resourcesABOUT MT AUTHOR GUIDELINES CLASSIFIEDS EDITORIAL CALENDAR MEDIA GUIDE MASSAGE MART SCHOOLS & EDUCATION FEEDBACK
Discovery: Finding Insights and Each Other in Different Disciplines
Recently I've been thinking about all sorts of things which are hidden from our daily direct experience. That general category is what links nearly everything that catches my attention and then demands some kind of investigation.
Low Fat vs. Low Carb & the Power of Protein
A science-based website recently posted a nice summary of 23 randomized, controlled trials from peer-reviewed journals pitting low-carb diets against low-fat diets.
Building Bridges with Discipline
As practitioners of traditional Chinese herbal medicine, our role is to educate patients and medical practitioners about the various safety aspects of our medicine. Medical doctors that embrace Chinese medicine want to collaborate and include Chinese herbal medicine in more aspects of clinical care to support their patients.
Hip Flexor Contractures & LBP in Above-the-Knee Amputations
Patients with above-the-knee amputations (AK or AKA) are particularly prone to developing hip flexor contractures. Not to be confused with muscle tightness, contractures are a permanent shortening of tissues which cause deformity or distortion.
How to Reach Your World With the Chiropractic Message
My latest effort to share chiropractic occurred in mid-May while I was sitting at an introductory parent information night for high schoolers. The IT instructor informed us that each student would be receiving a computer for all their studies.
Parker University Embraces New Era
Change is in the air at Parker University, which recently announced the selection of both a new president and a new consultant for its seminar program.
Sleepless nights, anxiety, mood swings, euphoric energy bursts, obsessive thinking, and a strange feeling in his chest. That is what Matt was experiencing when he first entered my practice. Rather than being concerned, he was loving every minute of it.
Billing Timed Services
Q: I do not always use physical medicine services but in my state I do have a scope of practice that allows me to provide many of these services. I am trying to understand what "direct one-on-one patient contact" means in relation to physical medicine services.
The Need for Standards
ISO-TC-249: You may look at these letters and numbers and wonder what they are and what they might mean. They turn into: International Standards Organization- Technical Committee – 249. There is a global organization called The International Organization for Standardization.
Constructing Our Reality, Part 2
My last article discussed perception and its relationship to the primary channels. Before we get to the channels most commonly used to treat sensory disturbances, the small intestine and triple heater, we should first talk about the bladder channel.
In This Current Age of Anxiety
Anxiety, also referred to angst or hysteria, goes by many names. One, popularized by the sagacious Zhang Zhong Jing, who many practitioners of Chinese Medicine may be familiar with, is known as Restless Zang/Fu disorder.
Prostate Cancer Risk
A large study published in January 2016 in the American Journal of Clinical Nutrition showed that men who are vegans had a 35% lower risk of developing prostate cancer compared to non-vegan men. The study followed more than 26,346 men who are part of the Adventists Health Study-2.
Distal Style Treatment of Neurogenic Pain
Treat locally or distally? This question has frequented my thoughts for the treatment of pain throughout my acupuncture career. Each style has strengths and weaknesses, thus the versatile practitioner would do well to forgo dogmatic adherence to any one style in deference to the needs of the individual patient.
With Low-Back Pain, Sometimes Little Things Matter
Typical treatments for low back pain involve large muscles like the quadratus lumborum, iliopsoas, and piriformis. However, there are situations when a very small muscle, the multifidus, can play a significant role in the diagnosis and treatment of low back muscular or spinal injury.
Transforming Las Vegas
On a warm spring day in Las Vegas, Sonia Kim, clinic front desk staff, is busy preparing for a full day of intern shifts at Wongu Health Center. She greets patients, makes sure documents are properly signed, and lets the interns know that their patients have arrived.
Holistic Skin Care and Modern Technology
Anti-aging is a concept that we hear in reference to skin rejuvenation and growing older on a daily basis. Aging begins as soon as we are born; therefore "pro-aging" is embracing all stages of life gracefully, with vitality, wisdom, joy, and gratitude as the goal.
Billing One-on-One, Direct Patient Contact
This is often misunderstood and leads to trepidation when documenting and subsequently billing timed services.
Keeping Malpractice Allegations at Bay
It has been suggested that in the litigious environment in which we live, the practice of chiropractic should be defensive and practitioners should constantly be watching their backs. An element of defensive practice is a good idea.
News in Brief
NYCC Aggregates Degree Programs in New School; Palmer Chancellor Receives Education Award From ICA; Oklahaven Announces "Have a Heart" Winners.
A Different Way of Looking at It
The way you and your chiropractic colleagues access information has changed over the past decade. According to a recent survey conducted by Dynamic Chiropractic, almost half (48 percent) of DCs read online articles on their personal computer or laptop daily.
Understanding Levels of Evidence
The concept of levels of evidence is a cornerstone of research literacy and a great starting point for understanding basic principles of how research works.
One of the most common trends to see in clinical medical practice and public health is the cycles of health "buzzwords." These come and go depending upon the current cultural zeitgeist. One year, "parasites" are causing all the issues, and the next year it's "candida."
Finger (Pad) Pointing: Repetitive-Use Injury Waiting to Happen
"My wrist and hand hurt. I spend all day working on computers and then I come home and spend more time on a computer, usually playing video games."
A Whole-Body Approach to Chronic Tension Headaches
Nearly every day in our practices, we see patients with chronic headaches that have not responded to traditional treatment. They present in our offices with a feeble hope that "maybe" a chiropractor can help.
Living Well: Lessons From Our Oldest Old
Aging is a significant public health problem, important to chiropractors in practice and important to DCs who teach students training to become chiropractors.
Streamline Your Front Desk
Your front office can be your greatest source of efficiency or it can be a constant bottleneck. Increasing the productivity of this area, while not sacrificing the quality of patient interaction, can be a little tricky. However, with some focused effort and intention, your front desk can keep your practice running smoothly.
March, 2010, Vol. 10, Issue 03
Rib Pain "Can't Get No Respect"
By Erik Dalton, PhD
The legendary comedian Rodney Dangerfield coined the phrase "can't get no respect." After careful consideration, I think the same thing could be said of rib pain. It is amazing how little attention or appreciation rib pain receives in the massage therapy community.
Clients typically blame "between-the-blade" pain on tight muscles. Session after session, the therapist beats on the rhomboids and lower traps, only to amplify the problem. In many cases, a simple functional evaluation leads to the true culprit: fixated ribs and intervertebral joints. Not to say muscles don't play an important role in creating and perpetuating rib misalignment, but the muscle itself usually is not the primary pain generator. Highly innervated joint capsules, spinal ligaments and nerve dura often prove to be the main events (key lesions) responsible for long-term pain and disability.
Hypertonic knots palpated in the lamina groove indicate joint dysfunction and an exquisitely tender iliocostalis muscle at the lateral rib angle tells us the rib is fixated in either internal or external rotation (See Fig. 1). I've found external rib torsions to be more common and symptomatic. Below is an example of a sequence of events leading to development of this condition.
Luke, a marathon cyclist, acquired a bad habit of hyper-extending his head, neck and shoulders during training and racing events (See Fig. 2). He presented with dull and sometimes stabbing shoulder-blade pain particularly after a long ride. Luke confided he'd become a "therapy-junkie" over the past three years and sported bruises along his scapular border to prove it. Seated examination revealed tissue-texture abnormality (palpable knots) in the lamina groove at the T3-4 level on his right side. Although neck hyperextension failed to reproduce his symptoms, chin-tucking did flare sharp scapular pain and also caused bony knots to rotate back against my fingers (See Fig. 3).
It was apparent the T3 vertebra was unable to glide forward on T4 during neck flexion, causing the transverse process of T3 to rotate to the side of the motion-restricted joint (See Fig. 4). Adhesive facets usually are an easy fix in acute cases, but long-term cartilage jamming might lead to tissue degradation, protective muscle splinting and osteoligamentous canal pain.
I opted for greater mechanical advantage and specificity by placing Luke in a lateral Sims position (side-lying with arm behind the back). With thumbs meeting in the lamina groove, a slow sustained pin-and-stretch technique was applied to the T3 transverse process as Luke resumed chin-tucking (See Fig. 5). Soon, the deep fibrotic rotatores, multifidi, intertransversarii and levator costalis began to melt, allowing the T3-4 facets to disengage. When it was no longer possible to feel the T3 transverse process pushing against my thumbs, Luke was asked to repeat the neck-flexion test. Although range of motion and pain during chin-tucking had greatly improved, he still felt a deep ache at the extreme end of neck flexion.
In the presence of a dual fixation (rib and vertebral blockage), the associated rib must be carefully evaluated and treated. It's not uncommon for ribs to lose joint-play due to ongoing mechanical stress (microtrauma). To assess, simply follow the T3 rib out to the iliocostalis muscle attachment at the rib angle (medial scapular border) and palpate for extreme tenderness (See Figure 6). Since Luke had a positive "jump reflex" at the iliocostalis, we were able to confirm the presence of an externally torsioned T3 rib.
Fortunately, treatment for the rib torsion is almost identical to the pin-and-stretch technique above, except the thumb pressure is now applied to the superior border of the rib shaft. As Luke began the chin-tucking motion, I asked him to slightly left rotate his head to increase stretch on the rib. This enhanced the ability of my thumbs to internally rotate the rib shaft back into sequence with the rest of the costal cage. However, the rib torsion was a little more stubborn than the vertebral fixation, and when it did completely release, I could hear some crepitus in the costovertebral and transverse joints. To maintain mobility, he was given home-retraining exercises and advice on repositioning his bicycle seat to decrease head hyperextension.
This technique uses bones as levers to release myospasm in the deep transversospinalis and erector spinae groups. Once vertebral and rib fixations have been properly assessed and corrected, normal tone usually is restored to neighboring paravertebral tissues. Once these articular structures recover normal movement within the kinetic chain, deep-tissue work in the area is painless and enjoyable. However, if this articular stretching routine fails to free the dual fixation (due to chronically degraded cartilages), refer the client to high-velocity thrust.
Another commonly misassessed "between-the-blade" pain generator is termed a dorsal dish. Inaccurate understanding of the biomechanics of this dysfunction frequently causes therapists to escalate the pain and sometimes injure the client. Visual observation and thoracic spine palpation reveal a flat spot (approximately T3 to T7) where there should be a convex curve (See Figure 7). If you have access to a plastic spine, contour it until you've established normal lumbar, thoracic and cervical curves. Then, place the spine prone on a table and notice how the T-spine's gentle convex curve continues through the shoulder blades. Now, with a couple fingers, press down on the T5 transverse processes and observe what happens. If your pressure is equal with both fingers, the facet joints will approximate each other causing the intervertebral joints to close bilaterally.
Therapists unfamiliar with the Laws of Spinal Motion commonly dig on the bony knots lying deep to the thick layer of paravertebral tissue, thinking they're releasing trigger points or muscle adhesions. Unfortunately, placing downward pressure on already chronically locked joints really hyperexcites joint mechanoreceptors. Prolonged over-approximation of joint surfaces compacts and, in time, degrades the articular cartilage. Tissue damage might stimulate an inflammatory response that hyperexcites the sensitive chemoreceptors. When mechanoreceptors and chemoreceptors "gang-up" and bombard the neuronal pool with continual noxious stimuli, pain-delivering nociceptors fast track the information to the thalamus, gray matter and other cortical centers. The brain usually responds by locking down the area with protective myospasm. Session after session, the therapist digs on the fibrotic knots until the client finally terminates therapy and moves on in search of someone who can help break their pain-spasm-pain cycle.
Fixing the Flat Spot
Since we're dealing with joints that won't open, examination and treatment follow the same side-lying T3-4 protocol discussed in Luke's case, with two exceptions.
When evaluating the dysfunction, begin spinal-groove palpation one segment below the flat spot and proceed headward with client in flexed position performing chin-tucks. So, if your client has a T3 to T7 dorsal dish, begin at T8 and move up segment by segment, assessing and correcting all vertebra and rib problems on the client's right side. Then, roll them over and perform the identical routine on the opposite side.
Once normal vertebral/rib motion is restored, deep-tissue techniques must be performed with the client prone. Standing on the client's right side, reach across and place extended fingers in the lamina groove so you can hook and scoop the spinalis, longissimus and paravertebral fascia medial to lateral. Ida Rolf used to say, "Dig a hole to allow the spine a place to come back to." After you dig the "guy wires" out of the groove and restore left-sided paravertebral muscle extensibility, walk to the other side and repeat the procedure. Once spinal compression and buckling are removed and extension is restored to the dorsal dish, it's time to share a simple home-retraining exercise.
My favorite (of many) is still the "wall press." With the client standing away from the wall, arms extended, ask for a deep inhalation effort and chin to chest flexion maneuvers. To help neurologically reprogram thoracic extensibility, simply tap with a finger at the T5 spinous process as the client inhales and chin tucks. Engaging the respiratory diaphragm helps expand the costal cage front-to-back and side-to-side. This inhalation movement (respiratory enhancer) activates the scalene, which pull up the top two ribs, the pectoralis minor which helps lift ribs 3-5 and the serratus anterior and posterior, which provides a little "bucket-handle" movement through the lower costal cage.
Pain manifests if a rib loses the ability to properly coordinate movement with the rest of the ribs and spine as part of a functional unit. This would be similar to a rowing team where one oarsman uses his oar out of sequence with the group. Altered rib function can cause difficulty breathing, restricted shoulder movement, referred pain to other areas, and reactive muscle guarding.
Additionally, misaligned ribs can pinch intercostals nerves, sending excruciating pain through the length of the rib and, occasionally, the chest wall (the old heart attack scare). Since rib dysfunction is frequently misassessed and, therefore, improperly treated, do your clients a favor and incorporate some spinal biomechanic principles and articular stretching routines into your toolbox of touch.
Click here for previous articles by Erik Dalton, PhD.
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