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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 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.
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.
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.
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 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.
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.
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.
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.
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.
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.
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.
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.
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.
The Visual Error Scoring System: A Concussion Tool
Postural stability and oculomotor function are the most easily recognized physical indicators of neurologic motor dysfunction associated with concussions.
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.
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.
May, 2013, Vol. 13, Issue 05
Technique Synergy: Blending Unique Combinations for Success
By Whitney Lowe, LMT
Specific techniques and modalities are the key tools of our profession. But as any artisan or craftsmen will tell you, each tool is only as good as the person using it. Sometimes, we may look to one specific assessment or treatment technique to give us the key results we are looking for.Yet, in reality, the most effective approach might be a unique combination of different methods—technique synergy.
Synergy can be defined as the interaction of elements that, when combined, produce a total effect that is greater than the sum of the individual elements by themselves. So, how do you know which different techniques to combine together for the greatest effect? The key lies in understanding the physiological effects of your treatment or assessment techniques so you can choose the most effective approach. Let's look at an example of how several different assessment strategies were combined together to produce more effective evaluation methods for identifying carpal tunnel syndrome.
Variation on Common CTS Evaluation Procedures
Carpal tunnel syndrome (CTS) is the most common median nerve pathology. Yet, there are still challenges in recognizing it, especially in the early stages before symptoms are prominent. Nerve evaluation tests need to be more sensitive to identify the problem at different stages of severity. The sensitivity of the test refers to how accurate it is at identifying the problem when it is present. Below are several variations on standard carpal tunnel syndrome assessment tests that make them more sensitive, and consequently more able to identify a problem before it is severe. These descriptions are excerpted from an article originally published in the Journal of Bodywork & Movement Therapies.1
Massage therapists routinely treat clients with carpal tunnel syndrome. Yet, they do not have the high-tech diagnostic procedures like nerve conduction tests available for identifying possible median nerve involvement. Therefore, the reliance on physical examination to support (or replace) findings from nerve conduction studies is very important. When performing any of these procedures, the practitioner should remember that exaggerated neural sensations may be indicative not only of mechanical compression neuropathy, but of a host of disorders that cause increased neural sensitivity. Appropriate contraindications for proper treatment should be carefully weighed after gathering evaluation information.
Phalen's Test is the most common special orthopedic test for evaluating carpal tunnel syndrome. To perform this test, the client presses the back of the hands together so the wrists are flexed close to 900 (Figure 1). If the sensory symptoms of pain, paresthesia or numbness in the median nerve distribution are reproduced within about 60 seconds, the test is considered positive for median nerve compression in the carpal tunnel.
When this test is performed, the wrist is in flexion, which decreases tension on the median nerve. If there is increased tension on the median nerve, there is a greater degree of sensitivity in the evaluation procedure and it could therefore pick up less severe conditions.2 Greater sensitivity would therefore result if the wrist was held in flexion (Phalen's test position) while the upper extremity was held in a position that increases neural tension on the remainder of the median nerve. An upper extremity position that would increase tensile stress on the median nerve, while compressing it at the carpal tunnel region, would include lateral flexion of the neck to the opposite side, shoulder abduction, elbow extension, and wrist flexion (Figure 2). This test would be performed unilaterally, unlike the standard Phalen's test, which is performed on both sides at the same time. Make sure the cervical region is laterally flexed away from the side that is being tested.
Another relatively new evaluation procedure that has demonstrated greater accuracy than the Phalen's test is the hand elevation test. In this procedure the client holds the hand as high as comfortably possible overhead (Figure 3). If neurological symptoms in the median nerve distribution of the hand are reproduced within one minute, the test is considered positive.3 Neural tension in the median nerve could be added to the hand elevation test to make it more sensitive. With the arm held overhead, the neck is laterally flexed to the opposite side. Additional tension on the median nerve is added by putting the wrist in extension (Figure 4). Another variation would be keeping the wrist in flexion (as in the Phalen's test wrist position).
Increased neural tension is already a component of this test. The wrist is held in extension and supination. While in this position, the index finger is pulled into hyperextension as far as motion allows (Figure 5). The finger movement can be performed by the practitioner or by the client.4 If neurological symptoms are felt within about one minute, the test is considered positive. As with several CTS tests, this test is considered more accurate when combined with other procedures to produce a comprehensive clinical picture.5
The tethered median nerve stress test already involves tension on the median nerve at the wrist. Additional neural tension can be added to the proximal upper extremity to make this procedure more sensitive. Positions to add include lateral neck flexion to the opposite side, shoulder abduction, elbow extension and forearm supination. Note that not all of these motions need to be added. In some cases symptoms will be exacerbated with addition of just one position.
Accurate evaluation of soft tissue pathologies is an essential element of effective treatment. No diagnostic procedures have proven to be the gold standard for accurately identifying carpal tunnel syndrome. Electrodiagonstic testing, which is commonly used by medical professionals, has demonstrated limited effectiveness. It is also not available to most manual therapy practitioners. There is, therefore, a need for alternative accurate physical examination procedures for CTS. Common physical examination procedures are not always sensitive enough to identify the pathology when it exists. Some of the variations described in this article could prove to be useful adjunctive evaluation procedures that help the manual therapist gather more precise information about their client's soft-tissue pathology so that appropriate treatment or referral may result. These variations on standard CTS evaluation tests show that applying biomechanical principles to various assessment procedures allows us to combine the different strategies together for more accurate results. And that is the key benefit of technique synergy.
Click here for more information about Whitney Lowe, LMT.
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