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A Well-Kept Secret: 5 Element Acupuncture, Part II
Supervising acupuncture interns at a TCM college, it has always struck me how funny it is to hear the clinic manager tell the patients that the Five Element clinic specializes in treating emotions, as if patients with physical pain have no emotions!
God and the Chiropractor
My wife went to church last Wednesday night and brought home a CD of the pastor's message. As she handed it to me, she said, "You should listen to this; you'll like it." Our family regularly goes to church and our faith plays a major role in our lives.
Pain Is Only a Piece of the Puzzle
More often than not, when a patient presents to the office, it is for a pain complaint: headache, neck pain, low back pain, sciatica, carpal tunnel, etc.
Managing Tibialis Posterior Tendon Injuries
The tibialis posterior is the deepest, strongest and most central muscle of the leg, with fibers originating from the tibia, fibula and interosseous membrane.
Joint Supplements for Athletes (Part 2)
A fairly recent discovery in nutrition supplemental medicine has proven to be a breakthrough in maintaining athletic joint health. Research suggests a combination of undenatured type-II collagen and tetrahydro-iso-alpha acids helps revitalize joint function and performance in athletes.
Treating GERD and Incontinence: Focus on Trigger Points
Gastroesophageal reflux disease (GERD) is defined as the regurgitation of stomach acid in the esophagus. Previously, it was thought that GERD was caused by a hiatal hernia, but recent trials suggest the cause is an inability of the hiatal sphincter to contract normally.
Will You Be an Amplifer or a Mute?
These times are changing, and changing quickly. There have been many challenges to this profession throughout the past few years. The challenge is to talk, then talk and talk some more about this medicine.
There Really is No Room for Sexism
Recently, Matteo* (a transgender male) approached me during a break in an advanced shiatsu class in Berlin where he was one of two men in a group of 20 women. "Pamela. Don't forget to remind the translator to include male endings."
Viewpoints: Massage Reduces Nonspecific Shoulder Pain, Improves Function
While seemingly universal, pain and stiffness in the shoulders can be a significant cause of disability. Often a pain that does not go away on its own, shoulder complaints tend to linger, sometimes for 12 months or longer.
How We Can Help the Injured Brain
The majority of patients with mild traumatic brain injuries recover within seven to 10 days. If concussion signs and symptoms continue beyond seven days, the diagnosis changes from acute concussion to post-concussion syndrome.
TCM Congress in Rothenburg is Largest in Western World
In the medieval town of Rothenburg, deep set within the Bavarian countryside in Southern Germany, the TCM Kongress Rothenburg each year draws around 1.200 participants from more than 40 different countries to attend the biggest TCM conference in the Western world.
Synergy Doesn't Happen in Silos: Acupuncture in Hospitals and Other Healthcare Settings
As acupuncture and traditional East Asian medicine continue to intersect and integrate with biomedical approaches, the conversation about integration expands and becomes richer.
News in Brief
ACA Exec. Vice President Out, Acting EVP In; F4CP Executive Director Retires; New ED Named.
An Excerpt from TCM Case Studies: Pediatrics
This excerpt is reprinted with permission from Jamie Wu. TCM Case Studies: Pediatrics was released in 2014 by People's Medical Publishing House.
Striking a Blow to the Medical Monopoly
The U.S. Supreme Court has issued a landmark ruling in North Carolina State Board of Dental Examiners v Federal Trade Commission.
What Do You Know About Physician Compare?
Physician Compare is a website that allows consumers to search for and obtain information about physicians and other health care professionals who provide Medicare services.
The Need for a New Medical Model: A Challenge for Biopsychosocial and Ecopsychologica Medicine
Chinese medicine speaks of alignment between humans, heaven and earth. It is a complex view with a focus upon relationship. These are comprehensive ideas with no specific terms in contemporary medical practice.
Recreational Cannabis Use and TCM
Many people are drawn to cannabis for its effects physically, mentally and emotionally. Medically, cannabis has some legitimate uses, however the scope of this article is limited to the recreational use of cannabis.
The Way We Are Designed: A Conversation with Gil Hedley, PhD
I was first introduced to the work of Gil Hedley by Tom DiFerdinando. He gifted me Gil's DVD series.
Treating Beyond Pain
More often than not, when a patient presents to the office, it is for a pain complaint. Headache, neck pain, low back pain, sciatica, carpal tunnel... The pain is often the focus of the patient's mindset, and they don't often have any thought of what comes after the pain.
The Dietary Supplement Research Dilemma
I do not care what the truth is, one way or another; I just want to know it. And when it comes to dietary supplements, the truth can be hard to find for a number of reasons.
Keep Seniors Safe: Age-Proofing the Home
I want to give Dr. Claudia Anrig kudos for her Dec. 1, 2014 column, which highlighted safety issues youngsters might encounter in the home.
Older Patients, Stroke Risk and Manipulation
The first population-based study in the United States to evaluate stroke risk following spinal manipulation – and the first involving older adults – suggests that "[c]hiropractic cervical spine manipulation is unlikely to cause stroke in patients aged 66 to 99 years with neck pain.
The Body's Load-Sharing Hub: The Thoracolumbar Fascia
Have you ever wondered why you swing your arms when walking? It's largely due to kinetic energy being stored and released in the thoracolumbar fascia (TLF), as forces from the lower body transfer upwards - and vice-versa.
Consider, for example, direct mechanical force-transmission from the lower extremity to the pelvis and the trunk, as load (tension) is transferred between the hamstrings, the sacro-tuberous ligament and gluteus maximus, and on to the contralateral latissimus dorsi, by means of forces transmitted via the superficial and deep layers of the TLF.
Because of their direct connections to the TLF, this transferred load also directly influences the behavior of the erector spinae muscles, as well as external and internal obliques, transversus abdominis and serratus posterior inferior ... and more. Any dysfunctional situations, in any of these (or anything they connect to and with), has the ability to alter the function of all the other listed muscles, with unpredictable symptoms emerging relating to either restriction, pain or motor control, or all of these.
The "load-transfer" process involves a virtual spring-loading of the amazing TLF junctional area, the hub, where forces from the lower body, upper body, abdominal area and the trunk are spread and shared. This virtual hub contains some remarkable features where distribution of load is even more concentrated – such as the Lumbar Interfascial Triangle (LIFT) - which is discussed later in this article.
Therapists Need To Know About The TLF
How might awareness of these links help your work to be more effective? Quite simply - manual therapists (and those working with movement/exercise methods) who understand the multiple connections formed, via the TLF, can focus their methods more appropriately.
For example, a painful knee can - in many cases - be shown to be connected to gluteus maximus dysfunction, which may itself be being negatively influenced by inappropriate load reaching it from the contralateral latissimus dorsi – which is itself being influenced by myofascial events in pectoral and cervical structures.
Stecco et al (2014) describe their findings following 12 successive dissections: "In all (12) subjects gluteus maximus presented a major insertion into the fascia lata, so large that the iliotibial tract could be considered a tendon of insertion of the gluteus maximus ... [explaining] ... transmission of the forces from the thoraco-lumbar fascia to the knee ... possibly explaining why hypertonicity of gluteus maximus could cause an iliotibial band friction syndrome (IBFS) or, more generally, knee pain."
Sliding And Gliding Between Fascial Layers
Each layer of dense fascia is separated from the layers above and below by a thin layer of loose connective tissue that permits the different deeper layers to slide on each other. This allows the multiple directions of force, generated by different muscular orientations, to be transmitted smoothly.
Where unexplained musculoskeletal dysfunction exists (restriction, or pain for example) it is possible that reduction in the sliding/gliding function between the different fascial layers that make up the TLF, might be causing it to fail in its efficient transmission of load/force.
When it is healthy and operating normally, this remarkable structure, (the TLF) structurally and functionally connects the legs to the arms, the abdominal muscles to the low back muscles, the hamstrings to the neck, the gluteal muscles to the arms – simultaneously transferring forces in multiple directions, while also allowing sliding and gliding functions between its various layers of deep and superficial fascia and muscle. It therefore deserves the focused attention of all manual therapists – for when it is not functioning well due to trauma, inflammation, overuse, misuse, disuse and or age - a variety of symptoms can emerge – ranging from back pain to poor motor-control and balance problems.
Helene Langevin and her colleagues (2011) have shown that reduction of fascia's gliding potential in the thoracolumbar area (described technically as "reduced thoracolumbar shear strain"),is strongly associated with increased thickness of some fascial layers in the TLF, and in males in particular, this seems to predispose to low back pain. This gender-bias between a free sliding motion of fascia in the TLF, the thickness (or "densification") of some connective tissue layers, and low back pain, remains unexplained. Note: Some of the main reasons for fascial dysfunction are discussed later in this article.
As previously mentioned, the thoracolumbar fascia (TLF) integrates forces deriving from connective tissues, as well as numerous active muscular structures that attach to the fascial layers, including aponeurotic and fascial structures that separate paraspinal muscles from the muscles of the posterior abdominal wall.
The superficial posterior layer of the TLF is mainly an aponeuroses of latissimus dorsi and serratus posterior inferior, while deep to this is sheath that encapsulates the paraspinal muscles that support the lumbosacral spine.
Where this sheath meets the aponeurosis of transversus abdominus, it forms a seam-like ridge (known as as a raphe [pronounced "rafe" – see illustration of the TLF]. This dense septum is the junction of the structures anterior and posterior to the spine - where the Lumbar Interfascial Triangle (LIFT) is formed.
The LIFT is a remarkable structure (a "roundhouse" in Tom Myers terminology) that helps to distribute load from the abdominal and extremity muscles into, across, and from, the TLF.
Inferiorly, all the layers of the TLF fuse, to merge with the posterior superior iliac spine, and the sacrotuberous ligament, (which links directly to the hamstring group) - assisting in support of the lower lumbar spine and sacroiliac joint, and sharing load with the lower extremity.
Load reaching the LIFT from the abdominal muscles, latissimus dorsi, the lower extremity and pelvic muscles, are therefore appropriately distributed, in order to assist in stabilizing the spine, trunk and pelvis.
Strain Transmission During Stretching
Research has now explained more about how muscular forces are transferred – largely via fascia – to surrounding and distant tissues. For example, Franlklyn-Miller and colleagues (2009) have shown that when the hamstring group of muscles are stretched – as in straight-leg raising – whatever the degree of force being used in that stretch is multiplied greatly – so that 240% of that load reaches the iliotibial band, and 145% of the load transfers to the same-side low back, via the TLF.
The evidence is quite clear therefore – that the use of the word isolated in conjunction with the word stretching is difficult to justify. We need to learn more about which tissues are affected when stretching or compression is used – where load transfers to – and from - and where dysfunction might be coming from when we identify it!
The TLF As a Sensory Center
The thoracolumbar fascia is a richly innervated, with marked differences in the distribution of the nerve endings, over various fascial layers: The superficial fascia contains a dense presence of sensory mechanoreceptors (such as Pacini receptors and Ruffini endings). Substance P-positive free nerve endings—assumed to be nociceptive—are exclusively found in these layers. "The finding that most sensory fibers are located in the outer layer of the fascia, and the subcutaneous tissue, may explain why some manual therapies that are directed at the fascia and the subcutaneous tissue (e.g. fascial release) are often painful."
How Fascial Problems Start
Fascial dysfunction may result from slowly evolving trauma (disuse, overuse and misuse), or sudden injury (abuse) leading to inflammation and inadequate remodeling (such as excessive scarring or development of fibrosis):
The more manual therapists know about and understand structures such as the TLF the more they will be able to understand their patient's symptoms, and be able to help them towards recovery from pain and restriction.
New Book on Fascial Dysfunction
In my new book, Fascial Dysfunction: Manual Therapy Approaches, I have explored and explained fascia's multiple roles in the body, as well as the ways fascial dysfunction starts and develops – based on translation of the avalanche of scientific research that is emerging.
In addition, the book contains guides to assessment protocols (including a chapter by Tom Myers), as well as chapters that examine a wide range of fascia-focused treatment approaches - involving contributions from approximately 20 leading experts.
In a future article, I will focus attention on which manual approaches have demonstrated evidence of efficacy.