Lost A Sale, But Initial Phone Consultations — A Big Part Of Brilliant Customer Service
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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.
Online Marketing Basics: Website Creation
The various online marketing options make it a challenge, especially when all you want to do is help your patients feel better. With such a broad topic, I'm going to share some basics you should know about website creation.
ASA Ready to Impact Profession
The American Society of Acupuncturists (ASA) is a 501(c)6 (pending), not-for-profit collaboration among state based, acupuncturist professional associations.
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.
Healing Trauma: Cultivating Resilience and Presence Through Mindfulness, Part 1
All humans, by the very nature of being human, will experience moments of trauma and suffering. What, then, makes the difference in how the individual who experiences trauma, suffering, and spiritual loss reacts to such experiences?
What to do When Today Sucks
Have you ever had one of those days when nothing went the way it should have? The patient with migraines got worse instead of better from a treatment similar to one you've effectively used on him before.
It's Time to Wake Up
It is time for this profession to wake up and tell someone about the healing benefits of acupuncture. This is the time for Asian Medicine. Its popularity, growth and unusual acceptance is nothing short of amazing.
Fish Oil: A Key Component to Positive Clinical Outcomes
Patients seem to be presenting with more complex problems, and many are responding to care more slowly or have completely unexpected results. Why?
Acupuncture Treatment of Trauma in the Canine
From 1972 until 1976, John Ottaviano and I were treating dogs at five different veterinary clinics in the Los Angeles county area. Usually, we were at a clinic for seven to eight hours.
Relationship Marketing: A Modern Approach
Remember when you used to get real letters in the mail? Not the automated type, but the real deal, hand written with a personal message just because someone was thinking about you? You know what I'm talking about.
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.
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!
The Ethics of Herbal Prescribing
While teaching ethics classes, I often encounter licensed acupuncturists who are surprised that our use of herbs and supplements has a specific section in the material. It is often an aspect within ethics that clinicians don't think of in practice.
Learning the Transformative Language of the Channel System: The Sinew Channels
The Chinese medical classics describe the energetic terrain of the body in much detail. The acupuncture channel systems, as presented in the Ling Shu illustrate the various expressions our qi energy can take.
Teaching Qi Gong to Children
Many of us have come to embrace Qi Gong or Tai Chi practice as a regular part of our lives. Qi Gong has been a stabilizing factor in my life for the last twenty years.
Healing the Core: AWB Nepal Earthquake Relief Project
With almost 9,000 people killed during the earthquakes in April and May, another 23,000 suffering injuries, hundreds of thousands left homeless when entire villages collapsed, and many sacred sites destroyed, no one in this country of approximately 28 million has been left untouched by the disaster.
Exercise Recommendations for Healthy Aging
Aging is inevitable, but how you age is not. Common physical signs of aging include decreased muscle mass, decreased muscular power, increased body fat, and decreased aerobic (lung) capacity.
An Unexpected Superfood: All About Eggs
About 40 years ago, excessive dietary cholesterol was labeled a public health concern. Specifically, it was thought that there was a causal link between consumption of cholesterol-laden foods and increased risk of heart disease.
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.
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.
Preaching to the Choir: How to Extend Our Reach Beyond the CAM Community
Professional conferences offer unique opportunities to network, be exposed to cutting-edge innovators, share your interests and work, and be inspired.
Integrative Sports Medicine
One of the most rewarding and challenging clinical scenarios is the treatment of athletes.
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.
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.
Patient Retention Techniques
When talking about techniques to grow your business, we tend to focus on the "large" aspect of the patient base, that is, on strategies to attract new patients. However, it is important to remember that "loyal" is equally, if not more, important.
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.
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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