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Cryotherapy Centers: Should You Try One?

by Pain Doc | Nov 2, 2019 | Self Treatment

Whole Body Cryotherapy (WBC) is starting to trend in the health and wellness arena. As a big proponent of non-medical self-care methods to achieve and maintain health, it piqued my interest when I first encountered it. No, it’s not a place that uses crying as a form of emotional therapy, as the name could suggest. Cryotherapy is the application of cold to the body for therapeutic effect. It is one of the two, basic modalities that have been used for centuries to reduce pain; the other, of course, being heat. Ice packs, ice baths, ice massages and frozen hand-held metal applicators are common ways to apply cryotherapy. Ice is 0⁰ Celsius (32⁰ F) so when it contacts your skin, which is about 91⁰ F plus or minus a couple of degrees depending on the outside temperature, heat flows out of your body since energy flows from high concentration to low (diffuses). It is the movement of heat out of your body that the brain perceives as cold (it is not “cold” moving into your skin).

But what happens if instead of 0⁰ C, you exposed your skin to -100⁰ C (-148⁰ F)? That is what a cryotherapy center offers, and will be the focus of this article.

Does Cryotherapy Work for Pain?

We already have a good understanding of what happens when human tissue is exposed to such extreme cold temperature, since cryotherapy has been around for decades. Cryosurgery, a form of cryotherapy, is highly focused cold using liquid nitrogen or argon gas to treat dermatological conditions such as warts and benign tumors, as well as cancerous tumors of the liver, kidneys, bones, lungs and breasts. It is also used for anesthetic purposes to deaden irritated nerves. Since human cells are about 75% water, when you apply sub-zero temperature to them the water crystallizes and denatures the cells, effectively killing them. The body then replaces the dead tissue with new cells. Cryotherapy centers, however, do not offer cryosurgery. They apply extreme cold to the whole body not to kill cells, but to “shock” the body’s central nervous system, causing it to initiate physiological processes that benefit pain reduction and tissue healing (explained later).

There are many studies in the medical literature that support the use of cryotherapy for inflammation and pain. In one study, patients suffering from adhesive capsulitis of the shoulder were randomly divided into two groups. One group had whole body cryotherapy along with physical therhapy (PT), and the other only PT. The results showed that while both groups improved, the group receiving WBC plus PT experienced significantly greater improvement in shoulder range of motion, subjective pain, and functionality.¹

Another study examined the effects of WBC on fibromyalgia, a systemic condition that involves heightened sensitivity to pain throughout the body. In the 100 person study, fibromyalgic patients treated with cryotherapy reported a more pronounced improvement of the quality of life compared to the non-treated subjects, as indicated by their scores on qualitative indexes (questionnaireson functionality/ quality of life). The researchers speculate that the positive result was due to cryotherapy’s effect on reducing pro-inflammatory mediators involved in the modulation of pain.²

My Experience at a Cryotherapy Center

I am fortunate to live in a city where cryotherapy is offered. Last week, I visited one called U.S. Cryotherapy to find out for myself what this new pain relief trend is all about. It’s a franchised business with locations in ten states including here in California, Arizona, Texas, and Florida. Upon meeting the owner, I discovered that you do not need to have a professional license (M.D., R.N.) in order to own or operate a center. Apparently, the corporate attorneys made sure that the services offered do not violate any laws regulating the practice of medicine in the state. This also suggests that the services are relatively safe to do without direct supervision of a doctor or nurse, which is reassuring.

I filled out a general medical history form on a wall tablet (touch screen). This lets the technicians know if you have any condition that might make cryotherapy risky, such as heart problems. After that, I got a tour of the facility and was shown the main cryotherapy services: whole body cryotherapy (WBC) and localized treatment cryotherapy. I decided to try WBC first. They have you remove your clothes and provide shorts (yes, you go in a freezing room bare skinned!). You put on a terry cloth head band that goes over the ears to protect them from the cold, a towel face mask to cover your nose and mouth, a pair of large wool mittens to protect your hands, and wool loafers. At this point, I am wondering what I have gotten myself into, as I have never experienced being in sub-zero temperature in bare skin!

Whole body cryotherapy chamber, -150 degrees F.

The WBC room resembles a meat locker,with a warmer holding room that you stand in prior to entering and a reefer-style heavy stainless steel door. The technician stands at the control console outside the room, which hasa large window so that you can be monitored constantly. H e sets the time and temperature, and when the temperature reaches 100 degrees below zero Celsius, he then gives the sign to enter.

I enter, and at first it doesn’t feel as cold as I thought—a crisp, dry cold enveloping my whole body. Later, I found out why. According to their website:

“Cold air therapy in the whole body chamber is a dry fresh, oxygenated air so you won’t experience shivering, goosebumps or other reactions that you might associate with being cold. Because of this technology, unlike an ice bath or immersion, cryotherapy is not painful. During the treatment, your skin temperature will decrease between 30-45 degrees over 2.5 to 3.5 minutes inside the chamber.”

Now this is interesting. With dry air (much of the water vapor removed) you can handle lower temperatures than if you were to soak in an ice bath. You see, heat travels faster through a liquid than it does through gas (air—CO₂, O₂, N, and H) which is why most people can’t handle more than a few seconds of being submerged in a bathtub full of ice water. The dry, sub-zero temperature air of WBC enables you to stay exposed for 2-3 minutes enabling more therapeutic effect.

At the one minute mark, I was getting really cold, and started to walk around and move my arms to generate some heat. But even then, it was a different kind of cold I haven’t experienced before. I wasn’t shivering. My teeth weren’t rattling, and I did not get goosebumps. It was just a sensation of homogeneous, intense cold. I noticed some small ice crystals forming on my arm, because as heat leaves the surface of the body it interacts with the air causing any remaining water vapor in the air to crystallize into frost. Was I going to make it?

At the two minute mark, I noticed my heart was beating faster. This is a sympathetic nervous system response to extreme cold and is a desired response as it stimulates the release of endorphins and norepinephrine by the brain. Endorphins are the “feel good” hormone that reduce pain and stress, and creates the sense of euphoria. Norephinephrine, also called noradrenaline, is a neurotransmitter released during times of stress that boosts focus, attention and mood. Scientists also found out that it suppresses the production of tumor necrosis factor (TNF), one of several inflammation-promoting biochemicals. This sequence of events occurs in response to what is called “cold shock,” and is the therapeutic goal of WBC. Cold shock is caused by a hypothermic event (a big, sudden temperature drop at skin, such as that caused by WBC) causing heat to leave the body much faster than usual, which vasoconstricts (tightens) the blood vessels of the extremities (another sympathetic nervous system response) and diverts blood from the arms and legs to the core to keep the vital organs warm.

As the effects of cold shock continue, any musculoskeletal pain present (strain, acute or chronic injury, or arthritis) is lessened. Blood vessels constrict, blood flow slows down, inflammation drops, and pain signals traveling from pain site to brain slow down significantly because action potentials (electrochemical charges) move slower in colder environments.

At 2:15 into the treatment, I sensed my cold tolerance quickly being reached and was ready to get out the chamber ASAP (but, this could partly be due to apprehension as it was my first experience). I reached 2:30, and eagerly exited the chamber. The technician used a laser thermometer on my skin and reported that my skin temperature dropped about 50 degrees.

Upon exiting the waiting room of the WBC chamber, I felt invigorated. Although I am in pretty good shape musculoskeletal-wise, I have minor aches in my feet and shoulders, mostly due to my age and years spent as a chiropractor. But after the cryotherapy session, these aches were significantly reduced, almost down to zero.

When you exit the chamber and return to room temperature, the heat from the warmer air moves into your colder skin, which is sensed by your central nervous system. This shuts off the cold shock response, and the body returns to homeostasis: the constricted blood vessels dilate back to normal and oxygen-rich blood moves into the extremities again. So if you have, let’s say, knee swelling and inflammation, the constriction and then dilation of blood vessels effectively “wrings out” inflammation and then draws in oxygenated blood and nutrients to the knee, much like squeezing out dirty water from a sponge and then releasing it, letting it soak up clean water.

Cold shock followed by room temperature helps to move stagnant blood and inflammatory chemicals out of an injury site, and bring in fresh, oxygenated blood, similar to wringing out dirty water from a sponge.

Here is a short video provided by U.S. Cryotherapy that explains how cryotherapy works:

Is a Simple Ice Pack Just as Good as Whole Body Cryotherapy?

WBC produces a much different effect than using localized ice, which also reduces pain by localized vasoconstriction and slowing down pain signals. The big difference between the two is that ice application does not initiate the systemic (body-wide) cold shock response like WBC does, so you don’t get the additional anti-inflammatory benefits previously described, or the endorphin and norepinephrine release. Local cryotherapy application is also superior to an ice pack because it is able to apply lower temperature to your skin. Most physical therapists will tell you to ice for 20 minutes max, but that is not possible with localized cryotherapy because of the much lower temperature it provides. Two to three minutes is the longest time human skin can take with cryotherapy.

How Often Should You Get Cryotherapy?

Whole body cryotherapy treatment guidelines for pain reduction depend on the goal. If you are post-surgery or have an acute (recent) injury, daily to multiple per day exposures for a week are appropriate. If you have chronic joint pain, a wellness routine is more appropriate, which can be once to twice a week treatments. Lastly, you can do it for general wellness on an as-needed basis. You’ll get a jolt to your circulatory system; increased heart rate (strengthens heart muscle like exercise), endorphin release, and according to the folks at U.S. Cryotherapy, improved sleep and mood.

Now with WBC under my belt, I decided to try localized cryotherapy on my chronic elbow strain and hand. For this procedure, I sat in a recliner while the technician used a machine to blow cold, dry air around my elbow. While he did this, he used a laser thermometer to monitor skin temperature. He directed the cold stream of air back and forth in quick, short strokes over the painful areas. The air is so cold that you cannot leave it in one spot for more than a few seconds; otherwise you can get tissue damage. Overall it felt as intense as the chamber, except localized. After the 3 minute treatment, the pain was reduced about 70%.

After You Do Cryotherapy

After your cryotherapy session, you can engage in 20 minutes of exercise on a treadmill or stationary bike. This enhances circulation and flushes out of waste products. They also have a red light therapy chamber you can use immediately after doing WBC, as well as Pulsed EMF (uses pulsed magnetic waves) which can further reduce pain and even accelerate healing of tissues. I previously wrote about the benefits of both of these modalities as I have used them myself, with success. They make excellent home therapy devices.

What Health Experts Say About Cryotherapy

You may have heard of Wim Hoff, known as the “Iceman.” He is a Dutch athlete famous for being able to withstand extremely cold temperatures. He does this regularly because he believes exposure to cold is good for your health. According to Hoff:

“Proper exposure to the cold starts a cascade of health benefits, including the buildup of brown adipose tissue and resultant fat loss, reduced inflammation that facilitates a fortified immune system, balanced hormone levels, improved sleep quality, and the production of endorphins— the feel-good chemicals in the brain that naturally elevate your mood.”

Wim Hoff opines that modern living, where man is always wearing layers of clothes and living in temperature controlled environments dulls the body’s innate responsiveness and adaptability to its natural environment, which makes modern man more susceptible/ less resistant to disease. You don’t need to emulate Wim Hoff (the physical feats he does in cold would kill most people), but realize there are health benefits to exposing your body to cold.

Mark Sisson, a popular health blogger noted for his “primal” philosophy of mimicking prehistoric man’s lifestyle to strengthen your health (which I follow loosely), states that occasional, intentional exposure to cold will “improve your focus, confidence, and mental resilience…and that these benefits will carry over into all other areas of life.” He adds, “Anecdotal evidence from [extreme cold] enthusiasts also suggests that toughing out a cold shower or committing to a focused cold therapy regimen has profound mood elevating effects.” Those who endure the unpleasantness of being subject to extreme cold do so because they know that feeling good is just around the corner.

According to Dr. Rhonda Patrick, PhD., an expert in longevity science, just a 20-second immersion into freezing water a couple times a week can increase norepinephrine levels 200-300 percent. Imagine what 2-3 minutes would do. This will increase your heart rate, constrict blood vessels, and release glucose into the blood for your skeletal muscles. As previously mentioned, norepinephrine also acts as an anti-inflammatory by reducing tumor necrosis factor, a substance associated with practically all inflammatory-related diseases.

When you do whole body cryotherapy or other extreme cold practice, it basically conditions your body’s innate, adaptive mechanisms. Your body’s ability to handle large temperature swings is actually a health metric, like cardiovascular fitness and mobility. We tend to lose this as we age, which is why the elderly are more vulnerable to heat waves and are usually the first casualties when one strikes. Exposing yourself to very cold temperatures for short periods to increase your tolerance to cold is intuitively a good, health-promoting activity.

One thing that I should point out about cryotherapy is that it is not recommended post exercise. When you do an intense workout such as a marathon, the post-workout inflammation in the muscles should be allowed to run its course. This builds muscle adaptation to exercise by conditioning its restorative/recuperative mechanisms. Doing cryotherapy immediately after exercise, while it feels soothing, interrupts the process. It inhibits the “adaptation conditioning” of your muscles and you will not increase your endurance.

The Final Verdict

If you have any form of musculoskeletal pain and are fortunate to have a cryotherapy center nearby, give it a try. It’s one of those things that, while not a magic bullet for pain, has enough anecdotal evidence to validate its claim, as well as science. 100 degrees below zero Celsius while in your shorts can understandably intimidate some people, but it’s not that bad—you are in there for less than three minutes, and it’s dry cold, which your body is able to tolerate better. Whole body cryotherapy’s value is its ability to “comfortably” produce cold shock, reducing inflammation and pain and stimulating endorphin and norepinephrine release which improves mood, mental clarity and sleep. Do not use it post-exercise; rather, consider using it a couple of days after orthopedic surgery; after any recent soft tissue trauma (sprain/strain, whiplash from car accident, sports injury); if you have a chronic musculoskeletal condition such as knee osteoarthritis or shoulder problem; or, for general wellness.

If you don’t have a cryotherapy center in your town, there’s another way to get the benefits of extreme cold therapy: get a freezer chest and fill it with water and ice so that the temperature is near freezing. Then, you’ll need to brave the initial shock of submerging yourself, and see how long you can tolerate it. Since it’s cold water and not cold air that you are using, it won’t be as comfortable as using a cryotherapy chamber; you will likely shiver due to the faster heat transfer properties of water vs. air. Here is a video of Brad Kearns, co-author (with Mark Sisson) of the Keto Reset Diet and cold therapy enthusiast, on how to set up your personal cold therapy center:

Lastly, if this isn’t an option for you, try turning your shower water to cold for a minute or two. It’s best to just go for it and not try to ease yourself into it—turn that knob and tough it out. Do it in the middle of your shower and finish with a couple of minutes of warm water, or finish your shower with two minutes of cold water. You will feel invigorated; trust me. Do it every time you take a shower, or every other time– the more you do it, the better you’ll adapt. Keep in mind all the health benefits of cold exposure you’ve learned here; hopefully this will motivate you to take some action.

¹ Sang-Yeol Ma et. al, Archives of Physical
Medicine and Rehabilitation. Volume 94,
Issue 1, January 2013, Pages 9-16.

² Lorenzo Bettoni et. al, Clinical Rheumatology. September 2013, Volume 32, Issue 9, pp
1337–1345.

Is it OK to Adjust Yourself and Others?

by Pain Doc | Oct 23, 2019 | Uncategorized

If you’ve ever had a kink in your neck, or felt your upper or lower back needed some “cracking” because you sensed restricted movement, then you are probably familiar with the benefits of spinal adjustments; also called manipulation.

So what exactly is a spinal adjustment?

Basically, it is a hand-delivered force into an improperly moving joint done to make it move normally. Vertebrae can get “stuck” in a rotated or bent position by numerous ways, such as sleeping on your stomach with neck twisted or a sports injury. This can feel very uncomfortable and may even cause sharp pain, arm numbness or headaches.

It is roughly estimated that about one million adjustments are done in the U.S. every business day, mostly by chiropractors. It is their “bread and butter” treatment because chiropractic is based on the belief that abnormal spinal alignment contributes to poor health, and manually correcting the alignment can improve health. Because they do it the most, chiropractors are considered the specialists most proficient at spinal adjustments/ manipulation.

According to ShareCare, about 30 million people see a chiropractor each year, mostly for various types of musculoskeletal pain and dysfunction. The benefit is improved range of motion (flexibility) and decreased discomfort/pain. Some patients experience other symptomatic improvement such as cessation of a headache or clearance of congested sinuses (there are medical models to explain this, but this isn’t the focus for this particular article). While there are pockets of naysayers, it is fair to say that getting your neck and back adjusted can be good for you.

Are You Actually “Adjusting” Yourself When You Crack Your Neck Yourself?

If you or someone you know “crack” your joints by twisting your neck or low back until you hear a pop. I personally know someone who has a daily routine for this, using her hands to forcibly twist her neck by grabbing the top of her head and chin like in the picture above, and rotating her head far to the left, then right; and then twisting her spine while sitting. I noticed that she gets an unusual amount of popping when she does this; seemingly with little effort. This excessive popping indicates that the spinal facet joints have become hypermobile from overstretching—they’ve lost some of the ligamentous support, allowing the joint to move more than it was designed to. Hypermobility of joints accelerates wear and tear, leading to bone spurring and disc thinning, which can eventually press on nerves inside the spine causing pain and weakness in the extremities. Although, as far as I know, there are no conclusive studies on the benefits or harm of cracking your neck often, I believe that it is best not to do it for these reasons.

The next question is, if you are able to pop your own neck or low back by forcibly twisting it, are you essentially adjusting it? Are you getting the same benefit as an actual chiropractic adjustment?

This is not easy to answer, because in order to get a scientific-based answer to this, a large study (many people) is necessary, which hasn’t been done to my knowledge. Also, the outcome (result of cracking vs. adjusting) is difficult to measure. As a chiropractor myself, here is my explanation of the difference between “cracking” your own neck and getting a chiropractic adjustment:

When you “crack” your neck yourself, you are essentially twisting or bending (depending how you do it) all your neck vertebrae at the same time. At some point, you get cavitation—the popping sound made by collapsing pockets of dissolved gases in the small facet joints of the cervical vertebrae, due to the expansion of those joints as you bend your neck to the side. There is a sense of pressure release and improved neck flexibility afterwards. Sometimes it can be verified by checking range of motion before and after; sometimes not. People who do it will typically say “it feels good,” or “it relieves pressure.”

On the other hand, a chiropractic adjustment to the neck targets just one vertebrae—the problematic one identified by palpation and/or x-ray, so it is more precise. It also incorporates an external force—the hand thrust—that forces the vertebrae into the direction where it is deficient; i.e forces it back to its normal range of motion.

Most people will tell you that the feeling after a neck adjustment is very different that the one you get by merely twisting your neck: it is a focused, louder sound and you feel a heightened sense of things immediately afterwards, similar to having a wax earplug removed or clogged nasal sinuses suddenly cleared. This may be explained by improved nerve firing, better circulation and restored neck muscle balance.

So these are the differences between cracking your own neck and having a chiropractor adjust your neck. But again, there are no studies I can reference that proves the superiority of one over the other. Currently, the evidence is subjective, or anecdotal.

Is It Easy to Do Adjustments Yourself?

If you have ever been to a chiropractor, you know that it does not take long for the chiropractor to do an adjustment – about 5 seconds total, including the palpation (feeling for the joint’s movement) and set-up of the thrust. On the surface, an adjustment seems like a relatively simple procedure to do (although more subtleties are involved that you don’t notice). In other words, it’s not brain surgery. This apparent simplicity is what encourages some people to try it on themselves or their housemate, partner or friend. They take note of what their chiropractor does and perhaps watch YouTube videos of chiropractors adjusting patients to see how it’s done. I even made a video on chiropractic adjusting a couple of years ago which you can see here. I will venture to guess that a lot of “adjusting” occurs outside of chiropractic and physical therapy offices.

So, is self-adjusting, or adjusting a housemate safe? Can it be beneficial? Most would say no, for the obvious reasons—you need to get proper training, it could be dangerous and you could hurt someone, etc.

There can also be legal implications to this, such as practicing without a license.

Obviously, the best solution is to seek the services of a licensed, experienced chiropractor who knows the ins and outs of adjusting. However, I do understand that some people cannot afford to see a chiropractor, or don’t have access to one; or simply don’t want to see one for personal reasons but still desire to obtain the benefits of spinal adjustments. As a big believer and advocate of self-care for managing musculoskeletal pain, I have an atypical perspective on this, which I’m sure most chiropractors won’t agree with. My view is that, with proper guidance, every day people can learn to do modified adjustments, or joint mobilizations to relieve pain and discomfort on themselves and others. These are basically targeted stretches that have elements of joint mobilization. Before I describe them, I will explain the distinctions between adjustments, joint mobilization and stretches.

An adjustment is a short lever, high velocity manual thrust into a joint. Short lever means that you contact a small protuberance of a bone and use it as a lever to move the whole bone (see diagram below). If it’s a spinal vertebra, you can use the bone’s transverse processes or spinal process as a lever to move the whole vertebra. You locate these structures, contact them with your hands, decide which direction you wish to move the bone, and thrust in the appropriate angle and depth.

The term joint mobilization is used to describe longer lever, lower velocity force applied to a joint; for instance, using the femur bone for leverage to manually circumduct the hip joint.

Stretches of course apply to the soft tissues—muscles, ligaments and tendons. They are done to elongate contracted fibers to increase flexibility, and are done by isolating the muscle and elongating it with movement. Stretching ligaments requires you to move the joint to its end range of motion, and then a few degrees past it.

Together, adjustments, joint mobilization and stretches are the three, primary tools of manual therapy for the musculoskeletal system. Note, however, that soft tissue mobilization is a term used to describe various forms of deep tissue/sports massage, and can also be considered manual therapy.

In my opinion, it is fine for someone to learn how to do modified forms of adjustments. Manual therapy is one of the safest forms of therapeutic intervention; even safer than taking aspirin. So if you’re an athletic trainer, massage therapist, acupuncturist or anyone else who is interested in learning how to adjust yourself or someone else, know that there are options. I believe the time has come for people to learn how to do basic manual therapy for the benefit of others. The trend may lead to a dramatic decline in neck and back pain in the population, much like how the fitness craze starting in the 80’s made people more lean and fit.

In the coming days, I will explain how to do some basic adjustments and joint mobilization moves that you can try—on yourself, and others. The key to doing these is to do them slowly and stay focused on what you are doing. Avoid sudden jerks especially to the neck. It’s not an issue when people stretch themselves and help stretch others. The techniques that I believe are safe and appropriate for non-trained people to do are similar in scope and complexity, but with some focus on moving the joints. Stay tuned!

Are Massage Guns Good For You?

by Pain Doc | Oct 11, 2019 | Myofascial Pain

If you are on Facebook, you’ve probably seen the relentless advertisments for massage “guns.” These are heavy duty, hand-held vibrational massagers that sellers claim provide a number of benefits; namely increasing blood circulation to muscles, reducing muscle tightness, reducing pain and improving muscle recovery from sports activities. The ads suddenly exploded on the scene a couple of months ago. There appear to be multiple sellers selling the same device, with brand names including Halo Pro, G3, Hypervolt, XVan and Intellitop and most if not all are manufactured in China. The price ranges from about $100 – $225.

Below is a screenshot of the Amazon listings of these products. Apparently, they are selling like pancakes:

But are massage guns really good for you? Are they worth the money you spend? Or, are they just old technology being packaged as something new and innovative, using exaggerated claims and expensive marketing? Or perhaps…can massage guns be harmful to you?

Well, let’s break it down, piece by piece. First of all, there isn’t much medical technology involved in these massage guns. At the heart of these massage guns is a variable speed motor and armatures that together produce rapid oscillation of a rod, to which you can attach various treatment heads. That’s it. It’s essentially the same engineering as a jigsaw/ reciprocating saw, with a shorter depth of movement.

You apply it to a large muscle, such as the quadriceps (thigh muscles), gastrocnemius (calves), erector spinae (back muscles), or if you are a bulky weight lifter, the biceps and triceps muscles. If you want to use it on the smaller posterior neck muscles, there is a horseshoe shaped attachment available.

Mind you, the force generated by these massage guns is significant: people with smaller and/or more sensitive muscles will not be able to handle it, and may even get bruised. These massage guns, in my opinion, are better suited for those who have a larger muscle mass than most people; muscle that is well-conditioned from training; i.e hypertrophied muscle.

Are There Health Benefits to Deep Vibration?

The sellers of these hand-held massage guns instruct the user to place the treatment head over the belly of the muscle (thickest part; usually in the middle), applying a downward force as shown in the picture above. You can keep it stationary or slide it up and down the muscle, applying light to heavy pressure.

In order to get an idea of what happens to the muscle when you use a massage gun on it, it helps to understand the anatomy and physiology of muscle and surrounding tissue.

Starting from the top, your skin: is your skin firm or saggy? This depends on the quality and density of collagen and elastin fibers that form your dermis, or lower layer of skin. Younger people have firmer, resilient skin, thanks to dense and higher quality (less degraded from age) collagen fibers. People 50 and over, not so much. So if you are in your 30s, that’s a plus for you if you want to use a massage gun. Your skin is likely tougher and able to handle the force of those vibrations.

Small blood vessels and nerve endings are present just below the dermis, or hypodermis. When these vessels dilate, you get hyperemia, or reddening of the skin.

Next in line, your subcutaneous fat. This is the fat directly underneath your skin, laying just above your muscle whose function is to provide a protective cushion for the body. Its thickness varies, depending on the location in your body; your age, sex (females tend to have more subcutaneous fat as a percentage of body mass), and health status. If the subcutaneous fat over your muscle is a good inch or more thick, this provides a barrier to the vibration and absorbs and dissipates some of that force. So, thicker subcutaneous fat is another plus for massage gun use.

And third, the target of the massage gun– skeletal muscle. Muscle is denser and heavier than fat as it is comprised mostly of protein; specifically actin and myosin, the specialized fibrous protein that comprise the contractile units. Muscle is covered by fascia, a tough fibrous webbing that lends support to the muscle as it contracts.

Skeletal muscle covered in fascia (electron microscope)

Blood vessels penetrate the muscles, supplying them oxygen and nutrients and transporting waste products away. Below is an illustration of the vessels that service the upper leg muscles. It shows the large caliber vessels– the femoral artery and veins, and the smaller branches that attach to multiple areas of each muscle.

Lastly, be aware that there are nerves in the area. The femoral and sciatic nerves pass through the leg muscles, and smaller divisions branch off and attach to multiple areas of each muscle to provide direct stimulation from the brain.

Thigh muscles showing location of major arteries, veins and nerves

So, when you place the massage gun over the skin and press into the muscle, it pulsates rapidly and with each stroke the skin, fat, muscle, blood vessels and nerves get compressed and then rebound hundreds or thousands of times, depending on how long you apply the massager

Here are the physiological effects of the massage gun:

Blood in the vessels of the skin are repetitively blanched and dilated, reddening the surface of the skin. In some cases, capillaries may burst, and if enough of them burst you will get visible bruising (small volume blood leakage into the tissues).
Special sensory nerve endings in the skin fire. These nerve endings detect vibration, pressure, and light touch. Any neural input is sent to the brain for processing, and complex interactions with other nerve pathways may occur causing distal/secondary effects such as change in heart rate and blood pressure.
The collagen in your skin gets stretched/worked. This could loosen the skin over time.
The subcutaneous fat gets compressed. Fat is enclosed in tough, fibrous tissue so there is no effect on fat mobilization.
The muscle absorbs the force. While muscle cells are very durable, it is possible that some of the actin and myosin proteins could be damaged especially those with smaller and/or less conditioned muscles; or older people. This could affect muscle contraction and strength.
The nerves that cause muscles to contract by depolarizing the muscle membrane fire repeatedly, causing small muscle contractions and some fatigue (try curling a weight after using a massage gun on your biceps, and see if you have full strength). If you have an abnormally contracted muscle, this may help it regain normal tone by hyperpolarizing the nerves that stimulate it, causing them to deplete their neurotransmitter temporarily.
If there is scar tissue around your muscle or fascia, the repetitive force of the massage gun may help loosen it by stretching the shortened fibers. This could help regain some lost range of motion and improve flexibility of the muscle.
The deeper blood vessels in the legs may absorb some of the force, if you angle it just right. This could be a dangerous, especially for those who have blood coagulation problems. It could loosen a thrombus (blood clot resting in a vessel) causing it to detach. This could cause a stroke or pulmonary embolism, two potentially fatal conditions. So be careful if you use the gun on your legs, especially your calves.

So what’s the final verdict? Are massage guns worth it? Will they work as advertised?

As in many cases like this, it depends. My advice is that it wouldn’t hurt to get one if you know that this kind of massage makes you feel better– relaxed, invigorated, less muscle pain, or other perceptible benefit.

Secondly, don’t think these massage guns are a magical, new technology. They simply are another form of vibrating massage devices, which have been around for decades. However, they do have one good selling point, and that is ergonomics. They are much easier to handle, and lighter, than the old generation of vibrational massagers like the one below. This means you have better control on applying the massage.

Older generation portable, vibrational massager

These massage guns are also convenient for travel, as they take up a relatively small space in your luggage. For those who travel frequently, it could be a good way to reinvigorate your leg and feet muscles.

I can see the massage guns being a better choice for massaging a trigger point, or patch of scar tissue. The interchangeable heads allow you to focus the pressure over a smaller area, too.

And finally, don’t overdo it. Longer time does not always translate to better for you. Due to the massage gun’s power, I’d say two minutes maximum for any large muscle like the quadriceps group; and one minute max if you are massaging your neck muscles. Get the blood circulation going, and stimulate the muscle just enough to get it to loosen, and no more. If you take blood thinners to reduce blood clotting, I would avoid using it on your legs. Instead, opt for a Swedish style massage from an actual massage therapist. And warning, some people get nauseous from strong, high frequency vibration, and it’s worse the closer you are to your head (inner ear/ vestibular apparatus). The vibration generated by a typical massage gun is strong enough to move the fluid in your inner ear, which may cause nausea and vomiting in some people, so be careful.

Here is one of the better selling massage guns on Amazon. It seems good quality, and has many positive 4 and 5-star reviews, with over 3,500 reviews as of this writing.

A massage gun can be a good addition to your arsenal of home therapy tools. Make sure to visit our homepage, where you can find free self-care videos on the 15 most common presentations of musculoskeletal pain. You will discover the tools and equipment that I personally recommend for pain management at home. There are not many, because not all products are worth your time. As a chiropractor, I’ve tested nearly a 100 therapeutic products on my patients over 20 years, and based on their feedback and treatment results, these are the products I recommend. Opt in to my “Pain Relief Tips” newsletter to get great ideas o how to minimize pain and increase strength and flexibility in your body.

The Stages of Pain and Tissue Repair

by Pain Doc | Oct 6, 2019 | Sprains and Strains

Musculoskeletal pain typically involves a movable joint—the articulation (connection) of two bones that, working with muscles, help generate movement and force. Common culprits are the knees, hips, spine and shoulder. The source of pain can be tendons, ligaments, cartilage, bursae, muscle tissue and/or bone.

Acute pain refers to pain that is sharp and intense in nature as opposed to diffuse and duller intensity. It comes from either a new injury or damage event, or an exacerbation (flare up) of a prior injury; i.e. re-injury. What I mean by “damage event” is that you do not have to experience an external injury such as a fall or sports accident in order to experience acute pain. It can be the result of gradual wear and tear of a joint, such as acute onset knee pain that starts the moment cartilage erodes down to the bone; or a lumbar disc that spontaneously bursts after many years of weakening.

When pain is acute, there is redness, swelling, heat and sharp pain. These are the four hallmarks of inflammation. Inflammation, while it gets negative press, is actually a life-saving, natural process when it occurs in response to tissue damage. Its purpose is to summon all the biological and biochemical agents that are necessary to limit tissue damage and initiate healing. Without going into too much detail, there are a host of biochemicals released by injured tissues and cells that (1) cause blood vessels to dilate and become more permeable, which produces swelling; (2) regulate blood clotting to stem bleeding; (3) initiate fibroblast activity—the cells that secrete fibrous, reparative tissue over the damage; and (4) summon macrophages to the area– large cells that clean up debris.

The goal of treatment during the acute phase of pain is to reduce pain intensity; reduce swelling, and stabilize the injured area to prevent aggravation. RICE—Rest, Ice, Compress, and Elevate the area– is a good guideline for managing acute pain. You need to be patient, as healing takes time; and do the things that help your body heal naturally on its own. This will determine how well your healing goes, and in some cases will mean the difference between healing 100% or developing chronic pain from the damaged tissue.

As a side note, be cautious using anti-inflammatory medications after you sustain an injury. Remember, the inflammatory process is part of the tissue healing process so you don’t want to suppress it entirely; just manage its intensity. Diligently applying cold therapy is a better option; use the NSAIDs and cortisone only when the pain is unbearable and you cannot afford to be without the use of that painful body part for very long.

The acute stage lasts 1-3 days and is followed by the sub-acute stage, which may last several weeks. During this stage, swelling subsides, fibrosis is finishing up, blood vessels are repaired and pain gradually decreases. The goal of treatment during the sub-acute stage is to introduce movement, reduce pain and enhance healing. This includes active and passive joint mobilization, massage/soft tissue work; and sometimes pro-healing modalities such as infrared, laser and pulsed EMF.

The last stage of an injury/damage event is remodeling. The newly formed tissue and fibers become more organized and stable as you move the damaged area through its normal range of motion. This can last several months, and even years. The goal of treatment during remodeling is strengthening and restoring range of motion. Therapies include joint mobilization, spinal manipulation, soft tissue work such as active release therapy; and resistance and coordination exercises such as weights, theraband, and balancing exercises.

Chronic musculoskeletal pain refers to pain that remains after an injury or damage event has gone through the acute, sub-acute and remodeling phases. Chronic pain is typically less intense and more diffuse (less focalized), and may be intermittent (comes and goes). For some people, chronic pain significantly reduces quality of life by causing impairment in the ability to engage in certain activities of daily living such as bending at the waist, lifting, and raising one’s arm above shoulder level.

Chronic pain can assume psychosomatic qualities, where the individual can actually perpetuate and even worsen the pain through his/her thoughts and beliefs; i.e. believing and accepting one’s pain to be catastrophic and life-changing. When this occurs, it negatively changes behavior in a way that inhibits pain resolution. The person becomes over-cautious and limits his/her activities to avoid pain, which promotes atrophy, weakness and loss of muscle coordination. Because of this, a standard of care for musculoskeletal pain is to encourage the patient to have a positive attitude during his recovery; continue with his everyday work and leisure activities as best he/she can, and work through the pain and try to tolerate it as the area heals, remodels and strengthens.

Is Chronic Pain a Life Sentence?

Since chronic pain has gone through the stages of healing, can it ever be resolved 100%? By definition, chronic pain is persistent, ongoing pain. But there are cases where chronic pain made a turn for the good, and totally disappeared, even after decades of pain. What is necessary for this to happen is the tissues–ligaments, tendons, muscles, or cartilage– need to have some regenerative capacity left, and those regenerative capacities need to be optimized so that the healing is enough to stop the pain generating areas. Pain that doesn’t go away at first is often a sign of sub-optimal healing. The key is to find out what is causing this; remove it, and do things to enhance your body’s ability to regenerate the damaged area such as changing your diet, doing prescribed, therapeutic exercises and even changing your mindset if necessary. Only then do you have a chance to eliminate chronic pain once and for all.

The Critical Exercise Most Everyone is Not Doing

by Pain Doc | Oct 6, 2019 | Shoulder Pain

The idea that exercise benefits your health is a medically and scientifically proven, and perhaps more importantly, socially accepted concept. We can now call it a fact. Research conclusively shows that regular physical activity promotes multiple improved health metrics such as lowered LDL and increased HDL cholesterol levels; decreased triglyceride levels; healthy blood pressure, brain health, improved bone density, increased insulin sensitivity and more. Exercise is also positively correlated with longevity. We know exercise is important if we are to stay healthy, maintain a high quality of life, and live longer.

When it comes to exercising, there are basically three groups of people who engage in it:

1. The elite, professional athletes whose livelihood depends on their physical abilities and talents. These people have the benefit of professional trainers and unlimited facilities and equipment to get their bodies in shape. Not something the rest of us can say.

2. The fitness fanatics who hit the gym 3-7 times a week; sometimes more than once a day; keep abreast of the latest exercise techniques and have a better grasp on the science of fitness—basically those who make fitness a central part of their life.

3. The everyday Joes and Janes who take aerobics classes; jog, use a treadmill or Stairmaster and/ or lift weights, as best they know how.

Which group do you fit in?

There are two, textbook categories of exercise: resistance and endurance. In resistance exercise, you apply resistance to your muscles via traditional weights; other heavy objects (medicine balls, tires, sandbags); friction, rubber tubing, and even your own body weight (planks, squats, TRX). In resistance exercise, the primary goal is to strengthen your muscles by stimulating your body to produce more actin and myosin myofibrils, the specialized protein structures that do the actual contraction. The more myofibrils your muscle cells (muscle fibers) have, the bigger your muscle; the bigger your muscle, the greater its potential for generating power.

In endurance exercise, the goal is to improve a muscle’s ability to function for a longer duration before fatiguing. These exercises are more commonly called aerobic or cardio exercises since a big part of improving muscular endurance is to strengthen the heart and lungs. Distance running and wind sprint running; Stairmaster™, cycling and aerobics classes are examples of endurance exercises.

It’s not entirely clear what precisely happens when muscles increase endurance from these exercises, but we do know that placing a sustained, increased demand on the heart, which is the essence of cardio exercises strengthens the heart, a muscle itself, enabling it to pump a larger volume of blood with each contraction (called stroke volume) to skeletal muscles to meet their oxygen and glucose (fuel) demands. Endurance exercises also increase the number of muscle cell mitochondria, the organelles where ATP, the “energy currency” of cells, is manufactured. Generally, more mitochondria means more ATP production. By the way, if you find yourself out of breath after engaging in a level of physical activity comparable to walking up one flight of stairs, you likely have poor cardiovascular fitness.

A third type of exercise that is gaining popularity is muscle coordination or functional exercises. These exercises focus on doing movements that are commonly required in everyday life, with the goal of strengthening/ improving the synergy and coordination between the muscle groups that create that movement. Examples include walking up a flight of stairs; lifting and carrying luggage; lifting something from the floor to a higher level; lifting and carrying something heavy on your shoulder; pulling and pushing something heavy; jumping; sitting down and getting up, crawling on the floor, and so on. Movement patterns such as these involve several synergistic muscle groups such as leg, buttock and back muscle groups that contract in a precise sequence and amplitude determined by your brain. A primary goal of functional exercises, therefore, is to improve the neurological component of muscle group contraction so that your body responds more efficiently to its environment. To get a sense of how functional exercises work, check out the website Functional Patterns.

This brings us to the fourth exercise that most people forget. Resistance exercises strengthen the muscles; cardio exercises improve muscles’ endurance; and functional exercises improve the coordination of muscle groups involved in common movements, so what is missing? The one exercise that people forget, and should incorporate into their workouts are joint exercises.

In joint exercises, the goal is to mobilize and strengthen all the components of the joints—joint articulations, tendons, capsules, ligaments and deep muscles. This requires moving the joint through all its ranges of motion, with and without resistance. The resistance used in joint exercises is not as strong (use lighter weights) as that used in resistance exercises done to increase muscle mass, because gaining muscle mass is not the goal of joint exercises. Whenever connective tissue (ligaments, tendons, bone) and muscle are stressed, the body senses it and makes adaptations: it increases their mass and produces more supportive collagen fibers. This is called Davis’ Law, which describes how soft tissue remodels along the axis of force. The benefit is healthier, sturdier joints that resist degeneration better, and improved strength/ power generation.

Joints are a biomechanical wonder that are an essential component of your locomotor system—the parts of your body designed to generate movement. They enable your skeleton and muscles to do work; i.e. generate power. Recall from basic science the simple machines: pulleys, inclines, and levers with fulcrums. As a machine, your musculoskeletal system incorporates all three; especially levers and pulleys.

Let’s take your arm for instance. Your upper arm bone, or humerus connects to your lower arm bones, the radius and ulna via a joint we all know as the elbow joint. This is a lever and fulcrum system such as the one illustrated above, with the humerus being the effort arm of the lever and ulna/radius being the resistance arm; the elbow being the fulcrum, and the biceps and triceps muscles being the force generators (effort). The elbow joint is a critical component of this simple machine, as it stabilizes the system while allowing movement. Its main components are the cartilage-lined ends of the long bones; the musculotendinous attachments to the long bones; and a capsule made of dense, connective tissue. When you do joint exercises, you target all these structures.

elbow joint and major ligaments and tendons

There are several types of joints in the body, classified by their construction and movability. The type we will focus on are the synovial joints, which is the type that enables the greatest arcs of movement compared to other joint types. Examples of synovial joints are the facet joints of the spinal column; the shoulder, elbow, wrist, and finger joints; and the hip, knee, ankle and toe joints.

To exercise a joint, start by moving it in all directions possible (active motion). If you find a joint is offering restriction in one direction, you can passively move it; i.e. relax the muscles of the joint and use your opposite hand to move it, or ask a partner to move it; gradually pushing into the restriction and breaking through the mechanical barrier (but make sure it is not contraindicated; check with a specialist first). Areas of joint movement restriction are usually caused by scar tissue adhesions where scar tissue from previous injuries adheres to adjacent tendons, inhibiting movement in a particular direction.

After doing active and passive joint movement, apply resistance. There are several options, which depend on the joint you are exercising. For the shoulder joint–the joint in the body that has the most versatility– you can use dumbbells or Theraband™ tubing. If you have pre-existing shoulder problems, it may be better to start off with Theraband tubing. If you have no shoulder joint problems, then start out with 3 – 5 pound dumbbells. You can do these exercises standing up, sitting down, or lying prone or supine (refer to diagram below). Basically, you move the resistance doing shoulder forward flexion, extension, abduction, adduction, and internal and external rotation (see diagram below). Occasionally hold the position at ¼, ½, ¾ and end range for a few seconds, then return to full movement.

basic shoulder joint strengthening exercises

Next, transcribe circles with your arm, starting with small ones and increasing in circumference; then reverse directions. I will post a video of these exercises later, so stay tuned.

For the hip joint, do active mobilization by doing a hula hoop motion with your pelvis while standing. This rotates your pelvis over your femur heads in the acetabulum (socket), which moves the hip, a ball-and-socket synovial joint, in all directions. Next, use Therabands™ or ankle weights for the resistance and move your hip joint in flexion, extension, abduction and adduction; hold for a few seconds in each position, then transcribe varying sized circles with your leg. This can be done standing up or lying on your side. This action stresses the hip joint components, thickening and strengthening them.

Similar approaches can be done for the elbow, wrist, finger, knee, ankle and toe joints.

Sometimes a joint “dries up” after years of insufficient movement. This is common in office workers whose job description centers on typing/data entry. In this position, the shoulder joint is relatively static (upper arm angle doesn’t change) and synovial fluid doesn’t adequately circulate around the joint surfaces. Synovial fluid is the equivalent of motor oil for joints, allowing them to move nearly friction-free. When you don’t move your joints enough, synovial fluid levels drop and some friction sets in. This causes your joints to feel achy and stiff. Sometimes you may even hear grinding sounds with shoulder movement when levels are low. Lubricin is another substance in the joint capsule that contributes to smooth joint movement by protecting the cartilage-secreting cells. It, too, can dry up if there is insufficient joint movement.

If your joints feel stiff, apply heat, like an infrared lamp for 20 minutes followed by active and passive stretching in all ranges of motion. Movement will re-stimulate the secretion of synovial fluid and lubricin. Do twice a day for two weeks, then as needed. Infrared heat is a superior heat modality for the shoulder joint due to its ability to penetrate deep into the body. I made a video that shows how to rehab shoulder joint pain using myofascial release and red light therapy, which you can view below if you have shoulder problems:

You really don’t want to go too long with achy, stiff joints because it typically worsens; often resulting in a “frozen” or locked joint that is prone to accelerated degeneration (osteoarthritis) and partial disability (the x-ray image below shows what advanced degeneration of the shoulder joint looks like). This is why joint exercises are so important, especially for those over age forty, the approximate age when the brain’s secretion of human growth hormone (HGH), the “fountain of youth” hormone sharply drops, causing connective tissues throughout the body to lose their resilience. Just know that placing controlled, directional stress to your joints via these joint exercises will trigger your body to build them up, strengthening them.

Bottom line: Incorporate joint exercises into your workout routine. Target the heavy use joints first—your shoulders, hips and knees. Allowing your joints to weaken can lead to loss of support, joint degeneration, chronic pain, partial disability and reduced quality of life so make sure to strengthen those joints using the methods described above.

01/29/2020 UPDATE: Just completed the video that shows some joint strengthening exercises for the Big Three: Shoulder, Hip and Knee joints.