Lost A Sale, But Initial Phone Consultations — A Big Part Of Brilliant Customer Service
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The Modern Acupuncturist
You studied ancient Chinese medicine, but I'll bet you don't practice it! Contrary to popular belief, our medicine has evolved A LOT over the years. Let's take a brief walk through history and discover the differences between ancient and modern acupuncturists.
Marijuana, Apathy and Chinese Medicine, Part 2
A talented young woman presented herself with emotional mood swings, which included being nervous, anxious and jittery.
The Source-Luo Point Combination
The luo collaterals are part of the acupuncture channel system presented in the Su Wen and the Ling Shu (The Nei Jing). The function and clinical application of the luo mai are primarily presented in chapter 10 of the Ling Shu, however, they are also found in others chapters in the Su Wen and the Ling Shu.
ACA or ICA: Which Best Represents You?
Last June, I was honored to represent Texas ICA members as their representative assemblyman at the ICA Annual Meeting in Kansas City.
Giving Vets the Care They Deserve
The Department of Veterans Affairs (VA) administers the largest integrated health care system in the United States.
Leg-Length Inequality and Pelvic Fixation: A New Approach to the Negative Derifield (Part 2)
As we noted in our previous article, with a positive Derifield (+D), the doctor observes the reactive (shorter) leg in the prone position that becomes longer or "crosses over" in the flexed position.
First Do No Harm?
There's no questioning the frightening nature of breast cancer, which strikes one in eight women in the U.S. – eclipsed only by skin cancer in terms of prevalence.
Our Biggest Challenges to Compete in Wellness Care
In the first article in this four-article series [May 1 DC], I made the case that chiropractors should either embrace offering lifestyle wellness in their practices or face the possibility of losing their place in the wellness care marketplace.
TMF 2015 Scholarships
The Trudy McAlister Foundation (TMF), a nonprofit organization established to support students who are on track to make contributions either to clinical practice and/or to the understanding of the role of Traditional Oriental Medicine, has announced the 2015 scholarship recipients.
How One Little Symbol (#) Gets You More Patients
Are you struggling to get more fans or followers for your acupuncture practice? Or are looking for ways to simply connect with your patients? Or do you just want to know how to keep them engaged (comments, retweeting, liking and sharing)?
Acupuncture and the Pulse
In 1991, I attended a martial arts workshop hosted coincidentally by Sung Baek, a martial artist and the head of his lineage as a Korean trained acupuncturist. I was enamored by the details Sung could attain from the pulse, as told to me by some of his apprentices.
Green Tea Improves Cognitive Function in Elderly Subjects
Publishing their results in the journal Nutrients in May 2014, researchers showed that drinking the equivalent of 2-4 cups of brewed green tea (or bottled tea) daily improved cognitive function or reduced the progression of cognitive dysfunction in elderly subjects.
The Nectar of Plants: Essential Oils and Chinese Medicine
Essential oils are a very hot topic these days, especially with the likes of the Ebola virus and the resurgence of measles lurking in our awareness, but when I first became interested in Chinese medicine, essential oils weren't on the radar screen for acupuncturists.
Spieth Thanks His Chiropractor After Historic Masters Win
Jordan Spieth didn't just capture the hearts of golf enthusiasts worldwide with his record-setting, wire-to-wire victory at the 79th Masters Tournament.
Rethinking Musculoskeletal Pain – A Public Health Perspective
The American Public Health Association (APHA) is the world's oldest and largest association of its kind, founded more than 140 years ago and boasting over 25,000 members.
Use Technology to Gain New Patients and Improve Efficiency
From the smartphone in your pocket to your microwave oven, advancements in technology have made almost every aspect of our lives easier.
We Get Letters & Email
A House Divided? (May 1 issue) provoked significant response from readers. Here are several of the surprisingly similar comments we received.
A Poor Choice for Pain Relief
Acetaminophen is the most popular pain reliever in the U.S., accounting for an estimated 27 billion annual doses as of 2009. With 100,000-plus hospital visits a year by users, it's also the most likely to be taken inappropriately.
What Does Success Mean to You?
Recently, I was asked to speak to young, budding businesswomen about running a successful business — and at first I thought, "Me? You want me to speak to others about success?!"
Breath: The Movement of Oxygen and Energy
I remember with surprising clarity the first time a patient started crying during an acupuncture treatment I was giving. This is now quite a long time ago, back in 1999, when I was a student.
Reducing the Autogenic Inhibition Reflex: Making Weak Muscles Strong
The autogenic inhibition (AI) reflex is a sudden relaxation of a muscle in response to excess tension.
The Year to Make Things Happen
It is hard to believe that the Year of the Ram – 2015 is half over. Time seems to be moving especially fast. This is the year for things to happen for the acupuncture profession.
Calculating Billable Units
I recently learned of an office that was audited based on the number of acupuncture sessions performed in one day. Is there a maximum number of sessions that can be performed in one day?
Acupuncture in the U.K. Today: A Personal View
When asked to write a short piece on the current state of the U.K. acupuncture profession, my first response was to say it has all been relatively quiet.
Green Tea Improves Cognitive Function in Elderly Subjects
Publishing their results in the journal Nutrients, in May 2014, researchers showed that drinking the equivalent of 2 to 4 cups of brewed green tea (or bottled tea) daily improved cognitive function or reduced the progression of cognitive dysfunction in elderly subjects.
March, 2010, Vol. 10, Issue 03
Evaluating Neurological Symptoms
By Whitney Lowe, LMT
In massage therapy, the tendency is to focus on the role of muscles in pain or injury, sometimes to the exclusion of other soft tissues. Nerves are one of these often forgotten tissues, yet they play a critical role in many pain complaints. Neglecting these tissues can lead to inadequate treatment and the development of chronic pain conditions.
With all the work we perform on soft tissues throughout the body, the absence of knowledge of nerve-tissue disorders is serious. Massage can be an exceptional treatment approach for numerous nerve pathologies because soft-tissue therapy can successfully address nerve compression and tension disorders. Effective treatment of these disorders must begin with accurate evaluation of the client's primary problem. When performed effectively, simple manual examination is one of the most effective tools for evaluating nerve system function.
One might be inclined to think evaluation of nerve-tissue disorders should be left to primary care professionals who have access to MRI, EMG and nerve-conduction testing. However, while high-tech diagnostic studies are effective in certain circumstances, they are not always accurate. For example, median nerve compression does not always show up in nerve-conduction tests for carpal tunnel syndrome.1,2 While no single testing method is always correct, manual neurological examination has a high degree of reliability and should always be a part of a comprehensive evaluation.3,4
Structure, Function and Pathology
The motor versus sensory fiber make-up of peripheral nerves is an important characteristic to note when evaluating neurological symptoms. Most major nerve pathologies affect the peripheral nerves. Peripheral nerves have a dorsal root that carries sensory information and a ventral root that carries motor signals (See Figure 1). The nerve roots blend together shortly after leaving the spinal cord, converging to create the major trunks of the peripheral nerves. These nerves then course through the upper and lower extremities as well as other regions of the body. Most peripheral nerves carry both motor and sensory fibers, but a few carry one or the other almost exclusively.
Compression pathologies are the most common type of nerve injury. Compression can occur anywhere along the length of the nerve from the nerve root all the way to the distal end of the nerve. Pressure on a nerve root is called a radiculopathy. Examples include herniated intervertebral discs, spinal tumors, bone spurs and spinal stenosis, which is a narrowing of the intervertebral foramen where the nerve root exits the spine (See Figure 2).
When pressure is applied to a nerve further along its length in the upper or lower extremity, it is called a peripheral neuropathy. Common examples of peripheral neuropathies include carpal tunnel, thoracic outlet and piriformis syndromes. In a peripheral neuropathy, the nerve can be compressed by muscle, fibrous bands, bone, tendon, local inflammation or other factors. Treatment focuses on reducing compression on the affected nerve, so the practitioner must distinguish where that adverse compression is occurring.
Evaluating for the location and type of nerve pathology is necessary for selecting the most appropriate treatment strategies. Evaluation seeks detailed information on the client's symptoms. Acquire as much detailed information from the client as possible through the history and physical evaluation.
Most of the large peripheral nerves carry both motor and sensory fibers, which have different symptom patterns. Consequently, when there is damage to the nerve, there may be motor and sensory symptoms. However, some nerves carry a much larger percentage of either motor or sensory fibers. In these cases, it is more common to see one type of symptom pattern than another.
For example, if the piriformis muscle is entrapping the posterior femoral cutaneous nerve in the gluteal region (See Figure 3), symptoms are most likely to be pain or paresthesia in the posterior thigh because this nerve is predominantly a sensory nerve innervating the posterior thigh. If the piriformis is compressing the superior gluteal nerve, the most common symptom is weakness in the hip abductor muscles because the superior gluteal nerve is mostly a motor nerve supplying the hip abductor muscles.
The most common sensory symptoms from nerve compression are pain, paresthesia (pins and needles), numbness, burning or electrical-type sensations. Sensory symptoms from nerve compression usually are felt distal to the site of compression. There are exceptions to this guideline, but it generally holds true.
The symptom pattern for compression on a nerve root usually is different from compression on a peripheral nerve. This distinction has important ramifications for treatment. When pressure is applied to a nerve root, the symptoms might be felt anywhere within a specific dermatome. A dermatome is an area of skin supplied by a single nerve root. Figure 4 shows the C8 dermatome, which is the area of skin supplied by fibers that originate from the C8 nerve root (between the C7 and T1 vertebrae). Dermatome maps such as the one in Figure 4 are common in anatomy books. However, these are not absolute, nor is every person exactly the same. There can be slight variations in the dermatome due to anatomical anomalies. In some cases, nerve-root compression symptoms are only felt in a portion of the dermatome, which makes it challenging to pinpoint the problem.
The symptom pattern for compression on a peripheral nerve occurs in regions that overlap the dermatome. Each peripheral nerve supplies sensory innervation to a particular area of skin in the extremity; this is called that nerve's cutaneous innervation. For example, the cutaneous innervation of the ulnar nerve is limited to the ulnar side of the hand as shown in Figure 5. Recognition of nerve symptom patterns requires knowledge of each peripheral nerve's cutaneous innervation or each nerve root's dermatome. Clearly there is overlap between the cutaneous innervation of the ulnar nerve in our example and the C8 dermatome. Such overlap makes clinical analysis more challenging. So, how do you figure out where the symptoms are originating?
The best way to determine the site of compression is through accurate assessment. In general though, if symptoms exist throughout a complete dermatome, then you likely have a nerve root issue (radiculopathy). Choosing tests that further evaluate that nerve root would be the next step. If the symptoms are confined to one nerve's cutaneous innervation, then a peripheral neuropathy is likely. However, because nerve-root compression symptoms can occur in only a portion of the dermatome, further testing would be warranted to rule out nerve-root involvement.
For instance, if a client presented symptoms along the medial side of the arm and forearm extending into the hand, involving the C8 dermatome, it would indicate a C8 nerve-root pathology. If the symptoms were felt only on the ulnar side of the hand, the problem would likely be due to pressure somewhere along the ulnar nerve distal to the nerve root. But, due to dermatome and cutaneous innervation overlap, further testing would be warranted. In addition, further testing would be needed to determine the location of that compression along the path of the ulnar nerve. Treatment could then be directed to the most appropriate location.
When evaluating neurological symptoms, do not assume there is always a mechanical compression or tension problem. Numerous systemic disorders such as multiple sclerosis, myasthenia gravis or diabetes can also produce peripheral neurological symptoms, as could myofascial trigger points from distant muscles. These other pathologies should always be considered as a possibility, and referral is suggested.
Nerve pathologies affect motor function when motor-nerve fibers are involved. The most common symptom from motor-nerve compression is weakness or atrophy in the muscle(s) supplied by the affected nerve. Numerous anatomical references show where motor branches depart from major nerve trunks to supply innervation to muscles. As with sensory symptoms, the affected muscles are distal to the site of compression. Consequently, the more distal the compression site, the fewer muscles will be affected. Figure 6 shows a schematic for compression at two different locations along a nerve and how it affects the muscles innervated by that nerve.
Muscle weakness and atrophy are the most apparent symptoms from motor-nerve compression. However, in some cases pathologies develop from altered biomechanical patterns resulting from muscle weakness induced by nerve injury. Most of our movements involve complex coordination patterns of multiple muscles to accomplish a task. Weakness or atrophy from nerve compression in one of these muscles can cause resultant problems that might not seem related.
Here's an example of motor weakness contributing to a different pathology. The long thoracic nerve innervates the serratus anterior muscle, which is crucial for moving the scapula properly during shoulder abduction. Tightness in the scalene muscles can compress the long thoracic nerve and cause weakness in the serratus anterior muscle. Carrying a backpack, book bag or other heavy item with a shoulder strap could also compress this nerve. When the serratus anterior is weak, the coordination of movement between the scapula and humerus in abduction no longer functions properly and can lead to shoulder impingement syndrome. You might not think of nerve compression as a primary cause in this condition, but muscle weakness from nerve compression is at the root of the problem.
More massage therapists today are working in clinical environments and with clients who have a wide variety of pain and injury conditions. It is crucial that practitioners understand how the symptoms of nerve conditions might present. In some cases, the client should be sent to another health professional for further evaluation, especially when the problem is out of the practitioner's scope of practice or experience level. In other situations, massage can be an extremely important part of the treatment process because few other approaches treat the soft tissues with the degree of specificity of massage therapy. In future columns we'll explore treatment strategies that can be used to address various nerve pathologies.
Any practitioner who wants to address the full gamut of soft-tissue disorders is strongly advised to learn more about function and pathology in the nervous system. Understanding nerve structure and function will aid in treating these conditions. Applying quality clinical reasoning and evaluation skills is part of this process and can greatly improve the outcomes for clients.
Click here for more information about Whitney Lowe, LMT.
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