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Let the Patient Tell Their Story
Often when a patient presents with an injury, they want to tell their story. People by nature like to talk about themselves, particularly when they're worried about their health.
The Science Behind Happiness
Are you happy right now? Whether yes or no, there are a myriad of reasons why you feel that way. A whole academic discipline has developed to find out what causes or obstructs happiness, and how to amplify it.
The Truth About Herbs
I appreciate the effort and research put into the article written in the June issue of Acupuncture Today regarding pesticides and Chinese herbs.
A Glimpse Into China's Top Brain Hospital
The sounds of the city pass through the open window are overwhelming the microphone - car horns, construction machinery - and then there's the family at the adjacent bed talking loudly on cell phones, yet you can still hear the faint beep of our patients monitoring equipment.
History of Animal Acupuncture: Part II
In Part I of this article, I had gone back to 1969 and tried to describe the atmosphere and events of that year that engulfed many of the younger generation, some who were all the core members of the National Acupuncture Association.
MPA Media Wins Seven Publishing Awards
MPA Media, publisher of Acupuncture Today, among other titles, has been recognized for editorial and design excellence with an unprecendented seven publishing awards by the ASBPE, the nation's largest organization for business-to-business publications.
When Big Pharma Meets Chinese Medicine
Earlier this year, Bayer made a media splash with their decision to buy the Dihon Pharmaceutical Group Co., a Chinese TCM manufacturer.
News in Brief
NBCE Launches Computer-Based Testing Era; California Chiropractors Get Expanded DOT Exam Privileges; New Jeff Hays Documentary.
Improving Our Political Effectiveness
The November 2014 elections are right around the corner; members of Congress, governors and state legislators are all running. Now is a good time to talk frankly about our overall political involvement.
Thoracolumbar Syndrome: The Great Mimic
The thoracolumbar junction is a common area of joint dysfunction. The most obvious cause is dysfunctional breathing or lack of diaphragmatic breathing. Treating this breathing problem will ultimately be the long-term cure for the syndrome.
If You Get a Request for Records, Respond!
In our previous two articles, we discussed two of the main reasons for denial when chiropractic records are reviewed by Medicare contractors.
Get Ready For AOM Day
This year, AOM Day 2014 falls on Friday, (October 24th). This is a great opportunity to make your AOM Day celebration or event even bigger by extending it throughout the weekend!
Medicalization and Mindfulness
The past several years have seen a veritable explosion of research on mindfulness. Research abstracts we've published in each issue of Health Insights Today under the heading "Mind-Body News" have increasingly reported on studies about mindfulness interventions.
Thoughts to Live By
When speaking to your patients about their health make sure to ponder the following points and have them assess if they are making themselves even more sick by the thoughts they have about life. Are these some of the traits and thoughts that your patients might have?
A Healthy Dose of Failure is Vital to Your Success
As an acupuncturist I tend to see people after they have already suffered for years and "tried everything." They are so desperate for some relief that they want to know everything about how to get better, right now.
Rethinking GMO: Less Panic, More Context
Some of you may have noticed that after writing parts 1 and 2 of “Genetic Modification of Organisms for Human Consumption” a while back [Nov. 15, 2013 and Jan. 1, 2014 issues], part 3 never appeared.
The Problem With Prolonged Sitting
We need to constantly talk to our patients about spending less time sitting and about what can go wrong with poor sitting postures. The fact is we sit too long in repetitive malpositions.
The Spirit of the Point
After receiving a large amount of positive feedback on my San Zhen Protocols series, I have decided to focus this article on some relevant clinical aspects of acupuncture therapy prior to moving on to San Zhen Protocols III.
Uncle Sam Needs You
Scrutiny into the Department of Veterans Affairs (DVA) continues to grow after efforts to reform the DVA by the former Secretary of Veterans Affairs, Eric Shinseki, were deemed "a stunning period of dysfunction" by Senate Minority Leader Mitch McConnell (R-Ky.).
Help Secure Our Future by Sharing It
The National Board of Chiropractic Examiners (NBCE) conducts one of the most comprehensive surveys of the U.S. chiropractic profession every 4-5 years.
A Commonly Missed Spinal Fixation: The Upper Lumbar Spine (Part 1)
When we think of lower back pain, we tend to think in terms of the lower lumbar spine and the SI joint. These joints and their discs are obviously important. However, we tend to miss fixations that occur just above – in the upper lumbar spine. Three questions come to mind: 1) Why is the upper lumbar spine so important? 2) Why do we miss the fixations here? 3) How can we adjust them?
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 more information about Erik Dalton, PhD.
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