression & anxiety. It relaxes the nervous system, removing threat and giving it less reason to output pain or restrict movement. This is why after a suitably deep massage we often feel less pain and can move more freely. The effect will not necessarily last forever (we have all seen how the initial pain often returns after a few days) but it can be a way to speed up recovery, allowing us to train more intensely without increasing the risk of overload and injury. We all enjoy a firm massage but putting up with too high a pressure runs the risk of doing the opposite.


Massage can help runners, just probably not for the reasons traditionally given. By relaxing the nervous system (as opposed to winding it up), massage can aid recovery, allowing you to train vigorously without increasing the risk of injury. The skill of the massage therapist, therefore, lies in applying a suitable amount of pressure at the right time. Talk of ‘breaking down scar tissue’ or ‘realigning tissues’ is outdated and can lead to runners putting up with unnecessary pain that can actually delay recovery.


Also, if you missed it, we had Matt on the podcast last week, give it a listen here: “Helping Runners With Matt Phillips” 

Articles Of The Week April 25, 2021

Admitted from the authors, more research has to be done on this, but this is important. Many in our profession use essential oils, however, after this study, you may want to re-think this in your practice if you are using them.

Scientists find new evidence linking essential oils to seizures – Beth Newhart

There have been studies to show how blue light therapy can help with sleep and Seasonal Affective Disorder (SAD), but could it help with concussions? Well, we know massage is effective with helping sleep, so maybe both could be good?

Can Blue Light Therapy Help Concussion Symptoms? – Ashley Brzezicki

“There is no shortage of press about the positive effects of meditation on people, and there are plenty of studies to back them up. But there is also evidence—evidence that’s been growing for decades—that prolonged meditation can have a drastic negative impact on some people. This doesn’t make the practice bad, or invalidate the help it has given to many … but ask yourself if you’ve ever heard anything about the possible dangers of meditation. Why is that?”

Why Does Nobody Talk About The Dangers Of Meditation? – Jordan Heath-Rawlings

Could these COVID lockdowns be affecting our mental health? For sure! But there’s good reason why and it’s affecting how we focus along with other cognitive functions.

Brain fog: how trauma, uncertainty and isolation have affected our minds and memory – The Guardian

A number of years ago I took an IASTM course so I could save my hands. There were some pretty bold claims in the course and honestly I never really questioned it till years later. However, here’s the good and the bad of this technique.

IASTM Whatever Butters Your Bread – Taylor Laviolette