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What's New in the NCCIH Strategic Plan
The NIH National Center for Complementary and Integrative Health (NCCIH) released its draft strategic plan 2016-2021 for public comment in early spring of 2016.
Work Stress and Musculoskeletal Health: Do Your Patients Get the Connection?
Most people underestimate the impact their job has on their health, especially if that job isn't particularly physically demanding. Big mistake.
Chiropractic in the Eyes of the Public: 2nd Gallup-Palmer Poll
The second Gallup / Palmer College poll has been completed, yielding significant additional data regarding Americans' experiences with and perceptions of chiropractic care.
What are the Meridians?
The meridian and collateral system (jing luo, hereinafter referred to as "Meridians") is comprised of the main meridian channels (jing mai) and the collateral vessels (luo mai). Jing takes from meaning of the Chinese word pathway (also jing) and are the main branches of the system.
Lessons from Functional Neurology
Chiropractic neurology, also known as clinical neuroscience or functional neurology, is moving the chiropractic profession forward by leaps and bounds.
International Congress on Integrative Medicine
"Bridging Research, Clinical Care, Education and Policy" was the theme for the International Congress on Integrative Medicine and Health 2016 (ICIMH).
Guidelines for the Use of Modifier -52
Modifier -52 identifies that a service or procedure has been partially reduced or eliminated at the physician's discretion. This is to indicate the basic service described by the procedure code has been performed, but not all aspects of the service have been performed.
MPA Media Wins More Publishing Awards
The American Society of Business Publication Editors (ASBPE) has honored Dynamic Chiropractic with a national award and two regional awards for editorial excellence, and sister publication DC Practice Insights with two regional awards for graphic design excellence.
Traditional Chinese Herbal Medicine in Taiwan Hospitals
This spring, a team of Western medical doctors and TCM practitioners from Cleveland Clinic traveled to Taiwan to visit Kaiser Pharmaceutical Co. (KP), and China Medical University (CMU), Taiwan's leading integrative medicine hospital.
The Professional and Practice Benefits of Political Activism
Welcome to election season, a vital part of our American culture. Every two years, without fail, we are bombarded with TV, print materials and phone messages seeking our vote.
Don't Ignore the Lower Half of the Pelvis (Part 1)
When your patient complains of lower back or pelvic pain, but your usual treatments are not getting the job done, what do you examine and treat? You may be missing important structures in the lower half of the pelvis.
Less Time Than Required
Q: When is it appropriate to use a modifier -52? Can I use it for a timed service when I do less than the time required by the code?
Let's Talk About Biceps Injuries at the Elbow
While most muscles cross over only one joint, the biceps crosses two joints: the elbow and the shoulder. Injuries to the lower biceps cause considerable elbow pain. Here's how to assess and treat an injury to this area conservatively.
A Study of Relationships
Sa-Ahm's five element acupuncture method is known to be one of the most effective acupuncture techniques in Korea because it gives an instant response at the time of treatment and has a high success rate in resolving chronic problems.
Are Probiotics Doing More Harm Than Good?
Considerable controversy exists concerning the efficacy of probiotic supplements. Very few human studies show any real positive impact on the microbiome or health. The "promise" of probiotics is based on the few animal studies that suggest a positive effect.
Time to Fight for Your Medicare Right
I have heard a lot of noise and a lot of debate about what is going on with Medicare. As an ACA delegate, I often get asked: 'What is the ACA even doing?'
The National Institutes of Health (NIH) lists more than 80 common autoimmune diseases including asthma, Crohn's disease, Guillain-Barré syndrome, multiple sclerosis, myasthenia gravis, psoriasis, rheumatoid arthritis, and lupus.
Adventures with the Pericardium
My previous column on the San Jiao deserves equal time for SJ's loving partner, the pericardium. I nicknamed SJ the travel meridian – but pericardium can also play a crucial role in air travel.
Know Your Research: Tips for Evaluating Literature Reviews
Clinical and experimental studies are not the only types of published research we might encounter as we look for evidence to inform our practices. One of the most useful types is the literature review, which summarizes a group of studies.
Overuse Injuries in Young Athletes (Part 1)
More than 45 million children ages 6-18 participate in some form of organized athletics, and 75 percent of American families with school-aged children have at least one child participating in organized sports.
Analyzing Acupuncture Case Studies
Confirm the answer quickly by the elimination method. Take this case study as an example. After two treatments for back pain, a patient presents for a third session complaining of rapid breathing and wheezing that is made worse during cold weather.
Illuminating the Hidden, Freeing the Source
Amongst the Primary Channels, from a classical point of view, the small intestine is perhaps the most important channel to understand. It is one of the least used acupuncture channels in modern acupuncture, yet it within it can be found a wealth of theories from the Ling Shu.
December, 2012, Vol. 12, Issue 12
Tissue Density Restoration Massage for Restless Leg Syndrome
By Linda LePelley, RN, NMT
Restless Leg Syndrome (RLS) is a disorder that drives the sufferer to move their legs in response to irritating and strange sensations. It can range in severity from being a slight annoyance, to an intolerable condition that disturbs restorative sleep and diminishes the overall quality of life.I often recall a patient I cared for as an RN Supervisor in a convalescent home. She would get up almost every night, walking up and down the halls. When asked why she wasn't sleeping, she would replay, "Oh, how I wish I could, but these running legs won't let me sleep!" Several medications were used, but none were very helpful. The common belief was that there just wasn't much that could be done about it. Whenever I had the chance, I would take 20 minutes and massage her legs for her. She loved it, and sometimes it would help her sleep, but it always came back. Had I known then that I was on the right track; I would have found the extra time required to give an effective treatment, one that provided long-term results.
A Common Phenomenon
As a massage therapist who successfully treats clients diagnosed with RLS, as well as several who have complained of the symptoms without having been diagnosed, I have noticed a common phenomenon in each. Their legs are permeated with elevated tissue density (TD). The increase in density ranges from diffuse pockets of rubbery firmness noted in the deeper muscles of the thighs and calves, to large areas of firm, rigid tissue. Compacted together, with decreased motility, the muscles and connective tissue can feel so dense that the only movement is at the knee. People told by their sleep partners that they kick around a lot at night also have elevated TD in their leg tissues. I suspect they are in a latent stage of RLS, where their bodies are responding to the irritation, but they have not yet consciously experienced the unpleasant sensations.
I believe that RLS is caused by a combination of tissue condensation as well as an accumulation of a form of plaque that is in any one of a multitude of states of viscosity and density, possibly due to varying degrees of localized tissue hypo-hydration and mineralization; as well as heat, pressure and gravity. It engulfs and traps nerves, which irritated, begin to twitch. A skilled massage therapist can feel the presence of this accumulation in body tissues and return it to a more normal density, thereby releasing the affected nerve endings and restoring circulation, function and mobility, relieving pain and, in the case of RLS, the ability to relax and rest peacefully.
I need to clarify my use of the word "plaque" as it relates to tissue density formation. I do not have scientific verification that the substance to which I speak is actually plaque. I refer to it as such for this reason – I cannot find a better descriptor that fits what I palpate and treat. I find no mention in medical references or research papers of the presence of plaque in the body other than "atherosclerotic" plaque, which is specifically located within the walls of arterial vessels; "senile" plaques, which develop in the brain and are associated with Alzheimer's disease; a psoriatic plaque; and dental plaque, which builds up on the teeth.
I developed my treatment method with no pre-conceived idea of what I was doing or why, my intention was simply to do whatever the client felt was doing the most good. If they preferred petrissage over tapotement, the tapotement was eliminated. If they wanted just the painful area focused on, I did not include the rest of the "routine" I learned in school. I assumed in the beginning that each client would have their own individual preferences, so it was very interesting to me that over time, I was using the same procedure on everyone, with the only real variations being the location of the pain. This is how I developed the treatment before considering what the cause of so much pain and dysfunction might be. While my ideas about the nature and cause of what I address with TDR massage may contain inaccuracies, my methods of pain relief and the restoration of sensation and mobility are beneficial and effective.
I've found that musculoskeletal pain and dysfunction can be felt by the MT in every client. No matter where it is located, it has a definite texture and density to it and, if you can feel it with your hands, you can help heal it. It may be very subtle, but it is palpable. Clients often ask how I know something hurts. I explain what I feel and show them how to find it. It sometimes takes several attempts for them to do so, but they are always amazed that these secondary structures are within their tissues and they had never been aware of it before.
The reason I call these palpable structures "plaque" is because it behaves like plaque as I understand it. In the beginning, it is soft and malleable, it seems that over time it becomes denser, firmer and eventually mineralizes and hardens into a bone-like crust. I surmise that it is the stuff that arthritis is made of, as well as a number of other painful conditions. That's the bad news.
I call it plaque, it acts like plaque, and I treat it like it is plaque. But here is the good news. Plaque is 60% fat. It doesn't matter how mineralized, hard and crusty an arthritic joint is, if I am correct (as all my work has indicated); under the right conditions, it is as solid as a sand castle. Slowly melt the fat and gently dissolve and massage away the residue. It sounds simple enough, and it is, however, it takes time and patience. All dense tissues, whether or not they are associated with a joint, respond to the same treatment.
You may have noticed that I do not name specific muscle or anatomical locations. This is a purposeful omission. In regard to TDR massage, the only location that matters is where the client is experiencing discomfort, and where the TD is elevated. The focus needs to be on the locus of the density, and TD elevations arise in all tissue types. It should be addressed as a whole, not manipulated separately, muscle away from connective tissue, or apart from fluids.
In the years I have been a massage therapist, I have noticed that very often people seem to forget the severity of their discomfort once they have been relieved of it. I have had people come into the clinic stating that they are in severe pain, the medicine or shot the doctor gave them hasn't helped much, if at all, and I was their last-ditch hope for relief. More often than not, massage does relieve their condition. Then later, when they come in for a regular massage, I might ask about the knee or shoulder pain they'd had and they will vaguely recall it. In one case I was told, "Oh yeah, that. The doctor gave me a shot and it hasn't bothered me since," to which I ask if it was a shot they got after the massage treatment, or had it been the one they got before they came to me. It was the one given six weeks before they saw me that had been given the credit. I suggest the establishment of a pain level and duration of discomfort statement from clients before treatment. This way you can make them aware that they had a problem and it was massage therapy that helped them. Also, in the course of providing TD massage, the density of the affected tissues can change dramatically. It makes sense to document before and after depictions of TD and pain levels to be able to communicate with the client and health care team accurately. Without substantiating documentation, all statements about treatment results are simply anecdotal stories.
To administer an effective TD massage treatment for RLS, you will need to focus entirely on the legs. Explain to your clients in advance that they should not expect a full body massage along with the RLS treatment. While an hour is sufficient, an hour and a half is an ideal amount of time for an RLS treatment because it allows 20 minutes for each of the four "sections" (thighs to knees and knees to ankles on each leg), with 10 minutes for assessing and recording your density map.
You might create a rudimentary TD map by drawing a small-scale outline of your client's legs on a piece of paper. Palpate your client's legs carefully, from the top of thighs, inner and outer, down to the ankles. Mark your map with all you find, noting tenderness/pain with the 1/10 pain scale, record areas that are more dense, areas with hardened ridges, as well as areas that are as hard as bone, or flaccid. This will give you a good idea of what you are starting out with and something to compare the end results to. A more comprehensive method of tissue density mapping is available, but this basic map is all you need to get started.
When doing an RLS treatment, use the same caution you would with any massage and remember the basic rule of Tissue Density Restoration (TDR) massage, use as much pressure and movement as you need, without causing pain. Use a table warmer and/or some warm packs to help reduce the amount of time it will take to soften the tissue. Make your client comfortable in the prone position. While still respecting the flow of blood and lymph from distal to proximal, I start each leg at the thigh and then work my way down the leg. You need the more proximal area to be cleared up first, creating a pathway for improved circulation as you work your way down the legs.
From a seated position, using both hands, apply warm massage cream to client's thigh. With both hands grasp the medial thigh and gently rock it towards you a few times, feeling for areas of tightness or hardness. Hand over hand, starting at the top and then slowly working your way down; drag the tissues from inner to outer thigh, going deeper as becomes possible, with the intention of moving all the muscles freely over the bone. As you determine the areas of elevated TD, you will likely find ridges which are tender and resistant to movement. Use large, flat-handed circular movements, and then careful petrissage to help narrow your focus to these areas, apply as much movement and pressure as you can without going over a three on the 1/10 pain scale. Take note of the area at the medial aspect of the knee. It often forms a large, sensitive plaque within which nerves are engulfed and irritated. Much of your time may be spent here, carefully massaging crusted-over nerves, which feel like large, firm strands and bands. They will respond to warmth and movement as well. As the firm areas shrink away, you will use smaller circular movements, eventually using just your fingertips. You will note that as the tissue warms up, it softens and becomes more mobile, and eventually, you will be able to work the palpable areas out altogether. Use the same technique on the lower leg and repeat on other side. In the course of working the back of the upper thigh, you might note the elevated TD extends into the anterior thigh as well. If so, you will need an additional 10 minutes for each leg. I suggest you work on the anterior thigh with the client in a side-lying position; the slight gravity assist makes it easier to locate and clear denser areas. Please note that the times I give are just generalized suggestions, gauge the results only by what you feel, not by how much time was spent.
When additional treatments are needed, try to schedule them as closely as possible. two and even three times in a week is best. The longer a period between treatments, the longer the individual treatments take to become softened enough to dissipate the elevated TD.
Once an area has been completely restored, the tissue will be malleable, warmer and relaxed at rest, with no tenderness. It depends on the client how long complete restoration will take. I often have had people cleared up in three to four treatments, but there are those that clear up immediately and a few that take six or seven sessions. I suspect the reasons for the differences in the timing of completion depend on age, how long the problem has existed, diet and hydration, as well as a number of other possible factors. Once restored, the tissues seem to stay healthy and pain-free for quite a while. Once a client is aware of the condition of elevated TD, they can take measures to prevent reoccurrence by making sure to not just move their bodies through space, but to move their tissues around as well. This can be done with a good towel rubbing over joints after a bath and by receiving regular massages.
My nursing home patient and friend, passed away about a year before I realized that I could have provided her with real, long-term relief. It is my goal to let it be known that there is a way to relieve RLS and many other musculoskeletal pains, free of harmful medications, and it is in the hands of massage therapists to do so.
Click here for more information about Linda LePelley, RN, NMT.
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