Mel Siff Blog

If any one thing that characterises the resolution of musculoskeletal pain
and dysfunction, it is the large number of different approaches which enjoy
some measure of success. It has never been established that there is
definitely one best method of treating problems of the back, shoulder, legs,
arms, yet the claims of many qualified and ‘informal’ therapists suggest that
they alone have developed methods that are far better than any others. In
fact, some of these therapists use such a mixture of different methods, that,
given sufficient time, effort and psychological stroking, they have to
produce some progress.

Some of these therapists, especially those with informal or self-awarded
‘credentials’, spend an inordinate amount of time applying an extensive Read more…

For newcomers, these P&Ps are Propositions, not facts or dogmatic
proclamations. They are intended to stimulate interaction among users
working in different fields, to re-examine traditional concepts, foster
distance education, question our beliefs and suggest new lines of research
or approaches to training. We look forward to responses from anyone who has
views or relevant information on the topics.

PUZZLE & PARADOX 72

The effects of joint manipulation or mobilisation may not be as clearly
related to traditional explanations of their underlying mechanisms as
suggested by various therapists.

Most sports scientists, physiotherapists and athletes are very aware of the
various classes of mechanical ‘realignment’ of joints (including
manipulation and mobilisation) that are applied by physical therapists or
chiropractors. These twists, thrust, pulls or pushes of the spinal column,
in particular, are often accompanied by an audible ‘click’ or ‘pop’.

The professional therapists who apply this form of treatment attribute any
subsequent relief from pain or mobility symptoms to processes such as the
reduction of subluxations, stretching of connective tissue, the release of
nitrogen bubbles within the joint fluids, the realignment of joint surfaces,
nerve release and so forth.

This type of procedure is the central foundation of chiropractic and to
manipulative therapy in physiotherapy, with its users totally committed to
its effectiveness. Some long-term studies, however, indicate that joint
manipulation or mobilisation makes no statistically significant difference to
the rate or degree of recovery of the client from pain or malfunction. In
some cases, these procedures have resulted in far greater damage to the
patient, with periodic reports of hemiplegia, quadriplegia or exacerbation
of existing spinal damage appearing (frequently a result of inadequate
collaboration with medical, radiographic or surgical experts).

While the controversy between the merits and demerits of manipulative
procedures will no doubt continue to rage, this is not the main thrust of
this P&P. What appears to remain uncertain is the reason why these
procedures are successful in certain instances. All of the reasons
mentioned above need to be examined carefully before we can state
scientifically that there is a cause-effect relationship between any of them
and rehabilitation from back pain and/or dysfunction.

For instance, let us examine the contention that a quick, sharp thrust of
certain vertebrae will stretch the ligaments in that region and produce
greater mobility at that level. This presumes that a rapid movement will
cause permanent plastic deformation of the connective tissue, which happens
to be viscoelastic in nature. This means that rapid thrusts should evoke a
more elastic response from the appropriate vertebral ligaments, rather than
plastic deformation, which usually is a result of prolonged stretching above
a certain threshold level of strain in the tissues. So, if plastic
deformation is unlikely, this leaves only one other alternative, namely
tissue rupture, which is the last thing that any therapist wants.

However, all of this presumes that the therapist can produce sufficient
manual force to deform ligamentous tissue, which is highly unlikely, because
of its enormous mechanical tensile strength.

This immediately leads us to the hypothesis that many ‘back problems’ are
due to subluxations (small dislocations) of the vertebrae relative to one
another. We immediately have to ask if normal daily activities can
temporarily stretch enormously strong ligaments sufficiently to permit these
subluxations to persist for prolonged periods until the therapist
intervenes.

We have to examine the proof for the existence of these temporary
subluxations such as MRIs or CAT scans – is there unequivocal evidence to
show that ligaments (which are extremely inextensible) can be temporarily
stretched to allow adjacent vertebrae to stay dislocated relative to one
another? If so, then it will be interesting to carry out a biomechanical
analysis of the stresses and strains involved. It will be even more
interesting to understand how the slightly, but powerfully stretched,
ligaments manage to return to their original length along an hysteresis path
that shows no residual strain after prolonged stretching.

Even if one suggests that the subluxation or displacement that is reduced by
manipulation is the sum of tiny contributions from many vertebrae, it does
not eliminate the fact that ligament is very difficult to deform, especially
if subjected to a single sharp thrust.

What then of traction, that is probably used as widely as manipulation? Can
one state that traction stretches ligaments as well and relieves pressure on
nerves? Or is the idea of traction simply to overcome a persistent myotatic
stretch reflex which has temporarily forgotten to become inoperative or a
Golgi tendon reflex that has omitted becoming involved?

Possibly this would then offer a more rational approach to explain why
manipulation might relieve back pain or dysfunction. Such an hypothesis
would suggest that the muscles cause the ligaments to be pulled in a certain
direction, thereby producing and sustaining a subluxation. Of course, we
then have to examine how long a stretch reflex can remain operative and how
long a muscle can remain submaximally contracted. In the case of some back
pain sufferers, we might have to wonder at the impressive local muscle
endurance involved.

There are several other questions remaining regarding manipulation, such as
the cause of the ‘pop’ or click’. If it is indeed produced by the release
of air or nitrogen bubbles into the joints, then this would imply the
occurrence of cavitation, which is known to produce very detrimental shock
waves in engineering systems. If gas bubbles are released in the
cerebrospinal fluid, does this not imply the possibility of micro-shock wave
damage to structures in the spine, especially if manipulation is applied
regularly? Is there any evidence for the release of gas bubbles with
manipulation and, if so, are there any studies to show that they are
harmless artifacts?

Maybe the acute relief afforded in certain cases is more a consequence of
neural stimulation rather than mechanical realignment, caused by stimulation
of the nerves passing from the foramina of the spine. Would this also be a
reasonable hypothesis? Naturally, this would give us the opportunity of
invoking the ubiquitous placebo effect!

This P&P could be extended into the broader territory of deep transverse
friction, structural integration (‘Rolfing’) and so on to create a broader
base for examining the mechanical manipulation of the entire musculoskeletal
system. Indeed, this would probably be of enormous value in removing some
of the controversy associated with all of these procedures.

Comment on any of the issues raised by the above focus on manipulation and
mobilisation as currently practised by various therapists, quoting any
scientific studies which appear to support or disprove the value of these
procedures and the explanations presently given to validate them. Regarding
the mechanisms involved – Is it in the back or is it all in the head?

——————

Mel Siff

Comments on the possible role of magnets in sport usually produced little
serious discussion and a lot of flaming, anecdotal claims, beliefs and
testimonials, instead of scientific rebuttal or proof to assist and guide
users.

For example, here is a discussion in which I initiated several years ago on a
sports medicine group.

Someone wrote:

<<I have recently heard about the use of magnets to improve sleep, by
sleeping on a magnetic mattress cover and enhanced physical performance
through wearing magnetic shoe inserts or wrist bands. >>

This drew the following response from Bill:

<Dr Siff, I have seen lots of sarcasm, but little useful information in
response to your question on this subject. I find it interesting that people
who subscribe to a sports medicine list are so skeptical of alternative
approaches. How many of you can tell stories of athletes who were written
off, got non-traditional treatments, and came back stronger than ever?>

Mel Siff:

ARE WE GUILTY?

Bill is quite correct in pointing out that many sports scientists may be
prematurely or dogmatically dismissive of unusual ideas or methods. The
attitude is often one of “if the New Agers, the Alternative Healers, the
Russians or non-PhDs produced it, then we should not take it seriously”.

ARE WE UNFAIR?

Firstly, one must understand the point of view of Sports Scientists, who
often have to grin and bear the absolute nonsense that some of these New
Agers, Traditional/Alternative Healers, Russians and non-academics
proliferate in the media, simply because the media has to sell by quoting
anything that will attract the public attention. Either that or they manage
to sell miraculous devices or cures on the basis of esoteric Egyptian
cardio-divination, or magnetopulsatory deep tissue manipulation or something
that sounds equally impressive.

IS ANYTHING EVER TOTALLY WRONG?

All scientists demand some form of controlled, reproducible proof that
something works or is correct. Herein lies the problem, because it is very
rare to find ANY system that fails to work with EVERY single subject. There
is just enough chance of a placebo effect working in any group to ensure that
some individuals will gain some benefit from almost any procedure (or the
opposite!). One can fool most of the people ALL the time (or rely on the
belief or faith factor to do the same). This is why so many philosophies,
ideas, methods and devices persist. As long as only a very few successes
occur, the system will never die out, because the supporters or purveyors of
such systems obviously will report only their successes – just like many
scientists!

So, something works for the wrong reasons! Is this wrong or is it going to
discourage the cranks or their victims? Not at all, because someone who was
desperate over something or other has been helped where all else failed.
What else does the average person want but pleasure, success and freedom
from pain/discomfort? The scientists are unhappy and frustrated; the media
are happy selling the news; entrepreneurs are happy selling voodoo at a
great profit; the clients/victims are happy being more comfortable than
before (though poorer and none the wiser – which really does not matter to
them!). People will change only if the scientists are helping them more than
the alternative evangelists. Isn’t this part of the old lament that too few
sports scientists are practitioners or work closely enough with the
practitioners?

There are several messages to sports scientists – we have to:

1. Sell our scientifically validated concepts or devices better than the
successful unscientific practitioners or charlatans

2. Investigate exactly why some strange systems work sometimes and use
science to improve on or use them (besides the placebo effect, there may be
unknown principles that have yet to be discovered)

3. Attempt to ensure that the scientists work more closely with the media to
ensure more balanced reporting (dreamland!)

4. Convincingly prove why certain systems are nonsense and why they work
with certain susceptible folk

5. Learn how to use or exclude the placebo effect more effectively

6. Grin and bear it!

IS IT POSSIBLE?

It is relevant that we examine the above option No 2 to ascertain whether or
not human performance or health may be influenced by magnetic and other
fields.

Unfortunately, many of the persons using magnets, needles, coils, crystals,
pendulums. . . , you name it, act and talk like medieval magicians with a
sufficient smattering of misused scientific terms such as energy, fields,
force fields, quantum healing, wave resonance and neuroimmunological
response to convince their potential clients.

This automatically causes scientists to dismiss them and anything associated
with them. The proliferators of such systems are often their own worst
enemies – instead of working with the scientists and doctors, they often
align themselves against science and modern medicine. The alternative folk
decry the scientists, the academics and the doctors, who respond by decrying
them and nobody gets anywhere. It is time that we had much more
collaboration between all of us, even if our reflex response is to
immediately trash a ‘weird’ idea. This is what Bill was implying – why don’t
we all work together to sort out fact from fiction, as well as examining the
grey areas in between?

We are all human and even scientists respond emotively to concepts, devices,
people and the environment, so communication has to be enhanced by making
definite efforts to bridge communication gaps rather than conceptual gaps.

So – is the idea of biological systems being affected by environmental
fields (such as magnetism) so outrageous that it does not warrant further
examination? Being modern scientists, it is quite simple to begin this
voyage of discovery – enter the library CD-ROMs, send out a few requests to
the appropriate user group and we are well on your way.

DO MAGNETS WORK ?

Yes and no – there has been considerable work done to investigate the effect
of various forms of magnetism and electromagnetism on the body, but all too
often, the evidence for the definite effects of modalities such as pulsed
Electromagnetism is equated with the eeffects of those small ceramic magnets
that are sold at high cost to gullible patients. This simply confuses the
issue and the subject stagnates.

In the USA, any of the books by Dr Robert Becker (The Body Electric, Cross
Currents and many academic articles), Pilla, Bachman, Brown, Spadaro and
many others are relevant; in Russia, the early work of Kholodov is
invaluable; in Europe, several French and German workers have researched
much of this field. There are literally thousands of articles published in
peer-reviewed journals on the effects of electromagnetic fields, magnetism,
gravity etc on biological systems. Popular books such as Cycles of Heaven
(Playfair and Lyon), the Electromagnetic Web (I cannot lay my hands on the
author’s name at present) and the above-mentioned books by Dr Becker are
useful in providing useful cross-references and some basic knowledge of this
confusing field.

For anyone in the USA, there was even a major conference that was held in
Chicago on PHYSICAL REGULATION by the Society for Physical Regulation in
Biology and Medicine (9-12 Oct 1996). The renowned Dr Spadaro hosted the
event.

THE IMMEDIATE FUTURE

When this correspondence has stimulated enough interest in this field, it
would be useful to share feedback on scientifically possible or valid ideas
on electromagnetism and sporting performance with one another via this user
group. I keenly await this information.

——

Mel Siff

The issue of applying ice to soft tissue injuries often arises in therapeutic
circles, especially with regard to the possible risk of damaging the tissues
by direct application of cold.

This is quite a common controversy and is a consequence of the fact that
students often are taught methods which have been passed on like some sort of
rehabilitation scriptures, without the underlying science being adequately
understood or explained.

This idea that uncovered ice can cause tissue damage seems to be an
extrapolation from clinical cases of ‘frost-bite’ caused by prolonged
exposure to zero or sub-zero temperatures. Time certainly is a factor, with
risks of tissue damage increasing with time. Exposure of extended areas of
tissue to near zero temperatures for 5-10 minutes has never been observed to
cause tissue damage, so, if the ice is used as a massaging agent (i.e., one
type of ‘cryokinetics’), being moved regularly from site to site around the
injured area, it is extremely unlikely that any tissue damage will be caused.

The risks posed by low temperatures are a function of the temperature and
the time, with lower temperatures increasing the risk and dramatically
shortening the time of safe exposure. In the case of clinical ice
application (assuming that the ice is not supercooled in a deep freeze to
well below zero Celsius or 32 F), the fact that the surface of the ice in
contact with the skin is melting without resolidifying means that the
temperaure being applied cannot be lower than the freezing point of water (or
any body fluids).

Thus, ice massage with a fluid layer of water between the ice and the skin
can never impose sub-zero temperatures on the tissues, least of all those
lying much deeper than the superficial layers. According to the laws of
physics, there is always a temperature gradient across any given system
which has a hotter and a colder end, with the lowest temperature being at
the surface directly in contact with the skin and the highest being in the
layers furthest from the skin.

In other words, near zero Celsius temperatures may be achieved only in the
most superficial layers of the skin – but only if one assumes that the system
is not generating its own internal heat. Unless the patient is dead or his
circulation is very seriously impaired, this assumption is incorrect and any
drop in temperature is going to be countered to a certain extent by heat
produced by the body.

The near zero temperature of melting ice on the surface of the skin is
certainly not going to freeze any of the body’s tissues (which, due to their
content of various mineral salts, fat etc, freeze at temperatures well
below the freezing point of water), so it would appear illogical to suggest
that superficial ice application (especially if massaged over the surface
for short periods) can damage any of the tissues of the body.

If the patient does not tolerate cold easily, displays psychological or
physiological sensitivity to ice application or has clinical local
hypocirculatory problems (and such reasons are often more of a problem than
the physiological risks of freezing), then one may use an INTERVAL
CRYOKINETIC method of applying ice for 2-5 minutes at a time, removing it
for a brief rest interval of a few minutes, then re-applying the ice for a
few interrupted applications. This interval ice massage approach also tends
to counter the arguments put forward by those who feel that the ice pack
must be insulated from the patient’s body – especially if you have to work
with someone who still refuses to accept the underlying physics or the lack
of evidence that brief (non-supercooled) ice application does not cause
tissue damage.

It also has to be asked if the use of ice needs to be taken literally. One
has to ask if there is any evidence showing that application of very cold
water (say, at temperatures of 1-5 Celsius or 34-44F) is significantly less
effective than ice at zero Celsius. Possibly the less stressful method of
very cold water may be a useful alternative to anyone who is violently
opposed to the use of ice for certain patients or in certain situation.
Certainly, from my own research and experience I have found that immersion
of entire limbs in very cold water, combined with natural pain-free movement
(another form of cryokinetics – movement in icy water) can be very effective
in enhancing rehabilitation.

One might even consider the gradual acclimatisation of the patient to
increasingly lowered temperatures by using water which becomes progressively
colder – something we may call CRYO-ADAPTIVE THERAPY. This adaptation to
cryotherapy may be achieved by use of gradually decreasing (or discrete
decrements) temperatures or by gradual increase in the duration of exposure
to cold water or ice (up to a sensible or practicable limit).

Sometimes the application of ice may be combined with deep transverse
friction, electrostimulation, myofascial trigger point application and other
techniques to enhance the overall rehabilitation process. One word of
caution is necessary – the above physical and physiological analysis is
based on the use of ice at its normal freezing point, not lowered by
prolonged refrigeration in a deep freeze to temperatures well below zero
Celsius. ‘Normal’ melting ice application of limited duration CANNOT freeze
extensive volumes of biological tissues, so that the fears voiced by the
insulated ice brigade are unfounded.

Mel Siff

Mel Siff sets you straight on some common misconceptions held the world over on stretching and warming up

Recently we have been discussing the effects and value of stretching before
or during training, so I wish to elaborate a little on this topic.

At the very outset, one needs to note that stretching is not the same as a
warm-up, so what I am referring to here is the way in which some very brief
episodes and patterns of flexibility training can be included in a “warm-up”
(or more accurately, the pre-event preparation phase). If anyone is
interested in flexibility training as something distinct from the warm-up,
then Ch 3 of “Supertraining” addresses this topic in depth.

While prolonged yogic or static type stretches held for many seconds at a
time may decrease the ability of the muscles to produce maximal strength for
many minutes afterwards, the use of controlled dynamic stretches which
imitate parts of the sporting movements, as well as brief, intermittent,
progressive isometric stretches or sports related contract-relax stretches
should have minimal adverse effect on subsequent exercises or lifts, especial
ly if they are blended progressively into slow execution of the actual
lifting or sporting movements, done with no added loading initially.

All in all, the entire warm-up session would not last more than 5-8 minutes.
If you wish to dispense with any form of separate warming-up, then simply
carry out your training exercises with very light loads on the bar and
progressively take it from there. Many competitive lifters follow this sort
of regime without injury, so, if you prefer this approach, as they say, “go
for it!”, as long as you don’t force yourself into very heavy, complex,
explosive or forceful actions before you feel well prepared and dynamically
supple enough for them.

For those who like PNF, it is useful to note that PNF may involve both static
or dynamic ’stretches’. Actually, PNF uses Specific Relaxation techniques
and Specific Activation techniques in very specific patterns and not just the
contract-relax, hold-relax regimes popularised by many speakers in the
stretching field. Russian scientists, including Iashvili, have carried out
considerable research in this field and have shown that active flexibility
correlates more strongly with sporting proficiency than passive flexibility
(Siff ‘Supertraining’ 2000 Ch 3).

They have shown that greatest improvement in functional flexibility is
achieved via integrated strength-flexibility exercises. This would seem to
run counter to the common belief that all stretching should be done with
muscles completely relaxed, but the latter method is primarily for mechanical
deformation of connective tissue rather than for functional sports
flexibility.

The regular use of fixed cycles, ’spinning’ and treadmill walking or jogging
at low pace tends to decrease the functional range of movement of the hip
flexors in particular, unless adequately balanced by “functional” flexibility
regimes to counter this effect, so one needs to be cautious about the overuse
of cardiovascular machines in health clubs (‘Supertraining’ Ch 3.5).

Since some people report that they do actually feel better prepared to
undertake a give exercise or session by doing some stretches, then there is
no reason not to go ahead and apply them in short efficient bursts, leading
into more dynamic versions of whatever they are currently doing. One should
never forget the value of achieving the appropriate mental state before
exercise, and if some brief familiar intervals of relatively harmless,
well-proven stretches help you in this regard, then continue in this vein.

What you can do to enhance your workout further is integrate mental
preparation (visualisation and motivation) regimes into this flexibility
preparation phase. This type of integrated mental-physical procedure is
lacking from most sport specific flexibility regimes and you will find that
the tone of your entire session can be uplifted very significantly before you
begin the main action!

If anything, you could replace your cycling with mild skipping or broomstick
simulations of all the lifts that you are going to do in that session, so
that your warm-ups involve gravitational loading and mild impact. By all
means, end off with some cycling (followed by hip and trunk extension
flexibility actions), especially since mild cyclical activities can
facilitate restoration and enhance capillarisation (see Russian research
articles by Zalessky, Birukov, Sinyakov and others in Part 1 of Siff MC &
Yessis M ‘Sports Restoration and Massage’ 1992).

For those who are interested in gaining a basic knowledge of “PNF stretches”,
then consult Ch 7 of “Supertraining”, where I now have included diagrams of
the main movement patterns that one needs to use in sport. If you are
interested in learning directly from the horses’ mouths, the two therapists
who wrote the first and definitive book on PNF were Knott M & Voss M,
“Proprioceptive Neuromuscular Facilitation”. Remember that more recent
research modifies some of the explanations and methods, but, all in all, this
is the bible on PNF. Note well that it is not intended for sports users, but
for therapists and as such, needs to be interpreted for sporting applications
(which I have attempted to do in “Supertraining”).

Mel Siff