resourcesABOUT MT AUTHOR GUIDELINES CLASSIFIEDS EDITORIAL CALENDAR MEDIA GUIDE MASSAGE MART SCHOOLS & EDUCATION FEEDBACK
Know Your Research: Tips for Evaluating Literature Reviews
Clinical and experimental studies are not the only types of published research we might encounter as we look for evidence to inform our practices. One of the most useful types is the literature review, which summarizes a group of studies.
What's New in the NCCIH Strategic Plan
The NIH National Center for Complementary and Integrative Health (NCCIH) released its draft strategic plan 2016-2021 for public comment in early spring of 2016.
Don't Ignore the Lower Half of the Pelvis (Part 1)
When your patient complains of lower back or pelvic pain, but your usual treatments are not getting the job done, what do you examine and treat? You may be missing important structures in the lower half of the pelvis.
Guidelines for the Use of Modifier -52
Modifier -52 identifies that a service or procedure has been partially reduced or eliminated at the physician's discretion. This is to indicate the basic service described by the procedure code has been performed, but not all aspects of the service have been performed.
Chiropractic in the Eyes of the Public: 2nd Gallup-Palmer Poll
The second Gallup / Palmer College poll has been completed, yielding significant additional data regarding Americans' experiences with and perceptions of chiropractic care.
Traditional Chinese Herbal Medicine in Taiwan Hospitals
This spring, a team of Western medical doctors and TCM practitioners from Cleveland Clinic traveled to Taiwan to visit Kaiser Pharmaceutical Co. (KP), and China Medical University (CMU), Taiwan's leading integrative medicine hospital.
The National Institutes of Health (NIH) lists more than 80 common autoimmune diseases including asthma, Crohn's disease, Guillain-Barré syndrome, multiple sclerosis, myasthenia gravis, psoriasis, rheumatoid arthritis, and lupus.
The Professional and Practice Benefits of Political Activism
Welcome to election season, a vital part of our American culture. Every two years, without fail, we are bombarded with TV, print materials and phone messages seeking our vote.
Work Stress and Musculoskeletal Health: Do Your Patients Get the Connection?
Most people underestimate the impact their job has on their health, especially if that job isn't particularly physically demanding. Big mistake.
Overuse Injuries in Young Athletes (Part 1)
More than 45 million children ages 6-18 participate in some form of organized athletics, and 75 percent of American families with school-aged children have at least one child participating in organized sports.
Illuminating the Hidden, Freeing the Source
Amongst the Primary Channels, from a classical point of view, the small intestine is perhaps the most important channel to understand. It is one of the least used acupuncture channels in modern acupuncture, yet it within it can be found a wealth of theories from the Ling Shu.
Time to Fight for Your Medicare Right
I have heard a lot of noise and a lot of debate about what is going on with Medicare. As an ACA delegate, I often get asked: 'What is the ACA even doing?'
MPA Media Wins More Publishing Awards
The American Society of Business Publication Editors (ASBPE) has honored Dynamic Chiropractic with a national award and two regional awards for editorial excellence, and sister publication DC Practice Insights with two regional awards for graphic design excellence.
Less Time Than Required
Q: When is it appropriate to use a modifier -52? Can I use it for a timed service when I do less than the time required by the code?
Adventures with the Pericardium
My previous column on the San Jiao deserves equal time for SJ's loving partner, the pericardium. I nicknamed SJ the travel meridian – but pericardium can also play a crucial role in air travel.
Let's Talk About Biceps Injuries at the Elbow
While most muscles cross over only one joint, the biceps crosses two joints: the elbow and the shoulder. Injuries to the lower biceps cause considerable elbow pain. Here's how to assess and treat an injury to this area conservatively.
What are the Meridians?
The meridian and collateral system (jing luo, hereinafter referred to as "Meridians") is comprised of the main meridian channels (jing mai) and the collateral vessels (luo mai). Jing takes from meaning of the Chinese word pathway (also jing) and are the main branches of the system.
Lessons from Functional Neurology
Chiropractic neurology, also known as clinical neuroscience or functional neurology, is moving the chiropractic profession forward by leaps and bounds.
Are Probiotics Doing More Harm Than Good?
Considerable controversy exists concerning the efficacy of probiotic supplements. Very few human studies show any real positive impact on the microbiome or health. The "promise" of probiotics is based on the few animal studies that suggest a positive effect.
A Study of Relationships
Sa-Ahm's five element acupuncture method is known to be one of the most effective acupuncture techniques in Korea because it gives an instant response at the time of treatment and has a high success rate in resolving chronic problems.
Analyzing Acupuncture Case Studies
Confirm the answer quickly by the elimination method. Take this case study as an example. After two treatments for back pain, a patient presents for a third session complaining of rapid breathing and wheezing that is made worse during cold weather.
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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