resourcesABOUT MT AUTHOR GUIDELINES CLASSIFIEDS EDITORIAL CALENDAR MEDIA GUIDE MASSAGE MART SCHOOLS & EDUCATION FEEDBACK
Using the Lens of Chinese Medicine
One of the most common medications I see in clinical practice on a daily basis is fluoxetine or Prozac. Consequently, I hear many complaints concerning the side effects of this medication and am frequently asked by patients to help manage these side effects with acupuncture and Chinese medicine.
Upgrade to "Parker 2.0" in Las Vegas
Continuing your education and refining your practice: two key elements of a successful chiropractic career. Parker Seminars promises both as it celebrates its 65th anniversary in Las Vegas next February, according to Parker University President, Dr. William Morgan, and seminar consultant Dr. Mark Sanna.
Pediatric Asthma: A Case Study
I have had very good success with pediatric asthma, combining acupuncture with Chinese herbal products. Treatment is given over four to eight months, twice monthly, with herbal formulas rotated every month.
Six Things Every DC Should Know About the Zika Virus
The Zika outbreak continues to spread across the continental United States and U.S. territories. We offer this brief overview on this important public health problem for the practicing doctor of chiropractic.
Decoding the Mystery of Medical Insurance Acceptance
In the constantly evolving profession of acupuncture, one of the least understood areas is medical insurance acceptance. The profession is filled with controversy surrounding this topic: Is it ethical?
National Board Apologizes for Testing Issues
The National Board of Chiropractic Examiners (NBCE) has issued a formal apology following a series of computer-based testing malfunctions that impacted two separate examinations (March and June 2016) and caused "widespread confusion and frustration" to the nearly 1,500 examinees taking the tests.
Getting Paid by Medicare Is Getting a Major Adjustment
The 2015 Medicare Access and CHIP Reauthorization Act (MACRA) was signed into law to implement a new approach to clinician payments and replace the Sustainable Growth Rate formula.
Workers' Back Pain: Causes, Costs & Solution
You will want to share two important papers published in the past several months. Why? When read separately, each provides valuable information relevant to your patients, community and practice; together, they tell a compelling story.
First Annual ICD-10 Updates Take Effect
Yes, there was an update to ICD-10 codes on Oct. 1. It was a regular update to the diagnosis coding system and will take place every Oct. 1, just as it did when the ICD-9 system was in place.
Treating Peripheral Neuropathy: Multi-Faceted Approach Including Laser Therapy
Peripheral neuropathy affects at least 20 million people in the United States1 and nearly 60 percent of all people with diabetes suffer from diabetic neuropathy. Many suffer from the disorder without ever identifying the cause.
Update from the International AIDS Conference
The 21st International AIDS Conference in Durban, South Africa, brought together more than 15,000 of the world's leading scientists, activists, funders, policy makers, and consumers from 153 countries.
ITB Syndrome: Treat the Tensor Fascia Latae
Iliotibial band syndrome is usually the result of repetitive knee flexion, such as in runners or cyclists. Pain may be experienced in the knee and/or the hip. The patient may express a sense of the hip dislocating, popping or snapping.
Pediatric Footwear: Function Over Fashion
As practitioners, it is not uncommon for parents to bring us their children to treat or ask us questions related to the pediatric population. Children's feet tend to be a perplexing region for parents and practitioners alike.
Natural Cancer Prevention: Pomegranate for the Prostate
In recent years, the ingestion of pure pomegranate juice (8 ounces per day) has been shown in clinical studies with human subjects to slow, and to some degree, reverse, the progression of prostate cancer – the second leading cause of cancer death in North American men.
Power to the Patient
Against a backdrop of splintered political parties, polarizations within nations, civil unrest, and distrust of established government (such as the growing anti-Washington, D.C. sentiment) comes the not-so-surprising finding that health care authorities and practitioners (with perhaps the exception of insurers) are turning over more and more powers to the individual patient.
Going Beyond Just Feeling Good
We all know that most patients come to us for some pain complaint: neck pain, back pain, sciatica, carpal tunnel, etc. We also all know that acupuncture is a great first-line care for these issues, as well as supporting overall health and wellness.
U.S. Olympians Have a DC in Their Corner
It's probably old news to you that doctors of chiropractic play an increasingly prominent role in treating athletes, from youth sports participants to weekend warriors, to elite / professional competitors.
Four Ways to Attract Patients
Acupuncturist A has been in practice for six years and has struggled since day one. She spends as much time and money on marketing as she can, but since her practice is slow, her budget isn't that big.
Integrative Cancer Care: Chiropractic for Chemotherapy-Induced Hiccups
Hiccups (singultus) are a frequent occurrence during cancer treatment. The cause of the hiccups may be the chemotherapy drug itself, such as Cisplatin; or the prophylactic use of corticosteroids such as Decadron, which is used to prevent nausea and/or vomiting.
Treatment Success at the Won Institute
According to the World Health Organization's 2003 report titled, "Acupuncture: Review and Analysis of Controlled Clinical Trials," acupuncture has been shown to improve many physical, emotional, and mental conditions.
August, 2014, Vol. 14, Issue 08
Searching for Trigger Points: Tips to Consistently Relieve Pain
By Valerie DeLaune, LAc
How much do you really know about trigger point therapy? Most likely you received 15 to 30 hours of training in trigger points in your massage school, or at least have purchased charts with referral patterns and books on trigger points.But did you learn a systematic approach to identifying likely culprits and resolving perpetuating factors – the things that cause and keep trigger points activated? Would you like to dramatically increase your success rate with resolving your client's pain? Since about 75% of pain is caused by trigger points, learning how to treat them is essential to a successful medical-massage practice.
Your Brain on Trigger Points
What you do with your brain is far more important than what you do with your hands. Massage therapists can successfully treat trigger points by applying pressure for eight to sixty seconds, by repeated stroking or with a combination of or variations on those techniques. But for any technique to work (whether manual therapy or needling), it must be applied in the correct place.
Trigger point therapy is like doing "detective work," you need to know how to use the "pain guides" to determine which muscles to search for trigger points. You also need to know how to assess your clients for perpetuating factors, the conditions that cause and keep trigger points activated. Teaching self-help techniques helps your clients participate in their healing process and provides them with tools they can use in the future.
Medical histories and pain mapping: get a comprehensive medical history from your client which at a minimum identifies all of the potential perpetuating factors that may be causing their trigger points. Go through the medical history at the beginning of the first treatment and ask questions to clarify the information they have given you; this should take about 1.5 hours for the first session. Continue to ask them questions as your treat them and spend a few minutes checking in with them and taking notes at the beginning of each subsequent treatment.
Have them mark their pain patterns on some kind of outline of the body before each treatment (known as "pain mapping") and ask them to rate the intensity and frequency of their symptoms so that you can track progress, or lack thereof. Try and get them to be as specific as possible so that you can match their referral patterns with common patterns on charts. Don't let them mark "x"'s or big circles, or color in large areas a solid color. Show them your trigger point referral pattern charts and explain to them that you are trying to match their pain patterns with some common patterns so that you will know where to start looking for the source of their pain.
Even if they are not improving, you can use that information to modify your treatment. Chances are you haven't located all of the trigger points that need treatment, there are perpetuating factors that still need to be addressed, or you need to refer them out for further evaluation since about 25% of pain is caused by conditions other than trigger points.
Use pain guides: about 74% of commonly found trigger points are not located within their area of referred pain. Unless you know where to search for trigger points, and you only work on the area where your client feels pain, they probably won't get relief. Familiarity with referral patterns gives us a starting point of where to look for the trigger points that are actually causing pain, but you must understand how to use the pain guides so that you will know which muscles to check.
For example, if your client has pain in their temple area, you need to know to check the temporalis, upper trapezius, sternocleidomastoid and some of the muscles in the posterior neck. Of these muscles, only the temporalis may contain trigger points which are located within the area of pain referral, so most of the time, unless you know which muscles to check, you won't come across the trigger point by accident.
It's not sufficient just to have a set of charts on your wall to look at and try to find referral patterns, since none of them have all of the potential referral patterns diagrammed. You also need to keep in mind that the books and chart sets only diagram the most common referral patterns and trigger point locations. Your client may have an uncommon referral pattern and trigger point locations. Pain guides and referral pattern diagrams are only a starting point.
Also, keep in mind that trigger point referral patterns from multiple trigger points can overlap, causing a composite referral pattern, as is often the case with migraines and other headaches. Buy at least one comprehensive trigger point book that includes pain guides so that you can see a list of muscles to check for any given part of the body, and buy a set of referral pattern charts to keep on your treatment room walls.
Often trigger points in different muscles can cause very similar referral patterns. For example, common referral patterns caused by trigger points in the supraspinatus, infraspinatus and scalenes are almost identical. One way to narrow down the culprit(s) is to know the symptoms and perpetuating factors for each muscle.
Spend some time reviewing your clients medical history form, pain mapping diagrams, and your chart notes and compare them with information for each muscle found in a comprehensive trigger point book. Trigger points can cause many non-pain symptoms which can help you narrow it down. For example, if your client comes to you with symptoms such as headaches in the frontal area and/or base of the skull, but also reports eye or ear symptoms such as tinnitus or eyelid twitching, that would be a clue to check the sternocleidomastoid muscle for trigger points. Trigger points can cause symptoms such as diarrhea, urinary frequency, menstrual cramps, dizziness and buckling or locking knees – symptoms most clients or health care providers wouldn't think to associate with trigger points.
You should decide which trigger points to treat first. Doctors Travell and Simons, who wrote the two-volume set of medical texts on trigger point treatments, listed muscles in their book's pain guides in the order they found were most likely to be causing the pain referral. In the previous example, they list the trapezius first and the posterior neck muscles last. But keep in mind, that depending on your geographic locale and practice specialty, you may find the order might be different for your practice; your clients will have different patterns depending on their work and hobbies and underlying medical conditions.
You also need to be familiar with primary trigger points and satellite trigger points. Once a trigger point has referred symptoms to any given area for any length of time, trigger points will form within the zone of referral, known as satellite trigger points. Then the satellite trigger points will cause their own symptom referral pattern, causing what I call a "trigger point chain-reaction." For example, there are at least eleven muscles that may contain trigger points which refer pain to the posterior portion of the deltoid muscle (the levator scapula, scalenes, supraspinatus, teres major, teres minor, subscapularis, serratus posterior, latissimus dorsi, triceps and iliocostalis thoracis). If you only treat the satellite trigger points in the deltoid, the deltoid pain will keep returning because you didn't treat the primary trigger points.
If your client has multiple symptomatic areas, don't try to treat everything in one session. Have your client prioritize their two areas of most concern, and focus on those. If you try to do too much, you likely won't treat any one area well. If your client has widespread pain, chances are they have some kind of systemic perpetuating factor that needs to be addressed and you will need to refer out to a practitioner who can order laboratory or other tests. During subsequent treatments, you may decide to continue working on the same area before moving onto another symptomatic area, or you may decide that other areas of pain are related and need to be addressed before the primary area of pain can be completely resolved.
Any decrease in intensity and/or frequency of symptoms, or decrease in size of the symptomatic area is an improvement that indicates that you treated at least some of the pertinent trigger points. Be sure to ask how they felt immediately after the last treatment. If they felt better even for awhile, ask what they were doing when their symptoms returned. Often that is a clue to at least one of their aggravating perpetuating factors and an indication that it needs to be addressed for lasting relief.
Next, identify and eliminate perpetuating factors. Trigger points may form after a sudden trauma or injury or they may develop gradually. Common initiating and perpetuating factors are mechanical stresses, injuries, nutritional problems, emotional factors, sleep problems, acute or chronic infections, and organ dysfunction and disease, though there are many more. If perpetuating factors aren't identified and treated, your client may improve temporarily, but their symptoms will keep returning. Most clients will have multiple perpetuating factors. When you buy a trigger point book, make sure it contains extensive sections on perpetuating factors and become very familiar with each factor and its symptoms.
Because resolving these factors are crucial for long-term relief, you need to be familiar with all of the potential perpetuating factors and the symptoms of each. For example, if your client is suffering from fatigue, depression and insomnia, you might suspect anemia or hypothyroidism, and you may need to refer your client to a health care provider who can order laboratory tests.
Even if it is not within your scope of practice to diagnose and treat many of these perpetuating factors, as a massage therapist, it is important that you have some ideas of whom you can refer your client to, who can diagnose and treat particular perpetuating factors that you suspect.
Learn self-help techniques so you can teach them to your clients, if it is within the scope of your practice. Refer them to books that reinforce self-help techniques for perpetuating factors, pressure techniques and stretches, especially if it is not within the scope of your practice. Clients who use self-help techniques and eliminate their perpetuating factors get better at least five times faster than those who just have you work on them.
Be careful not to overwhelm your client with too many suggestions; if you give them too many, they likely won't do anything. My recommendation is to recommend to clients no more than two self-help techniques per session, typically one pressure and stretch combination and one perpetuating factor to resolve. Help them find a way they can be successful so they will want to do more. For example, if you think walking would be beneficial for your client, suggesting an hour per day five days per week might be unrealistic for that client. Ask them if they could manage 20 minutes per day for three days per week. At their next visit, ask them how it went. If they weren't able to do it, find out why and problem-solve with them to see if you can find something they can/will do. Once they feel the benefits, they will likely want to do more. Above all, don't criticize them for failing to follow your suggestions. Keep a problem-solving dialogue going with them to try to find something they can achieve and feel successful.
A Protocol, Not a Technique
The trigger point protocol developed by Dr. Janet Travel and Dr. David G. Simons includes additional diagnostic techniques such as range-of-motion evaluation and gait analysis, but the treatment tips given here are the most easily integrated into your existing medical massage practice and most likely within the scope of your practice.
While there is a lot of information to learn about trigger points and how they develop in each muscle and manifest symptoms, fortunately there are now several good sets of charts and reference books to choose from. Trigger point continuing education classes are offered around the country, including several 100+ hour programs that teach the full protocol. Learning about trigger points will improve both your assessment skills and your success rate.
Valerie DeLaune is a licensed acupuncturist and certified neuromuscular therapist. DeLaune has authored eleven books on trigger point self-help techniques. Pain Relief with Trigger Point Self-Help, a book on CD ROM was released in 2004 and the print format was released in 2011. DeLaune teaches workshops in the U.S. and currently resides in Alaska. For more information, visit www.triggerpointrelief.com.
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