On stretching
Feb. 12th, 2019 08:33 pm![[personal profile]](https://www.dreamwidth.org/img/silk/identity/user.png){kind=small}
kaberettI was recently linked to Paul Ingraham's article on the point (or lack thereof) of stretching, which I read with interest not least because stretches form a significant component of my physio programme.
Subjectively (or, looked at another way, with a sample size of one), regularly stretching my calves significantly reduces how tense they are by default, which in turn reduces my pain. Reduced pain levels are most noticeable when I'm lying down and trying to sleep, but it really does appear to be consistently the case that when I'm stretching, I hurt less. Calf stretches (when combined with strength training) also have the fascinating-to-me effect that shoes with high heels stop being actively more comfortable than flats. I'd been working on the assumption that this is the reverse causality to implication of long-term high-heel use in shortening calf muscles (study), i.e., my leg muscles are generally tighter than average to compensate for connective tissue laxity associated with Ehlers-Danlos Syndrome.
I also stretch my upper body, mostly to encourage me to release tension in my upper back. Again, my experience is very much that this does reduce pain (in addition to "just" feeling good), albeit indirectly.
Ingraham says:
The argument as I understand it is that stretching prior to exercise doesn't alter the incidence of injury, doesn't "warm up", doesn't prevent Spatzen (DOMS, delayed-onset muscle soreness) and if anything is associated with a mild deterioration in athletic performance.
However, also cited is a Cochrane review finding that static stretching has no impact on muscle contractures.
The one consistent measurable effect Ingraham cites is increased flexibility, though this appears to be due to increased tolerance of the sensation of stretching, at least for short-term stretching sessions; as of 2010 (the same year as the famous small-scale study on the effects of high heels) the effects of long-term stretching programmes (>8 weeks) had not been evaluated; a 2018 review of 3- to 8-week stretching programmes found similar results. I'm not, however, turning up anything on longer-term stretching programmes as they pertain to EDS -- or, for that matter, anything suggesting that the result found for high heel use was erroneous.
Thoughts etc cheerfully solicited; I'm enjoying chewing over this and reassessing the place stretching has in my maintenance regime!
Subjectively (or, looked at another way, with a sample size of one), regularly stretching my calves significantly reduces how tense they are by default, which in turn reduces my pain. Reduced pain levels are most noticeable when I'm lying down and trying to sleep, but it really does appear to be consistently the case that when I'm stretching, I hurt less. Calf stretches (when combined with strength training) also have the fascinating-to-me effect that shoes with high heels stop being actively more comfortable than flats. I'd been working on the assumption that this is the reverse causality to implication of long-term high-heel use in shortening calf muscles (study), i.e., my leg muscles are generally tighter than average to compensate for connective tissue laxity associated with Ehlers-Danlos Syndrome.
I also stretch my upper body, mostly to encourage me to release tension in my upper back. Again, my experience is very much that this does reduce pain (in addition to "just" feeling good), albeit indirectly.
Ingraham says:
Stretching just doesn’t have the effects that most people hope it does. Plentiful research has shown that it doesn’t warm you up, prevent soreness or injury, enhance pe[r]formance, or physically change muscles. Although it can boost flexibility, the value of this is unclear, and no other measurable and significant benefit to stretching has ever been proven. [...] If there’s any hope for stretching to be medically useful, it might be a therapeutic effect on muscle “knots” (myofascial trigger points), but even that theory is full of problems.
The argument as I understand it is that stretching prior to exercise doesn't alter the incidence of injury, doesn't "warm up", doesn't prevent Spatzen (DOMS, delayed-onset muscle soreness) and if anything is associated with a mild deterioration in athletic performance.
However, also cited is a Cochrane review finding that static stretching has no impact on muscle contractures.
The one consistent measurable effect Ingraham cites is increased flexibility, though this appears to be due to increased tolerance of the sensation of stretching, at least for short-term stretching sessions; as of 2010 (the same year as the famous small-scale study on the effects of high heels) the effects of long-term stretching programmes (>8 weeks) had not been evaluated; a 2018 review of 3- to 8-week stretching programmes found similar results. I'm not, however, turning up anything on longer-term stretching programmes as they pertain to EDS -- or, for that matter, anything suggesting that the result found for high heel use was erroneous.
Thoughts etc cheerfully solicited; I'm enjoying chewing over this and reassessing the place stretching has in my maintenance regime!
(no subject)
Date: 2019-02-12 09:00 pm (UTC)(no subject)
Date: 2019-02-12 09:13 pm (UTC)I mean, there's a lot of data about stretching being good for flexibility, but that flexibility isn't necessarily a useful goal! I think it's pretty well backed up, I'm just also pretty sure it's not actually relevant to me and my weird (ha) edge case...
(no subject)
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Date: 2019-02-12 09:14 pm (UTC)As a warm-up, yeah, it's mostly worthless (and/or possibly mildly unhelpful, unless what you're doing REQUIRES you to get into your flexibility as, say, my chosen athletic pursuit often does) -- do the gentler/slower version of the thing you're going to do as a warm-up.
But I'm much more dubious that stretching has no effect on muscle contracture/chronic hypertonicity, and I will need to read through all the cites in detail to see how much I agree with the methods and how much I agree with the conclusions drawn from them. So, uh, maybe after I've caffeinated and done some housework?
(no subject)
Date: 2019-02-12 09:16 pm (UTC)Like, the one on muscle contractures is a Cochrane review -- I've not read it in detail but I have skimmed the abstract and I do tend to trust Cochrane...
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Date: 2019-02-12 09:27 pm (UTC)You do mild muscle warmups (compared to your major workout), ie a bit of walking or some light jumping jacks, and maybe then stretch if you need the mobility or possibly go into your major workout/routine/whatever, and THEN stretch.
In the case of me - and I am EMPHATICALLY NOT hypermobile - it's also bemusing to say "it has no effect except flexibility" . . . because for me flexibility = mobility. It means "I can turn my head to a normal range of motion period, possibly even without pain."
So I would want to dive RIGHT INTO precise methodology of all the studies being cited, because like . . . I promise there is a DIRECTLY correlated relationship between "I am actually doing stretches as often as I should be" and "my basic range of motion and ability to do things as related to said without pain" - just not so much that it works Perfectly on its own (and sometimes I need someone to stab me with needles to get some muscle to let go enough to LET me stretch usefully, sigh).
But I am also increasingly of the inclination that it really feels like with bodies-and-pain-to-do-with-bodies the most important empirical evidence appears to be, like. Yours, personally. Does this make your body hurt less? It's probably important to do then. And I'm not even sure that's "placebo" even, so much as "bodies are so weird it may actually be difficult to get ANY consistency in this fiddly nerve-and-muscle shit on the level that our studies want".
Which is a large-scale problem that we need to fix, but on a "okay but what to do about it NOW?" is . . . yeah.
(no subject)
Date: 2019-02-12 09:40 pm (UTC)But yeah I can fucking tell you that my empirical experience of MY body as someone slightly hypermobile is that if I don’t stretch regularly, my muscles will lock the fuck down into a horrific hypertonic mess, limiting ROM AND just as importantly causing me significant pain. And I haven’t done Science and written things down and tracked it with large sample sizes so I can’t reasonably cite it as such but this has been well supported by my career as a body worker as being... relatively common, we’ll say.
(no subject)
Date: 2019-02-12 09:48 pm (UTC)So at least some of what's going on is that PE classes for me at school (and AFAICT what a lot of recreational runners still do)... absolutely did start off with stretching! We were taught to start with static stretches to "warm up"! So I'm parsing it as framed as rebuttal to that, which makes a certain amount of sense to me, I'm just also quite Headtilt at how it... might or might not apply to me.
(also HI FRIEND WHO LINKED ME THIS I'm not cross with you or thinking poorly of you or whatever, I've just been enjoying chewing on it and wanted to share with the class. <3)
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Date: 2019-02-12 10:02 pm (UTC)I use stretching to try and improve mobility, and to try to reduce pain associated with things like tendinitis, plantar fasciitis, and the occasional (probable; mild) round of carpal tunnel.*
It's nice that that's supported by some degree of evidence, but it's ... luck? I've used stretching as a warm-up, but most of the things I currently use are not, according to this definition, stretching.
ETA: I also tend to come at it from the angle of "things that make you happier in your body are categorically good things," which. That's not what he's arguing against, but the "lol also stretching feels good, now ignore that" was rather odd, given where I start.
Unrelatedly, I love how that site does their footnotes. More people could do that and I would be happy to see it.
*This is actually my doc's assessment of it. I work on a keyboard and do a lot of things with my hands, but if I can keep myself out of pain and surgery by stretching - which I've done for several years, now? Great!
(no subject)
Date: 2019-02-15 07:36 am (UTC)I am not ever going to give you shit for useful self-dx. Carpal tunnel: It A Thing.
And yes AREN'T they good footnotes.
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Date: 2019-02-12 11:25 pm (UTC)Muscles aren't the only thing that get stretched in some stretches, either. A physio I saw at Trinity (because it had a weekly visiting physiotherapist, because musicians) gave me a set of stretches designed, she said, to stretch a nerve. They certainly helped me. I don't know if the thing about stretching a nerve was a simplified-for-non-physiotherapists explnation or actually true. But I know that when my plantar fasciitis was at its worst, I could make my feet hurt by nodding my head forward, without actually moving my feet or legs or putting any pressure on them. I'm pretty sure that is a nerve thing or some other tissue, because I don't have any muscles that directly join my neck to my feet.
I think there *are* benefits to flexibility per se: namely, that if one is optimally flexible, one is going to be able to use more of the range of motion of various muscles, which means probably more strength. For me stretching gets important not just because my muscles work harder because my joints are bendy, but also because that working-harder thing is happening under the load of whatever I happen to be doing, and e.g. my hamstrings are going to be way tighter than my quads if my hamstrings are doing a bunch of postural work normally done by my pelvic ligaments, and then I run into knee problems (or whatever) because of the imbalance of flexibility that results. Essentially some of my joints end up too flexible and others end up not flexible enough, this is terrible and leads to abnormal function and pain, and stretching helps even things out.
I also think that stretching done slowly might well help with proprioception, not necessarily immediately, but longer-term. (And stretching done too fast is just asking for trouble, at least for me.)
+1 re nerves
Date: 2019-02-14 07:44 pm (UTC)(no subject)
Date: 2019-02-15 11:08 am (UTC)also: HUH re proprioception, I think I have previously met that concept but not... got my act together to consolidate it all, which is I think particularly interesting in terms of how it feeds in to the discussion elsethread about how, actually, increasing tolerance to stretch might itself decrease pain because "pain" is "I'm not sure what this nervous input is so it might be bad and I don't like it, abort abort abort"...
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Date: 2019-02-12 11:35 pm (UTC)I stretch because of my empirical observation that it reduces pain and immobility, and that's all I need it to do. I know there are lots of things it doesn't do, but yin yoga helps me so dang much, I'm not giving it up.
(no subject)
Date: 2019-02-13 04:05 am (UTC)(no subject)
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Date: 2019-02-13 04:06 am (UTC)HOWEVER.
I definitely find that stretching helps both with flexibility as well as with static pain I have from bad posture, RSI, chronic fatigue, and so on. I need more time to go through these references.
I discovered Kit Laughlin's books through a neighbour and can definitely recommend them, especially the "Overcoming Neck & Back Pain" text. The "Stretching & Flexibility" book is really aimed more at instructors who could use it in a class setting, but I like it as a reference.
There is also The Trigger Point Therapy Workbook which my neighbour swears by, but I haven't spent much time with.
Anecdata
Date: 2019-02-13 07:32 pm (UTC)Based on my experience: I have no clue whether the theory behind trigger point therapy has any sort of evidence behind it or is even scientifically coherent -- but if I look up a hurting body area in the book and follow back to where they suggest trigger points might be referring pain to that area from, I will frequently find a "hot spot" in the muscle, and digging a thumb or knuckle or implement into it until it loosens up will often improve the pain significantly.
Interestingly, this has helped even when the original cause of the pain is an acute injury -- so I know the muscle knot can't be the original cause and I know there's actual tissue damage that needs to heal, but it seems like the injury has also caused adjacent muscles to lock up, maybe as a protective reflex, and if I can convince them to un-spasm themselves, overall pain can drop.
Re: Anecdata
From:Context of two kinds first, then thoughts
Date: 2019-02-13 04:34 am (UTC)By diagnosis I am a paediatric-onset persistent pain human with strong elements of central sensitization who is currently about nine months away from graduating (if all goes to plan) with a masters degree in physical therapy from the University of British Columbia. I am neuroatypical (autism spectrum and social anxiety), have mild hypermobility (and an injury history to match), and am currently in a five week placement focused on persistent pain at a hospital in Vancouver BC.
I am a long-term friend of ~recessional and ~staranise (who emailed me to consider chiming in) who often responds best to email because oh my fucking god grad school is eating my face.
That said, Paul Ingraham is a fascinating human being whose work I (a pain geek) straight up can only engage with about 8-10 times per year, because he often leaves me going '... okay, so what do I actually do here?' once I've read all the way through.
He is great, but very focused on exactly what research can prove about the human experience as a whole.*
As such, the lived experience of Ehlers-Danlos and fibromyalgia humans cannot match what he talks about. Your mileage by definition will vary from what he can talk about. You are not a stereotypical human.
In my experience (and what I can support via research reading into physical therapy, persistent pain, hypermobility disorders, and psychology) what stretching actually does is persuade your body that it is safe to move into a particular range of articulation.
Safety sensation in movement should not be disregarded. If I feel safe putting weight on my left hand, I can do much more than if I don't feel safe doing so.
Research cannot prove that muscles actually 'warm up', stretch, or change shape based on static or dynamic stretching programs.
That does not mean they don't work, don't have significant effects for individuals, and don't allow increased mobility for people.
What it does mean is that research cannot conclusively say This Is A Thing For All The Humans We Examined.
For the love of whatever you hold dear, do not stop doing something that helps you, personally, A Human Individual, move with less pain and better range of motion because it can't be proved.
The research on persistent pain humans says the more we can do without flaring ourselves up, the better: motion is, annoyingly, lotion to pain, so long as you stay within the safety guidelines.
Stretching absolutely counts as motion. If it helps, use it. If it doesn't, don't, and don't let What We Can Prove prevent you from using things that work for you.
Humans are notoriously individual in experience and reaction to stimuli.
*: I would happily buy this man his drink of choice for a while and listen to him rant on the subject of How Do Humans, but damn can his writing be withering to a student or educated layperson regarding what actually works.
Re: Context of two kinds first, then thoughts
Date: 2019-02-13 05:27 am (UTC)Re: Context of two kinds first, then thoughts
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From:(no subject)
Date: 2019-02-13 01:39 pm (UTC)Then I had a bunch of PT (a couple of places, at different times, for different things) and am now stretching beforehand, because that's what they had me doing at the PT places. And wondering whether that's because the physical therapists were using old methods, or because in PT (at least this PT) the stretching is a thing in itself. I had stretching-only sessions before they started on strengthening exercises, at all the PT places.
I think more research may be called for, and I don't know whether Ingraham addresses this. Anecdotally, there is one of the PT-derived exercises that has hurt when I did it without stretching, but that's not even "this exercise requires stretching first," it's "one of the several times I've done this without stretching, my muscle cramped."
(If I do find anything, I will probably post on my own journal, unless it's today or tomorrow, in which case I'll come back and comment here.)
(no subject)
Date: 2019-02-13 08:36 pm (UTC)And for me personally, it gives me a bit more confidence in ignoring suggestions from randoms to stretch things that haven't helped me when I've tried them before.
(no subject)
Date: 2019-02-14 09:13 am (UTC)(no subject)
Date: 2019-02-14 09:31 am (UTC)Please do! I was intending to but hadn't quite got around to it.
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Date: 2019-02-15 05:39 am (UTC)(no subject)
Date: 2019-02-15 07:39 pm (UTC)But all this together got me thinking about muscle chains and reciprocal inhibition, in which activity of the agonist (muscle or chain) tends to enable activity of the accesory(ies) or muscles in the same chain, and inhibit the tension of the antagonist. And how exercises that look like 'stretching' could leverage this tendency and balance out or reset dysfunctional in/activation. Rather than lengthening it by traction, 'stretching' by activating its antagonist may temporarily abate the tight muscle's chronic activation.
(no subject)
Date: 2019-02-15 07:44 pm (UTC)ooooooooooooooooooh.
(no subject)
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Date: 2019-02-16 01:56 pm (UTC)(no subject)
Date: 2019-02-16 07:00 pm (UTC)My impression is that the issue isn't that the study is poor, but that it's a really really interesting study at the very start of research into this potentially-huge new angle. So it needs to be replicated and extended and a tonne more research needs to be done before we know whether it's a thing and if so WTF is going on.
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Date: 2019-02-16 06:39 pm (UTC)Good luck stretching your way out of stiffness if it’s caused by drug side effects, for instance.
... except that's what I do on most days.
During my Epic Psychiatric Misadventures nearly a decade ago, after one med switch I started waking up stiff and achy every morning. And that was when I established a regular yoga/stretching/miscellaneous practice, because gently working my joints and muscles into their normal-for-me range of motion (and beyond if it's something specific that actually needs increased ROM) makes me mostly stop hurting.
I mean. I am sure Ingraham is correct in the point he's making that sensations of "stiffness" can have causes other than mechanical shortness of the muscles. And the pain relief in my cases is probably operating at least in part through mechanisms other than "muscles are too short, make muscles more long".
NONETHELESS. I do, in fact, regularly stretch myself out of stiffness caused by drug side-effects. That is literally a thing I do.
Anecdata and muscle 'knots'
Date: 2019-02-23 12:14 am (UTC)First, the anecdata: when I used to fence, I used to do the prescribed warmup, and still come feel stiff and achy the next day. Then one day I ran late and went straight into a little warmup, no stretches, and a full fencing session. And felt great the next day. Turns out that the stretches (reasonably extreme) were doing the exact thing they were supposed to prevent, so they definitely fell under 'bad stretching'.
Secondly, I practice a kind of slow rotation whenever I feel tight or painful in particular locations - I'm not sure whether this is a part of 'stretching' as you understand it, but it's been exceedingly useful in improving mobility and preventing muscles from locking in bad postures.
Thirdly, the designation of muscle knots as 'myofascial trigger points' just about blew me away. I come at this from equine physiotherapy, where muscle knots are well known and... are given a different explanation and a different context, though the treatment (gentle rubbing across the direction of the fibres) is not too dissimilar.
This - because I have some personal experience with the phenomenon that matches what I've learnt about them - makes me somewhat sceptical of Ingraham.
Relevant to interests?
Date: 2019-04-03 11:00 am (UTC)Re: Relevant to interests?
Date: 2019-04-05 09:43 am (UTC)Oooh, thank for rec! Seeing if I can track down a copy :)
Re: Relevant to interests?
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