Tuesday, October 20, 2009

Stretching Part 3: Take-Home Points and Conclusion

The controversy over what stretching technique to use, how long one should use the technique, and how frequent should the technique be used is very evident given the information that I have provided in this three part series. The lack of clear cut answers can generally be attributed to lack of quality research available to answer some of the above questions. However, the following major points can be made as a review of the material alluded to in this three part series:

1. the increase in ROM experienced with any stretching protocol is likely due to an increase in tolerance to the discomfort associated with the stretch rather than an actual increase in extensibility of the muscle tissue itself;

2. regular stretching will result in an increase in performance markers such as isometric force production and velocity of contraction but will have no effect on the efficiency/ease of movement

3. acute/pre-exercise stretching does not have a positive effect on performance markers but is associated with an improved running economy/efficiency. Therefore, acute stretching prior to leisure running may be of benefit but is not recommended in advance of performance dependent sporting activities;

4. it appears that a single 30-second stretching bout once a day may be the most effective practice and that periods greater than 30 seconds are no more effective; this however is dependent on the individual who is performing the stretching and serves as a general recommendation. Therefore, adjust the duration of stretching accordingly.

5. in terms of modalities such as ice or heat applied prior to stretch, it does not matter as both appear to improve the outcome of a stretch not by affecting tissue temperature but by adding to the analgesic effect of the stretch;

6. if the main objective of stretching is to prevent injury, then the recommendation would be to eliminate the stretching and increase the warm-up; therefore, it would be a better idea to spend time performing a thorough warm-up, and not so much time stretching prior to activity. However, as mentioned above, it is dependent on the activity that is being performed and the goals of that activity.

7. Finally, due to poor quality research, a recommendation on the optimal stretching technique that would allow for the most efficient increase in ROM is difficult to develop. The focus should be on duration, frequency, and individuality of the stretching protocol rather than a blanket recommendation.

In closing, it is hoped that this three part series has provided some enlightenment on a topic that many trainers/therapists recommend often based on traditional strength and conditioning practices rather than evidenced-based practice. With an increase in research dedicated to the seemingly simple topic of stretching, we will soon have clear cut answers to some of the remaining questions that I have outlined above. For now, if someone asks you about stretching in terms of incorporating it into a general exercise regiment, the one thing you can say with certain is that “it depends.”

If you have any questions or comments on this topic or any other topic related to neuromusculoskeletal health, please feel free to contact me at info@saudeclinic.ca or visit my website at www.saudeclinic.ca

Here's to your saude!

Dr. Henry

Tuesday, July 14, 2009

Stretching Part 2: Can it decrease risk of injury and/or improve performance?

In the May edition of my post, we talked about stretching and its effects on the muscle tissue itself. This edition will focus on the question: does stretching improve performance and thereby reduce the risk of injury?

Let’s begin by clarifying the role that stretching could play in reducing the risk of injury. The argument behind this proposed benefit is that it allows for increased muscle extensibility and decreased muscle stiffness via changes in the visco-elastic properties of muscle tissue. For purposes of a review, visco-elasticity of biological tissue implies that upon holding tissue under tension for a prolonged period of time, the force required to hold that tissue at that length is reduced over time. This implies that a tissue can therefore withstand more tensile force at a specific length without experiencing damage. This has obvious implications for athletic events in terms of reduction in injury and improvement in performance. If an athlete can achieve increased ROM without injury and by using less energy to achieve that range, then theoretically, that athlete’s performance will improve and her/his risk of injury will be reduced. However, as mentioned in May’s post, increases in ROM are achieved via increased stretch tolerance on the part of the subject in the long-term, rather than a change in the mechanical or visco-elastic properties of the muscle (Hollie et al, 2006, Magnusson et al., 1996). Also, in regards to improved performance, it is almost impossible to objectively measure performance during an actual athletic event due to the confounding variables inherently present. However, specific performance related outcome measures have been used in the literature to determine the effect of stretching on performance. Shrier in 2004 performed a review of the literature and found that of the 23 articles that looked at the effect of pre-exercise stretching on isometric force, isokinetic torque, or jumping height, 22 of them showed no benefit of stretching on the specific performance tests analyzed. So, what this means is that stretching technically has little to no effect on performance. But does it have an effect on other aspects of athletics, such as running ability?
Shrier (2004) also reviewed 5 studies on the effect of stretching on running performance. One study specifically looked at running economy and found that stretching had a positive effect improving the efficiency of running. However, the study only included runners with short and/or stiff hip flexors or extensor muscles. Therefore, whether or not stretching is beneficial for those who are fairly flexible in the above mentioned muscle groups remain unanswered. With respect to running speed, four studies were of acceptable quality to qualify for the review, and of those four, two had equivocal results, while the remaining two reported contradictory findings. One study reported beneficial results with dynamic stretching, while the other reported detrimental outcomes to running speed with static stretching. This may imply therefore, that dynamic pre-exercise stretching is beneficial when attempting to improve running speed and that static stretching may limit the ability to achieve optimal running speed.

Results from Shrier (2004) were the exact opposite when the literature on regular stretching was reviewed. What qualifies as “regular” varied between the seven studies that found benefit to stretching. Generally, regular stretching can be considered stretching that is performed at regular frequencies throughout a week period and for a predetermined length of time. This is in contrast to the stretching described above as “acute/pre-exercise” stretching where stretching is only performed before an athletic event or a specific bout of exercise. The evidence suggests that with regular stretching, force production and velocity of contraction both increase, while it had no effect on the economy of motion. As mentioned above, this is in stark contrast to the effects of acute/pre-exercise stretching on performance in which no effect was reported on isometric force production and velocity of contraction, but a positive effect was seen with running economy.

So, what does this all mean? Well, the benefit that you experience from stretching will depend on your specific goals. If your goal is to improve the efficiency of your runs, then acute/pre-exercise stretching performed dynamically may be of more benefit. But if your goal is to improve the amount of force and speed that your muscles can produce at a given length as in most athletic events, then regular bouts of stretching may be of benefit, and you should avoid acute/pre-exercise stretching all together. Now, in terms of injury prevention, the theory remains that with improvement in specific measures of performance, one would ultimately reduce the risk of injury. However, it is important to emphasize that you have to know when to use stretching and what type of stretching to use at that specific instance. This will be topic of Part 3 of this three part series that can be found in the next edition of my blog posts.

Here's to your Saúde!

Dr. Henry


Hollie, F., Simon, D., Harvey, L. A., and Gwinn, T. (2006). Can apparent increases in muscle extensibility with regular stretch be explained by changes in tolerance to stretch? Australian Journal of Physiotherapy 52: 45-50.

Magnusson, S. P., Simonsen, E. B., Aagaard, P., Sorensen, H., and Michael Kjaer, M. (1996). A mechanism for altered flexibility in human skeletal muscle. Journal of Physiology 497(1): 291-298.

Shrier, I. (2004). Does Stretching Improve Performance? A Systematic and Critical Review of the Literature. Clinical Journal of Sports Medicine 14: 267–273.

Monday, June 1, 2009

The future of chiropractic!

Hi everyone!

I apologize for the absence but my computer has been on the mend. Don't worry... I backed it up!! The continuation of the stretching piece is coming but in the interim, here's a story about a project and a fellow chiropractor who is truly inspirational... Dr. Deborah Kopansky-Giles. I first met Dr. Kopansky-Giles at an Ontario Chiropractic Association sponsored event where she reported on the preliminary results of her work at St. Mike's Hospital. It was truly inspirational and an eye opener for me as to the possibilities for the profession. I have attempted to follow in her foot steps on two separate occasions but haven't had much luck. I haven't given up however and am continuing to foster those relationships in hopes that they will develop into similar positions for chiropractic within hospital settings.

Check out the link for the full story! http://www.thestar.com/article/642057

Here's to your Saúde!!

Dr. Henry

Thursday, May 7, 2009

Stretching Part 1: Are you really lengthening muscle?

For years, stretching has been promoted as an integral part of any exercise program because of a reported decrease in risk of injury by improving range of motion (ROM), reduction in pain, reducing stiffness, and increasing overall athletic performance. Many different stretching techniques exist and therefore many different recommendations also exist, some based on scientific literature and others based on traditional strength and conditioning practices. However, new research has challenged these long-held concepts about common stretching programs and it is the hope of these series of articles to clarify some of those concepts and clear up the misconceptions through highlighting some of the new recommendations.

In this first installment, we will reveal what is actually happening during a stretch and how stretching appears to be increasing extensibility of muscle. In the second installment, we will talk about the role that stretching has to play, if any, in reducing the risk of injury and improving athletic performance. In the final installment of this three part series, we will summarize the current literature on the best stretching techniques to use, when to use them, and how frequent stretching is to be performed.

Let’s begin by talking about what happens during a stretch. There is a vast amount of evidence to support that stretching will improve ROM of a joint by allowing the muscles that cross that joint to be more extensible. If you think of a thick elastic band that undergoes repetitive stretching or a prolonged stretch, the elastic band will become less resistant to stretch over time due to the heating effect that occurs to the band with repetitive motion. The theory behind stretching is similar, except instead of elastic bands, we are dealing with living muscle tissue. There is a special property of living tissue that is referred to as viscoelasticity. What this means is that upon holding living tissue under tension for a prolonged period of time, the force required to hold that tissue at that length is reduced over time. This implies that a tissue can therefore withstand more tensile force at a specific length without undergoing damaging changes to the structure of that tissue. So, what this means is that a muscle tissue that is stretched is theoretically able to produce more force at a specific length without causing injury. This has obvious implications for performance. If an athlete is able to produce more force at a greater ROM without undergoing injury, then theoretically they are likely to have greater success than their counterpart who is limited in force production at extremes of ROM. This will be discussed further in the follow-up installments in this three part series.

However, this is not the whole picture. Recent evidence has suggested a neural based reason for the apparent increase in ROM that is seen with stretching. How does the nervous system influence ROM and what is the difference between objective and apparent increases in ROM? Well, all of us have experienced that uncomfortable sensation that is associated with stretching which feels like a numbing pull on muscles. It is not really painful but it is not comfortable either. That sensation is the key to improving apparent ROM. Before we continue, let me define what I mean by apparent and objective ROM. Apparent ROM implies that the joint appears to be traveling through a greater ROM because of nervous system factors, when in fact there is no change in length of the muscle if measured histologically. Objective ROM is when there are histological increases in ROM meaning that the muscle tissue itself has actually become longer. The majority of ROM increase that is experienced during stretching is achieved through apparent increases in ROM. That is that the increase in ROM that is seen with stretching is a function of an analgesic effect that occurs during the stretch. In other words, it hurts less to stretch!! We actually become numb, in a sense, to that uncomfortable sensation associated with stretching, and therefore over time and with repetition, we can take our joints to extremes of ROM.

It is important to note that this effect is subtle and does not mean that if held and pulled to an extreme ROM, a muscle will increase extensibility without causing damage to that muscle or an associated joint! Taking a joint to extreme ranges is always dangerous and should be done under the supervision of a qualified professional, if done at all! Stretching as normal however, has many other proposed benefits that will be discussed in my next two blog post, so please look out for these along with my other monthly installments on neuromusculoskeletal health.

If you have any questions related to this article, or any neuromusculoskeletal related questions, feel free to contact me at info@saudecentre.ca. Also, if you or anyone you know has an injury or musculoskeletal complaint, please feel free to let them know about my services or direct them to my website www.saudeclinic.ca.

Here’s to your Saúde!

Dr. Henry

Wednesday, April 29, 2009

Swine Flu

Hello again,

With the WHO declaring a Phase 4 Pandemic alert (http://www.who.int/csr/disease/avian_influenza/phase/en/index.html), people should get prepared for the possibility of a full blown pandemic. There are simple and effective ways of combating and reducing the risk of contributing to the spreading of the virus and help to contain the disease. Below you can find information on effective means of preventing spread of human swine influenza.

1. Sneeze and cough into your sleeve!!! If you do sneeze/cough into a handkerchief, tissue paper, or your hands, remember to wash your hands thoroughly afterwards. Influenza and the common cold are spread through contact with bodily fluids, most commonly nasal and oral droplets. Check out this link, you'll get the picture... http://www.coughsafe.com/media.html.
2. Frequent hand washing is a must... most effective with soap and water. Disinfectant alcohol based hand sanitizers are also good.
3. If you are feeling ill or if you feel like you're coming down with something, be sure to avoid contact with others, do not go into work, and see your doctor. This way, you'll ensure that you're not infecting other people. Also, if you are feeling fluish, it is wise to wear a mask to avoid human air born transmission of the disease.

For more information and answers to many questions, check out this link... http://www.phac-aspc.gc.ca/alert-alerte/swine-porcine/faq_rg_swine-eng.php#tphp.

Here's to your Saúde!!

Dr. Henry

Tuesday, April 7, 2009

Back pain: Kids get it too!!

Hello again!

The inspiration for this post came from the number of friends of mine who are teachers and I suppose my, what seemed to be, never ending schooling. I was asked back in October to contribute to a community newpaper piece focusing on advise for parents and young students on how to avoid back pain due to heavy back packs. These things sometimes weigh as much as the little guy or girl carrying them!! No wonder their parents bring them in with pain...

Check out the link for the full story: http://www.yorkregion.com/article/82893

Remember, pack it light, wear it right!!

Till next time, here's to your Saúde!

Dr. Henry

Thursday, April 2, 2009

Stretching: The truth! By Dr. Doug Richards...

Hello again!!

Dr. Richards is one of the most influential professors that I encountered while going through 9 years of post-secondary education. He is a legend in the sports medicine world and a mentor to many. I use the foundational information that he presents in this lecture with my patients on a daily basis to help dispel the many myths about stretching!

Please find below his email explaining how to check out his lecture and vote! So please check out his lecture, learn something new about stretching, and vote for him!

Message sent on behalf of Dr. Doug Richards ...

Dear PHE and Varsity Blues alumnae and alumni,

I am writing to ask for your support in this year's TVOntario Best Lecturer contest. I am honoured to have made it to the finals. The winner among the 10 finalists will be decided by viewer voting, as well as by a panel of judges. Viewer votes are critical - I need your support to win!

In past years, finalists from smaller universities have done better, in part because their smaller communities have rallied to vote en masse for their nominees more effectively. With your help, we can show them that U of T has as much school spirit as they have at those schools!

Please help me out with your votes (you can vote as many times as you like :) )! You can even win a 50" flat-screen plasma HDTV by voting!

You can vote for me on-line through this link: www.tvo.org/TVOsites/WebObjects/TvoMicrosite.woa?bivote2009?550_321.

You can view my lecture (on stretching) on-line through this link www.tvo.org/TVO/WebObjects/TVO.woa?video?BL_Lecture_20090308_838185_DougRichards.

Note that "rating" my lecture video is not the same thing as voting in the contest - please vote, too.

Thank you so much for your support.


Dr. Doug Richards
Medical Director, David L. MacIntosh Sport Medicine Clinic
Assistant Professor, Faculty of Physical Education and Health
University of Toronto

Tuesday, March 31, 2009

My new website!

“To your health!” That’s a quote from a trip that I took to Africa two years back. We were in Timbuktu enjoying a gin and tonic after coming in from exploring the Sahara in a nasty sand storm. I heard the same quote but in Portuguese that summer while celebrating my grandmother’s 80th birthday. “A sua saúde!” is what my family and I wished my grandmother as we celebrated a great life. I found this to be a fitting reminder of the importance of maintaining a balanced healthy lifestyle through spiritual reflection, an active lifestyle, and a balanced diet. That was the common thread between all the people that I met on that trip and the inspiration behind Saúde (see http://forvo.com/word/sa%C3%BAde/ for the correct pronunciation of “saúde”).

I would like to invite you to experience Saúde. Please visit my new website to find out more! www.saudeclinic.ca If you know of anyone who has an injury or a chronic complaint, is looking for a second opinion, or is looking to prevent an injury from occuring, please feel free to direct them to my website as well.

Here's to your Saúde!

Wednesday, March 11, 2009

Back it up!!

So I've been a self-employed entrepreneur for 2 years now working on many different health related initiatives and projects and needless to say, I've learned a ton of valuable real life lessons!! Today was another lesson learned... in every instance, BACK UP YOUR STUFF!!! It's happened to all of us... it's late and you're just about finishing what you're working on, or you go to turn on your computer getting ready for a presentation, and smoke begins to come out of the back of the laptop... BRUTAL!! I recently had the unfortunate experience of losing valuable information on a computer at a friend's office despite the fact that there were signs/symptoms of imminent disaster... things slowing down... weird error messages... etc...

So, the lesson for today is:

Step 1: go out and buy an external hard drive from any of the big box stores & USE IT!! Plug in your computer everyday and back it up.
Step 2: sign up for a web-based off-site server back-up service

It's not bullet proof but it at least lowers your risk.

I know... not really health related but if you think about all the stress, anxiety, increase in blood pressure, increase in cortisol (stress hormone), experienced as a result of the experience, it is in fact health related!

Lesson learned... don't let it happen to you!

Keep well,


Sunday, February 22, 2009

My first post....


Welcome to my blog! I never thought that I would actually begin doing this, but after watching my good friend Yuri Elkaim share his passion and knowledge with so many people in such an easy way, I knew I had to give it a shot!

My name is Dr. Henry Candelaria and I have recently taken the dive and entered into business for myself in the opening of Saúde Centre of Physical Rehab and Therapy, a new manual therapy and rehab clinic in Toronto's Little Italy. I love the name... because no one knows how to pronounce it! (see http://forvo.com/word/sa%C3%BAde/ for pronunciation) It's great! It gives me an opportunity to explain the meaning of the word to everyone I encounter. Similar to the French word santé, saúde is the Portuguese word for health commonly used to wish someone well while sharing a drink. I thought it was a fitting name given the neighbourhood in which I was establishing myself (surrounded by great restaurants and lounges), my Portuguese heritage, and my profession.

At Saúde Centre, I strive on facilitating a multidisciplinary rehab approach focusing on functional rehabilitation of musculoskeletal (MSK) injuries. The clinic team is committed to offering the highest quality conventional and non-traditional MSK health services in a way that stresses humanity, compassion, and quality-of-life for our patients. Saúde is distinguished from other rehab centres by providing excellent customer service, and evidence based manual therapy and rehab to the community. We pride ourselves on providing the best in interdisciplinary functional rehab as well as expertise in the best alternative treatments and manual therapy approaches to MSK injuries. We aim to be the first choice for individuals who have experienced an injury, sports related or otherwise, are preparing for surgery, have had surgery, suffer from chronic pain, have experienced a work place or motor vehicle accident (MVA) related injury, or are simply looking to improve their overall MSK health and well-being.

I hope to use this blog as a means of regular contact, sharing new information, updating you on my professional progress, opinions, venting, and updating you on the Saúde project. I hope you will find it informative and intriguing.

If you're in the Toronto area, please feel free to come by and check us out or simply to say hello! If you're not, please check out our website (www.saudeclinic.ca) for more information on what we do, the services we provide, and to meet our team members!

I look forward to meeting you in cyber space or in person.

Keep well.