Great question here about scar tissue and the use of SMR (foam roller) and other implements from Chris and Mark Young had some great comments too in response to my foam roller posts.

Foam Roller Exercises : Just Say No

I figured that I get lots of questions on the standard 4 phase Z Health approach I would republish the answer here for everyone.

Mike,

What do you suggest for removal of scar tissue if self release (foam rolling, baseball/lacrosse/golf ball) is removed from the picture?

Chris

Great question Chris.

I think the bigger question is “What can’t you do?”

Now this may be a problem for various reasons and scar tissue may be one of them.

I tend do the the following to get athlete bodies working correctly again:

1) joint mobility work

2) visual work (eye movements actually)

3) vestibular work (head rotation, tilt or chin down or up)

4) hands on work

Most of the time on a first session, joint mobiity work is enough.  Guy came in a while back and his shoulder did not go all the way when moving it out in front.  Joint mobility work (Z-Health) on the same side wrist, opposite hip, opposite foot/ankle got his arm almost all the way up (was only at about 70% before).

If joint mobility work is not having a good response, I will test their eye reflexes (PREP, taught in Z Health I Phase).   PREP=postural reaction to eye position.  If they were not normal, they do drills with an eye position and joint mobility.

Example: bad ankle

A female athlete came in a while back with an ankle issue.  In order to get her hip muscles to fire better, she had to move her eyes up and while holding them up, do some ankle joint mobility work.  Hip muscles (glute med, psoas and RF) fired up and her gait (along with her ankle) was much better.

If eyes + mobility don’t work I will add in vestibular work, using PNRT (postural neck reflex test).  A recent athlete came in post ACL replacement and post Physical Therapy  and on his first visit the joint mobility was not working, so I tested his eyes and they were normal (PREP test only), but his PNRT was positive (not normal) for his head rotated right. So his drill was an ankle mobility drill with his head turned right.  Moved much better, knee was much better.  (note I find it is rare to find ONLY vestibular issues)

Some times it is a combination of all 3

Mobility +  eyes + inner ear = optimal function and movement

This is hold the brain gets information to execute movements too (joints + vision + vestibular).  We are reverse engineering better movement by fixing the “bad” signals!

If that still does not work, I will check the tissue by just moving it in specific orientations at 3 different layers 1)skin 2) fascial 3) deep.   Note, most of the time I am not FORCING the tissue to move, I am holding it in a specific orientation and then using joint info, visual (ocular motor too) and inner ear (vestibular) work to ALLOW it to release.  I am working to find the correct combination to the safe via spinning the dial, vs trying to blow up the safe.

Another Example: Powerlifting and hamstring strength

Awhile back a powerlifter came in and her left hamstring would not fire up to 100% and gait could be better.  At the time she was deadlifting about 3xs body weight.  Went through the testing above, using a gait assessment after each drill.

On a manual muscle test, the left hamstring was still weak and gait was off.  Ending up doing a right elbow circle (neuro reflex to the opposite knee/hamstring aka probably interlimb coupling), with her head rotated right (vestibular input), with her eyes open and in the up position (looking up), while I held deep (not remotely painful) pressure on the whole hamstring (all 3) in a position to the “right.”

As she rotated her head and did the elbow circle, I could feel the hamstring tension to the right melt and it moved easily.   Had her walk and gait was much better, left hamstring fired up great.  Later I heard her DL went up, but hard to say what I did was directly related to it; but moving better is always a good adaptation.

I hope that helps a bit.

Summary

Basic joint mobility work is Z-Health R Phase, eye and head movements (vestibular) is Z Health I Phase, hands on work (holding tissue) is Z-Health T Phase (level 4) work.  Minimal amount to get the job done = less collateral damage to fix later (although I don’t see them again as much which is my goal, but is a crappy business model–hahaha)

Most don’t need direct tissue work right away, but that is not to say it can’t work.  Physiology is messy and many things can work.

If anyone has comments/questions on this one, post away in the comments!  Comments make me feel all warm and fuzzy and it is getting colder here in Minnesota now.

Rock on

Mike T Nelson

PS
If you want any info on the Z Health certs, let me know and drop me an email or give them a call and tell them I sent ya.  I am NOT an employee of Z-Health, but I do make a few bucks off of cert referrals.   Again, I would never recommend something that I don’t use myself or feel that works great.

Foam Roller Exercises Are the Bomb and Will Solve Everything!

Below is a funny video about how foam roller exercises will fix everything, even if done in pain.

A newer study below looked at the effects of a very hard and stiff foam roller- Multilevel rigid roller (MRR) and a standard Bio-Foam roller (BFR).
Let’s see what they found

Standard Foam Roller

A Do it Yourself “Hardcore” Roller

What they found is that the Multilevel Rigid Roller exerted more pressure.   Hello McFly, really?  You are telling me that if I get down and roll around on a rolling pin it will be more pressure on my IT band than a foam roller?  Do we really need research to tell us this?

Wrong Questions

They are asking the wrong question here for this study.   If you want a better answer, you need a better question.  A better question is “Does rolling on a foam roller (SMR) result in better long term performance?”

While I have not seen any direct research on that question yet, my answer is NO.

I’ve outlined it in this post below

Get Off the Foam Roller

Why I have No Love for the Foam Roller

My biggest issue with foam rollers is that people do their foam rolling in pain.  Ironically, most are rolling around humping their foam roller trying to get OUT of pain.  Creating MORE pain to get OUT of pain makes about as much sense as coming to see me about your right shoulder that is painful and I take a cow brander and brand your opposite shoulder.  I can guarantee you that your right shoulder will not be painful (and that will be $110 please too.)   Did I solve anything?  Nope, I did not change the underlying issue of your right shoulder?  Nope!  But I sure a heck altered the signal to your brain regarding your right shoulder pain and now it is NOT painful.

Enough With the “Hardcore” Painful Soft Tissue Work

Keep in mind that pain is a creation of the brain and is very complex.    Think of it as the “check engine light” on your car.  When it comes on, you are not sure what is going on, but something is not right and you better stop the darn car before you rip up the engine.   So you bring it to the dealer, they charge you a crap ton of money and hook up their computer to see what is going on.  Hopefully they then fix the underlying issue and you are on your way, albeit with a lighter wallet.  

Pain is telling you that something is not right, and you better go get it checked out by a professional.

See this video below that explains the process of pain

What To Do

You need to teach your brain that movement is NOT painful.  While that is easy in theory, in practice it can be a bit tricky.    Most will get huge benefits from active joint mobility work (like Z-Health).  All the drills have to be done so they are not painful to begin the re-education process.  The brain works by prediction and association.  Move in pain and that 3 pound thing at the end of your spine starts to associate movement with pain.  This is not what we want.  We want pain free movement.

What are your thoughts?  Are you going to continue to move in pain in the interest of feeling better?

Rock on

Mike T Nelson

PS

If you are interested in a custom movement coaching session to increase performance, feel better and move better, drop me a line.

Contact Mike T. Nelson to set up an appointment today by clicking HERE

REFERENCES

A comparison of the pressure exerted on soft tissue by 2 myofascial rollers.
Curran PF, Fiore RD, Crisco JJ.

J Sport Rehabil. 2008 Nov;17(4):432-42

Dept of Orthopaedics, Warren Alpert Medical School of Brown University/Rhode Island Hospital, Providence, RI 02903, USA.

CONTEXT: Self-myofascial release (SMR) is a technique used to treat myofascial restrictions and restore soft-tissue extensibility. PURPOSE: To determine whether the pressure and contact area on the lateral thigh differ between a Multilevel rigid roller (MRR) and a Bio-Foam roller (BFR) for participants performing SMR. PARTICIPANTS: Ten healthy young men and women. METHODS: Participants performed an SMR technique on the lateral thigh using both myofascial rollers. Thin-film pressure sensels recorded pressure and contact area during each SMR trial. RESULTS: Mean sensel pressure exerted on the soft tissue of the lateral thigh by the MRR (51.8 +/- 10.7 kPa) was significantly (P < .001) greater than that of the conventional BFR (33.4 +/- 6.4 kPa). Mean contact area of the MRR (47.0 +/- 16.1 cm2) was significantly (P < .005) less than that of the BFR (68.4 +/- 25.3 cm2). CONCLUSION: The significantly higher pressure and isolated contact area with the MRR suggest a potential benefit in SMR.

What are your thoughts about ART?

This was a good question that I received about 3 times in the past week, so I thought I would address it here.

It is a general question, so I will answer it in relation to general prinicples. Again, everything needs to be custom to the athletes that you work with of course.

For more info, click the links below

Get Off the Foam Roller

Myth Busters-Painful Soft Tissue Work

Some have believed based on my posts above that I am against soft tissue/hands on work; and that is not true at all. I am against PAINFUL soft tissue work!

All of the ART therapists that I have met so far have been great and extremely knowledgeable. Some do painful soft tissue work and others do not (although they are much less common). I don’t believe pain is needed to get a result and will actually diminish your results. You are normally seeing an ART person to get out of pain or change a motor pattern/pain.

Don’t try to blow up the safe when you just need the correct combination to open the door.

Here is another great post by Carl Valle at Elite Track and my response to it.

Soft Tissue Therapy by Carl Valle (click the title to open it)

My response to Carl.

Hi there Carl! Thanks for the kinds words as it means a lot coming from someone such as yourself.

In relation to experience with athletes that is an excellent point. To date, I have done a fair amount of Z Health sessions (I do have the exact number documented and not pulled out of thin air if you need further info).

Note that when I say Z Health this may apply to dynamic joint mobility work, visual testing/movements, vestibular work or even hands on work (which means that I am holding
tissue/joint/muscle in a specific orientation while they perform an exercise).

I agree that most of these are not what would be considered high level athletes and more weekend warriors types. I was able do a session with a recent Olympic competitor and was able to get her out of pain for the first time in years (see link below)

Z Health and Marathon Running

The same principles would apply to high level athletes.

I agree 100% that soft tissue work done correctly can have HUGE changes for people. No question about that!

You point about most businesses is a good one. I do run a business in the private sector.

Clients/athletes come to a professional in the field for results. My guarantee is that if I can’t get your pain to less than a 2 on a 1-10 scale in ONE session, it is FREE. No results=no money for me=out of business.

Down with foam rollers! Preach on.

Yes, there is research on eccentric stimuli to help encourage remodeling, esp in the case of
tendonOSIS as you know. I like to think upstream—-what causes tension on the muscles/tendons?

Control from the nervous system, so if we can alter that signal, over time the structures will adapt.

Carl said “..but the direct approach WITH motor changes and other elements is a full approach.”

Yes! I have had cases where I’ve needed to do hands on (touch an athlete just as you would touch them to guide them during an exericse) to get a result. In one specific case I held the hamstrings in a specific orientation with the athlete doing an opposite elbow circle (joint mobility), with her head turned to the right and eyes in the up position.

Her hamstrings worked much better afterward and total time of the drill was about 1 minute (getting to that point was about 40 minutes in that case though). She had to follow up and do a similar drill (without hands on work) 3xs a day for about 3-4 weeks for it to “stick”—there is never a free lunch

In general, I do the minimal approach to get the maximal results. Precise joint mobility work seems to get me there about 70% of the time ( I mean 72.8958859% of the time, hehee). The more times I work with athletes and as their movement progresses, the more other work they will need—hands on (guided exercises), visual (eyes held in a specific position), and vestibular (head motions) ; but with all things “it depends” as I may skip around depending on the client. I like to start simple and then only add complexity when the simple looking things do not work.

I hope that answers the ART question!

Any follow up points, thoughts, clarifications, please post them in the comments below.
Thanks!
Mike T Nelson

Q and A Time!
You ask, I answer. Here is a very common question I get and thought I would address here. Any future questions you want answered, please post them in the comments section and I will add them to the list.
Thanks!

Question
You seem to be a proponent of non painful soft tissue work, but very few do this and yet they get results. How can non painful tissue work even work? I thought the point of tissue work was to get in there to break up scar tissue, adhesions, etc? Please explain.

Answer
Thanks for the question. You are absolutely correct that I am not a fan of painful soft tissue work at all as wrote in my Get Off the Foam Roller post for the reasons outlined there.

Your question about how can other get results is a good one. My thoughts are that they are simply providing a new “stimulus” to the nervous system and probably also altering the “perception” by the nervous system. This is based off of the Neuromatrix of Pain by Melzach and Wall. The premise is that pain can be from all sorts of stuff and since pain lives in the brain, our options are to alter either the stimulus or the perception of it. Even though some work is painful and I feel that this has consequences elsewhere in the body in terms of OVERALL function, it does work in some cases to change the stimulus and perception.

Biomechanical Approach
I do feel that thinking in terms of only a biomechanical approach (this muscle is tight/short, locked long, weak, etc) will eventually run into a ceiling as it is the nervous system that controls the show; so we should shift our thinking towards neurological solutions to neurological “movement problems”. I know this was a longer transition for me as I did the biomechanical route for many years and even went to graduate school for biomechanics during my first go round. Does this mean that those using a biomechanical approach can not get results? Of course not, but I don’t feel it is optimal and at some point you may be back to where you started as you chase things around the body. Remember that the body is HIGHLY INTEGRATED and complex. Physiology is messy.

Myth Busters to the Rescue!
Here is an analogy–ever watched the show Myth Busters? I love that show, and there is an episode where they put money into a very expensive safe and then proceeded to use a cutting torch to get into the safe. They got in, but found that they vaporized all the money in the process! Crap! I think painful, high force tissue work is like breaking into a safe with a cutting torch. Does it work many times? YES, of course! Does it result in OVERALL better function–sometimes yes and sometime no. I think by using the correct combination on the lock (propricoptive, visual, vestibular and even hands on work via Z Health) you can get into the safe in a much safer and effective method.

What is too Painful?
If you have to change the tone of your face (look like you were sucking on a lemon ya sourpuss or any extra tension) or change your breathing (this counts breath holding), it is too much pressure/pain. Either way, you want to test it and see if there was the desired result.

Hope that helps!

Thanks to Smitty at Diesel Crew for running my article on foam rollers. Be sure to go to the Diesel Crew site and check it out as they do some great stuff there and tons of back articles too.

http://www.dieselcrew.com/articles.htm and
http://www.dieselcrew.com/

So I will probably known for a long time as the guy who dislikes foam rollers. The main points of the foam roller post was

1) don’t move in pain as pain shuts down the nervous system
2) it is probably not addressing the SOURCE of your issues

Can I point to tons of peer reviewed articles about foam roller? Nope. Up until now I have not found one (although I have heard of some new studies going on that are not completed yet). Here it is

I will fully admit that it is not a super cool, randomized, placebo controlled, double blind, country wide, tons of people enrolled study; but it is a pilot study (smaller, easier to run). A pilot/smaller study is going to be a great place to start, since there are virtually no existing literature on the topic.

The summary of the study was that it did not show any change in range of motion (ROM) after a foam roller intervention. Not earth shattering, but I thought I would pass along the information.

I would be interested to see if the subjects were doing the foam roller work in pain/discomfort. Pain has “bad effects” on the nervous system (anyone getting tired of hearing that yet?)

New Blog Added!
New blog added, so check out Sara’s article below. Great information that everyone should read and pass on.

Pain is individual and Dependent

Foam rollers are common these days and can be found in every sports catalogue in various types, styles and colors. Many top coaches and trainers recommend their use by athletes of all types. Some people are even said to SLEEP with them (1) (you know who you are Mr. Kevin Larabee of The Fitcast fame).

Background and the reasons why people foam roll
The standard argument for self-myofascial release (SMR) on a foam roller is possible thanks to the principle known as autogenic inhibition. Unless you have been living under a rock, you have probably heard of the Golgi Tendon Organ (GTO) at some point. The GTO is a special mechanoreceptor (remember those from previous articles ) in this case found at the muscle-tendon junction. It’s job in life is to detect changes in tension in the muscle and to work as a safety mechanism by releasing muscle tension when the force becomes too great to potentially cause injury.

The fancy name for this reflexive relaxation is autogenic inhibition. When you apply force to the muscle via a foam roller you add muscle tension, and thus causing the GTO to relax the muscle.

Sounds awesome doesn’t it? Just 10 minutes a day and I should be all set right?

This simpleton argument has been questioned within the past few years (for an overview on reflexes click here ) Plus this argument also leaves out the whole rest of the nervous system! As I’ve said before, physiology is messy and seldom that simple.

A full discussion of the GTO is beyond this article (I hear a sigh of relief), but Fallon, JB et al. (2) stated recently, “The responses of the various muscle receptors to vibration are more complicated than a naive categorization into stretch (muscle spindle primary ending), length (muscle spindle secondary endings), and tension (Golgi tendon organs) receptors”. Cui, J. et al. (3) recently have shown in healthy humans mechanoreceptor(s) stimulation may even evoke significant increases in blood pressure. It is all connected via the nervous system.

Here the 2 main arguments of why I don’t think people should foam roll

1) Tissue properties

What are you trying to achieve? What is your goal? Most then cry “I want, better tissue properties”–ok, fair answer, but what does better tissue properties get you? Most are after better muscle function and some to get out of pain and better tissue properties is a step in that direction.

The nervous system is the key (notice a theme yet?) Now before you get all crazy on trigger points and how they effect muscular force (which is a good point), how did the trigger point get there? I’ve done a fair amount of cadaver work and so far I have yet to see one trigger point. Actually non-fixed (fresh) tissue does not hold tension on its own. I have yet to see a slab of muscle get tense! Yes, certain structures are stiffer than others, but I have yet to see any muscle or tendons that resemble piano wires that I see most people’s necks. The nervous system is controlling the level of tension.

Plus the thought of adding high amounts of external tension to your body in order to relieve tension seems odd to me. So I should add the thing I am trying to reduce? I know physiology is messy, but food for thought.

2) Foam rolling can be painful.

Pain will actually inhibit your gains. Now I know some will get up in my grill about how they are making gains in the gym and they are in pain and I agree that this can happen, but my argument is that it is not OPTIMAL.

First, what is pain?

The International Association for the Study of Pain defines pain “as an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.”(4)

The take away here is that pain is associated with actual or potential damage. Pain is produced when the brain perceives that danger to body tissues exists and that action is required as a survival response. Imagine early cave man days and Captain Caveman sticks his hand in the fire. What happens next? He yells some unintelligible explicative and promptly removes his hand from the fire! Pain is an ACTION SIGNAL—move your darn hand out of the fire!

Remember that pain does not live in the ankle that you sprained or Captain Caveman’s hand, but it is an interpretation of the brain. The signal from your Captain Caveman’s hand is sent up to his prehistoric brain where his brain then interprets the degree of pain.

It was rumored that civil war soldiers that lost entire limbs were initially NOT in pain since they were so grateful to be alive that the thought of even loosing a limb was nothing compared to be pushing up daisies.

It is true that if the damage sustained is severe enough, the pain and resultant shock can become the highest threat and require a survival response (5).

The brain and the nervous system control ALL muscle movements. When pain occurs it inhibits the nervous system as a protective mechanism.

Remember that the body only cares about survival and does not give a hairy rat’s butt about performance. If I injure my elbow, my nervous system will start to shut down the muscles around that joint as a protective mechanism to try to prevent further damage (ala arthrokinetic reflex).

So the windy road back to our friend the foam roller. If you are on the ole foam roller before a training session and it is painful, you are turning on the “neurologic brakes” and thus decreasing your performance.

Confession time
I used have athletes foam roll over there ITB/TFL (lateral quad) and if they yelped in pain I would promptly declare “You there– you have some ITB/ TFLs that are so tight you can bounce quarter off them” and would promptly have them do multiple foam roller sessions each day.
n>Most times in a few weeks the pain would become less and I would then declare “Good thing I fixed that issue,” but did I? Why were they still foam rolling (albeit in less pain). Wait, I thought this was the solution? Why did I not see a huge change in their movement? Are they doomed to the foam roller the rest of their life?

What do you think is causing those “tight” muscles you are foam rolling?

Hmmmmm. I have an idea!

The joints (along with the nervous system) are causing those “tight” muscles, and this is one of the main tenets of the Z Health system. If the joints are sending noxious stimuli to the brain (which may or may NOT be painful, remember that interpretation of the signal in the brain), the brain will try to protect the joints by decreasing strength done by the muscles around it (and other muscles also). If you have tight hamstrings, foam rolling your hamstrings will probably not solve the issue LONG TERM. Working on the foot/ankle and some times elbow circles may help hamstring issues, but that is another topic.

Anyone want to buy a foam roller?
The current trend in some areas seems to be going to more and more aggressive pain inducing massicistic massage. If I had no scruples, I would file IP on a foam roller with spikes on it! Seriously, I think that could have been my retreat to Fiji idea. If someone reads this and does do it, please drop me an invite to your private dessert island.

Foam roller work must also follow the SAID (Specific Adaptation to Imposed Demand) principal meaning that your body will ALWAYS adapt to EXACTLY what you do. So we know that doing foam roller work will make you better at doing foam roller work. Last I checked, there was not a foam roller competition, but maybe they have one now. I doubt there is much positive transfer from foam rolling to many other activities, but I will leave that for you to test out.

Does this mean that all soft tissue work is bad?
Of course not! A foam roller even by most of its biggest advocates admits that it is rather limited and works well primarily for the lower extremities. Massage has a neat feature where the hands working on you are attached to someone else’s brain that can intrepid what the heck is going on and adjust accordingly. Last time I checked, foam rollers were pretty dumb (another free IP idea is a “smart foam” roller that increases density in response to force). Even some ART practitioners are experimenting with lighter pressure with good results. I do think there still is a tendency to only treat the site of pain (although this is changing) and many times the relief is short lived.

So what do I do? Help!
I am a realist and know that very few are going to have a foam roller burning party based off of one article on my blog, but one can dream right. Wait, check that, Al Gore just called and said that the burning of foam rollers is bad for green house gases so please recycle them instead. No green credits for you, bad dog. Instead, you could use it in place of board presses at your local gym.

To quote Jim Wendler “You don’t have to smuggle the foam into a commercial gym like you would the boards. You can simply state that it is a rehab tool. And when you say “tool” you can smile and make sure the Jabroni at the front desk knows that you are actually talking about him.” (6)

1) At minimum, don’t do any foam roller work before a training session and maybe only some light work afterwards

2) Make sure it is NOT painful, especially if you are doing it before a lifting session. Remember pain decreases performance.

3) Try replacing some foam roller work with some precise joint mobility like the Z Health Neuro Warm Up

4) Find a trainer/therapist that uses non painful hands on work combined with active mobility work. A Z Health Level 4 (hey, that is me—shameless I know) is a great place to start. Even many of the R Phase movements can have profound results on soft tissue due to the involvement of the nervous system.

Any comments, let me have em’

Rock on
Mike N

REFERENCES
1. Dr. John Berardi: G-Flux Simplified. March 3, 2007. The Fitcast Insider www.thefitcastinsider.com. Accessed June 5, 2007.

2. Fallon J. B., V. G. Macefield. Vibration sensitivity of human muscle spindles and Golgi tendon organs. Muscle Nerve. 36(1):21-29, 2007.

3. Cui J., V. Mascarenhas, R. Moradkhan, C. Blaha, L. I. Sinoway. Effects of Muscle Metabolites on Responses of Muscle Sympathetic Nerve Activity to Mechanoreceptor(s) Stimulation in Healthy Humans. Am J Physiol Regul Integr Comp Physiol., 2007.

4. [IASP] International Association for the Study of Pain. 2008, Jan 3. IASP home page. http://www.iasp-pain.org. Accessed Jan 3 2008.

5. Dr. Eric Cobb. Personal communication. December 19, 2007.

6. Foam Pressing, 2007, Jim Wendler http://asp.elitefts.com/qa/default.asp?qid=48812&tid=102 Accessed Jan 7, 2008.