Occasionally, I get questions about  the effectiveness of Active Release Techinques (ART) or what it is, so I thought I would look into this form of treatment to understand it a little better.  I spent some time researching ART on various websites including the ART provider’s information and the ART website.  

The basic idea is that a series of hands on techniques based on massage are used to diagnose and treat pain from muscle and soft tissue tightness. 

From activerelease.com:

“The basic premise is simple, just not easy. Shorten the tissue, apply a contact tension and lengthen the tissue or make it slide relative to the adjacent tissue.  It’s as simple as playing a piano and just as difficult.”

 This treatment idea is similar to “anchor and stretch” or “pin and stretch” techniques commonly used in massage.  This is a more detailed explanation on Aetna’s website under the Experimental and Investigational Interventions section:

 “Active release technique is a patented soft tissue system that treats problems with muscles, tendons, ligaments, fascia and nerves (e.g., headaches, back pain, carpal tunnel syndrome, shin splints, shoulder pain, sciatica, plantar fasciitis, knee problems, and tennis elbow).  These conditions have one important commonality — they often result from injury to over-used muscles.  Each ART session is a combination of examination and treatment.  The ART provider uses his/her hands to evaluate the texture, tightness and movement of muscles, fascia, tendons, ligaments and nerves.  Abnormal tissues are treated by combining precisely directed tension with very specific patient movements.  These treatment protocols – over 500 specific moves – are unique to ART.  They supposedly allow providers to identify and correct the specific problems that are affecting each individual patient.  Active release technique is similar to some massage techniques, albeit more aggressive.” (1)

 The mention of hands on treatment to break up adhesions to restore optimal texture, motion, and function of soft tissue is prevalent in all of the information that I found.  One of the main differences compared to massage/stretching is that a contact point is maintained with the hands while the patient actively moves his/her body to provide longitudinal movement of nerves, ligaments, fascia, and muscles to assist the treatment.

 The list of conditions/injuries that ART can help is too long to list, but it seems to be the majority of issues neuromuscloskeletal.   According to the websites I found, it is more successful, effective, and cost effective than conventional therapies.  The results are mentioned to be more predictable, but no clarification on how they are more predictable.  Although it is not stated outright, it is suggested that you can resume normal physical activity faster after ART. So is this the panacea of treatments?

All of the information I found stated only ART credentialed providers can tell you if ART will work for you.  If ART was based on sound scientific principles why couldn’t anyone with an appropriate anatomical education be able to determine if ART would work?  The active release technique website (an ART provider)  says that their treatments are very different from other soft tissue, bodywork, massage, or other therapy. I think it is interesting that they just left the last option as other therapy.  Are there no ‘other therapies’ that could be slightly similar to ART?

 If you go to activerelease.com the first thing you notice is their logo and then a banner that reads “The Gold Standard of Soft Tissue Treatment.”  Unfortunately, they don’t have anything to support this claim.  A search of PubMed finds several studies on ART, but they are case studies using multiple techniques including ART, and small pilot studies with varying results.  Despite the lack of proof of it’s effectiveness there are thousands of ART providers and there are no shortage of testimonials across the web as to it’s effectiveness.  But just because there is a lack of proof of it’s effectiveness doesn’t mean it does not work.  Based on descriptions of the techniques and YouTube videos, massage therapists and PT’s have been using similar techniques with good results for years.

Based on the information I found it seems like ART is just clever marketing of new techniques to do what we already are doing (or at least should be doing).  These techniques may be more effective, but the problem is that nobody has properly researched the techniques to see if they are more or less effective.  So what is your opinion? Is this just clever marketing or truly a different set of skills we should have for our patients?

1) Aetna Clinical Policy Bulletin Chiropractic Services. http://www.aetna.com/cpb/medical/data/100_199/0107.html .  Accessed 10/5/11.

Barefoot and natural running advocates tell us to observe children run barefoot so that we many learn to run “naturally” in order to avoid and manage our own running related injuries. However, such statements are inherently flawed. As physical therapists, we know that children also get injured while running. In fact, recent studies show that there has actually been an increase in the number of children’s running injuries.1 This increase is likely due to the fact that more children are participating in organized sports but rarely receive proper running instruction. In reality, children are different than adults, and they are plagued by their own unique set of risk factors for running related injuries.
Because children’s bodies are still growing and have not fully developed, they are susceptible to running injuries that most adult runners never encounter. Thus, the incidence and type of running injuries children suffer from are very different than the injuries we see in adults.2
One major difference between adults and children, for example, is that approximately 1/3 of children’s running injuries are due to falls. Younger children with little running experience are particularly prone to traumatic fall injuries when running.3 However, running related injuries due to a specific trauma are actually rare for adults,4 and those that do occur are most often the result of an isolated incident.
Children’s increased risk for falling is not just simply because their bodies are different but it is also attributed to their limited proprioception and body awareness. In fact, children’s brains function differently than adults’ brains. One review demonstrated that adults approach the same physical task very differently than children do, and adults are better able to mentally coordinate, anticipate, adapt, and orient their bodies in a more fluid manner than children when ambulating.5
Adults have more proprioception and body control because they have more mature, developed sensorimotor systems and access higher level brain functions to perform physical activities when compared to children. Before puberty, children primarily show activity in subcortical regions of their brains during physical tasks, while adults primarily rely on the more sophisticated cortical regions of the brain to direct and integrate movements for the same task. 5,6
A lack of body awareness and “clumsiness” are the most likely reasons that children, specifically small children, are prone to fall injuries while running. And while children are at a greater risk for falling during running than adults, they are by no means exempt from the non-traumatic running injuries adults face. They are still susceptible to the strains, sprains, and tendonitis’ to which adult runners are prone.2,3
So arguments that adults should try to run “naturally” like children in order to manage and treat injuries are invalid. Children’s bodies are different, the way they control movement is different, and their injuries are different too. There is nothing “natural” about an adult trying to run like a child. In fact, as physical therapists, we should not watch children run so that we can learn about natural running. In contrast, we need to observe children run in order to recognize and identify the signs and symptoms of running injury in the children themselves and help them progress into healthy running as they mature.
Certain observations are critical to correctly identifying a running injury. Children are not always forthcoming about pain or difficulty when running, especially when it’s part of an activity or sport they love. Like adult runners, children too can have a great fear of losing the ability to run, so we need to carefully observe for signs of injury and ask specific questions in order to recognize the red flags.
While the child runs, look for pain that alters running stride. Note antalgic gait, unsymmetrical strides, aberrant movement patterns, and excessive twisting, rotating, or lateral movement. All of these signs can be indicative of injury.
We must also observe the child when they are not running and identify pain that interferes with everyday activities. Signs of an injury will likely include limping, avoidance, and often an inability to negotiate stairs properly. With more severe injuries, children will often verbalize complaints about pain at rest or pain that interferes with sleep. Furthermore, always keep in mind, that taking medication for pain and inflammation due to running automatically indicates a running injury. Under no circumstances should a child be taking any medication, injected or oral, in order to run on painful injury. 7
Proper rehabilitation must address aberrant movement patterns and teach the child balance, proprioception, and body control. Rehabilitation exercises should be implemented so that the child can achieve several running specific goals, to include: maintaining stability over an aligned foot, controlling dynamics of arm swing to achieve a balanced body, progressively controlling weightbearing through the first ray, and maintaining stable posture with a straight kick back.8 An example of a running specific balance exercise and its progression is given in Figure 1. Children should practice and learn these running balance exercises both barefoot and shod; however, protective training shoes should be worn when they initially return to actual running. Running without proper protection can be dangerous for an injured child.
As a profession, we currently have no consensus whether or not going barefoot or wearing barefoot-simulated shoes reduces nontraumatic running injuries. However, recent reports have shown that they do actually increase the risk for serious running injures.9 An injured runner is already at risk for developing further injury. Thus, having an injured patient run without protection will only put them at greater risk to suffer a more complex injury and completely lose the ability to run. Additionally, children are required to wear shoes in PE class, USA track & field events, cross country, and almost all organized sports that require running. Therefore, children must learn to run in shoes. An injured child should initially use a more protective shoe to return to running and may “shoe down” for performance once they have progressed and recovered from injury. Return to run programs should be tailored to meet each child’s activity specific goals for participation.
Barefoot, young children are not “natural” runners; like adults, they too are at risk for running injuries. As physical therapists, we need to observe them and guide them, not for our own benefit but for theirs. We need to be able to recognize the signs and symptoms of injury, help them develop proprioception and body control, and progress them through a proper return to run program.
We teach our children who participate in track & field to run in performance enhancing track spikes. What can be more unnatural than that?

Figure 1: Single leg running: Have the patient balance on one leg and hold upright posture so that, from each side, the ear, shoulder, hip, knee, and ankle maintain a straight plumb line. From the front, the stance foot should be aligned forward directly under the knee and hip. The unweighted knee should be flexed into a straight kick back position. Weight should remain evenly balanced through the foot, the hips should remain level, and the trunk should remain stable. As the patient holds this posture, they maintain their elbows flexed at 90o and reciprocally swing their arms forward and backward in the sagittal plane at the level of the hips in order to balance their body as they would during running. Arm swing motion should occur at the glenohumeral joint- not the trunk. Have them maintain stability for several seconds while performing dynamic arm swing, and avoid lateral hip movement, trunk twisting, falling forward, and arms crossing midline. They should then switch legs, and repeat several times. This running-specific exercise should be practiced barefoot, shod, and on uneven surfaces as the child progresses.

References:

1. Soprano JV, Fuchs SM. Common overuse injuries in the pediatric and adolescent athlete. Clin Pediatr Emerg Med. 2007;8:7–14.
2. Seto CK, Statuta SM, Solari IL. Pediatric Running Injuries. Clin Sports Med. 2010;29:499-511.
3. Mehl AJ, Nelson NG, McKenzie LB. Running-related injuries in school-age children and adolescents treated in emergency departments from 1994 through 2007. Clin Pediatr. 2011;50(2):126-132.
4. O’Connor FG, Wilder RP. Textbook of Running Medicine. New York, NY: McGraw-Hill Professional Publishing; 2001:4.
5. Quatman-Yates CC, Quatman CE, Meszaros AJ, Paterno MV, Hewett TE. A systematic review of sensorimotor function during adolescence: a developmental stage of increased motor awkwardness? Br J Sports Med. 2011. Published Online.
6. Thomas KM, Hunt RH, Vizueta N, Sommer T, Durston S, Yang Y, Worden MS. Evidence of developmental differences in implicit sequence learning: an fMRI study of children and adults. Journal of Cognitive Neuroscience. 2004;16(8);1339-1351.
7. Wilk B, Nau S, Valero B. Physical therapy management of running injuries using evidence based functional approach. J Am Med Athletic Assoc. 2009;22:5-6.
8. Wilk B, Muniz A. An Evidence-based Approach to the Orthopaedic Physical Therapy Management of Functional Running Injuries. APTA Combined Sections Meeting. Hilton Riverside Conference Center, New Orleans, LA. 10 Feb 2011. Conference Presentation.
9. Giuliani J, Masini B, Alitz C, Owens BD. Barefoot-simulating footwear associated with metatarsal stress injury in 2 runners. Orthopedics. 2011;34(7):320-3.

As consumers we are using social networks to manage just about every aspect of our
daily lives. From the way we rate and purchase items to the way we plan our
next vacation, we depend on our networks to help us make decisions. We share
our lives with others. We seek connection and access. We find value in our
networks; they enrich us, expand our knowledge and extend our relationships. So
how are we using these same networks to guide our health and our most important
health decisions?

Today patients are participating actively in all aspects of personal health
information. Patients are searching for the best knowledge and recommendations
to empower themselves for a healthier life. Many turn to social network groups
for support, reassurance and specific health news. A recent article entitled, Healthcare
Performance Management in the Era of “Twitter” discusses how social
networks improve patient care by connecting healthcare providers and consumers

[1]. According to the article, 61% of Americans are turning to the Internet for
health information, particularly for consumer reviews and comments.
“Internet-enabled communities of patients and providers are coming together to
communicate and collaborate,” explains Brian Klepper, Ph.D., Healthcare Analyst
and Consultant, Health 2.0 Advisors. “In so doing, these virtual communities
are reshaping the way healthcare is delivered and consumed,” he says. Further,
a recent Pew Internet Study suggests, “The Internet has changed people’s
relationship with information. Our data consistently show that doctors, nurses
and other health professionals continue to be the first choice for most people
with health concerns, but online resources, including advice from peers, are a
significant source of health information in the U.S”

[2].

[3]. Other healthcare connector sites include PatientsLikeMe.com where patients can
compare care options and outcomes with specialized groups [4]. Sermo and
Doximity are web and mobile based social networking platforms where physicians
can share insights about medicine and specific cases.  

Social media has created new possibilities for patient and provider communication.
These tools allow healthcare communities to connect and form support networks
that were unimaginable a short time ago. Such networks, in turn, create new
platforms for healthcare providers to listen to their patients and provide them
with resources to be more accountable. Networks empower recovery and increase
the potential for better health outcomes. The power of a network depends on its
activity and participation. Historically, healthcare professionals have been
slow to adopt. In 2011, that rate of adoption has accelerated; we may finally
be at a tipping point.

Resources

 1.            Cooper,
L.F. and S. Aluise (2010) Healthcare
Performance Management in the Era of “Twitter”: Harnessing the Social
Networking Phenomenon, www.hpminstitute.org/Era_of_Twitter.

2.            Fox, S. (2011) The
Social Life of Health Information, 2011 Pew Internet, www.pewinternet.org/Reports/2011/Social-Life-of-Health-Info.aspx.

3.            Hanluain, D. (2011) Doctors
Embrace Facebook, Twitter. Mobiledia, www.mobiledia.com/news/82375.html.

4.            Hawn, C., Take two
aspirin and tweet me in the morning: how Twitter, Facebook, and other social
media are reshaping health care. Health Aff (Millwood), 2009. 28(2): p.
361-8.

So how are healthcare providers using social media networks to engage and empower
patients? Medical professionals are experimenting with many types of electronic
tools to help manage health costs and improve the quality of care. Online
social networks offer a unique platform allowing healthcare providers to
connect with patients as a larger population. Providers can make
recommendations for treatment, comment on the latest medical findings and
respond instantly to patient inquiries. At Sarasota Memorial Hospital in
Florida patients “tweet” their doctor when they have questions about their
care. At Chicago’s Rush University Medical Center physicians keep connected
with patients through Facebook so that they are notified of their recovery [3].
During a real-time brain surgery in March 2009, doctors at Detroit’s Henry Ford
Hospital answered questions via “tweets,” broadcasting to more than 1,900
followers

Both can be beneficial, but which is superior with respect to pain relief and dependence on narcotic analgesics? An ice pack or a cryocuff?   A recent article in the Examiner explains….

Running.  For some it is the means to a healthier body.  For others, it is much more than that.  Some runners hit the pavement to stay in shape, improve their heart health, relieve stress or lose weight.  Others look at running as something they “should” do, but they just can’t quite figure out how to get started.  Still others can’t imagine life without running – the act of running is a driving force in their life that provides euphoric happiness. 

No matter what type of runner you are or may hope to be, however, one thing is clear – it is important for runners to know how to avoid injury.       

The good news is that runners no longer need to search for information related to various aspects of running from a variety of sources, nor do they need to worry about whether the information they find is accurate and reliable.  NYSM now has the info runners need, and has packaged it all in one convenient place.  Their new book, titled Running Without Injury, is a collaboration between sports medicine specialist, Dr. Michael Neely, and physical therapist, Krista Simon, with added contributions from a number of physical therapists and staff members of NYSM.  The book is geared to runners at every level, from those just looking to begin a running program to experienced competitive runners, and it provides loads of information that runners can use before, during and after they run.

Running Without Injury is intended to teach runners how to avoid injury, as well as how to improve performance.  It includes a step-by-step guide geared to easing into a running routine, from getting ready to run by first obtaining a proper medical and biomechanical assessment and choosing the right running shoes to proper warm-ups and stretching, cross-training techniques, nutrition and hydration, clothing and other tips that can help runners remain healthy and injury-free.  There is information for experienced runners interested in training for distance events and the book also addresses what to do for minor aches and discomfort that may occur when running so that full-blown injuries are less likely to occur.  In the event that an injury does arise, there is even a section that helps runners deal with the emotional process of dealing with an injury.

Dr. Neely, Krista Simon and the various other contributors from NYSM were able to provide information related to the sport of running from varying perspectives.  For one, they are experienced in the treatment of running injuries and have shared their medical expertise within the book.  NYSM treats a wide variety of running injuries and we understand what causes injuries and how they can best be prevented.  As an added bonus, both Dr. Neely and Krista are avid runners themselves, as are many of the other staff members of NYSM.  They have competed in marathons and other distance events, and they understand the sport of running from a runner’s perspective, enhancing the level of information that they were able to provide to others engaged in the sport.  Through this connection, the book better addresses the psychological aspects of running and the effect running injuries can have on an athlete.

Runners of all levels, as well as anyone interested in considering the sport of running, can obtain a copy of the Running Without Injury book absolutely free!  Simply stop into any of NYSM’s three Manhattan locations to obtain your copy today.  After reading the book, you should be able to lace up your sneakers with more confidence the next time you are ready to hit the ground running!

(If you would like to book shipped to you, please help us out and pay $10.00 for printing, shipping and handling, make a credit card payment here.  In the comments section be sure to include your shipping address, the address associated with your card is NOT saved).