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Paul Ingraham is a Vancouver science writer and a former Registered Massage Therapist. He left that profession over concerns about pseudoscientific beliefs and practices and went on to create PainScience.com, a website about the science of pain, injury, treatment, and rehab, where he has published hundreds of articles and ten books on these themes, the most successful of which is his guide to the tricky topic of “trigger points.” Today, Paul talks with Brodie about the science behind trigger point release, myofascial release and other manual therapies. This candid conversation reveals our real understanding of manual therapy and the careful steps runners need to make when being treated by therapists. Check out Paul's website and books here PainScience.com More trigger point info: https://www.painscience.com/index-trigger-points.php Also check Paul's book: https://www.painscience.com/tutorials/trigger-points.php Relevant links based on our conversation: https://www.painscience.com/articles/does-fascia-matter.php https://www.painscience.com/articles/does-massage-work.php https://www.painscience.com/articles/counterstimulation.php https://www.painscience.com/articles/placebo-power-hype.php Follow follow Paul on twitter Become a patron! Receive Run Smarter Emails Book a FREE Injury chat with Brodie Run Smarter App IOS or Android Podcast Facebook group Run Smarter Course with code 'PODCAST' for 3-day free trial.
Expand your running knowledge, identify running misconceptions and become a faster, healthier, SMARTER runner. Let Brodie Sharpe become your new running guide as he teaches you powerful injury insights from his many years as a physiotherapist while also interviewing the best running gurus in the world. This is ideal for injured runners & runners looking for injury prevention and elevated performance. So, take full advantage by starting at season 1 where Brodie teaches you THE TOP PRINCIPLES TO OVERCOME ANY RUNNING INJURY and let’s begin your run smarter journey.
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On today's episode, the science of trigger points with Paul Ingram. Welcome to the Run Smarter podcast. The podcast helping you overcome your current and future running injuries by educating and transforming you into a healthier, stronger, smarter runner. If you're like me, running is life, but more often than not, injuries disrupt this lifestyle, and once you are injured, you're looking for answers. and met with bad advice and conflicting messages circulating the running community. The world shouldn't be like this. You deserve to run injury free and have access to the right information. That's why I've made it my mission, to bring clarity and control to every runner. My name is Brodie Sharp, I am a physiotherapist, a former chronic injury sufferer and your podcast host. I am excited that you have found this podcast and by default, become the Run Smarter Scholar. So let's work together to overcome your injury, restore your confidence, and start spreading the right information back into your running community. So let's begin today's lesson. If the name rings a bell, that's because Paul Ingram was on quite recently. He was on in April, episode 229. And the title was when to get medical scans. If you haven't listened to that episode, Paul is the creator of pain science.com tons of relevant information to do with being a runner. Um, but just understanding pain science, I think all runners can best like, that's why I've dedicated so many episodes to it, because I think it's so relevant to injured runners, um, or if you're getting niggles or, you know, any future injury, I think people would be really, it's really key for people to know about pain science, but tons of other things on there about Um, surgeries or particular, I think he said he was delving into stress fractures last time we had him on, but other manual therapies, tons of stuff on that website, so go check it out. Um, Paul Ingram after our last conversation, I quickly asked if I could have him on again to talk about trigger point release right up his alley and he was more than happy to do it. So we jumped on another call and talked about the science behind trigger points, but also around, you know, Myofascial release and just, I guess, massage things in general. He was, Paul Ingram is, or was a massage therapist, um, not currently practicing, but went through his three years studies of massage therapy. And since started questioning a lot of the narratives, questioning a lot of the science, um, very closely related to Alice San Vito who we've had on the podcast before to talk about the benefits of massage and the science pine massage. And after our recording, he actually said that, um, he studied with Alice San Vito like at the same time. So, um, strange coincidence there, but, um, the conversation today, really, really engaging a lot of stuff. There's can get a little bit like science heavy. Um, a lot of it's kind of theoretical. Hopefully you hold on. It's, it's a really nice interview throughout a lot of takeaways and Finish off with a really nice boat on top. So I hope you enjoy it. Let's take it away. Paul, welcome once again to the podcast. Thanks for joining me for round two. Thank you. Glad to be here again. And it's a particular topic that I'm excited about because I have, I've talked to Alice San Vito on the podcast before about massage and trigger points and her particular views and sort of bringing a lot of those particular concepts to the forefront of people's minds. But I'm really excited to talk to you about it. You're very well-versed based on the pain science podcast, the pain science website and all that sort of stuff. So yeah, I do wanna start off because you were a massage therapist originally. I wouldn't mind you just casting back to that time in your life and particularly around what was taught. And whenabouts was it like, um, how long ago were you studying those things? Uh, it's getting to be a shockingly long time ago. Now I started studying massage therapy in 1997. Yes. Okay. In the previous century. Yeah. And it was a three year program. So 97 to I graduated in 2000 and started working in Vancouver. And I worked as a massage therapist in Vancouver for 10 years until 2010. And so that was my clinical career. I go way back and, and I learned about trigger points during school from a mentor, from one of the instructors at the college, and it wasn't really being taught in the classes. We actually didn't really learn about trigger points or trigger point therapy. in school, despite the fact that we had a long three-year program, unusually long for massage therapy, Trigger Point certainly came up and was covered, but not in any detail. And yet I had this mentor, I went to see her as a patient. and learned about trigger points from her. And she started, I think, enjoy teaching me about them. And so I got this crash course, not crash, I got a detailed course one-on-one with this instructor and the ideas of trigger point therapy, really in its heyday, you know, it was really hot back then. Still unknown to lots of people, but getting big, getting popular. And I got it from her, and she was very knowledgeable about the topic. So that's since, you know, I first learned about trigger points in 1997. Wow. And I guess back then when you were going through that, that three year course, what sort of techniques and, um, I guess the mechanisms behind those techniques were taught. Um, I don't know that I learned anything about how trigger point therapy was supposed to be working in. my courses. I don't recall if it was taught. If it was taught, it was so overshadowed by what I was learning one-on-one with that mentor that that's all I remember. But certainly she explained it to me. That's where I began. I essentially just took her word for it. What she taught me was the classic trigger point dogma still dominant to this day, lot more people today. And I just, you know, I just swallowed it whole and ran with it for many, many years. If people are familiar with that dogma kind of teachings about trigger point, do you mind explaining what she said? Yeah, sure. I mean, it's, uh, there's a really easy short version and that this is the idea that muscles get, uh, sore spots that are basically tiny little cramps. That's the plain English version of the hypothesis. The slightly more complicated version is the energy crisis hypothesis. The theory here is that the muscle is essentially choking off its own blood supply and getting caught in a metabolic vicious cycle, getting irritated by the lack of oxygen, producing more waste products, which irritate it further, which make it clench more, around and gets worse and worse and causes a very irritable little patch of tissue. That is the conventional wisdom that was a hypothesis put forward by the people who originally created the idea of trigger points. And that is still the explanation accepted by most massage therapists and other practitioners of trigger point therapy. be today. I think that if you went to see a massage therapist today and they did Trigger Point therapy on you, there'd be about a 90% chance, 80 to 90%, that is the explanation they would give you if they gave you one. Outside of Trigger Point release, what other techniques are being taught? Like I know... Alice was talking about, you know, massage is designed to increase blood flow, remove lactic acid, like all of those particular, I don't know, um, ideas behind massage was, were you being taught very similar merits? Yeah, I think that the massage therapy education in that era and still probably quite a lot today, is dominated by a lot of really, you know, classic myths about how massage therapy does what it does. Facial release has been ascendant for the last 20 years. I didn't see much of that in school, but it was coming. So that's maybe one thing that's changed quite a bit. you'd often, you would, you'll often hear the idea that massage is working by releasing fascial restrictions. That's a very popular notion today. And I'm sure it was being tossed around in the late 90s when I was in school, but you're asking me to dig deep into the memory banks here. I don't entirely remember. You're doing a very good job of doing it. I don't know exactly what we were taught those, low those 25 years. ago, but I know it was, you know, basically, you know, the greatest hits of massage mythology, things like increasing circulation and releasing tight muscles and relieving trigger points and detoxifying and so on and so forth. Lots of, lots of old chestnuts of, you know, what massage is supposedly good for. Yep. I graduated 10 years ago and I struggled to remember what was happening then. So you're doing a fantastic job. Well, plus my head is so cluttered with everything that I've thought about and written about ever since. So it's a, yeah, it is great. I'm sure I would actually be shocked if I could go back and, you know, see what I was being taught in 1998, I'd probably be horrified and amazed at the things that I've forgotten. Well, I know when I was studying physio that... A lot of the content had to cover us working in hospitals, us working in private practice, all these different conditions. And a lot of it was not reserved for massage techniques. I know we had one workshop on massage techniques and it took maybe an hour, an hour and a half. And that's all we got. And that was extremely brief, extremely very, very similar to what you're talking about, in terms of the benefits and the mechanisms behind massage. So yeah. Not a lot, but I'm curious to hear as you entered the field, as you entered the profession and started working, how long did it take you to start questioning those theories? Because I kind of know the end result of where your career took off towards. At what stage did you start maybe questioning those particular methods and start thinking about, yeah, I guess going against the grain? Yeah. You could divide it into two. It really wasn't even until I was actually done my clinical career that I really first started to seriously question some things, particularly trigger point therapy, which had been a bedrock of my clinical practice. So that's one perspective is that it just took a really long time and really that shift. is actually pretty recent. The other way of looking at it is that I was skeptical and suspicious from day one. And part of the reason that I took to trigger point therapy very early was not just that I was learning it from a mentor, but because it seemed like an answer to the question, where's the beef? I wasn't that impressed with what I was learning in school. I didn't see a lot of clarity. about what massage was supposed to be achieving physiologically. I think I probably sensed very early on that things like increasing circulation were pretty hand-wavy, didn't have a lot of substance to them. So from the earliest days, I remember wanting more, wanting to understand better, and being really impressed by the complexity and subtlety of physiology, being really humble. So even though I took to trigger point therapy early and made it the basis of my practice and it seemed like a pretty decent answer to the question, what are we doing here really anyway? I also didn't take it that seriously. And I was always very cautious with my confidence and not being over confident about what I was doing. So I was in a good position from the beginning to eventually start asking much harder questions about what, what is that trigger point therapy stuff? Really? What's going on there? And, uh, and then it started to happen in a rush approximately 10 years ago, a of clinical practice, I started noticing mostly on social media a lot of people were starting to question the conventional wisdom and the dogma about trigger point therapy. And the full transition, you know, it took at least three years. for me to fully get on board and go, okay, I need to, I need to update my beliefs here. It's time, it's time to have a good, hard look at myself and what I believe and why I believe it and a lot changed. A lot of things changed. Yeah. And I, a very similar pattern happened with Alice, Alice San Vito talking about her insights was once she started. like mingling with really science minded practitioners who started questioning those beliefs. And without any real, like that sort of got her brain like sort of self evaluating being like, Hey, what evidence am I holding onto? Like, why do I hold true these sort of beliefs? And that sort of got her started on that journey. And I remember like, we learn massage techniques, like physiotherapy, a lot of it is release work, massage, trigger point therapy, dry needling, mobilizations. And I know spine mobilizations is a big part of our practice. And I remember just maybe one or two years out of graduating, like just having drinks with my physio mates, one of them said like, what does mobilizations actually do? Like, you know, you're poking into a joint and you're doing that at a rhythmic sort of motion. And what's actually, it shouldn't really be doing anything cause you're not really doing much. people feel a little bit better, which is kind of my years of practicing as a therapist. you kind of get this confirmation bias because you do this treatment under a like theoretical way. You sort of have this theory of why it should work and then you do the therapy and then they feel a lot better. The patient itself, they have less pain, they're moving better, they're feeling better and it kind of just confirms your hypothesis. And did you see a bit of that like as you were treating these patients and kind of going on this theoretical... hypothesis that trigger points existed, and then you do your therapy and people would have resounding successes. Wouldn't that, did that help confirm your bias initially, or what were your ideas around that? We tell a lot of stories to ourselves and to our patients in this field. The same kind of stuff happens again and again, but we tell different stories about it at different times. And there's kind of this interesting phenomenon that it doesn't really matter what stories we tell about what we're doing and what it's supposedly, what effect it's supposedly having on the body. The results are kind of the same. Happy patients who feel somewhat better for a bit. And lasting, profound and lasting relief is relatively rare. But lots of people feel somewhat better for a while. And there's a lot of customer satisfaction, which is different from feeling better. And they tend to overlap the Venn diagram of, you know, actually feeling better. And being a satisfied customer, it's a lot of overlap there. It's hard to separate them. So that's an interesting phenomenon. And yeah, I saw, I mean, I had a ton of clinical experiences that superficially they seem to confirm what I believed. What I think is going on here must be right because look at these results. The most important thing that so many practitioners miss is what are the patients saying, the ones who don't come back? What are they saying? And particularly as the publisher of painscience.com, I have access to a lot of dissatisfied customers. I have heard from an awful lot of people over the years who weren't so happy and have pretty strong complaints about their experiences trying to recover from their running injuries with the help of a physiotherapist or a massage therapist. People don't... typically tell their therapist when they're not happy, but they tell me, I get a lot of this in my inbox. And so a lot of my earliest skepticism was seeing that disconnect. And, and then of course, also realizing I probably have patients like this too, who, you know, the ones who didn't come back, the story they tell, uh, would not confirm what I believe. That was one of the early chinks in the armor of my confidence. And I was already pretty deliberately humble and trying really hard not to drink my own Kool-Aid. So it wasn't too hard to start thinking, hmm, maybe I'm not doing what I think I'm doing. Maybe this isn't what I think it is. But yeah, there's a, I mean, I had just a buttload of clinical experiences that seemed like perfect examples of miracle cures with the power of trigger point therapy. I also had a number of personal experiences that felt a lot like that. And it wasn't, you know, I think it was probably about 2014. So four years after clinical practice, I wrote an article about my doubts. And the way that I introduced it was by saying I've, I got a lot of great anecdotes. about trigger point therapy, but I no longer trust them. I no longer trust what I thought they meant because there are just so many ways that we can misunderstand our own experiences in therapy and our own as patients and practitioners either way. Yeah, I quickly learned that exactly what you say, the ones that don't come back, they're the ones that you need to be You kind of want to know their story. You kind of want to know their particular outcome and what they're thinking, but you know, they don't come back. See, it's very hard to contact them again. But I also, the same way that you said. The ones that do come back that aren't that satisfied, they still want to be polite and they kind of say, yeah, I'm kind of getting better. And I quickly learned that. And I like had to really sit them down and say, you let me know if you're not getting better because we need to know if what we're doing is working. So I want a really honest opinion. And then that answer would dramatically change. And so, you know, I'm not really feeling much better. And, you know, it's, it, people just want to be. They. don't want to stir up a fuss. They kind of just want to be polite and nice and agreeable. And that's what I'm glad that you pointed that. There's actually a word for that. I can't remember it right now, unfortunately. That'd be better material if I could remember it. But there's actually a word for the way that people want to please healthcare practitioners and say what they, what they want to be true and what they hope will, please the authority figure. And I've done exactly the same thing as you have, try to encourage people to be honest. And it's, I've always found it, amusing, kind of heartwarming, how there'd often be a little bit of resistance at first. You know, like they wouldn't quite be honest at first and you'd encourage them again. And then it would come out. There'd be the sudden flood of, well, actually, now that you, now that you really encouraged me to be honest, yeah, I'm kind of still limping a lot. I still can't run more than 3K. It was always struck me as kind of interesting. how strongly you had to encourage people to be honest about it before they actually would. Before you ask another question, can I jump in here? I want to say just a basic thing about trigger points that we should have gotten in earlier, but better late than never, which is just that we're dealing with the phenomenon of sore spots here. Trigger points... are, that's just the name or the label for the common phenomenon of sore spots, aching sore spots, which is totally a thing, regardless of the explanation for it. So when people talk about trigger points and trigger point therapy, it's, you know, that topic is fraught with the great weight of people's ideas about What is that? What's going on? How do you explain those sore spots? But literally nobody, not even the most skeptical of skeptics, questions that there's a phenomenon of sore spots. We get sore spots. And so just wanted to get that in there. Should have said it earlier. And I'm glad you said it, because that was going to be my next follow-up question, I was going to say like around, especially I should have waited. No, I'm glad you checked. Um, because if someone was to say, okay, you have tight fascia here, let me do some release work. Um, this is what we call my fascia release. It's going to free up your shoulder. Um, what would you say? Why, what makes you question that? that benefit exists? Is it just the fact that no one can physically create that breakup of tissue? Or is it too short lived? What's your what's your pushback against that theory? Against tight fascia as an explanation for a sore shoulder? If someone said, no matter where in the body, like, okay, if the therapist said, Oh, you have this really tight fashion, let's do some release work. And you say, well, that's only theoretical in terms of its benefits. Um, why are you saying that it doesn't work or it's that theory doesn't exist? Sure. And let me distinguish between facial, uh, therapy and, uh, trigger point therapy. There's some confusing overlap there. Uh, having a lot of sore spots. that are presumed to be trigger points is called myofascial pain syndrome. That's the sort of official label for that. And so that's got fascia in the term, but this is actually quite different from the concept of fascial therapy. Facial therapy is much more all about the fascia, whereas trigger point therapy is much more all about the muscle and what it's supposedly doing. Although many, many people now understand that we're not entirely sure what causes those sore spots and whether or not it's really muscle. So fascial therapy, that's manual therapy massage that is focused on trying to stretch and pull on the sheets of connective tissue that wrap everything in our bodies. that's basically our gristle. It is literally the same stuff as gristle in steak. It's connective tissue. So the idea that this would be helpful to pull on your gristle comes almost entirely from one source back in the last century when I was learning this stuff. And the main idea, the big idea, was that fascia can get distorted. Facial distortions was what it was originally called. And the facial distortion model became not the only but the main rationale for tugging on fascia. And particularly in the early days of fascial therapy, it was very fashionable to pull really hard. on the connective tissue to pull extremely hard on it. And you'd have to, to do anything to it because it's incredibly tough stuff. So the basic pushback against this, right, fascia, fascial therapy is super trendy and has been now, it's probably transcending trend now because it's, it's been popular for probably at least I think we could go with quarter century now. It's the main reason to push back against it is that the premise has never been validated. We have absolutely no evidence that fascia gets distorted. And even if it did, it's extremely unlikely that we can do anything about it. Basically, it's an imaginary pathology. The idea that something is wrong with your fascia that needs to be worked out by someone's hands is flawed at basically every level. Despite the fact that, you know, a ton of fascial science has been done, it is largely spurious and specious and has nothing to do with clinical reality. almost all of my work on this topic has focused on the fact that there's lots of interesting physiology, but it's all basic physiology, basic science that does not have any clear clinical application. So you've got a hypothetical, I would say imaginary problem with the fascia, and hypothetical, I would say imaginary ability to affect the imaginary problem. So that's, I just did the whole fashion speech there. I just, I just went for it. That's the fashion speech basically. But this is quite different. There's, I mean, there's overlap with the trigger point therapy thing, but it is different in important ways. This episode is sponsored by the Run Smarter app. This includes all my free and paid content, along with housing the patron exclusive podcast episodes. You can download this free app by searching Run Smarter app in your app directory and start scrolling through past podcast episodes, blogs and videos. You'll find categories like injury prevention, running misconceptions, strength and performance, and of course, injury specific information. You've already learned a lot listening to the podcast. Why not kick it up one more gear through the run smarter app. How about Gratston techniques and therapy? Have you done much research into that? Because I never heard that term Gratston technique until this podcast Graston. Yeah. Until the, the technique itself got, um, Well, until first of all, the podcast became quite popular, I started getting a fair few US and North American listeners, and then they would reach out to me and be like, what do you think of this? Like, I've had this done. And then I'd start seeing US clients that say, Oh, yeah, in the past, I had this, and the grass and stuff always came up. And from what I can tell, it seems to just be a soft tissue release technique. I'm curious to hear your thoughts on if you've looked at it in the past, if you've done some research and that sort of stuff. What are your thoughts? Sure. Yeah. And the, the technique you've named is that's a branded modality. An American chiropractor started that. Uh, the generic concept is, um, scraping tool massage or tool, tool assisted massage. And for those of you who are not initiated, the tools are impressive. They look wicked. They look mean. And they kind of are. It's like a surgeon kit. Yeah, there's very expensive versions of these tools are sold and they can be quite beautiful as physical artifacts, very impressive looking, Chrome. tools that look like they could take your head off and they just about do. Some practitioners of tool assisted massage are very brutal. And there's plenty of superficial tissue damage after some of these treatments. Other practitioners would argue against doing it that intensely. There's not actually a lot of connection with fascial therapy. Plenty of tool assisted massage. has been rationalized using fascia. But originally, it was pretty much a pure provocation therapy. And provocation therapies are, these are what I call, this is kind of a loose group of therapies that all have one principle in common, which is you gotta break some eggs to make an omelet. You've gotta piss tissue off. to provoke it into a more vigorous healing response. And there are certain precedents for this in biology, but basically it's kind of a wild guess that abusing tissue is somehow going to result in making it heal better. And that was the original idea. And if you examine a lot of the early claims, it's all, it's all just, you know, really typical pseudoscientific stuff, just, just physiological BS, just people, you know, therapists guessing about, you know, how they think their technique might work and, uh, and it's all very muddled and variable over the years and there's no coherent or consistent story about how that is supposed to help people. And yet it remains extremely popular, probably mostly because patients love stuff that's intense and makes a big splash, and makes it seem more worthwhile. basically the, you know, the principle that it's no pain, no gain. And, and, and boy, you get plenty of pain from to assisted massage and you get, and you get plenty of pain from really intense facial therapy and you get plenty of pain from really digging into your trigger points. Uh, and you'll notice as you study this stuff, this is a common theme that again and again. It's really intense stuff that gets the attention. And then sort of paradoxically, there's this almost reactionary class of therapies that go to the other extreme, and they're all about being really subtle. And that's the magic, is that it seems like I'm doing nothing, but I am. Right? So you get both extremes. You get, you know it's good. You know I'm doing something important to you because I'm a healthcare professional and I would never cause you this much pain for no reason. So here's a lot of sensation for you. And then the opposite extreme of I'm a tired old therapist, too exhausted to do anything intense, so I'm going to do subtle therapy instead. As the creator of pain science.com. You're talking, we've talked, we've kind of touched on a little bit trigger point release, my fashion release. Um, people seem to feel better afterwards. You know, you talked about that, that satisfaction that people get. Um, perhaps they were in pain, they lay down, they have these techniques done, they stand up, they feel significantly better. How long that lasts, you know, you said maybe short lived, but what a lot of listeners are probably asking like, why is it beneficial if you're saying that it's pseudoscience and you say it's all theoretical, then why do I feel better? Yeah. Um, this is the question I was the most looking forward to answering. It's challenging. And I think that I've got an unusual angle on it. My role on this topic, especially with trigger point therapy, is that I am a very advanced fence sitter. I am stuck between the skeptical position on trigger points and the credulous position on trigger points, to a degree that often surprises some of my most skeptical fans. So the first answer to the question, you know, why do people feel better? Why are they satisfied? Is because it's possible that trigger point therapy works. It's, it might actually be doing something. And just because we don't know what trigger points are, doesn't mean that poking them doesn't occasionally help. And I have had a number of profound experiences that despite the fact that I don't entirely trust my own perceptions and judgment are pretty hard to explain. Unless I decide that, yeah, maybe trigger point therapy actually does something to muscles or to my nervous system or whatever. And the thing about trigger point therapy that I find so fascinating is that more than any other therapy I can think of. It exists in a weird limbo between legitimate, legitimately interesting therapy that's based on science and quackery at the other extreme. It is nowhere, I really want to make this clear, trigger point therapy is full of sketchy ideas, but is nowhere near as bad. as a whole bunch of other popular and prevalent quackeries. It's nowhere near as bad. And the people who cooked up trigger point therapy in the first place were doctors who had some pretty decent scientific thinking and attitudes, were well aware that it was all hypothetical. frequently acknowledged that, constantly called for more research, they knew that they were speculating in a way that you do not see with a lot of the really rank pseudoscience. So my position. is that the controversy about trigger point therapy is a legitimate ongoing controversy. Some skeptics believe that the topic should be closed. I think that is premature, based, if nothing else, on the fact that the phenomenon, the clinical phenomenon of sore spots, is real. people have that experience all the time. It's ubiquitous, it's clinically relevant, these sore spots are routinely associated with the injuries that we get, with the problems that we have. It should remain an open discussion and an ongoing discussion for that reason if no other. But I also just think that it's simply not a finished topic. The science is half-baked, which is good news and bad news. It's tragic and ridiculous that it's only half-baked after this many years. But that is the unfortunate reality of mescalous skeletal medicine today. It is surprisingly primitive. All kinds of things that are considered mainstream have not actually been studied all that well. It isn't really surprising that it hasn't. been studied enough, it isn't surprising that it's half-baked. And it is half-baked. There is some legitimately interesting science there. So this is how I sit on the fence, in a way that drives people on either side of the fence nuts. Everybody wants me to come to their side of the fence. And they're always pulling on me from both sides for years now. And I just refuse. I'm staying up here. I'm staying on the fence on this one until I see a clear and compelling reason to get off the fence. So, that's my very long answer. The first part, my very long answer to the question, what's going on? Why are people satisfied? Well, maybe something happens. Maybe there is an actual active ingredient. But there's a whole bunch of other stuff going on in these therapeutic interactions. that can account for a lot of relief and a lot of satisfaction. And I suspect that that's mainly what you were asking about, yeah? Yes. Yeah, the non-specific effects. Because when you're talking about the this, but when you're discussing it, part of me thinks of, okay, there's obviously going to be some placebo effect, if not all placebo, because of the... the interaction with a therapist, the fact of being in pain and like, oh, this hurts, but this is gonna get me better. The beliefs that they have around it. You're never gonna really know until you have a double-blinded, like, you know, control or. You know, you have one that has trigger points done, one that has this complete control or blinded control, which you can't have in physical therapy. You can't have a group that thinks they're getting trigger point, but actually doesn't get trigger points. It's very hard to conduct that sort of study, which is probably why it's so hard to why you're sitting on the fence, because it's so hard to come up with an actual answer because people get better, but we're not sure of the mechanisms behind it. And As a, when I was studying physio back when we graduated, we learned about, um, electro modalities, which were like therapeutic ultrasound and those sort of um, devices that you plug into a wall, you know, you, you strap your electrodes onto the muscle and it sends some sort of frequencies to help healing. That's very easy to conduct a study and have like a placebo and a, um, you know, a blinded study and they have some sound that's not effective. Laser therapy, I love laser therapy for that, because there's nothing easier to create a sham for. And that's been done, you know, tests where there's, you know, the control group gets a laser therapy device that just literally doesn't do anything. It's literally just a red light, and the patient has absolutely no way of knowing whether that's a laser or just a red LED. And that's kind of the ultimate example of that. And as a result of that, we no longer use those because we, you know, emerging evidence has shown it's not effective. So we don't use it anymore, but it's very hard when, when it comes to manual therapy treatments to know, okay, how much is placebo, how much is not because of the pure nature that you can't separate the two. And when I was, you know, when I treat people have massage techniques, they feel a lot better, you know, sometimes it can, it confirms the biases of the therapist as well. more confident with their techniques and their the effects and their guarantees or promises start to become a little bit more solidified and they develop more prestige and they get better recommendations which then increases that placebo effect they start to you know develop a bit more of an aura about what they can deliver and that all just contributes to that placebo effect. Oh yeah we're kind of on a grants with that like Any sort of pushback or any sort of a grants with it? I don't know about pushbacks, but we can get, we can get more granular. I mean, when you, you know, when you ask what's going on, why are people feeling better if it's not, you know, if these things don't actually work. If so many of them don't them, why are patients happy? Uh, placebo is kind of the. elephant in the room, right? Like, you assume, you ask me that question, you pretty much assume the answer is going to come back, well, there's a bunch of placebo. But let's get a little more specific. And the problem with placebo is that it's one tiny little word that refers to a whole bunch of stuff. And some of that stuff is kind of important and interesting. And some of it... is not. So it pays to get a little more specific. So for instance, therapeutic alliance is a very specific phenomenon that occurs and is particularly potent and prominent in relationships with massage therapists, chiropractors, physiotherapists, the manual therapists, and alternative health care professionals in general because they spend more time with you. And what a therapeutic alliance is, is basically the more trust, collaborations, sympathy, empathy, intimacy there is in a relationship with a healthcare professional, the happier the patient is. And that can translate into real, like genuine optimism. Feeling like you've got, feeling like a healthcare provider is on your team. That's a big deal. Like that makes a difference to people. It's even if we don't make any reference to the physiology of what's wrong with them. You know, say you've got runner's knee, maybe anterior knee pain, patellofemoral pain, perhaps. Without any reference to what this, what does therapeutic alliance do to patellofemoral pain? Eh, even if it's nothing, it's still huge. It's still a big deal. for someone who's been grinding through two years of losing their hobby, to meet with a provider and feel like they get it and to have that connection and feel like, okay, this one is a serious ally. That's a big deal psychologically. And think about how powerful touch is for enhancing therapeutic alliance. Sometimes I thought that really all massage therapy is just... It's the therapeutic alliance profession on steroids because the touch is an incredibly potent way to enhance the collaboration and the sense of connection and the trust. But it gets better because touch, and now we see where things get weird with placebo. Um, one thing that placebo is, is expectation effect. It's a psychological effect of thinking that you're going to get a benefit from something. And we know that all kinds of things increase expectations. Um, with weird examples, famous examples in the world of placebo research, like, you know, the fact that different colors of pills make a difference. Take a red pill, it's more potent, delivers more placebo. Imagine how much touch enhances expectation. If you can rub someone and get your thumb on a spot that feels to them like it's profound, like that's a big deal, imagine what that does to the expectation of what that therapy is going to do. It's incredibly potent. That goes beyond what any pill can do, what a sugar pill can do. There's, I call it a sensation enhanced placebo. And I have a hunch that sensation enhanced placebos are the product for most manual therapy. That when you get right down to it, it's all about delivering a sensation that helps to tell the story of what is being done for the patient. And... It's really good at increasing expectations. Hmm. Yep. And then increasing expectations increases their satisfaction with Jen, like increases the likelihood of a positive effect. Yep. Hugely. And, and we have no idea how much, but it's gotta be a lot. Um, and there's more for sure. There's counter stimulation for instance. And. which I also suspect is just sort of a basic active ingredient in a lot of therapy. Counterstimulation is the idea that basically you can only feel so much at once. And there's a bunch of hard science in here, and we could get really dorky about it, but the basic idea is that sensations, just like they can enhance a placebo, they can also compete with pain, essentially drowning it out, at least temporarily. And there's probably ways to optimize therapy for that effect. And that optimization has probably occurred as a natural part of the evolution of the manual therapies over the years. Basically, therapists figuring out what gives the best counter stimulation. And we don't know how much patient relief and satisfaction is accounted for by this, but probably a fair chunk. It's probably a pretty good slice of the pie chart. And I would guess again, that just like there's lots of therapy that seems to be all about enhancing expectation effects with sensation, we're also optimizing for counter stimulation without even realizing it. Can I ask, because I have written down the question of like, when would these sort of treatments, these hands-on manual therapies be beneficial or like what's your recommendation of if someone or when someone should get these therapies? I have kind of my take and I wanted you to have just like impart your wisdom or your opinion on my particular philosophy because you talked about the Venn diagram, like the satisfaction of someone, what their expectations are and you know, they may get a placebo effect or some sort of benefits and it's usually short lived in most cases. You've got that one side, but then what overlaps is them actually getting better long-term benefits you know reducing the likelihood of If returning like that sort of thing the crossover between the two If someone comes in and they're expecting to have massage and expecting to have some sort of release What I would usually do is start with that and lead into that and sort of, you know, offer them what they would like. So trigger point release, massage, and as if they feel better, great, but come back and what we do is slowly over time. tend to go towards that other circle that other getting better. So maybe after two or three sessions, kind of 50 is starting to get them to educate about the injury, start doing some rehabilitation work, start to strengthen the area, start to modify their, their loading outside of their, their daily life starting to do what's what research has shown is good long-term benefits and sort of just slowly heading towards that direction and getting the best of both worlds. They're better initially for the short term while they're having these manual therapies done. They're satisfied, but then just slowly heading them in the right direction towards actually getting better. Would you agree with that? Because a lot of runners here are like, okay, you're telling us all this stuff, all this pseudo science, what do we actually do? What should we do about it when we're in pain? Do you have any opinions on that? Would you agree with that? Yeah, I mean, the number one job is to build therapeutic alliance and you can't do a very good job of that if your first reaction, you know, to what your patient wants is, well, that's bullshit. It's not going to go very well. If someone comes in and says, I, you know, I've, I've done a lot, I've seen a lot of therapists and I really kind of think maybe my issue is trigger points. I get this really nasty sore spot and I kind of, I got a strong craving for someone to work on that. Maybe with needles. at least and maybe something sharper can you do that for me you can't respond to that by saying that's garbage I'm not doing that they're just gonna walk out and it's completely legitimate as experimental therapy with informed consent, in my opinion. And I don't think everything is. For instance, I don't think that we should ever deliver homeopathy as a legitimately experimental therapy. Some things are just too far out in left field. But as an official fence-sitter on the topic of trigger point therapy, I'm pretty comfortable with the idea of saying to the patient, yeah, OK. do that. We don't really know exactly how that works or if it does, but it does seem to help people sometimes, so let's give it a try. And I have no problem with that at all. And then of course, yeah, you can, as time goes on, you can segue into, you know, the trigger point therapy can be the gateway drug to other approaches to the problem, uh, build therapeutic alliance and some satisfaction in the short term by, you know, giving the patient exactly what they want, uh, within reason, right? There are, there are limits and, you know, a good example of that would be, uh, if me in 2009 and said, you know, I hear you're really great with the trigger point therapy and I really want brutal, brutal trigger point therapy. I would have said, nope. And here's why. I was the gentle therapist and I treated a lot of refugees from extremely, from you could almost say abused patients and from refugees from abusive therapy. So that was not my cup of tea. And I think that there are, you know, there are real reasons to refuse to do excessively intense trigger point therapy because there's too great a risk of, of injury of making things worse. And so I do draw lines, but in general, I'm willing to, yeah, I'm absolutely willing to endorse an experimental therapy because it's all we've got really. You know, the, there's not. It's not like there's really hard evidence-based options to graduate to. Almost everything done for injured athletes is experimental. There's very little that isn't. So, and I suppose taking control back to the listeners, back to the runners who might be injured. All this topic around, you know, maybe it's pseudoscience, maybe it's all theoretical. You know, you should probably still do it if you find benefit from it, especially if you've had an injury in the past and manual therapy has been effective for you. Don't listen to this episode and think you shouldn't do it. It's still very valid for you to get those therapies done because it reduces your symptoms, but where I have my problem is just purely relying on. the manual therapy that might just be short-term. And you're just like constantly going back to that therapy and seeing short-term effects. That's where you need to really carry over into long-term. But what I get really annoyed about is the narratives that get attached to some trigger point therapies or other manual therapies when people are told that they have one leg longer than the other, their glutes aren't firing. I heard someone, one of my clients when saw a manual therapist really upset because they just gave her a long list of imperfections and why she's broken essentially and she was just horrified and really struggled to come to terms with am I getting better like what am I how can I get better if I have all of these um you know ailments And people can really associate those. They can find trigger points and say, Oh, that's because your glutes aren't firing. Oh, that's because your hips are twisted. Oh, that's because you have one shoulder higher, one leg longer. Your face is crooked, all these sorts of things. Um, and the narrative that they attached to it is really detrimental and really, um, it's really detrimental to their recovery. Um, I'm guessing you've seen a lot of these particular narratives and what's associated with them. Um, would you have any particular thoughts on that discussion? Well, I think humility is the antidote to all of this. As a patient, you want to be aware of any therapist who is overly confident about any theory of why you've got a stubborn problem. It's hard to overstate how much nonsense is in this field. And that's the result of decades of independent and freelance therapists trying to sell their services and create modality empires and brands. And it's just a ton of marketing and a ton of, you know, there's so much scientific uncertainty that it's very easy for. people to fill the void with their own ideas and their own answers. So as a patient, you just want to be extremely... you want to reserve judgment a lot and don't believe every story you hear about what is supposedly wrong with you. As a practitioner, you want to do an awful lot of framing your narrative. Probably try to tell less stories. in the first place and when you do tell them, when you do speculate about what's wrong, do it with greater caution. More, you know, more statements like, here's one possibility. There's probably several others I haven't thought of. Cause that's almost always the case. There's particularly in the, in the realm of messy, you know, biochemistry and systemic factors, there's all kinds of stuff that routinely does not get thought about, but absolutely could be relevant. And runners can kind of shift their focus and think that like therapists, like they're running a business, like it is a business. And sometimes some therapists have realized that fear or, you know, creating worry also creates reliance, like on that therapist creates a lot of buy-in and then creates, unfortunately, sometimes this really disempowering treatment approach where you're putting all the control into the therapist, they're in charge of like releasing, realigning and doing all that sort of stuff, which is really unfortunate. You know, you want to have control of your rehab to a certain point and you want to have You know, you want to be empowered. Do you want to say you can do these at home? You can do these particular exercises. You can progress on your own and you can start to forge your own path towards recovery. You've got control of the wheel in this particular instance. I'm just in the backseat showing you the map of what to do. And, but you particularly have that control, um, I think is, you know, where a lot of people need to find themselves. Yeah. And if nothing else, it's just a good antidote to, uh, to being fixed. be suspicious if you feel like you're being repaired. If that's the vibe that you've got glitches that need to be repaired by a therapist, be afraid. That's, you never want that. So whether or not you can fix yourself with self care, whether or not a therapist can tell you what to do at home that is gonna make all the differences, maybe, maybe not, putting your fate in the hands of therapists who believes that they know that you've got glitch X and that they can beat it out with a hard edge tool or a sharp needle or whatever it might be. Apologies for, you know, usually with interviews, I just ask questions and get answers, but I decided just on the back end, just to throw my opinions out there. You can tell that I'm quite, I've got a bit of a, you know. What do you call it? A pet peeve with a lot of these particular approaches, just because I've seen so many people that have just been all the work they've done has been undone by therapists talking about these sort of things. So apologies for that. But as we finish, is there anything in particular, any final takeaways or anything that we haven't talked about that you think the runners might want to have known that we haven't necessarily discussed? Yeah. Why don't we just talk a little bit about what, if any relevance, trigger point therapy might have to common running entries. And so we've established that it's, you know, experimental medicine at best. We've established that it's half baked. Okay, fine. But maybe we've also established maybe according to this guy, there could possibly be something interesting going on. What you want to look for. clinically the description of a trigger point is a spot that is sensitive to pressure that wouldn't normally be. So for instance, if you press... on one side and that spot feels fine, but you press on that spot on the other side and it's super sensitive. That's what I mean about it wouldn't normally be. Obviously, your eye normally quite sensitive. So, you know, it's not abnormal if your eye is sore when you poke it, but it might be abnormal if a spot in your deltoid or in your quads is unusually sensitive to pressure. So the sensitivity to pressure is a major characteristic characteristic is that tends to be associated with aching and sometimes throbbing. And it typically, not exclusively, but typically feels subjectively to you like it's muscle. Also usually not an obvious traumatic origin. So if you pull a muscle, if you strain or tear... muscle that usually comes with what we call an oh shit moment in the business. There's a lot of pain very suddenly, and trigger points don't usually work like that. This seemed as possible. There's a few that fire up to life surprisingly quickly, but usually it's not sudden like a trauma. So if you've got what feels like a sore, aching, sensitive spot in a muscle that isn't normally sore, and if it's near an injury, it might be worth rubbing it. yourself if you can. And I really wanna be clear about this. One of the worst things in trigger point therapy in the world of trigger point therapy is the conceit that we know what to do about this, that we know exactly how to press, poke, rub, scrape, burn, heat, chill, that we know what, we don't know what to do. We don't know what makes these spots better. There is no magic formula. So the way to do it, whether you're doing it on your own or whether you're doing it with the help of a therapist is to start slow, don't beat the hell out of it, and experiment, feel free to experiment and aim for what feels good because ideally, not always, but often and ideally, a little rubbing, a little pressure on one of these sore spots has a... weird, good pain-satisfying quality, and it can be surprisingly profound. I've seen people burst into tears with relief. I've had that experience, where I was absolutely nearly driven mad by a trigger point in my neck one year, and after months of frustration, I found the sweet spot. or rather my wife did, and rubbed just the right spot and just the right way. And I cried. I cried. It was so relieving. And that was the end of that problem. After months of pain, so there's one of my anecdotes, months of agony and frustration was essentially eliminated completely in about 10 minutes, where I had an incredible experience of that weird, good pain. So that's what you can look for. And sometimes some running injuries, that's going to be a difference maker. I think it's a good way to finish there. Cause it's a good way to get that other side of the fence that you're sitting on. Um, yeah, good way to get a nice balanced sort of view. And I think when we focus on, if we finish on the positives, I think that's a pretty good way to finish up an interview. So exactly where I was headed. Yep. Let's give them, let's give them something good. Yeah. Hopefully people have, um, paid attention long enough to get to the end of this interview, um, pain science.com. Everyone go check it out. There's plenty on like obviously pain, different conditions, different manual therapies, and very, if not all science evidence-based focus, so many references and articles in there. So go check it out and Paul, thanks again. once again for coming on and sharing your wisdom. Thanks very much Brody, it was fun. And that concludes another Run Smarter lesson. I hope you walk away from this episode feeling empowered and proud to be a Run Smarter scholar. Because when I think of runners like you who are listening, I think of runners who recognise the power of knowledge, who don't just learn but implement these lessons, who are done with repeating the same injury cycle over and over again, who want to take an educated active role in their rehab, who are looking for evidence-based long-term solutions and will not accept problematic quick fixes. And last but not least, who serve a cause bigger than themselves and pass on the right information to other runners who need it. I look forward to bringing you another episode and helping you on your Run Smarter path.