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Can Acupuncture Treat Knee Pain?
Recently, an article in the Journal of the American Medical Association concluded that, "neither laser nor needle acupuncture conferred benefit over sham for pain or function" among older chronic knee pain patients.
Online Marketing Basics: Google Ranking, Part 1
We all know there is so much opportunity with online marketing. And, let's face it, if you don't have a presence online with a website and social media, you are probably not where you want to be.
The Source-Luo Point Combination, Part 3
Dr. Nguyen Nghi (NVN) was born in Vietnam and is one of the most important scholars, writers, teachers and practitioners of modern time. Many of his theories and applications are the source of modern teachers from Europe and the United States.
Technology Meets Practice: Chiropractic Every Day
About a year ago, I had an interesting conversation with a DC who made house calls. When I asked why, she was quick to explain she learns much more about her patients when she sees them at home than she could ever observe in the office.
Making Public Health a Chiropractic Priority
As highlighted in this edition's News in Brief, Rand Baird, DC, MPH, FICA, FICC, editor and occasional author of our long-running column, "Chiropractic in the American Public Health Association", was recognized by the organization recently for 40 years of membership.
Colon Health and TCM
I still remember many years ago, the loud "Yuck" from my wife at the time when we were together watching the Chinese movie "Last Emperor."
Exploring and Learning from the Gift of Life
I'm grateful to have had the opportunity to teach cadaver dissection classes and workshops with Stephen Cina at the New England School of Acupuncture over the past seven years, first through the Sports Medicine Acupuncture Program and later as a NESA elective course.
The Roots of TCM in Depression Treatment
In traditional Chinese medicine, there is historical precedent for the treatment of so-called "Shen" (Heart-Mind) disorder, or disorder/dysregulation of the spirit, which is also considered as distinct but not separate from the cognitive function of the brain.
Lower-Extremity Overuse Injuries: Primer on Causes and Corrections
From ankle sprains to stress fractures, shin splints to plantar fasciitis, the research is clear: These common overuse injuries of the lower extremities – among dozens of others – may be related to abnormal foot function in your patients.
Melatonin: A Promising Natural Agent in the Prevention of ALS
A number of years ago, experimental studies suggested melatonin could block key steps in the development of Alzheimer's disease, primarily by acting as a brain antioxidant and inhibiting the build-up of beta-amyloid plaque in the brain.
The Art of Creating a Healing Space
I always advise my graduates to examine their group practice or treatment rooms with fresh eyes after they leave my CE workshops. I tell them, "Ask yourselves - is your space qi filled, welcoming and healing? Or is it cold and clinical?"
Data: The New Frontier in Health Care
Your practice is empowered with the data you need to improve patient health, run a more efficient (read: profitable) practice, get paid in timely fashion and help show the efficacy of chiropractic on the national stage in the midst of sweeping changes in health care!
ICD-10 Is Not Scary (and Not About Billing)
In my 13 years of consulting with doctors on billing and coding matters, ICD-10 has aroused the biggest combination of misguided fear and ignorance I can remember.
Adding Microneedling to Your Clinic for Results and Profit
Microneedling has taken the beauty world by storm over the last 10 years. Under the names dermaroller, microneedling or skin needling you will see these treatments listed in the services of nearly every fashionable beauty salon and day spa in the country.
A War You Can Help Patients Win
The average American consumes approximately 60 percent of calories from sugar, flour and refined oils. A donut is a good example of a so-called "food" that represents these calorie sources.
Merger Creates New Model of Care
Two San Francisco powerhouses of holistic healing, the American College of Traditional Chinese Medicine (ACTCM) and California Institute of Integral Studies (CIIS), are merging. Together they are building a visionary approach to applied integral health.
The Integrative Medicine Puzzle: Putting the Pieces Together
The conversation is changing in the broader healthcare community with patients actually moving the discussion toward more integrative topics. Patients today want to know their options.
Abdominal Acupuncture for Eye Healing: The Sacred Turtle and Ba Gua Map
Our ideas about western medicine have shifted in recent decades, while the public is asking more from health care providers.
Medicine as Metaphor
The practice of medicine is both an art and a science. We study and learn the system so that when the time comes to apply it, there is a greater possibility of successfully helping others.
Treating LBP in Golfers: Beyond Basic Assessment
The drive to master the most efficient swing demands a tremendous amount from the lower back. Maintaining stability in a flexed posture, supporting torso rotation and repetitively supporting the golf swing all put the lower back in a vulnerable position.
Treat Every Patient as an Athlete
Frontal-plane movement pattern dysfunction can set the stage for musculoskeletal injury. Frontal-plane stabilization is essential during the normal activities of daily living: think single-leg stance and gait cycle.
News in Brief
Support of F4CP Continues With Latest Donations; Walter Reed Honors Dr. William Morgan; Recognizing 40 Years of Public-Health Activism; Allstate Decision Reversed.
Aetna Updates 97140 Policy
In a development the Association of New Jersey Chiropractors is calling "a resounding victory for chiropractors nationwide," Aetna Insurance Company has updated its national reimbursement policy regarding 97140 (manual therapy), reaching an agreement two years after the association filed a declaratory judgment suit in federal court against the insurer.
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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