resourcesABOUT MT AUTHOR GUIDELINES CLASSIFIEDS EDITORIAL CALENDAR MEDIA GUIDE MASSAGE MART SCHOOLS & EDUCATION FEEDBACK
Raditation & Your Smartphone: Is it Worth the Risk?
If radial arteries could talk (and in my experience they can to some extent), they would say, "Step away from the smartphone." At least that is the message I am receiving loud and clear as I feel the pulses of many patients.
New Relationships, Old Trauma: AOM & Other Healing Strategies
Being in love is one the most beautiful and enjoyable experiences. Most of us are willing to pay almost any price to have that experience, and still often find it elusive or fleeting. Navigating the ups and downs of loving relationships are often challenging — even for the most psychologically balanced among us.
Is It Time to Rethink Mental Illness? (Pt. 1)
Invariably, patients will ask their chiropractor about depression or various mental illnesses. Some practitioners will reflexively offer a cervical adjustment, suggest St. John's wort or contemplate a referral to a specialist.
A Daily Strategy for Heavy-Metal Detox
In modern society, we are constantly exposed to heavy metals such as cadmium, lead and mercury. These heavy metals have no essential biochemical roles in our body, and conversely, can cause us a great deal of harm if they build up to toxic levels.
A Major Role in Back Pain: The Multifidus
Back pain affects roughly 80 percent of the population at one time or another and is one of the leading causes of doctor visits.
Bill With Confidence: Learn What to Collect
Q: I am trying to understand what I may collect from my patient when there is insurance. Do I have to accept the amount allowed by the plan or may I collect up to my billed amount? Please note, I am not a member of any insurance plan.
An Unexpected Diagnosis: The Result of Lacking Communication
A couple years ago I had a case that showed me the importance of open communication between health practitioners. We need to show up with less fear, and let go of our judgments so we can do better for the patient.
Why I Quit Doing House Calls
My father was a chiropractor who did house calls, so when I became a DC, I figured doing house calls was part of the job. My March article recalled my experience as a small boy, accompanying my dad while he went to patients' homes to treat them.
Balancing Spring Challenges
As the winter months come to a close and warmer spring weather appears, patients may begin to present with new challenging pattern presentations.
Women's Hormones: A Western & Eastern Perspective
Sometimes it may seem that you require a degree in medicine to understand hormones and how they function.
Give Yourself the Digital Advantage
When you see this article in the print version of this issue and swear you read it already, don't be alarmed: you probably did. That's because by that time, the May issue will have been available online in digital format for three weeks.
News in Brief
ACA Adopts New Governance Model; ACA 2017 Awards; CCA Helps Calif. DCs "Share the Love"; $1 Million to Help Advance the Profession; D'Youville Raises the Bar on Anatomy Education; ErRatum.
Taking the Chiropractic Message to the Press
"There is no better place on earth to have a news event," the National Press Club boasts, and it's easy to understand why: Every year, the 108-year-old Washington, D.C.-based organization hosts countless press conferences on the hottest topics impacting America and often the world.
Universal Design: Principles & Practice
In many respects, universal design serves as the core of ergonomics. It's also a good tool to use when designing a return-to-work program for injured and/or ill patients. Let's take a closer look at universal design and why it should matter to you and your patients.
Clearing Blocks: A Way to Improve Cosmetic Acupuncture
As a Five Element acupuncturist who teaches facial acupuncture classes nationally, I was surprised to learn that one of the basic principles I was taught in school is unfamiliar to most acupuncturists.
Creating Good Business Buzz
What do patients really think about working with you? Rarely do you hear the whole truth. Those who improve may be candid in their gratitude.
An Integrated Approach to Chronic Pain
Findings from a unique Medicaid pilot project in Rhode Island involving high-use Medicaid recipients from two health plans were recently presented to the state's Department of Health, demonstrating stellar outcomes with regard to medication use, ER visits, health care costs and patient satisfaction.
Is the New Medicare Reporting Exemption Right for You?
What you've heard is not a rumor – there will be exemptions for providers of Medicare patients, with no penalties assessed for offices that do not do Quality Payment Program (EHR, PQRS, MACRA and MIPS) reporting.
Eczema & Acupuncture: A Sound Solution (Part 1)
Eczema affects approximately 3.5 percent of the global population and is one of the most common skin complaints seen by dermatologists.
May, 2011, Vol. 11, Issue 05
The True Grit of Muscle Spasm
By Erik Dalton, PhD
Much has been written about loss of flexibility and range of motion due to fascial contractures, trigger points, spasmodic muscles and the like, with less emphasis on the neurology that may be initiating these soft tissue changes.Here are some thoughts on how injuries to joint capsules and spinal ligaments can reflexively spasm neighboring tissues leading to decompensation, altered movement patterns and pain-spasm-pain cycles.
When the brain senses bony instability or ligamentous damage in-and-around the spine, information is collected so split decisions can be made to determine the extent of threat to the individual and what actions (if any) need to be taken. Layering the area with protective myospasm is one such decision. It's the brain's reflexogenic attempt to prevent further insult to the injured tissues. By 'splinting' the area with spasm, the hypercontracted (shortened) muscles, ligaments and fascia effectively reduce painful joint movements. Splinting is a common form of protective guarding clinicians address day-in and day-out... but how does it develop and how should we treat it?
Recently, a chiropractic buddy referred a client named Hank who came in carrying a diagnosis of chronic muscle spasm. During Hank's history-taking, he related a story of a bending/twisting incident that occurred while lifting his toddler out of the back seat of the car. Apparently, this asymmetric spinal loading maneuver resulted in 'stabbing' back pain which almost brought him to his knees. After a few treatments, the chiropractor decided Hank's back was too locked up and needed some deep tissue and stretching work. His treatment plan was to have me 'dig out' the spasm and then he would mobilize the fixated spinal joints.
Observations during gait revealed a lack of smooth cross-patterned movement between Hank's torso and hips and very little "lift" in his antigravity spring systems1. In fact, he wobbled from side-to-side much like John Wayne's Rooster Cogburn character in "True Grit"2 (Fig 1). The chronic low back pain had disrupted Hank's hip abduction firing order pattern forcing him to recruit the ipsilateral QL (instead of gluteus medius) to hip-hike and lift the swing leg. It was obvious that Hank's lumbar spine had been locked with spasm for some time but elbowing the spasm didn't seem to be the answer.
History and Motion-Testing
Hank's back pain history and motion testing results suggested an unstable spine that had not been allowed proper healing time due to overstretching and chiropractic adjustments. The heat emanating from Hank's back indicated an active inflammatory process at work...probably due to articular cartilage derangement and/or spinal ligament damage. When pain and inflammation bombard the central nervous system, joint reflexes are stimulated that can disrupt normal low back myo-mechanics. To test, I asked him to slowly forward bend as I palpated for low back asymmetry. This maneuver intensified Hank's dull, aching pain on the right side at about L4-5. As he reached his end range of trunk flexion, I applied a little overpressure which caused the right L4 transverse process to posteriorly rotated against my palpating thumb suggesting the L4 facets on the right were unable to disengage from L5 (Fig 2). To verify, I had him stand straight and try to right sidebend his torso. Normally, I'd expect the L4 transverse process to left rotate against my thumb during this maneuver, but the joint mechanoreceptors refused to take the joint beyond its painful restrictive barrier by inhibiting the left spinal side-benders...particularly QL (Fig 3). While motion-testing the joints, I noticed lack of tone in Hank's multifidus muscle on the right.
Typically, when palpating deep lamina groove muscles (rotatores, multifidi, intertransversarii, etc.), I expect to feel 'knotty' fibrosis on the side of dysfunction. These are usually the first muscles recruited as the brain's neuromatrix scans and 'maps' the dysfunctional area. If it senses exceptional weakness, it'll stiffen these short-lever muscles to protect an unstable spine (Fig 4). The burning question is this: Does joint blockage or ligamentous damage always result in deep intrinsic muscle hypertonia (fibrosis) or, as in Hank's case, can the tissue sometimes become hypotonic or inhibited? Contrary to what I was taught in Philip Greenman's osteopathic model3, secondary muscle changes in the deep groove muscles from joint blockage do not always result in hypertonicity or spasm. In fact, Dr. Stuart McGill found that when a lumbar facet joint became displaced during a lifting incident, the multifidus on the side of the fixated facets began to atrophy within 24 hours.4 (Fig 5).
Calling in the Subs
When the brain senses weakness or injury in osteoligamentous tissues, it calls for help from middle layer (core) stabilizers such as the QL, psoas, transverse abdominis, etc. Regrettably, this middle layer postural support system is best designed for lumbopelvic bracing to allow global (extrinsic) muscles and fascia to carry out normal movements of daily living...not for facet joint stabilization. Therefore, when the middle layer is recruited to "sub" for fixated facets or damaged spinal ligaments, firing order patterns are skewed, motor recruitment is garbled, and coordinated movement suffers. Bottom line: Prolonged joint damage can set the stage for aberrant posturo-movement patterns which, in time, causes the brain, through the process of sensitization, to re-map and re-learn the dysfunctional movement as normal (neuroplasticity).
Due to our population's general lack of proper core support and our inability (through lack of good functional movement training) to adequately activate the middle layers, many, like Hank, find it hard to "hold on" until ligaments heal, fixated facets are released and myo-mechanics are corrected. Sadly, when the oxygen-burning middle layer muscles run out of gas, the load falls back to the damaged joint capsules, spinal ligaments and articular facets which further intensify the pain-spasm-pain cycle.
Regardless of the reason for loss of joint play, when vertebrae are not free to move, muscles assigned the job of moving them (prime movers) cannot carry out their duties and are substituted by synergistic stabilizers, i.e., the brain sends in the subs when a key player is injured. The final stage of dysfunction occurs when the middle and deep spinal layers both collapse causing the load to shift to global (outer layer) dynamic muscles such as the erectors, obliques and lats. These fast-twitch muscles burn glucose and are designed to provide bursts of energy. Spasm develops when they're forced to act both as movers and stabilizers. As they tire and tighten, the lubricating fluid between fascial bags begins to dehydrate and the facial envelops adhere to neighboring structures often resulting in a big 'wad' of hypertrophied erector spinae tissue that therapists beat on session-after-session.
Once ligaments and joint capsules have healed, manual therapists can help maintain flexibility by elongating cross-linked collagen fibers in the joint capsules and balancing the middle and outer musculo-fascial tissue layers. Myoskeletal articular stretching techniques designed to minimize the accumulation of nociceptive tissue irritants at the injured site help normalize afferent messages to the brain; thus reducing protective muscle guarding around the dysfunctional joint. Once pain-free movement is established, functional movement training effectively restores motor control patterns and allows the brain to reestablish optimal posturo-movement patterns.
Click here for previous articles by Erik Dalton, PhD.
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