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Patient Perception and the Farce of "Fast Relief"; A Fly in the Ointment; Persecuted for Choosing to Practice Chiropractic.
You are What You Eat Part II: Integrative Protocols
In the previous installment of this article I discussed important ideas concerning gastrointestinal health and foundational ideas from TCM, which can provide key insights into creating effective protocols for healing the gut.
Correcting Kid Logic in Health Care and Research Design
A recent broadcast on public radio described a fascinating phenomenon known as kid logic.
Helping Infertility Patients with the Spirit Essence
As many of you know, when it comes to treating infertility, we are dealing with a patient population that is, generally speaking, in emotional turmoil. These patients often experience fear, anxiety, despair, hopelessness, grief and anger.
Research Abstracts From the Journal of Manipulative & Physiological Therapeutics
Effect of Pain Relief on Lumbar Muscle Function and Activation; Effects of Thrust Amplitude and Duration of HVLA Spinal Manipulation; Immediate Effects of Upper Thoracic Manipulation on Cardiovascular Response.
Herbal Medicine: Go Mainstream
When it comes to practicing herbal medicine in a mainstream setting, there are a number of important points to understand when it comes to prescribing formulas. Some important questions to ask are - what method of prescribing and dispensing is most effective in this setting?
Chiropractic: The Right Choice for Relieving LBP
"Low back pain (LBP) is a common threat to medicine and a reasonable threat to all national health care systems. ... Reducing ineffective treatments is necessary to decrease the LBP associated costs."
Helping Patients Through Pregnancy Loss
There is a lot of focus in the acupuncture world on fertility and helping women get pregnant. It's exhilarating to hear the news that a patient is expecting a baby. The other side of that is pregnancy loss. That includes abortion, miscarriage or stillbirth.
Peer Points: Stories of Practice Success
When patients go see Arizona-based acupuncturist Jing Liu, it is to get top care from an practitioner well versed in all aspects of Traditional Chinese Medicine.
Economics of Complementary/Integrative Care
Although this column doesn't usually feature a book review, we're going outside of our usual public health format to discuss a new book written by Patricia Herman ND, PhD.
There Are No Secrets: Treating Complicated Conditions with TCM
Including standardized extra points, there are just over 400 acupuncture points on the body. You get 400 and I get 400 - same. Yet, time and time again treatment protocols are coveted as if they were some secret formula only intended for the right and privileged.
News in Brief
Controversial Florida PIP Law Under Review; D'Youville Chiro. Students Learning Art of Co-Managing; And the Award Goes To...; F4CP Recognizes Major Contribution by ChiroTouch.
Why You Should Get to Know the National Vaccine Information Center
Barbara Loe Fisher has been a diligent advocate for providing parents with the information necessary to make informed decisions regarding the usage of vaccinations for their children.
Going Shoeless: The Pros & Cons of Barefoot Running
With the subculture of barefoot runners and the products catering to them growing daily, just about every chiropractor has been asked at one point or another about their opinion regarding barefoot running.
What the Science Says About Magnesium Stearate
It's often been said that scientific studies can be used to support just about anything. But discoveries are never made one study at a time.
The Potter's Wheel: Reflections on Practicing in a Technology-Driven World
In my very early years of practice, an older patient named Cora would call me at home, usually late Sunday night after she had consumed an unknown quantity of beer.
Have a Heart: Say No to Soda
It's not enough that soft drinks and other sugar-sweetened beverages have been linked to cavities and weight gain, among other negative health consequences.
What They Don't Say Could Hurt You
I have written previously regarding the difficulties of drawing information from patients who are poor historians, forgetful or just plain uncooperative. The thought to revisit the topic occurred recently during preparation for an upcoming seminar.
Side Effects From Big Pharma: Wellbutrin – Dangerous for You and Your Baby
Are some of your pregnant patients taking Wellbutrin? If so, it could be a danger to them and their baby. This drug is extremely popular, but it has a serious history.
The Spirits of the Points: The Gall Bladder Official
The Gall Bladder is known as The Official of Decision Making and Judgment. In any given day, this Official makes countless decisions – conscious and unconscious, which influence every aspect of our being.
Energy is a hot commodity. Society pays dearly for it and for the expertise of those who know how to cultivate it.
A Building Block of Healthy Aging
Coenzyme Q10 has gained enormous attention in recent years, and with good reason —it's the Energizer Bunny of the cellular world.
Medicine Presents: A Great Opportunity
The changing nature of health care presents both opportunities and challenges. While we tend to focus on our profession, we can sometimes forget the impact other health care professions can have on us.
Happenings in Our Evolving Profession
Good things seem to be happening for our profession and recent developments show we are all on board. Talking about being on board, this September The Veterans Express-Purple Heart Tour is expected to make its way out of the station.
SOAP Notes: It's Time for a Cleaning
I have been planning for some time to write an article about how traditional SOAP notes do not fit chiropractic practice, and the unfairness of holding DCs to a model clearly created for and primarily applicable to medical physicians.
Remembering Joe Weider (1920-2013)
With the death of Joe Weider, the world's most famous body-building visionary, crusader, fitness magazine publisher and icon, on March 23, 2013, chiropractic has lost one of its greatest friends and supporters.
Some Thoughts on the TMJ
The temporomandibular joint is an interesting and dynamic articulation that can cause a lot of problems.
Let's face it – patient evaluation takes time. Unless you are really into the diagnostic evaluation game, you probably have found the formal exam protocol tedious if not downright annoying.
Are They Finally Fixing Medicare Reimbursement?
Even with federal sequestration cuts taking effect in March, including a 2 percent reduction in Medicare reimbursement to health care providers, hope may be on the horizon in the form of a much-anticipated, perpetually suggested overhaul of Medicare's Sustainable Growth Rate formula, which serves as the basis for determining physician reimbursement.
January, 2013, Vol. 13, Issue 01
Solving a Client Puzzle
How To Know Whether It's Tennis Elbow Or Nerve Entrapment
By Whitney Lowe, LMT
Suppose a client comes to see you complaining of lateral elbow pain. She reports that the pain has been going on for quite some time despite efforts to treat it. A first consideration might be that the client has lateral epicondylitis, commonly known as tennis elbow; not an unreasonable assumption since lateral epicondylitis is a common problem. However, it's also entirely possible that the client's complaint derives from another condition called radial tunnel syndrome.
The most effective results occur when you choose treatment techniques whose physiological effects best address the client's existing complaint. Conditions and treatment techniques both have physiological effects, which are the specific ways in which tissues respond either to the pain/injury or the intervention. Treating a client suffering from radial tunnel syndrome with techniques appropriate for someone suffering from lateral epicondylitis would aggravate the problem rather than help it. So, let's take a look at these two problems and explore how one might mistake radial tunnel syndrome for lateral epicondylitis.
Exploring the Conditions
Most people are aware that lateral epicondylitis is a chronic overuse condition affecting the common extensor tendons where they attach at the lateral epicondyle of the humerus. Despite the implication from its name, because it ends in –itis, epicondylitis is rarely an inflammatory problem and is not caused by the common explanation of torn tendon fibers. Instead, it is caused by collagen degeneration in the extensor tendons. Pain is most pronounced where the tendons attach at the lateral epicondyle of the humerus.
Epicondylitis presents several clear signs and symptoms that can be picked up during the evaluation process. There is likely to be pain with palpation of the extensor tendons and it is likely to be particularly tender where they attach at the lateral epicondyle. It is also common for pain to be reproduced when stretching the extensor tendons by moving the wrist into full flexion. Resisted wrist extension also reproduces the client's pain, especially if the affected tendons are palpated during the resisted wrist movement. (See Figure 1)
Unlike lateral epicondylitis, radial tunnel syndrome is not as common. However, when present, it can easily be confused with epicondylitis. Radial tunnel syndrome is frequently called resistant tennis elbow, because the symptoms are very similar to tennis elbow and they persist even after attempts at treatment (usually for lateral epicondylitis).
In the elbow region, the radial nerve divides into a superficial sensory branch and a deep motor branch. The primary problem in radial tunnel syndrome is compression of these branches as they course through fibro-osseous tunnels created by surrounding muscles, ligaments and bones. The deep motor branch innervates the wrist extensor muscles and is called the posterior interosseous nerve (PIN). Compression of the PIN most commonly causes weakness or atrophy in the wrist extensors because the PIN contains motor fibers almost exclusively. However, pain similar to lateral epicondylitis is possible because the superficial sensory branch of the radial nerve may also be compressed in this region. (See Figure 2)
Nerve compression occurs in radial tunnel syndrome where the PIN courses under the supinator muscle. The archway created by the edge of the supinator muscle under which the PIN passes is called the Arcade of Frohse. (See Figure 3) The Arcade of Frohse often has fibrous bands that compress the nerve causing the tunnel compression syndrome. These fibrous bands are small and deep under the extensor muscle mass, so they are challenging to palpate.
Although radial tunnel syndrome and lateral epicondylitis may initially present with similar symptoms, there are some key aspects of assessment that will help differentiate the problems. Lateral epicondylitis is most likely to cause pain during resisted wrist extension. Radial tunnel syndrome, on the other hand, is more likely to present with less pain but significant weakness during resisted wrist extension because it is the PIN motor fibers that are most affected.
Pain can be reproduced during palpation with both these conditions. However, when palpating the lateral elbow region, radial tunnel syndrome pain is more likely to be felt somewhat distal to the epicondyle in the soft tissues. Epicondylitis pain is predominantly in the extensor tendons and right at the epicondyle. In addition, pain arising from nerve compression in radial tunnel syndrome is likely to be less specific and extend into the forearm. Epicondylitis pain is usually far more local right at the proximal extensor tendon group and their attachments.
Based on her initial symptoms, our client could have either one of these conditions. This is a great illustration of why it is so important to perform a thorough assessment and not immediately jump to conclusions. Assuming she has lateral epicondylitis, the most likely treatment approach would include deep transverse friction of the common extensor tendons. The physiological effects of this treatment technique (stimulation of fibroblast activity which encourages collagen rebuilding) would match the physiology of the tissue injury (collagen degeneration). The friction technique would be valuable in addressing the chronic tendon degeneration of epicondylitis.
However, if the primary problem is radial tunnel syndrome, applying deep friction could significantly aggravate the problem by placing adverse pressure on the nerve. For radial tunnel syndrome it would be far more important to address muscular hypertonicity throughout the wrist extensors and the supinator muscle so they don't further compress the nerve. In addition, neural mobilization techniques for the radial nerve would encourage full freedom of movement of the nerve and eventually reduce symptoms. Neural mobilization engages gentle pulling actions during certain motions of the upper extremity that encourage smooth and free gliding of the nerve near any adjacent structures.
This case illustrates two very important points that will make your treatments more successful. It is valuable to know about soft-tissue pathologies in order to be able to distinguish between conditions. In addition, in cases like this, it is possible to make treatment errors that make a client's condition worse. Performing accurate assessment and considering the physiological effects of the treatment on the specific tissues being treated will make your treatments far more effective and successful.
Click here for more information about Whitney Lowe, LMT.
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