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Medicine is Clumsy, Don't You Be
All medical systems have clumsiness in them. If the technique isn't, the practitioner is. Everyone in every form of medicine is striving to improve. That is why we call it practice.
News in Brief
Dr. Frank Nicchi Receives Award at ACC-RAC; Sherman College Expands International Influence.
Marijuana, Apathy and Chinese Medicine, Part 1
This article was written in response to the unheeded acceptance of marijuana as a harmless substance that potentially does good when used for the medical relief of pain.
If Your Pro-Chiropractic Governor Resigned, Would You Be Prepared?
John Kitzhaber, MD, recently re-elected to a historic fourth term as Oregon governor, has resigned among alleged ethics violations by his fiancée' and first lady, Cylvia Hayes. I developed a personal friendship with John and consider him a good friend.
5 Tips for Using Pinterest to Market Your Practice
Pinterest is a very popular, but often under-utilized, social media platform where people can bookmark, or "pin," fun and interesting things from all across the internet.
5 Simple Steps to Create an Effective Marketing Calendar
In the educational experience of most healthcare practitioners, business and marketing are overlooked topics.
Trouble in the Wellness Waters?
Call me old-fashioned, paranoid or just old, but I do remember graduating from chiropractic college in the late '70s in the midst of the Wilk v AMA lawsuit.
Animal Acupuncture: A Case Study in the Treatment of Traumatic Injury in the Equine
The rise of animal acupuncture in the U.S. began in the early 1970's as a result of the work by members of the National Acupuncture Association in Westwood, Calif.
PCOM Granted Regional Accreditation
Pacific College of Oriental Medicine (PCOM) recently announce it has received regional accreditation from the Western Association of Schools and Colleges (WASC). This achievement reflects five years of hard work on the part of faculty, staff, and students.
The Challenges of Integrating Eastern and Western Medicine
My Masters thesis was titled, "The Challenges of Integrating Eastern and Western Medicine," which highlighted several reasons why it is hard for these two worlds to mix.
Make Every Day Mother's Day
May is a special month for many reasons. After a long, harsh winter, spring is at last in full swing. Memorial Day helps us honor those who have fought and fallen in the name of freedom.
Functional Impingement of the Hip (Part 2): Rehab Exercises
I find functionally impinged hips that don't move properly on so many of my patients. (See part 1 of this article for a description of the condition.)
Teach Your Patients About External Healing Applications
Since the skin is the body's largest organ, and is able to respond to both internal and external stimulations, communicate sensations to the brain, protect the body, breathe and even excrete toxins, it can be an excellent source of healing.
Applauding a Legacy of Leadership
Founding Palmer West President, John Miller, DC, HCD (Hon.), FICA (Hon.), a 1954 graduate of Palmer College of Chiropractic, passed away March 8, 2015 at age 83.
Talking to Patients About Medial Branch Neurotomy (Part 2)
Even when lumbar facet denervation (medial branch neurotomy) is successful, relief is rarely complete or permanent. Smuck, et al., reviewed 16 articles and found the average duration of >50 percent pain relief for an initial procedure was nine months.
The Acupuncturist's Problem
I want share with you some observations and insights into what seems to be the most common problem my colleagues in the acupuncture profession struggles with. If you also struggle with this problem, I hope you get a valuable "aha" moment from reading this.
Apple Takes a Bite Out of Research
The more than 700 million iPhone users have just been given the opportunity to "do their part to advance medical research."
How Much Do You Know About the Benefits of Birds Nest?
Edible bird's nest is the nest made by the Swiftlet bird of Southeast Asia that is usually prepared as a soup and prized in Chinese culture as a healthful delicacy.
Integrating Art with Clinical Practice for Patients with PTSD: The Artemis Project
Are you restricted by those one-on-one clinic dynamics? Why not join colleagues and clients in experimental group settings? Three of us volunteered to do just that in Austin on behalf of women veteranss from all branches of the service.
July, 2011, Vol. 11, Issue 07
Human Silly Putty
By Erik Dalton, PhD
Although "creep" is an engineering term, it also applies to human tissue...the lumbopelvis in particular. Spinal and sacroiliac ligaments, joint capsules, facet cartilages and especially intervertebral discs are viscoelastic and are somewhat similar to silly putty.Leave a ball of putty on a table overnight and by the next morning it's deformed into a flattened pancake. So be it with humans. We're taller in the morning than at bedtime, primarily due to disc and fascio-ligamentous deformation that occurs throughout the day. Of course, silly putty is much creepier than discs, fascia or ligaments but, in time, gravity will deform and sometimes strain all these materials.
As ligamentous creep turns to strain, soft tissues are no longer able to prevent separation of bone and that's when our problems begin. Contrary to what many docs tell their patients, most low back and pelvic pain does not result from a single traumatic lifting, bending or sports injury, but rather from cumulative viscoelastic creep due to lack of rest between loading cycles. According to Bogduk and Twomey, "After prolonged strain, spinal ligaments, joint capsules, and IV discs of the lumbar spine may creep, and may be liable to injury if sudden forces are unexpectedly applied during the vulnerable recovery phase."1 Bottom Line: Once viscoelastic tissues are strained, they're less likely to return to their original length and, therefore, are more prone to future injury.
I often scratch my head in wonder when reading research that dismisses the effects of gravitational exposure on human viscoelastic tissues. It's even more frustrating when scientists and clinicians discount the role distorted postural faults such as pronated feet, crooked SI joints, and forward heads play in commonly seen pain syndromes.2 Each-and-every day, the weight of gravity (14.7 pounds per square inch) pushes straight down on our bodies. These compressive forces should be equally distributed throughout the neuro-myo-skeletal system...but are they? Prolonged one legged standing (excessive weight bearing on one limb, i.e., performing bodywork) is an oft-overlooked culprit creating ligamentous creep that might be a precursor to more serious conditions like joint laxity, lumbopelvic instability, sprains and osteoarthritis. To demonstrate the phenomena of creep, let's look at the myo-mechanics of a fairly common pain-generating disorder called iliosacral upslip or "shear."
What Is An Upslip?
In those presenting with true iliosacral upslips, joint apposition between the ilium and sacrum is altered, i.e., "the sacroiliac grooves ain't grooving". Since these superior shears are more affected by gravity than other iliosacral dysfunctions, they have almost a zero chance of self correction. During history in-takes, clients often report the symptoms to be much more painful than expected from the injury they describe. In fact, many can't recall any precipitating event.
Typically, when we see this upward shearing force of ilium on sacrum, the person's SI joints are lacking either form or force closure. In form closure, SI joint stability is dictated by a series of ridges and complimentary depressions that produce friction and help interlock the two bones. But synovial joints like a little movement (joint play), not only to provide spinal shock absorption, but also to enhance lower extremity torque conversions and transverse rotations that travel up the kinetic chain and propel the body through space.3 Fortunately, Mother Nature has accommodated this functional demand by installing a back-up system researchers call force closure. Force closure stability is generated by contractive action of core musculo-fascial tissues such as the pelvic diaphragm, transverse abdominis, multifidus and thoracolumbar fascia. Together, they provide a sophisticated neurologic feedback mechanism that reflexively interacts with the brain to provide joint stability and coordinated movement...or lack of it as is the case in chronic upslips.
In the presence of chronic upslips, prolonged cyclical loading can deform SI joint ligaments to a point where an act as innocent as slamming on the brake, tumbling on one hip, or clumsily stepping off a curb, can jostle the joint enough to cause the ilium to "jump-a-notch" on sacrum. Here's a good "upslip" case study of a client named Marion who called complaining of stabbing buttock and low back pain.
Marion The Hairdresser
I'd treated Marion off-and-on for several years for neck, jaw and rib pain resulting from a severe whiplash injury, but today was different...her low back and hip were in a world of hurt. This was her first visit since becoming a momma a year earlier and her history in-take revealed two related factors contributing to her injury: 1) Cumulative viscoelastic creep (hypermobility) left over from the relaxin birth hormone, and 2) Prolonged one-legged cyclical loading at her hairdressing job.
A classic upslip case, Marion presented with acute right-sided lumbopelvic pain, funky gait and anatomical landmarks showing a 1 1/2" short right leg, lax sacrotuberous ligament right, OL and psoas spasm right, and superior/posterior right ilium. Spring testing of the right ilium (supine and prone) revealed no inferior glide. Marion's right QL fired before gluteus medius on the hip abduction test and she lifted the swing leg with the spasmed QL as she tried to walk. Although all her anatomical landmark and gait evaluations pointed to an iliosacral upslip, why do you think she could not identify a traumatic perpetrating event?
The books tell us iliosacral upslips are traumatically-induced injuries, but Marion first felt the excruciating pain when she got out of bed. Turns out, the incident that most likely pushed Marion over the edge occurred the night before as she stepped off a foot stool. That slight jar caused the hypermobile pelvic ligaments and restraining muscles to collapse and explode into a full-blown crippling hip spasm. Over the years, I've seen many cases like Marion's and I've noticed that in the early stages of ligamentous creep, the brain down-regulates nociceptive pain signals. But when the joint finally jams, the brain lights-up the central nervous system with pain and protective guarding to prevent further insult to the damaged area.
Fixing The Fixation
Here are a couple of techniques that helped fix Marion's upslipped hip. In Figure 4A, she's pulling the knee to her chest to inferiorly drag the ilium while I slowly elbow my way through the lumbodorsal fascia, QL, and iliocostalis myospasm. Once these hypertrophied (hip-hiking) soft tissues regain flexibility and mobility, a maneuver is used to get the sacroiliac "grooves-a-groovin." But before proceeding to the upslip correction, Marion is asked to do a couple minutes of deep abdominal breathing to help neurologically reset and relax the deep spasmed core muscles.
In Figure 4B, Marion lies supine and I apply an inferior tractioning force to drag the ilium to the first restrictive barrier feeling for neutral leg and hip alignment. By taking the limb into a bit of internal rotation, I'm able to bony-lock the hip allowing the tractioning force to travel through the SI joint. Using my body weight with her thigh securely arm-locked, a distraction force is applied as Marion forcefully contracts the QL and hip-hikes against my resistance. After a few seconds, she is asked to cough vigorously to help jostle the joint and reposition the soft tissues. Traction combined with the forced exhalation allows Marion's ilium to drop down into the groove "from whence it came." Note: The pain should immediately ease except in those with hypermobility issues or core stability problems in which case a referral to a good functional movement therapist is recommended.
Lastly, here's an effective home-retraining exercise I gave Marion. Lying supine, with her heels circling an exercise ball, she lifts her buttock and slowly rolls the ball side to side. I've found this simple routine helpful in normalizing neuromuscular firing patterns while evenly tonifying damaged ligaments. Rest, ergonomic retraining and regular follow-ups are mandatory until pelvic stability is established. Remember, the first couple weeks are critical; even the slightest jar can turn the ligaments back into silly putty.
Click here for more information about Erik Dalton, PhD.
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