Treating Your Pain with Evidence

When it comes to musculoskeletal (think back, neck, shoulder, hip, knee etc.) pain there are just about as many treatment options as there are colors in the rainbow. That can be a good thing as it allows people to seek out potentially helpful options. However, in a country where hundreds of billions of dollars are spent each year on managing these conditions it is important to have some current facts to support how we manage musculoskeletal pain. That is why we look to the research.

In 2017 a research article was published that summarized 146 other research studies on the best treatments for musculoskeletal pain. The article gave us insight into what areas we can focus on to help people feel better when they are hurt. This was a valuable paper because it got to the heart of a complex problem and was supported by solid evidence, not the most recent fad treatment option that are shared by friends on Facebook or that you find on Buzzfeed.

Exercise, The Key To Pain Treatment

The pyramid below is a basic representation of what actually works based on current research.

MSK Screenshot.png

The research article found that for musculoskeletal pain, exercise was the best treatment option available. The amazing thing about exercise as a treatment is that when someone is compliant with the exercise it has lasting effects. The trouble with more passive modalities such as acupuncture, TENS, ultrasound or manual therapy (hands on) techniques, is that when we follow individuals long-term the benefits decrease unless they are combined with exercise based interventions. It is amazing! A relatively low-cost treatment has a powerful effect to change pain for the long-term.

The Importance of Psychological Interventions

I do think that it is important to mention how important psychological treatments such as cognitive behavioral therapy and instruction on coping behaviors can be. It is important to always remember that none of us are just a bag of muscles and bones. We all have thoughts, emotions, feeling and perceptions, and all of those things can influence the pain that we feel. Because of that, it is important to dedicate time to making sure that our thoughts, emotions, feelings and perceptions are not interfering with our health and healing.

Pharmaceuticals and Surgery

Lastly, there are many cases where musculoskeletal conditions should be managed with surgery or pharmaceuticals such as NSAIDs or cortisone injections. However, those should be looked at as first line treatment options only in more rare circumstances. While also being costly, treatment of pain using pharmaceuticals and surgery comes at a greater risk of side-effects or complications. In most cases I highly recommend that an individual try more conservative options before moving towards injections or surgery to decrease the possibility of adverse effects as a result of these treatments.  As a former patient of mine once said, “No one ever dies of back pain, but some people have died from the treatment of back pain.”

So, next time your back pain flares up, or you try to throw someone out in your rec league softball and hurt your shoulder, consider trying conservative care before seeking out more involved treatment options. A physical therapist can be a great starting point that can help you determine whether or not you would benefit from conservative management with exercise or if you need to move further up the pyramid.

Babatunde, O. O., Jordan, J. L., Van der Windt, D. A., Hill, J. C., Foster, N. E., & Protheroe, J. (2017). Effective treatment options for musculoskeletal pain in primary care: A systematic overview of current evidence. PloS one, 12(6), e0178621.


Are You Still Doing Static Stretching As Your Warm-Up?

Almost without fail when you show up to an athletic event of any variety, (team sports, races, etc.) you will see someone with their knees completely straight trying their absolute hardest to reach their toes. They are most likely cringing as the pull on what are really tight hamstring muscles.

The Warm-Up Method Matters

A nice hamstring stretch may not be a bad thing every now and then, especially if your goal is to reach your toes with less feeling of pull in the hamstring. However, the warm-up before an athletic event is what can get you in “the zone” where you are ready to perform at your maximum. The 15-30 minutes you spend in preparation can be the difference maker in the outcome of your event. A well thought out and designed warm-up can help set the tone for a great practice or performance.

A warm-up for any athletic event needs to fulfill 3 purposes

  1. Reduce the risk of injury

  2. Improve performance in the event

  3. Improve mental focus before the event

What we are seeing from more current research is that static hold stretching, usually done for anywhere from 15 to 90 seconds, is not actually effective at reducing injuries, and may in fact limit your performance. It is true that static stretching will help to improve your range of motion, however, we can see similar improvements in joint range of motion with more active mobility drills as well.

RAMP Warm-Ups

What should you be doing for your warm-up before getting into your preferred sport? In general, warm-up programming has focused around a principle called RAMP (Raise, Activate, Mobilize, and Potentiate). Basically, you are looking at breaking down your warm-up into 4 phases.

Raise: Increasing your heart rate, breathing rate and blood flow

  • Lower intensity activities related to the sport being performed

Activate: Use the key muscle groups that relate to your sport

  • Think rotator cuff, glutes, hamstring and quads, abdominals/core, etc.

Mobilize: Move joints related to the sport through their complete range of motion

  • Very different than static stretching, this involves moving your joints through the full range related to the sport and doing so repeatedly

  • Can be completed in conjunction with activation of muscles

Potentiation: Sometimes better thought of as performance

  • High intensity activities more related to your sport

  • Plyometrics, jumping, sprinting, cadence work for distance events, reactive agility drills

The RAMP system of a warm-up is much more of an active warm-up than a general static stretching protocol. It involves getting the body ready for the task at hand. All of that said, it is not wrong to add static stretching into your your regimen especially if that has been your mode of getting your mind mentally prepared for your event. However, that stretching would best be added to the beginning of the warm-up, to avoid potential detrimental effects of static stretching on performance.

A Good Warm-Up Does Reduce Injuries

The beauty in all of this is that where research was not finding benefits in stretching, and may have actually been doing some harm on performance, dynamic warm-ups (RAMP) with a neuromuscular training component have been shown to help reduce injuries, at least in team sports.

The most heavily researched programs have been done on soccer (futbol) players, and the two that I recommend the most are the FIFA 11+ and the PEP injury prevention program. Both programs follow the RAMP method for warm-up and both have been shown to reduce injuries. In fact, the FIFA 11+ warm-up has been found to reduce all injuries by 39%. In females the FIFA 11+ warm-up can help reduce anterior cruciate ligament (ACL) injuries by 50%! That is incredible, and really speaks to how a dynamic warm-up can have a positive impact on performance and injury reduction.

For overhead athletes there are also helpful warm-ups. In a study done on handball players they found that a dynamic warm-up reduced shoulder injuries by 28%. From personal experience, I developed a warm-up program for softball players that lasts between 15–20 minutes, and according to one coach who transitioned from static stretching to the dynamic warm-up it is the “best thing we ever did.”

Implement Your Warm-Ups Early and Modify As You Go

In general some guidelines would be to start the warm-up routine before practices in the pre-season ideally for upwards of 9-10 weeks before the start of the season so that it has become routine and can be easily carried over into the season without lost time accommodating to the warm-up in season. Choose warm-up activities that can be modified to be easier or more complex depending upon your capacity and at what point you are in the season. Similar to most training procedures warm-ups can become routine and boring if they are not modified to help the athlete.

Get Help!

Now, all of this may seem overly complex for a coach or individual to plan and carry-out. However, there are resources available, and you can always reach out to a skilled professional to help you arrange and implement a more dynamic warm-up.

If you would like to get more information about how using a dynamic warm-up can help you or your team perform better while also reducing injuries please contact dallen@agadapt.com. If you have suffered an injury, and are in need of rehabilitation schedule an appointment or phone consultation.

Thorborg, K., Krommes, K. K., Esteve, E., Clausen, M. B., Bartels, E. M., & Rathleff, M. S. (2017). Effect of specific exercise-based football injury prevention programmes on the overall injury rate in football: a systematic review and meta-analysis of the FIFA 11 and 11+ programmes. Br J Sports Med, bjsports-2016.

Andersson, S. H., Bahr, R., Clarsen, B., & Myklebust, G. (2017). Preventing overuse shoulder injuries among throwing athletes: a cluster-randomised controlled trial in 660 elite handball players. Br J Sports Med, 51(14), 1073-1080.

Jeffreys I (2007) Warm-up revisited: The ramp method of optimizing warm-ups. Professional Strength and Conditioning. (6) 12-18

McHugh, M. P., & Cosgrave, C. H. (2010). To stretch or not to stretch: the role of stretching in injury prevention and performance. Scandinavian Journal of Medicine & Science in Sports, 20(2), 169-181.

Cramer, J. T., Housh, T. J., Johnson, G. O., Miller, J. M., Coburn, J. W., & Beck, T. W. (2004). Acute effects of static stretching on peak torque in women. Journal of Strength and Conditioning Research, 18(2), 236-241.

Gilchrist, J., Mandelbaum, B. R., Melancon, H., Ryan, G. W., Silvers, H. J., Griffin, L. Y., ... & Dvorak, J. (2008). A randomized controlled trial to prevent noncontact anterior cruciate ligament injury in female collegiate soccer players. The American Journal of Sports Medicine, 36(8), 1476-1483.

Mandelbaum, B. R., Silvers, H. J., Watanabe, D. S., Knarr, J. F., Thomas, S. D., Griffin, L. Y., ... & Garrett Jr, W. (2005). Effectiveness of a neuromuscular and proprioceptive training program in preventing anterior cruciate ligament injuries in female athletes: 2-year follow-up. The American Journal of Sports Medicine, 33(7), 1003-1010.

Nelson, R. T., & Bandy, W. D. (2004). Eccentric training and static stretching improve hamstring flexibility of high school males. Journal of Athletic Training, 39(3), 254.

Your Perception Matters

In a world of uncertainty it is always important to know what we don't know. In the world of health it is safe to say that we really don’t know enough. One thing that we are starting to get a grasp on is how very important our mindset and perceptions are in determining our health.

For many years now people have been aware of the “placebo effect.” In these studies, participants assume that the sugar pills they are taking are actually providing some type of therapeutic effect. The powerful influence of our mindset goes well beyond what we can comprehend. However, there are some poignant examples in fairly recent research that demonstrate how our brains can change the outcomes of our health.

Perception Alters Our Physiology

Consider this, in 2007, 84 hotel maids were divided into two groups. One group was instructed that their work alone was enough to achieve the recommended amounts of weekly physical activity. The other group was given no instruction at all. Four weeks later, the researchers checked in with both groups of hotel maids to re-measure some important health markers. The group that was told they were doing enough physical activity actually showed improvements in their blood pressure, hip-to-waist ratio, and a decrease in their body mass index (BMI). The group that was given no instruction showed none of those positive changes. These improvements were made without either group changing their physical activity!

It is phenomenal to think that by simply challenging our own perceptions we can see improvements in our health. The keyword in the previous sentence being perception.

Perception of Stress

Most individuals around the world are very familiar with stress. Not stress in the way an engineer might think about it, but stress from a mental and biophysical stand point. We can see that stress is having major impacts on our health. Interestingly enough, the degree that we perceive stress has a negative impact on our lives is related to having poor health and the risk of premature death. So, while most of us have stress, how we feel about that stress changes what it does to our bodies.

Perception Can Be Misleading

It is through these same perceptions that marketers make money. Someone who is skilled in psychology and knows how to adjust an audience’s perceptions, can play a big role in our behaviors.

For example, I often hear people use the following terms to describe their bodies: words such as tear, degeneration, bone-on-bone, the worst [insert body part] that a doctor has ever seen, disc bulge, nerve pinch, etc. All of these terms lead to perceptions of what someone feels about their body, and these perceptions influence their health. For this reason around 1 o’clock in the morning there will be numerous TV advertisements about the next best treatment option for all of the above problems. Most of those options have little to no research to support their use, and are most likely to only make a difference with the “placebo effect”.

There are a great deal of studies that show how individuals with numerous types of structurally pathologies will have no symptoms (references with the asterisks). Which indicates that in the realm of which pathologies count and which ones don’t probably comes down to what our perception of those pathologies mean. None of this indicates that the pain is all in your head. By no means. Only that what we think about what is going on in our bodies, actually changes our response to any given symptom.

The Brain Changes

The beauty in all of this is that our minds are extremely plastic. Our thoughts, beliefs and perceptions are constantly changing. As we continue to learn we change the way we perceive the world, as well as changing the way our bodies respond to the world we live in. Meaning, what we felt yesterday, (sadness, pain, fatigue, etc.) does not dictate what we will feel tomorrow (joy, strength, energized, etc.).

A lot of times all we need, to change the trajectory of our perceptions is some guidance. Someone to help us by setting a road map for our nervous system to change. That is where a skilled professional can be a huge help. From coach to psychologist, trainer to physical therapist, and chiropractor to physician you should be offered a plan to help you feel well and think well.

Keller, A., Litzelman, K., Wisk, L. E., Maddox, T., Cheng, E. R., Creswell, P. D., & Witt, W. P. (2012). Does the perception that stress affects health matter? The association with health and mortality. Health Psychology, 31(5), 677.

Crum, A. J., & Langer, E. J. (2007). Mind-set matters: Exercise and the placebo effect. Psychological Science, 18(2), 165-171.

*Brinjikji, W., Luetmer, P. H., Comstock, B., Bresnahan, B. W., Chen, L. E., Deyo, R. A., ... & Wald, J. T. (2015). Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. American Journal of Neuroradiology, 36(4), 811-816.

*Campbell, J., & Colvin, L. A. (2013). Management of low back pain. BMJ, 347, bmj-f3148.

*Guermazi, A., Niu, J., Hayashi, D., Roemer, F. W., Englund, M., Neogi, T., ... & Felson, D. T. (2012). Prevalence of abnormalities in knees detected by MRI in adults without knee osteoarthritis: population based observational study (Framingham Osteoarthritis Study). BMJ, 345, e5339.

*Girish, G., Lobo, L. G., Jacobson, J. A., Morag, Y., Miller, B., & Jamadar, D. A. (2011). Ultrasound of the shoulder: asymptomatic findings in men. American Journal of Roentgenology, 197(4), W713-W719.

*Nakashima, H., Yukawa, Y., Suda, K., Yamagata, M., Ueta, T., & Kato, F. (2015). Abnormal findings on magnetic resonance images of the cervical spines in 1211 asymptomatic subjects. Spine, 40(6), 392-398.

Annual Physical Therapy Check-Up!

In my early 20’s, I lived in Argentina for 2 years. During that time it never occurred to me that I should be seeing a dentist on a regular basis. Growing up my mom would set up my regular dental exams, and I would show up to the dentist office every 6 months. However, after living in Argentina and then on my own through the early part of college, I had definitely fallen out of the habit of attending regular dental exams. I had 8 cavities filled over a 4 week period. Needless to say, I never missed another dental check-up!

The practice of meeting with a trained expert is important in order to learn what we should be doing to keep our bodies in optimal condition! For the most part it has become common practice to see the dentist every 6 months, and to have a physical with a doctor every year. However, most people are not going to see their physical therapist for annual or semi-annual check-ups.

It is often understated how important a physical therapist can be in finding deficiencies in movement, strength, cardiovascular capacity or range of motion that can become detrimental in the future. Physical therapists are experts in movement! That is what they are trained to be. Whether it be identifying compensations or overcoming current limitations, a physical therapist can play a valuable role in keeping you healthy and well.

This is a really common story that I hear in my practice, “Well, my shoulder pain started about 4 years ago while I was doing some over head activities, and I felt a pop in the shoulder. It has been hurting on and off since then. I haven’t done anything besides take advil every now and then, but now I can’t sleep on that side. So, I figured I should finally do something about it.”

I love seeing people with any number of problems going on. It is really fun to diagnose their situation and get them on a path to meet their goals. However, I think about those times when the patient spent nights where they maybe only slept 1-2 hours or days when they missed work all because of their aches and pains in the shoulder.

I think about how that situation would have been different had that person seen their physical therapist every year for a check-up. Maybe it is not something that the patient would go out of their way to seek care for initially, because it is not interfering too much in their life at the start. However, it could be something mentioned and evaluated in an annual check-up. Then that person could be helped to get on an exercise regimen that could help their shoulder or other condition before it evolves into something more complex. That is the value in checking in regularly with your physical therapist.

As the saying goes “An ounce of prevention is worth a pound of cure.” When it comes to my teeth I know better than to skip out on my regular teeth cleaning and exam. When it comes to my physical health I know better than to miss out on a chance to be screened, and make sure that I am on the right track to a healthy life.

In the state of Minnesota anyone can see a physical therapist directly without a physician referral. If you would like to schedule an annual check-up with a physical therapist, please click here.

Who Is Your Physical Therapist?

The Best Treatments for Plantar Fasciitis

It’s 6:30 am, and the alarm goes off! You wake up a little groggy, but ready to start planning your busy day. You are lying in bed thinking about all of the things that need to be done and then, nature calls. You quickly throw off the sheets and step out of bed to an unwelcome shot of pain in the bottom of your foot. It’s that same unforgettable pain you experienced yesterday, and the day before that, and the day before that. Ugh!

Pain in the bottom of your foot (near your heel), regularly referred to as plantar fasciitis, is extremely common. Approximately 2 million Americans suffer from plantar fasciitis each year. For runners, plantar fasciitis is the most common condition that is diagnosed around the foot, making up 8% of all running related injuries. Unfortunately, many people experience the painful symptoms and experiment with endless proposed treatment options.

I have heard a fair amount of plantar fasciitis treatments. They range from rolling a frozen bottle of ice on the foot, running barefoot, and using odd-looking massage tools.

Additionally, everyone has their special favorite stretch that gets passed around like a secret recipe for the best chocolate chip cookies. Sure, it is probably a good stretch or a good treatment option, but even the best chocolate chip cookie recipe doesn’t work for everyone. We all have different taste preferences, likewise, we all experience different forms of plantar fasciitis and different feet!

There are so many different thoughts and recommendations available that it is important to follow the research. Fortunately, there are great research reviews that summarize the best treatment options for plantar fasciitis.

I will split up the treatment options into 3 sections: Things you should try because research supports them, things you can do because some research supports them, and things you should do in more rare circumstances because research doesn’t really support them.

Treatments You Should Try

Plantar Fascia Stretch: Seated with the painful foot and leg crossed over the other leg and then pulling up on the toes to feel a stretch along the bottom of the foot. This stretch should be done 3 times a day with ten holds of 10 second duration. Ideally the first round of stretching would be done before getting out of bed in the morning.

PF Stretch Seated.png

Calf Stretching: Can be done in any number of styles. A traditional runners’ calf stretch, standing with the painful foot and leg behind the other and keeping the knee straight as you lean forward (towards the wall), can be an effective stretch. With this particular stretch, try placing a rolled-up towel under the toes which allows for more stretch of the plantar fascia. However, listen to your body because the stretch should be gentle to moderate, not severe. Calf stretching should be held for 60 seconds, for up to 5 repetitions a day.

Calf and Plantar Fascia Stretch.png

Taping: Certain taping styles have been found to be helpful for plantar fasciitis. For the most part the researched taping styles rely more on stability taping around the foot, and can include some antipronation strips. Low-dye taping is commonly used, though high-dye taping can also be effective. Taping is usually reserved for licensed professionals to perform, though anyone can be taught the techniques, and try to manage them on their own. In a general sense the taping is designed to help with the forces through the foot to relieve some pressure off the plantar fascia.

Orthotics: Custom made foot orthotics can be beneficial for those that suffer from plantar fasciitis. However, treatment options can become very expensive when you seek an orthotic.

Studies that have compared custom orthotics to over-the-counter orthotics found that both are helpful with no significant difference between the two besides the price point. When purchasing orthotics, I recommend you try them on before purchasing. It is important to get a good feel for what type of orthotic feels comfortable to you. Check out Super Feet insoles, which typically cost around $50 (available at most specialty shoe stores).

Night Splints: If the plantar fasciitis symptoms have been lasting for more than 3-6 months, and you are having pain with the first step in the morning, then I highly recommend consistently wearing a night splint for 1–3 months. While many people have a hard time wearing night splints, they are helpful. Night splints can be purchased at most major retailers for $20–$50. The most popular night splint is a Strassburg sock because of its high comfort reviews. Anything you find should work, though you do want the pull to be from the front of your foot.

Hands on Therapy: There is some research that shows that a professional helping with some ankle and foot joint mobility as well as some soft-tissue work in the calf and foot can reduce pain. Since the symptom reduction is usually temporary, this type of treatment option is usually an adjunct to other treatments.

Dry Needling: The research for dry needling for plantar fasciitis is growing. As a whole dry needling research is still in the early phases. However, it appears that dry needling can be an effective addition to treatment for plantar fasciitis. Consider dry needling if your symptoms have not improved with other treatments.

Treatments You Can Try

Shoe Wear: Despite the overwhelming amount of research and recommendations about shoe wear, it doesn’t seem to have much of an impact. First, the important thing to consider is comfort. The shoes you wear should feel good and not bother you. Beyond that, consider switching between at least 2 different pairs of shoes during the week, whether it be that you are running or standing. Having a shoe rotation can help reduce plantar fasciitis risk by upto 72%.

Strengthen Up the Chain: Our bodies are not strictly divided into different parts. There is connection from the bottom up and from the top down. There is some rationale for strengthening the muscles around your hips, thighs, as well as the muscles of the back and the abdominal region.

Treatments for Rare Circumstances

Ultrasound: Therapeutic ultrasound may have some value in other conditions, but is not effective as a primary treatment for plantar fasciitis.

Steroid Injections: Getting a steroid injection into the plantar fascia has not demonstrated clinical benefit in 2 systematic reviews done on the subject.

As you can see there are a lot of things that you should do, can do, and should only do in rare circumstances for the treatment of plantar fasciitis. It is not an all-inclusive list of treatment options. I have tried to include the list of things that have some evidence to back up claims being made. This does not mean that a frozen water bottle wouldn’t feel good on the bottom of your foot, only that there is no research to say that it is making a difference. So, keep doing your favorite treatments, and add some of the researched options into your rehabilitation and recovery.

It is also helpful to work with a licensed professional to help you modify your activity to avoid further irritation to the plantar fascia, and to help you work through the recovery process. Physical therapists can be very helpful in diagnosing and treating plantar fasciitis.

Martin, R. L., Davenport, T. E., Reischl, S. F., McPoil, T. G., Matheson, J. W., Wukich, D. K., ... & Davis, I. (2014). Heel pain—plantar fasciitis: revision 2014. Journal of Orthopaedic & Sports Physical Therapy, 44(11), A1-A33.

He, C., & Ma, H. (2017). Effectiveness of trigger point dry needling for plantar heel pain: a meta-analysis of seven randomized controlled trials. Journal of Pain Research, 10, 1933.



Dry Needling in Physical Therapy

Poking into a structure that has been hurting may not make intuitive sense for pain relief. However, there appears to be value in having small filament needles inserted into an irritated structure.

The History of Needling for Medicine

Needling has been going on for millennia as more of an Eastern medicinal practice. Acupuncture as a practice may date back almost 8,000 years, though more certainly there is evidence of the practice appearing around 2,300 years ago. It was in those ancient texts that we can find information about meridians and the flow of Qi (chi), as well as how ancient Chinese people used acupuncture to resolve a variety of medical concerns.

Dry needling originated from studies based upon the principle of injecting very irritable muscles in the body with a small needle and some form of pain relieving substance. Then, it evolved as practitioners realized that they were seeing positive outcomes from the needle pokes alone without any injected substance. Thus, here we are currently with a more Western Medicine practice of using a small filament needle to address a muscle or fascia tissue that has become tender and painful (sometimes referred to as a trigger point).

The most frequently asked question that remains is: what is the difference between dry needling and acupuncture? The answer to that question is tricky due to the fact that both involve using the same or at least similar needles and the needles are poked into the skin to treat a given pathology. However, acupuncture is a treatment designed to affect the “energy” and Qi while working through meridians, while dry needling is a treatment designed to affect a specific muscle and the surrounding fascia and nerve tissue.

Research to Support Dry Needling

In comparison to other forms of therapies, dry needling itself is a relatively new treatment option. With any new treatment option the research is new and growing. However, at this point we are starting to see more randomized controlled trials and other studies about the effects of dry needling in rehabilitation. We have at this point research for the following conditions and anecdotes for treating a host of others;

  • Knee pain

  • Hip pain

  • Tendinopathy

  • Headaches

  • Neck pain

  • Shoulder pain

  • Low back pain and Sciatica

  • Plantar Fasciitis

  • Tennis Elbow

  • Myofascial Pain Syndrome

  • Fibromyalgia

Does it Hurt?

Between 60% and 70% of individuals will experience temporary pain during the actual treatment session. It is also not uncommon to experience soreness following the treatment. Not everyone does, but you may feel that for 24-48 hours you have soreness at the site of the needling. Icing and gentle massage to the area can help with the soreness. However, remember that this procedure is done to help reduce pain related to musculoskeletal problems, so any temporary soreness should not interfere with the benefits of having needling performed.

Making the Benefits Last

Dry needling itself should not be the only thing you do to help your painful condition. You should be performing exercises including stretching that have been prescribed by your physical therapist. The needling is intended to help you have less pain and move better.

Call now to schedule! 952-303-4550 Or book online at www.agadapt.com

White, A., & Ernst, E. (2004). A brief history of acupuncture. Rheumatology, 43(5), 662-663.

He, C., & Ma, H. (2017). Effectiveness of trigger point dry needling for plantar heel pain: a meta-analysis of seven randomized controlled trials. Journal of Pain Research, 10, 1933.

Dunning, J., Butts, R., Mourad, F., Young, I., Flannagan, S., & Perreault, T. (2014). Dry needling: a literature review with implications for clinical practice guidelines. Physical Therapy Reviews, 19(4), 252-265.

Gattie, E., Cleland, J. A., & Snodgrass, S. (2017). The effectiveness of trigger point dry needling for musculoskeletal conditions by physical therapists: a systematic review and meta-analysis. Journal of Orthopaedic & Sports Physical Therapy, 47(3), 133-149.

How to Reduce Stress with Diaphragmatic Breathing

“Slow down. Take a deep breath.” These are words we have all heard from our parents or mentors. The advice to focus on your breathing is more helpful than they probably even realized.

Many of us remember those dreadful days sitting in high school psychology class learning about the autonomic nervous system. The terms “sympathetic” and “parasympathetic” may ring familiar. While the terminology may sound confusing the basic phrase we commonly use to describe the sympathetic nervous system is “fight or flight,” and the common phrase for the parasympathetic nervous system is “rest and digest.”

Finding Balance in the Nervous System

As our bodies seek for balance, the sympathetic and parasympathetic nervous systems work as opposites of each other. For example, if you trip while you are crossing the street, you want your sympathetic nervous system to kick into high gear so that you pick yourself up and run across the road before getting hit by a car.

On the other hand, you do not want that same sensation of panic and protection when you are about to lay down to fall asleep. It is also not pleasant to feel that urge of “nature calling” from a parasympathetic drive while you are playing in a high level athletic event. The balance between those two systems helps us to stay healthy. More and more people in the United States are living in a constant state of “fight or flight.” In other words they are living in a constant state of stress and anxiety.

The Negative Impacts of Stress

Anxiety and stress weigh heavy as they negatively affect multiple bodily functions. Rapid heart rate, rapid breathing rate, high blood pressure, elevated pain states, digestion problems, lack of attention, and emotional reactivity are just some of the common effects of stress on our body.

All of these changes are managed by hormones (chemicals) in our blood. For the sake of simplicity, the hormone you want to think about is cortisol. An increase in cortisol is a sign of your sympathetic (fight or flight) nervous system getting turned up. Which is great when it is needed, but detrimental when it is not.

Most of us can think of individual moments when we know we are under a moment of increased stress such as moving, changes in jobs, or family emergencies. During those moments, our appetite changed, we noticed more tension in the shoulders or back, maybe a really fast heart rate, and potentially even some irritable bowel syndrome. Those are times where you may have started to notice some achy joints in your body. You become aware that you aren’t feeling quite as robust as you did 5 or 10 years prior. When stress is persistent, our bodies begin to sense the harmful effects of stress.

Conscious vs. Unconscious Breathing

This is where some of the research on breathing can improve our life! Now, I know that if you are reading this article, you have most certainly been breathing up to this point. No one taught you how, you just do it. In and out. Inhale and exhale. You just assume that when you fall asleep tonight that your lungs will continue to fill with air and provide your body with much needed oxygen.

That is because some of your breathing is managed by your brainstem (lower brain level) which does not require any cortex (higher brain level) functioning. However, at the same time, we have the ability to use our higher brain levels to override the basic brainstem breathing function. This is why you can hold your breath underwater, or when someone tells you to take a deep breath, you can do it on command.

The Anatomy of Breathing

Now we need to work through some of the basic anatomy of breathing. Most people recognize their lungs as two big balloons sitting inside their chest somewhere around their heart. That is a good starting point. Around your lungs there will be some ribs that run from the sternum and around to the thoracic spine (upper back), and then just below the lungs is an odd shaped muscle called the diaphragm.

The diaphragm is a dome-shaped muscle that runs from front to back and side to side and works to divide the space where our lungs are (thoracic cavity) from the space where our intestines are (the abdominal cavity). When the diaphragm contracts it effectively lowers the dome allowing an increased amount of space in the thoracic cavity for the lungs to expand and fill with air. However, as a back-up or secondary mechanism we can also generate space for the lungs by raising our rib cage using accessory breathing muscles.

These two different types of breathing have become popularized by the names horizontal (diaphragmatic) or vertical (accessory) breathing. Diaphragmatic breathing as a practice is effectively breathing in as large of a breath as you can with your lower ribs and abdominal space expanding out slowly without your shoulders elevating to compensate, and breathing out slowly while contracting your abdominal muscles to help exhale or expel the air in your lungs. On the other hand, vertical breathing looks more like you are shrugging and lowering your shoulders with each breath. The physiology of our bodies change based upon our breathing patterns.

The Benefits of Diaphragmatic Breathing

Sessions of focused diaphragmatic breathing can last anywhere from 5 to 30 minutes. The sessions usually involve a coach helping you become aware of your breathing pattern. Also, you will learn how to more effectively breathe with your diaphragm and maintain your focus on your breath as a mindfulness practice.

Research has shown that you can see positive effects on your blood pressure, pulmonary function, and increase your heart rate variability (HRV; one of the easiest ways to track your balance of sympathetic and parasympathetic drive) with diaphragmatic breathing. In a randomized controlled trial, researchers looked at the effects of a 30-minute session including 15 minutes of quiet normal breathing and 15 minutes of diaphragmatic breathing for 20 sessions over an 8 week period. They noted that after the study period participants in the diaphragmatic breathing group had significantly lowered their negative affect, improved their attention, while also lowering their cortisol levels in their blood. This study helps to highlight how diaphragmatic breathing can have a role in our physiology, emotion, and our attention, or in other words our mind, body, and spirit.

The Vagus Nerve

Returning to the ideas of the sympathetic and parasympathetic nervous system we can see that diaphragmatic breathing plays a role in helping with the balance between those two systems. The way it works is beautiful. In our bodies we have a very important nerve that often does not get enough discussion—the vagus nerve. The ever-so-important cranial nerve exits the brain and travels a convoluted path around many muscles and organs before reaching its destiny around the colon. The vagus nerve is the major player in the parasympathetic nervous system. Meaning that it is the connection of our “rest and digest” between our brain and our body.

Where things get really cool is that we can manipulate the drive of our vagus nerve called “vagal tone” by adjusting our breathing. That’s right, the slow controlled diaphragmatic inhale and slow exhale with some abdominal contraction can increase your vagal tone and thus rev up your parasympathetic nervous system to help you to relax. Remember “rest and digest!” As we increase our parasympathetic activity, we will naturally decrease our sympathetic nervous system activity, thus decreasing cortisol levels and decreasing stress.

A literature review on the topic of breathing highlights the vast ways that diaphragm breathing can help our health. The list includes

  • Improved heart rate

  • Improved blood pressure

  • Improvement in quality of life

  • Improvement in exercise tolerance

  • Improved blood lipid levels

  • Reduced anxiety and panic

  • Alleviate pain

  • Improve mood

  • Reduced fatigue

  • Reduced insomnia

  • Improvements in GERD

That list is convincing enough to practice diaphragmatic breathing at least 2 times a week. It may be important to get a coach that can help you through the process.

Step-by-Step Instructions for Diaphragmatic Breathing

So, how do you do it? Don’t feel discouraged; I have written out clear instructions to help you get started.

First; positioning does matter. You should get into a relaxed and comfortable position. Lying on your back with your knees bent up, lying flat on your back, or sitting in a very comfortable chair are all good choices.

Second; take a deep breath in. Preferably through the nose, though if necessary you can breathe in through the mouth. The key is to focus the breath so that you notice your lower ribs and abdominal region expand without your chest and shoulders elevating. Sometimes placing both hands on your abdominal region or one hand on the abdominal region and the other on the chest can be helpful. You should feel your hand on your abdomen moving, meanwhile your hand on your chest does not move. This breath in should be slow and purposeful. Your focus should be entirely on how you are breathing.

Third; breathe out. Now, after taking a slow purposeful breath in there will be a temptation to quickly exhale somewhat like a sigh so that you can quickly get back to breathing in. Resist that temptation. When breathing out, breathe out through the mouth with the lips slightly pursed together.

Breathing out should not feel like you are trying to blow out birthday candles on your 10th birthday, but rather that you feel some resistance to the breath at the mouth. The next thing that you should feel is that during the process of breathing out you should be slightly crunching your abdominal muscles. Your positioning will change what you feel in the abdominals. Lying down flat with the knees straight will require the most focus on the abdominals. You should feel that you are pushing out most, if not all, of the air from your lungs.

Fourth; repeat steps one to three.

Setting Goals for Diaphragmatic Breathing

The amount of time you should spend doing diaphragmatic breathing depends on what your goal is and how much time you have. I recommend to start with 5–15 minute sessions for 2 days a week. Three to five days a week is likely superior, butI cannot guarantee that from a research standpoint.

Another suggestion if you are willing to set aside more time is to do 15 minutes of normal breathing with your eyes closed while focusing on your normal shallow breath followed by another 15 minutes of diaphragmatic breathing as instructed above. The benefit of this method is that it helps your body learn to distinctions between the two breathing patterns.

Seeking Out Help

I do not intend to establish an argument that diaphragmatic breathing can or should replace psychological or physical treatments by a skilled and licensed professional. It is a great option for those that are looking to add some focused mindfulness into their regimine. It is not a “cure-all,” but rather a great tool to have in your arsenal.

As more individuals seek out ways to improve their health, it will become increasingly important to have well-established and researched interventions for those in need. There are certainly other options to help those in need of some mindfulness. I also recommend that individuals trial a free week of the Headspace (available to download in the iTunes or Android app stores).

If you or a friend or family member would like more information about diaphragmatic breathing, or are in need of other health related treatment, please feel free to reach out to me via email, phone, or schedule an appointment.

Rickard, K. B., Dunn, D. J., & Brouch, V. M. (2015). Breathing Techniques Associated With Improved Health Outcomes.

Ma, X., Yue, Z. Q., Gong, Z. Q., Zhang, H., Duan, N. Y., Shi, Y. T., ... & Li, Y. F. (2017). The effect of diaphragmatic breathing on attention, negative affect and stress in healthy adults. Frontiers in psychology, 8, 874.

Mehling, W. E., Hamel, K. A., Acree, M., Byl, N., & Hecht, F. M. (2005). Randomized controlled trial of breath therapy for patients with chronic low-back pain. Alternative Therapies in Health and Medicine, 11(4), 44-53.

Hopper, S. I., Murray, S. L., Ferrara, L. R., & Singleton, J. K. (2018). Effectiveness of diaphragmatic breathing on physiological and psychological stress in adults: a quantitative systematic review protocol. JBI database of systematic reviews and implementation reports, 16(6), 1367-1372.