Dry Needling vs. Acupuncture


By Steve Cuddy, MPT, ATC, PRC

September 1, 2016
The technique of dry needling (DN) dates back to the 1940s but has only gained mainstream acceptance in the physiotherapy and pain medicine world in the last couple of decades. DN is the use of sterile, single-use filiform needles (acupuncture needles) to treat soft tissue injuries and other pain conditions. In its purest form, dry needling is used to reverse myofascial trigger points (TrPs), which are believed to be major players in persistent pain cycles. TrPs are tiny, persistent contractions within muscle fibers (knots or ropey bands). They generate pain, are hyper-irritable and hypersensitive, and usually make the entire muscle feel both tight and weak.

Following specific precautions and protocols, the needle is inserted directly into the area containing the TrP and is manipulated in search of a localized twitch of the muscle. It is believed that the twitch is due to the needle stimulus setting off an involuntary spinal reflex that results in a contraction of the muscle. Twitches are correlated with pain reduction and muscle relaxation, which is usually more profound the more twitches elicited.

Similarities to Acupuncture?
When I propose DN to my patients I’m almost always asked how it differs from acupuncture. My explanation goes something like this: Acupuncture needles in DN were introduced in the late 1970s. Prior to that, “dry” hypodermic needles were often found to be just as effective as injections of anesthetics (“wet” needles) when inserted into tender points, taut bands of muscle fibers, or TrPs. Later studies showed that acupuncture needles were just as effective and tolerated better (for obvious reasons). They have been used by dry needlers ever since.

Acupuncturists practicing Traditional Chinese Medicine (TCM) indeed often use needles to treat musculoskeletal pain, sometimes using similar manipulation of the needle as dry needlers. Interestingly, many common TrPs overlap larger sensory nerves and acupuncture points. Because of these similarities some acupuncturists claim that DN is simply a subcategory of a more myofascial minded form of acupuncture.

The Needling Effect
The moment a needle is inserted into the skin a physiological, neurological, and immunological cascade occurs and is the same whether a physical therapist, chiropractor, or MD is performing dry needling or if an acupuncturist is practicing TCM with much broader goals than treating just musculoskeletal problems. Granted, this would be a western medicine, or biomedical, way of thinking. There are many different techniques used in both needling and acupuncture with many different intended results.

A needle inserted into tissue induces microtrauma and thus, an immediate inflammatory response. This includes, but is not limited to, an increase in blood flow through vasodilation (bringing oxygen and other nutrients) and the production of immune cells that act as healing agents by way of their inflammation-controlling and tissue-healing capacities. I explain to my patients that the soft tissue injury they’ve had didn’t heal correctly, so needling gives the body another opportunity to “get it right.”

There is also a pain modulating effect in which stimulation from the needle sets off a series of events in the nervous system. Research has shown that needle insertion turns on some of our natural pain-blocking and pain-relieving systems. The mechanisms for this are too numerous and lengthy to be explained in this article.

The Big Differences
The general theory, rationale, and mindset around the use of needles in dry needling is quite different compared to that in TCM. Dry needlers look at the needle as a tool specifically to treat myofascial issues. There is never mention of placement of needles along meridians or in a manner that will affect chi as in acupuncture. Our assessment focuses on dysfunction of the musculoskeletal and nervous systems rather than “syndrome differentiation,” which is an acupuncturist’s inspection of multiple bodily systems in order to form a treatment plan and, ultimately, a decision on where to place needles. We dry needlers are
singularly focused on regional healing and reduction of pain and movement dysfunction. Acupuncture is much more global in its intentions and, in fact, aims to affect every major system of the human body.

DN is one of many tools I have in my physical therapy toolbox. I don’t use DN on all of my patients, nor do a handful of them even want needles stuck in them. But if I do needle my patient they will never receive it without also receiving other modalities (such as soft tissue mobilization and exercise prescription) as well as a lot of explanation about their condition and what needs to be done to remedy it. Point being, DN should be viewed as just one of many options in neuro-orthopedic therapy and it is likely to be less effective when not combined with other treatment modalities.

(This article originally appeared in the September, 2016 issue of Austin Fit Magazine)


Managing Low Back Pain: Solutions that work no matter the severity, exact location, or precipitating event


We’ve all heard the statistics: 80 percent of Americans are bound to experience significant low back pain in their lifetime (and, as an instructor of mine once said, “the other 20 percent are lying”). Hundreds of millions of healthcare dollars are spent on back pain every year.

To make matters worse, we’re not even close to coming up with an agreed upon standard of care for low back pain. Currently, back pain is treated with every modality known to man. Ask twenty different clinicians how they would approach a given low back pain case and I guarantee you get twenty different answers.

How your low back pain is treated is ultimately based on the belief system of the good people you go to for help. Speaking on behalf of physical therapists (like me), what you’ll get treatment-wise is based on that therapist’s training and body of knowledge, the culture in which they work, the colleagues they collaborate with, and even their geography. Some therapists treat solely based on what has been shown in the research and some treat using what is tried and true and makes perfect scientific and physiological sense.

Low back pain is a broad topic. While there is no “garden variety” of back pain, I am happy to say that there are a couple solutions that work in almost every case no matter the severity, the exact location, or the precipitating event.

Most back pain is associated with a postural position of extension through the lower thoracic and lumbar spine. This is an arched back with a lower front rib flare. Pain is most likely from back muscles and surrounding soft tissues that become short and tonic. They get overworked and eventually hurt. Pain can also be from the compressive forces on the joints and discs of this part of the spine. There are certainly other mechanisms of back pain, but this is the most common picture of a low back pain patient.
(Side note: A more chronic type of back pain needs to be distinguished from a more severe situation. Symptoms such as severe pain down the leg, obvious weakness of leg muscles, or diminished bladder or bowel control need immediate medical intervention.)

When your brain senses pain, it essentially perceives threat. How we perceive the threat that pain is causing differs in everyone and is based on many factors. Usually the perception of threat can be dampened and the physiological effects on our body (like muscle tension and changes in breathing mechanics) minimized. But in other cases the threat that pain causes can overwhelm us and we start to feel a lack of control over it. “Fight-or-flight” will run rampant, and this same primitive mechanism that ensures our survival when the threat is real continues to churn 24/7 and actually becomes a detriment to our health. This is just more stress and the last thing we need.

In these cases, the Sympathetic Nervous System (SNS) needs to be dialed down and some control needs to be regained by the patient. There are many ways to give a locus of control back to the patient. The main methods I use are ones that combine control of breathing rate and mechanics with pain relief positions that target muscle imbalances. SNS overdrive and a hyperventilatory state (whether purely mechanical or via altered blood oxygen/carbon dioxide levels) go hand in hand. And pain control is significantly improved when low back pain sufferers find that there are actually positions and muscles that can be used to give immediate relief.

The 90-90 Hip Lift with Balloon is one such exercise. This technique is a staple of the Postural Restoration Institute® (PRI) and incorporates a lot of the components I’ve mentioned. By placing the feet on the wall it will be much easier to tilt the pelvis back, thereby reducing the amount of arching of the lumbar spine. This is flexion, and decompression of the lumbar segments occurs when we flex. This position also allows us to find and feel the elusive hamstrings and glutes that we are so often unable to contract for correct positioning of the pelvis and hips. These muscles exert a posterior tilt on the pelvis (again flexion) and will have an inhibitory effect on hip flexors that tilt the pelvis forward (extension).

Slow, methodical balloon blowing is one of the best ways to calm the nervous system. When we are in pain our SNS kicks into overdrive. Heart rate, respiratory rate, blood pressure, and stress hormones in the blood increase. Breathing tends to be more shallow and breath holding is common. Front, lower ribs are usually found to be lifted and are unable to drop fully upon exhalation. Lower ribs in back are usually splinted by tight back muscles and held in, accentuating the arching of the lower back. Blowing up a balloon slowly has an inhibitory affect on these processes and emphasis is placed on full exhalation in order to come out of this rigid position.

This technique is performed by doing a full exhalation, emptying the lungs of all residual air that may not be expelled in the type of rigid, shallow breathing seen while in pain. Full exhalation means that the diaphragm will achieve a relaxed position and its influence on pulling the spine and ribs into an extended posture will be minimized. A balloon also serves as resistance to exhalation so that abdominal muscles can be more effectively recruited. Toned and coordinated abdominal obliques are vital in making the solid connection between your lower front ribs and your pelvis.

At the end of exhalation there is a pause—a signal to the nervous system to chill out and rest. This is followed by a normal-sized breath in and another full exhalation. This is repeated until the balloon is filled and numerous sets are usually performed, though the beneficial physiological and neuromuscular effects can usually be felt in as little as one set.

This one simple technique brings key postural muscles back online, breathing under control, and a switch from Sympathetic Nervous System overload to a more Parasympathetic state. It is one of many techniques I use and is inspired by the Postural Restoration Institute®. It’s one that you can easily try at home to help reduce pesky low back pain.

This piece was originally in Austin Fit Magazine.

Steve Cuddy was voted as one of the best physical therapists in Austin in AFM’s Best Of cover story.

Postural Restoration-Inspired Yoga

The Power of Yoga in Postural Restoration


*This post originally appeared in Austin Fit Magazine ( www.austinfitmagazine.com )



performed by Stacey Lyn Gilmore

performed by Stacey Lyn Gilmore


As a physical therapist, I’m not alone among rehabilitation specialists in feeling that yoga can be both tremendously beneficial to some but frighteningly dangerous for others. I’ll recommend yoga in a heartbeat to many of my patients, but explain to some that yoga may not be great for their particular issues. Why not? Hyper-mobility, hyper-flexibility, and hyper-inflation can be too much of a good thing. Some folks don’t need more of it; they need to learn how to control it.

Over the last century, Western culture has diversified yoga from its original form. Traditional yoga emphasizes the blending of mind and body. These days there are many other subsets of yoga where the spiritual takes a backseat to the physical. The two may become more and more divergent and yoga (at least to me) begins to look more like a sport than a discipline. For some, yoga moves away from a practice of self-improvement and self-realization to one in which resolving one’s physical imperfections becomes the singular goal. I’m all for goal-setting and having improved physical health, but when it comes to yoga, there need to be boundaries—literally and figuratively—in many people’s practice.

Injuries as a result of yoga are probably overblown. Fervent supporters of yoga might address these reports as being a result of the meteoric rise in the number of people practicing within the last couple of decades. Perhaps they fall under the umbrella of the risks we all take by just getting out of bed in the morning. After all, there are inherent dangers in any recreational endeavor.

My perspective is that of a physical therapist who sees many yoga practitioners (and teachers) as patients. Their injuries are varied (though there are some common ones) and they are often a direct result of their yoga practice. They range from simple shoulder impingement to complex hip instability. We can almost always trace the issue directly back to poses that are being done incorrectly or in a manner that is beyond their joint or soft tissue’s physiological range of motion. They usually have little understanding that every joint has a neutral axis of rotation and many times there has been an overemphasis of moving the joint in only one direction. Simple modifications, a respect for neutrality, and an understanding of common human postural patterns like inherent asymmetry can usually correct these issues.

A fusion of modern, Western science, and Eastern tradition can help promote yoga as a powerful rehabilitative tool and limit the incidence of injury. At the very least, those passionate about yoga and are unable to continue their practice should seek out individuals versed in yoga, human biomechanics, and rehabilitative medicine. There are many yoga teachers who have programs that are mindful of moving their students within a more conservative range of motion while still realizing yoga’s intended physical and mental benefits.

Stacey Gilmore* of Counterpose Wellness has one such program. As a physical therapist and certified yoga instructor, Stacey utilizes the concepts of the Postural Restoration Institute® (PRI) to harmoniously blend traditional yoga values within the context of never moving beyond your limits. PRI principles emphasize that the body is not symmetrical and human anatomy and physiological function are not (and never will be) exactly the same on either side of the body. There are predictable patterns of imbalanced posture and movement that are driven by the asymmetrical nature of brain function and respiratory mechanics. An unintended consequence of yoga is that by treating the body as if it were symmetrical, patterns that are potentially damaging are reinforced. We now understand that if the body is repetitively forced to move beyond the physiological limits of these patterns, the susceptibility to injury is greatly increased. Stacey explains that her PRI-inspired yoga program “teaches boundaries that prevent moving into pathological positions.”

The concepts of PRI easily integrate into yoga, as both place heavy emphasis on linking breath with movement and posture, appreciating that homeostasis and well-functioning physiological systems require proper breathing mechanics. PRI-style yoga begins and ends with an ability to maintain a stable core to control rib and diaphragm position so that airflow reaches all areas of the thorax. Movement integrity is then built around this neutral axis of range of motion between the ribs and pelvis.

Finally, yoga classes are often structured in a way that reflect life as ever-changing, filled with ups and downs. Our bodies get stressed and hopefully can quickly recover. Humans thrive on this variability unless we get stuck in one extreme. Regulation of breath and optimization of airflow is a major goal in yoga as it is with PRI, since this is one of the ways that we can ensure balance between our sympathetic and parasympathetic nervous systems.

Here are a few examples of Postural Restoration-inspired modifications to some common poses.

Warrior 1 (Figure 1) is omitted due to the tendency for the left hip to overextend if put into external rotation while the pelvis is anteriorly rotated and the back is overextended. This pose is replaced with Crescent Lunge (Figure 2), which involves a Low Lunge and an Upward Salute. The emphasis here is on maintaining abdominal tone and a neutral pelvic and spine positions. The left hip is slightly extended but kept in neutral rotation.

Downward-Facing Dog (Figure 3) is modified to reduce an overextension of the entire spine (Figure 4). The lower back has a more neutral curve; shoulders aren’t put into end-range elevation; and abs are felt through the entire breath cycle so that airflow can expand the posterior rib cage.

Bharadvajasana (Figure 5) is a great example of PRI-inspired yoga. It will likely be done only to one side to help balance the asymmetry of the human body. Right hip is externally rotated, left hip is internally rotated, and the right chest wall is oriented to the right to optimize airflow into it.


*Stacey Gilmore teaches yoga from 12–1 p.m. on Fridays at Yoga Illuminated and at Luke’s Locker every other Sunday (check her schedule here).

Postural Restoration and the Autonomic Nervous System

Postural Restoration and the Autonomic Nervous System

Understanding how to control the nervous system to reduce stress can lead to an improved athletic performance


*This post originally appeared in Austin Fit Magazine ( www.austinfitmagazine.com )



Part I: Things to Remember

The Autonomic Nervous System (ANS) controls and fine tunes many important physiological functions like heart rate, breathing patterns, and the regulation of stress hormones and metabolites—which are essential when preparing an athlete for activity.

A properly functioning ANS helps the human machine rest when it’s time to recover.

Postural Restoration

Ron Hruska, founder of The Postural Restoration Institute in Lincoln, Nebraska, is a physical therapist who recognized common postural patterns in his patients that caused a variety of musculoskeletal and neuromuscular problems. He found that these patterns, essentially based on the asymmetrical nature of the human body, could be addressed through an understanding of the likelihood that one’s body becomes rigid and less adaptable the more one is driven by an over-stimulated or imbalanced autonomic nervous system. Rigidity can be thought of in terms of posture (increased muscle tone) as well as a lack of ability to flip from a stimulated to a relaxed state. Through objective testing, a PRI-trained therapist or strength coach can recognize the patterns of a poorly adapting patient or athlete.

Contrary to most methods of rehabilitation, this practice appreciates that the presentation of an athlete or patient—their posture and gait, range of motion, breathing pattern, sensitivity to pain and other stimuli—is, in part, a reflection of the state of their nervous system and the ANS in particular. This understanding helps guide the therapist or coach in developing a treatment or training program for the athlete.

Postural Restoration examination of a sympathetic-dominant patient shows that with an altered breathing pattern, neck and back muscles are unable to relax upon inhalation and exhalation in conjunction with poor abdominal activation. There is also increased muscle tone throughout the body, resulting in multiple areas of reduced range of motion and a greater tendency towards an asymmetrically positioned pelvis, trunk, and rib cage. Essentially, the body becomes more rigid and less able to move reciprocally from one side to the other.

An important PRI principle is that humans are biased towards their right sides—regardless of hand dominance—because of the lateralization of the brain. It is well-known that certain tasks and specializations originate on separate sides of the brain, and a PRI-trained therapist will use common orthopedic, neurological, and respiratory tests to determine how lateralized the patient or athlete has become.


A Postural Restoration therapist uses information like static position or posture, movement and gait patterns, the depth and rate of breathing, and even the degree of sensitivity to pain to help establish the influence of the nervous system. PRI principles hold that since the human body is not symmetrical—think of organ placement, the shape of the diaphragm and lungs on either side of the body, and the left-versus-right functions of the brain—there will always be a tendency towards lateralization, or the preference for certain activities to be done differently on one side of the body than on the other. In a calm state, humans are able to overcome lateralized tendencies and easily reciprocate with alternating movement. There are many examples of how the body is challenged by this, especially in a stressed state.

Important characteristics of patients who exemplify a stressed state or dominant sympathetic nervous system (the system responsible for our “fight or flight” response) include:

– A rapid and shallow breathing pattern
– Increased heart rate lacking rate variability
– Reports of stress and anxiety
– Fitful sleep and increased fatigue
– Poor recovery following workouts
– Slower healing of injuries.

Athletes affected by a dominant sympathetic nervous system may also report that their fitness has plateaued or even decreased, or that they feel overtrained and unable to recover due to injury or fatigue—a catabolic state where breakdown is occurring faster than repair.

Key Takeaways

Sympathetic control is the foundation upon which power and performance is later realized.

Most of the time, our bodies need to function more toward the parasympathetic (“rest and digest” or “recover and repair”) end of the spectrum. This is the autonomic state in which your body is more rested, has steady state function of multiple organ systems—cardio-respiratory, digestion, urogenital—and can repair and heal itself. It is vital for an athlete to be able to get his or herself into a parasympathetic state as soon after a workout or competition as possible.

Human performance and the human experience are enhanced when stress is controlled and movement variability is possible. Parasympathetic dominance is key to realizing this. The key to well-functioning parasympathetics is being able to control common problems like over-breathing and hyperventilation. Postural Restoration therapists recognize telltale signs like rib-flaring, deep lower backs, and overactive anterior necks as characteristics of a lack of parasympathetic control and the ANS in general. Posture and movement rigidity are soon to follow and non-traumatic and potentially traumatic injuries are the inevitable result. Learning proper breathing mechanics and strategies to control breath during daily activities will go a long way in maintaining a more balanced autonomic nervous system. afm

*Steve Cuddy was voted as one of the best physical therapists in Austin in AFM’s Best Of cover story. 

The Autonomic Nervous System and Athlete Readiness

(This post was originally written by me for Austin Fit Magazine www.AustinFitMagazine.com)

Organisms must adapt to environmental and physical demands to ensure their survival, and the athlete organism is no different. Adaptability and physiological variability ensures an athlete’s success in competition, in training, and in recovery. Humans are hardwired to be able to react to stressors, as well as quiet their system when there are few demands and rest is needed.

Problems occur when athletes can neither react to new stimuli and demands nor shut down when recovery is needed. We’ve all had bad training days where something just seems “off.” Either there isn’t the energy to perform or we’re over-stimulated, reaching physiological barriers early in the workout and at much lower levels of stimuli. As a physical therapist, I am constantly trying to get in touch with the state of my patients’ nervous system so that I can apply the most appropriate therapeutic intervention for their given level of sensitivity. I recognize that their objective (and subjective) presentation is a mere reflection of their holistic ability to switch on or switch off.

The autonomic nervous system (ANS) is a major player in unconscious, automatic functions of the human body, such as respiratory and heart rate, digestion, and blood pressure. This is opposed to the voluntary aspect of the nervous system–the somatic nervous system—that controls movement and sensation, or the wiring behind skeletal muscle activity.

Human performance is dependent on a healthy functioning neuromuscular system to perform complex movements, to move heavy loads, or to persist when the legs are burning. Tasks like these are primarily controlled by the somatic system (which, from an evolutionary perspective, is the more modern part of the nervous system). When presented with a challenge, the brain processes the variables and instructs the muscles to perform a task. We sense; then, we react. On a basic level, this is how the somatic nervous system works.

But on a deeper and more primitive level, the ANS is busy fine-tuning things. Due to its wide range of physiological effects, the ANS can be considered the gauge and control center for how the body reacts to those things that we really shouldn’t have to think about. Again, we sense and we react. But in this case, we may not even be aware of the bodily changes taking place, such as changes in heart rate, blood pressure, perspiration, or arousal level. It also applies to more complex changes in muscle tone, the secretion of sugar and other metabolites for use by our tissues, respiratory rate and pattern, and the release rate of stress hormones into the bloodstream.

Athletes with an adequately functioning autonomic nervous system are easily capable of preparing for competition and performing at an appropriate energy level. They can also return to a restful, quiet state when it’s time to recover. In other words, they can turn on when it’s “go time” and they can turn off when it’s not. This ability is vital to sustaining a regimented workout program, especially one that is structured and timed for a specific event. Understanding athletes’ biological readiness is key in applying appropriate workouts that will avoid the pitfalls of overtraining, poor adaptation to training, and, ultimately, injuries or burnout.

The ANS has two subdivisions, sympathetic and parasympathetic. The sympathetic nervous system (SNS) is responsible for “fight or flight.” It can be thought of as the part of the ANS that reacts to stress and stimulates physiological systems that prepare us for action. The parasympathetic nervous system (PNS) is responsible for control of activities when we are at rest (“rest and digest,” or “feed and breed”). Sympathetic and parasympathetic divisions can at once be thought of as opposite and complementary of one another. While the SNS quickly reacts to immediate stressors, the PNS looms in the background, constantly fine-tuning the body to maintain homeostasis, or system neutrality, finally taking over when there is no longer significant stress.

It is desirable for athletes’ SNS to drive them during competition and intense workouts. Remember: the ANS has a direct effect on important physiological systems, such as heart rate, breathing rate, and the mobilization of sugar and other metabolites used by muscles. It is the SNS that ramps up these variables to prepare us for and sustain us during athletic endeavors. However, all too often the SNS becomes over stimulated due to chronic stress or a poorly timed training regimen. The nervous system may get bombarded to the point that it is no longer able to switch off. We begin to get rigid—our physiology becomes less able to adapt to new stressors in a variable way and the body tenses up, causing the PNS to be suppressed.

There are methods to measure athletes’ physiological readiness as well as their neuromuscular adaptability. Austin coaches Aaron Davis and Ben House of Train. Adapt. Evolve. use the Omegawave system to measure their athlete’s readiness for upcoming training sessions. Through electrocardiogram analysis, factors such as fatigue and stress levels can be measured, allowing Davis and House to dose workouts through objective as well as subjective data. To a large degree, the Omegawave is quantifiably measuring the state of the autonomic nervous system. The volume, intensity, and type of workout or practice can then be fine-tuned and structured based on this personalized information.

Davis and House explain that, “as strength and conditioning coaches, we are dealers of stress, and we can only give you what your body can handle.” Omegawave (which is now being used by a variety of professional sports franchises) allows them to get a peek inside their athletes’ ANS, their potential physiological limitations, and their readiness for that day’s workout. This is an important factor in ensuring that the proper load and intensity can be applied in a manner that allows athletes to avoid nervous system rigidity and a musculoskeletal system that is unable to adapt. Without respect for how the autonomic nervous system functions, full athletic potential may not be reached, risk of injury is elevated, and burnout is inevitable.

Breathing Patterns and Performance: Lungs, Diaphragm, Ribs Can Impact Posture and Body Mechanics

(This post was originally written by me for Austin Fit Magazine www.AustinFitMagazine.com)

A variety of “hot” discussion topics and analysis fly through the fitness and strength and conditioning industries: minimalist footwear, CrossFit, to stretch or not to stretch, high intensity versus sport-specific training, and nutrition and supplements. And that’s just naming a few.

It can be overwhelming. What’s a weekend warrior to do?

One topic I notice in discussions among fitness professionals these days is breathing. A dialogue about breathing and breathing mechanics is entirely appropriate, yet it is a subject that is often overlooked by healthcare and fitness professionals. Good breathing with proper mechanics is hugely important for posture and dynamic body mechanics. Aside from their obvious important role in gas exchange, the proper function and movement of the lungs, diaphragm, and ribs will influence the position of bones (posture) and the ease with which people can move in and out of one position or another.

Everyone breathes by contracting and relaxing muscles. While this may be automatic and mostly subconscious, it’s important to recognize that like all skeletal muscles, the muscles involved in breathing attach to bones. Since movement of the bones depends on the function of the muscles that control them, it’s pretty important that muscles are working properly, turning on and off when they’re supposed to. Problems occur when a muscle or a group of muscles are overactive and don’t know how to turn off in a timely manner, or conversely if they aren’t turning on when needed. The muscles and bones involved in breathing are no different, and mechanical breathing disorders are much more common than one might think.

The diaphragm, our primary breathing muscle, is attached to the lower ribs and spine. While it plays a more important role in respiration than any other muscle, its role in stabilization and movement of the rib cage and spine is significant. Any disturbance in respiratory depth and rate will have an effect on posture because of the diaphragm’s attachment to the ribs and spine. For example, someone who is over-breathing (or over-inhaling) will have an overactive diaphragm. Just like with any skeletal muscle, if the diaphragm is overworked, it will develop a pattern of increased tone and tightness that results in an inability to relax and return to its resting (“off”) position. The spinal segments and ribs that the diaphragm attaches to will be pulled into positions that are then difficult to move out of. Postural changes and ability to perform variable tasks in multiple positions will be seriously challenged, all because of a diaphragm that doesn’t know how to relax.

I see many athletes who are exceptional at their sport but develop breathing patterns that lock them into postural patterns that they can’t get out of until they improve how they breathe. Picture  runners that have a very deep lower back curve, a very upright posture, with lower ribs that seem to stick out. This is called an extended posture, meaning the lower thoracic and lumbar portion of the spine is in extension (or bent back) with all of the complementary position issues related to that—a forward-tilting pelvis, lower ribs that are flared, shoulder blades that are lifted and rounded forward. They may even look like this when they’re not running, but this posture is accentuated when they run.

This type of posture is often associated with a breathing mechanics dysfunction. Airflow in and out is more challenged when the lower ribs are flared, so these folks will have to use neck and back muscles to help pull air in. They also may not be able to get air out efficiently (i.e.. their ribs never drop down from a position of inhalation) so they never come out of the overly extended position and into a more relaxed-looking flexed position. This is a very common presentation in my physical therapy practice. The causes are many and include poor habits, inherited genetic makeup, hyperventilation, sympathetic (or autonomic nervous system) overactivity, poor abdominal muscle activation, over-developed lats and pectoral muscles, a head-forward posture related to jaw or airway issues, and trauma (to the ribs, the spine, and even the brain). These are just a few causes, as this is a fairly complex issue.

Another very important point is this: the diaphragm is one of only two skeletal muscles in the body that is not paired (meaning people only have one) and it’s not shaped even remotely similarly on either side of the body’s midline. The right side of the diaphragm is very dense and strong while the left side is much thinner and weaker. Hence, when it is contracting, it exerts an asymmetrical pull on the bones it attaches to. In other words, when people are breathing hard, there is going to be a strong tendency for the spine and the rib cage to twist. And if a poor breathing pattern exists, the tendency for torque and twist is much greater.

Here’s another example: the CrossFit athlete with some hip pain who presents with an obviously imbalanced pelvis, ribs that are flared to the left, and a right shoulder that consistently looks lower than the left. Upon assessing his breathing pattern, it is clear that he is having trouble getting expansion of his ribs on the right and there is a very strong tendency to lift the left side of the rib cage on inhalation. This is a classic situation, especially for the CrossFitter who has overdeveloped lats, pectoral, and back muscles. He, too, is having trouble getting out of an extended posture and into one that allows the diaphragm to consistently completely relax on exhalation. The “on” postural position starts twisting his pelvis, spine, and ribs.

Most humans take eight to 12 breaths per minute at rest. Under stress and during exercise, the rate may increase two- to threefold. A faulty breathing pattern under calm circumstances may be bad enough, but there will certainly be repercussions in an active athlete with bad breathing mechanics. So if an athlete is having issues that don’t seem to be improving with traditional treatment, there may be a breathing pattern disorder that can be uncovered by someone trained in the assessment and treatment of these types of problems.

Why You Need To Be Able To Squat


(This post was originally written by me for Austin Fit Magazine www.AustinFitMagazine.com)

Squatting is at once a simple and complex movement. It is a functional movement—squatting is basic and evident in human movement from the time we begin to stand. Toddlers can squat with ease.

In some cultures it is more common for friends to converse, have tea, play games, or work while in a full squat position than sitting in a chair or on the ground. In many places, toilet openings are built directly into the ground rather than raised, meaning—that’s right—users have to be able to squat.

Go ahead; try it. A full squat means heels are on the ground and legs close together, with the ability to drop the tailbone all the way down to the heels. There should be minimal muscle activity at the bottom of the squat; the back should be rounded, and hanging out in this position for some time—without tipping over backwards—should be possible. Why is squatting so complex? Much is required of the body to allow this to happen, and there are many reasons why it may not be possible.

The ability to perform a full squat reflects a balanced and mobile pelvis, one that is able to transition out of the common anteriorly tilted position (that creates a deep, lordotic low back curve) and into a more posterior position (or lumbar flexion). It also demonstrates the ability to efficiently turn off or relax commonly over-active muscle groups, such as the hip flexors, back extensors, quadriceps, and calves. And being able to hold the position for any length of time is only possible if one can breathe into and expand the back of the chest wall using the diaphragm properly.

In sum, being able to fully squat means that the squatter can fully flex through the entire body, an ability that many believe is seriously lacking in modern-day society.


When Squatting is Difficult

Overdevelopment or overuse of the aforementioned muscle groups (hip flexors, back extensors, quadriceps, and calves) leads to postural changes that inhibit the ability to flex. One reason is that sitting and standing too upright with a forwardly tilted pelvis create hip flexors and back extensors that are too tight. Another reason is shallow breathing patterns or hyperventilation. And traditional weightlifting techniques (such as Olympic-style squats and power cleans, deadlifts, and lat pull-downs) have a tendency to place too great an emphasis on these muscle groups. Becoming too strong in these muscle groups while not countering with thoughtful training of opposite muscle groups and in multi-directional planes of movement can lead to serious movement impairments.

Quadriceps can easily become overdeveloped, especially when not enough work is done to strengthen the opposing muscle groups, the hamstrings, and gluteals. Quadriceps straighten the knees and pull the pelvis forward. To efficiently squat, the knees need to freely bend and the pelvis needs to rock back. Short quads that don’t relax fully will surely prevent a full squat.

Tight calves can develop for many reasons, but a big one is modern footwear with an elevated heel. Habitually elevating the heel will lead to tightness of the calves. This in turn will limit the ability to dorsiflex the ankle (the reverse of pointing the foot down), a key component of a full squat. Chronically tight calf muscles are usually the main reason that my patients may not eventually be able to perform a full squat, since a lifetime of short, tight calves may not be completely reversible.

Being able to fully squat is a goal that I set with most of my patients. At their initial exam, I find that only about 20-30 percent can do a full squat properly. For the record, I measure with shoes on and recognize that a typical running shoe with an 8-12 millimeter heel to midfoot drop will help a lot by unloading tight calf musculature. Is 20-30 percent a reflection of societal norms? Probably not, but these are people with musculoskeletal problems seeking treatment for issues that may be directly related to their inability to get into a position like this.


Why Squat?

My patients need to be able to squat because the position reflects a mobile, adaptable, and healthy musculoskeletal system. Let’s take the example of a cyclist with lower back pain after riding. A good riding position places the back in a sloping, rounded position from hips to neck. The position mimics the position of the hips and spine while performing a full squat. While riding at mild to moderate efforts, there should be minimal back muscle activity. But if the back starts to arch and the pelvis rolls forward, the back muscles become overused, strained, and eventually painful.

Cyclists do this for all of the reasons previously mentioned. They may also use their back muscles because they don’t know how to counter by using their abdominals. They may overuse their hip flexors because they can’t oppose them with strong hamstrings and gluteals. They may pedal with toes heavily pointed down because their calves are strong and short. And (most likely) they simply can’t breathe well when they round their back. So when this high aerobic activity demands more and more oxygen, cyclists tend to flatten their back to excessively open up the belly for breathing.

Inability to round the back and flex hips, knees, and ankles will ultimately affect body position. Practicing squatting can help. This normal activity reflects an ability to assume many positions in sport and daily life without compensation and strain and enables efficient breathing without the need for assistance from back and neck muscles.

So try it. You may be surprised.

Custom Foot Orthotics: Considerations and Principles




(This post was originally written by me for Austin Fit Magazine www.AustinFitMagazine.com)In the world of orthopedic rehabilitation, a debate rages regarding custom foot orthotics. The debate (though slightly less intense than the one about minimalist shoes) is about what orthotics actually do to help patients that other traditional treatment modalities cannot accomplish. Are they being used to take the load off of or support a painful structure? Are they directly or indirectly changing the mechanics of the foot or other lower limb joints? Or are they generally making positive, holistic postural or gait changes?

You will likely get a dozen different answers from a dozen different practitioners regarding what an orthotic really does and how an orthotic should be made. Consequently, there are many different styles of orthotics constructed from a wide variety of materials (foam, plastic, leather, and rubber) with different textures and densities. Orthotics are also cut to different lengths (from heel to toes, heel to just behind the toes, or heel to behind the ball of the foot), contoured to shape around the sides of the foot and the heel or made almost flat, and constructed to be very rigid, very flexible, or anything in between. What needs to be understood is that all of these factors matter, and they matter a lot.

And, by the way, there’s even a silly debate over what we should call them: orthotics, orthoses, an orthosis, arch supports, or custom foot beds. For this article, I’m using the terms custom foot orthotics or orthotics, and I’m going to give my opinion, which has evolved over the years and is obviously biased. But it is based on much experience seeing what works and what doesn’t.

I geek out a bit on this subject. As someone who has been using custom foot orthotics in my practice for more than 20 years, I’ve gathered quite a bit of knowledge in a variety of ways. My patients bring in a lot of different orthotics; I often use orthotics with my patients; and I don’t go the custom orthotics route at all if I can assist in making positive changes in a more practical or cost-effective manner. However, there are many times when it’s perfectly clear that there are ongoing barriers to completely solving a patient’s problem, and sometimes the source can be found at the feet.

I’m a physical therapist, so I feel suited to looking at the whole patient and using orthotics to help make beneficial changes, not only for foot- or ankle-specific issues but also for making more general changes in posture and gait. For example, it may be clear to me through a series of tests that a patient is making compensatory changes in his or her hip position because, when upright or walking, his or her feet are consistently positioned in a way that makes it impossible to maintain an ideal pelvic and spine position. Thoughtful and careful design of custom orthotics can have beneficial effects on situations like this by supporting loose structures or stimulating muscles to work or relax at the appropriate time. Orthotics may also have a more widespread effect by causing subtle changes in muscle patterns throughout the body.

Orthotics affect the foot in essentially two main ways. First, there is a sensory response, or stimulation of nerve endings in the feet, that creates a motor response, which is a reaction of the foot and ankle musculature. In the bottom of the foot, there are more nerve endings per square inch than anywhere else in the human body. So the greater the surface area of the foot that an orthotic can affect, the more nerve endings can be utilized for a proprioceptive response. I believe an orthotic will have maximum benefit for my patients if it can contour to as much of the bottom of the foot that the shoe will accommodate.

Second, a custom foot orthotic should be designed so that the bones of the foot are aligned as close to neutral as possible when at mid-range of motion. The big toe, foot, ankle, knee, hip, and pelvis also should be lined up properly. This goal of neutrality, as with any joint, will also improve the effectiveness of the corresponding muscles and tendons. Of course, all joints move in and out of neutral, and an orthotic needs to be flexible enough to let this happen. But with the proper use of materials, an orthotic can provide the best of both worlds. Creativity in design and in the materials chosen is necessary when, upon evaluation, it is found that the patient’s foot is pathologically loose or rigid.

Lastly, there is one important point that seems simple but is often overlooked; an orthotic needs to fit into the shoe seamlessly. Custom orthotic design should be fairly precise, and it’s a shame when they don’t fit properly in the shoe. Unfortunately, I see this far too often.

If you look at the bottom of the inside of the shoe, there is a distinctive shape, and that shape needs to match the bottom of the orthotic as closely as possible, or the orthotic position may be altered or slip around in the shoe. Changing the angulation of the orthotic inside the shoe will completely change how the orthotic design is influencing mechanics.

Beyond the Bruising

(This post was originally written by me for Austin Fit Magazine www.AustinFitMagazine.com)

I’m sure you’re seeing those perfectly round hickeys more and more. Gwyneth on the red carpet. Jen at her movie premier. Posh Spice at Heathrow. But now the guy in line in front of you at Whole Foods. And your neighbor after acupuncture. Or your triathlete friend after physical therapy. Cupping therapy is not just trendy or some ancient Chinese secret.  It’s being used more and more by therapists treating soft tissue problems for a variety of reasons and with excellent results.

In Western medicine cupping should be looked at as a therapeutic modality to treat soft tissue. It is usually used in conjunction with other modalities such as heat, acupuncture, dry needling, and especially massage. In traditional Chinese medicine (TCM), cupping has been used for thousands of years. Much like acupuncture, experiential use of cupping on patients with a variety of medical issues led to a system of integration into TCM, and today cupping is a very common part of any acupuncture session. In TCM, cupping is used to treat skin problems and musculoskeletal pain as well as digestion problems, skin conditions, anxiety, and respiratory conditions such as asthma and the common cold.

Those of us who treat predominantly orthopedic injuries appreciate cupping for its positive effects on the superficial tissues of our bodies (skin and subcutaneous fascia). In my practice, I find that most movement dysfunctions are highly correlated with negative changes in our skin and subcutaneous tissues. Chronic inflammation and edema have much the same effect on our tissues as normal aging and a decrease in physical activity. All of these can result in adhesions (or scarring) in the various layers of our fascia, a decrease in microcirculation, and an alteration in how the nerves in these tissues conduct information from our extremity to our spinal cord and brain.

Once any or all of these things happen there will be a reduction in the fluidity and efficiency of movement. We might simply see loss of range of motion or flexibility. Tissue imbalances can also create alterations in joint mechanics resulting in compensatory movement patterns. And there is often pain (sometimes significant) originating from the nerve endings caught up in these restricted tissues. Finally, because a very large portion of our body’s lymphatic system is contained directly under our skin, restrictions in the superficial fascia can seriously impede lymphatic flow and results in the accumulation of edema which will causes even further tissue dysfunction.

The principles of cupping are basically the same now as they’ve always been. A cylinder is placed over the skin forming a seal and air is pulled or drawn out. This creates suction and the skin (as much as four inches in depth) is pulled up into the cup. Immediately blood is drawn to the area and the pulling action stretches the superficial fascia. Sometimes the cups are removed quickly, sometimes they are left stationary for minutes at a time, and sometimes they are moved around over a targeted area of lubricated skin.

Cups come in a variety of shapes and sizes and can be made of different materials such as glass, plastic, or rubber.  Air can be drawn out quickly by igniting a flammable material on the inside of a glass cylinder or bulb (as seen in acupuncture practice), by manually drawing it out of a plastic or glass cup with a hand-held pump, or by mechanically drawing it out with a vacuum machine. Rubber cups are like mini plungers applied manually and typically are moved around over lubricated skin (great for home use). One cup at a time can be used, or multiple for a widespread effect. Whichever method chosen, the end result is an increase in blood flow to the area and a mobilization of the superficial fascia. There is almost always some degree of bruising from the disruption of the tiny capillaries in the skin and subcutaneous tissues.

Western physical medicine has adopted cupping based essentially on two principles: an improvement in the mechanical quality of the superficial fascia and an enhancement of the circulatory and lymphatic capability of cutaneous and subcutaneous tissues. The lifting action on the superficial tissues can have similar and sometimes more profound results compared to myofascial release techniques. There are many proposed theories regarding how myofascial manipulation can have immediate and lasting effects (too long of a discussion for this article), and those same principles apply to cupping or vacuum therapy. Furthermore, the effect that cupping has on the nervous system contributes to mechanical improvements by stimulating nerve ending that have a direct inhibitory effect on muscle tone and myofascial viscosity.

Improvements in circulation come from what you see when the skin is pulled into a hickey and results in redness or bruising. We can control the amount of suction by how much air we pull out of the cups. The more suction, the more blood that will immediately come to the area, in a sense feeding oxygen and nutrients to possibly stagnated tissues that lack efficient blood flow. The bruising is a result of micro trauma to cutaneous and subcutaneous capillaries and fascia. While this may seem a bit barbaric, the end result is that when the tissue heals we can expect a proliferation of the capillary system and a healing of the tissue in a more normal and healthy way (especially if proper exercise and nutrition advice is given to the patient). Also, this micro trauma creates a controlled and variable degree of inflammation, which is the body’s initial response to healing. The inflammatory and immune response of platelets, white blood cells, and other chemical mediators coming to the area is a good thing, again, especially if proper subsequent exercise and nutritional advice is followed by the patient. I have found that my patients bruise significantly less after just one treatment, a sign of improved tissue mobility and circulatory health.

Local areas of mild edema are treated well with cupping as the skin is lifted and the lymphatics in the subcutaneous fascia are stimulated. I explain to my patients that space is being created where there was not enough for the lymphatics to flow efficiently. Creative use of moving the cups over larger areas or by using multiple cups has a nice pumping effect on the lymphatics.

Clearly cupping shouldn’t be considered a stand-alone treatment. But when it is combined with other soft tissue and/or joint mobilization techniques and movement or postural correction exercises, cupping will greatly enhance the rehabilitation experience. The bruising is a small price to pay for healthier tissues and a more pain-free you.

Hamstring Stretching: How Much Is Too Much?

(This article was originally written by me for Austin Fit Magazine www.AustinFitMagazine.com)

Recently I had a conversation with a patient who was worried that she couldn’t bend over and touch her toes. She asked if she should be concerned and how could she improve her hamstring flexibility so that she would be able to reach her toes like she could when she was younger. She was worried that having tight hamstrings was contributing to some of her neck, back, and knee issues, and was causing her to have pain after most of her workouts.

This is a question I get at least on a weekly basis. And it’s an important question because going about stretching your hamstrings the wrong way can be a great source of instability through your pelvis and hips. There is, in my opinion, much misconception and misinformation about hamstring flexibility and flexibility in general. There is an optimal amount of flexibility for every joint based on functional and postural demands. We need our soft tissues to be mobile and responsive enough to allow us to move. But we also need them to be structurally sound to provide stability, which goes hand in hand with having the proper amount of strength and responsiveness to keep our bones in the right place at precisely the right time.

It is clearly a problem if you’re too tight and one or more joints can’t move enough to allow you to perform the simple movements you need for activities of daily living and for the more complex set of movements required for athletic endeavors or movement art. As a physical therapist, this is usually fairly easy to treat using whatever form of mobilization, exercise, or self-mobilization that I have in my toolbox. It may take some time to restore normal range of motion, but short and stiff tissues usually respond well to treatment applied with enough force and finesse.

More difficult is the situation where tissues are too long (Figure 1). Yes, it is possible to overstretch muscles and other soft tissues. With overly aggressive stretching the contractile elements of muscle fibers can be damaged along with the other connective tissues that envelop and surround the muscles. This can render the muscle long, weak, and chronically irritated (signaling to the chronic stretcher’s brain to “stretch more!” because that’s what they’re patterned to do when something feels tight and irritated). If addressed early in life (by stopping the over-stretching), muscle tissue can repair itself. But the later in life that one maintains a rigorous stretching program and long, excessively stretched soft tissues, the less likely they will ever rebound to normal range of motion.

Now back to my patient’s question.  Should she worry about her inability to touch her toes?  The answer is “maybe,” since it depends on how she bends over and whether or not there is proper amount of movement through the hamstrings, hips, and spine combined. Besides the hamstring’s function of bending the knee and extending the hip, the hamstrings act on posture to check or slow down the forward tilting of the pelvis. If the hamstrings are too long and not strong enough, it is likely that we will see the pelvis tilting too far forward resulting in a deep lumbar curve.  Habitually being stuck in this lumbopelvic position leads to a cascade of postural alterations.

A forwardly tilted pelvis is associated with lengthened abdominals and tight hip flexors.  This situation is one in which your abdominals are at a mechanical disadvantage for acting as the important “core” stabilizers that we all know they should be. With loss of abdominal tone the belly will protrude and the front lower ribs will flare, deepening the lumbar curve even more. Most people who have this deep lumbar curve develop, over time, hyperactive and short low back muscles (paraspinals, latissimus dorsi, quadratus lumborum) so that when they bend over their lower back cannot completely come out of a deep curve and they can’t fully round (or flex). This perpetuates the hamstring situation. Every time they bend they will utilize their excessive hamstring length and not appropriately round their back. This simply becomes how they move.  Sitting and standing forward bends in yoga are easy to do by pivoting through the hips and not rounding the back at all.  Dead lifts are performed with too arched of a back. Runners may over-stride and overextend their backs.

Whether an individual has tight hamstrings can only definitively be determined through a series of objective tests.  But a quick screen can give one a pretty good idea of their situation.  First, lying on your back see how far one leg at a time can be brought up and towards your head (with your knee straight).  I’ve found that on average men can get to around 80 degrees and women get closer to 90 degrees (Figure 2).  But keep in mind that if your pelvis is already tilted too far forward you may get a false impression that your hamstrings are short because they’ve been placed on stretch before you even start the test.  Finally, a good way to decide if your pelvis is in a good position is to look for a decent amount of rounding through your lower back when you reach to touch your toes. My golden rule is that you can touch your toes with normal lumbar flexion (Figure 3). If you can lay your palms on the floor (like many ex-dancers, gymnasts, and cheerleaders can) it is very likely you’re pivoting too much at the hips through excessively flexible hamstrings.

The main point is that when you feel your hamstrings are tight they may actually be too long and are just irritated. In this case, if you continue stretching you will actually be worsening the health of these tissue. You really may need to be strengthening them so that they can act as efficient pelvic stabilizers. Find a physical therapist to do a more in-depth assessment of your situation so you don’t risk making matters worse.