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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.
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?
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).
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.
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.
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.
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.
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.
Lessons from Functional Neurology
Chiropractic neurology, also known as clinical neuroscience or functional neurology, is moving the chiropractic profession forward by leaps and bounds.
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.
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.
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.
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.
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.
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.
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?'
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.
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.
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.
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.
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.
Exploring Charcot Marie Tooth Disease
The longer you stay in practice, the more likely it is that you will encounter a wide array of compromised health conditions that your clients present with. Sometimes a case that might look like a simple tendinosis or common carpal tunnel syndrome is exactly what it seems. But don't get caught in that trap! Often, what might look like a common or familiar problem on the surface may be something very different. For example, systemic nerve conditions are often mistaken for local nerve compression problems because the symptoms can be quite similar.
Charcot-Marie-Tooth (CMT) disease is a perfect example of a systemic disorder that can masquerade as one or several nerve compression pathologies. While this condition may sound like a dental issue, it is actually a hereditary neurological disease named after three physicians living in 1886 — Jean-Martin Charcot, Pierre Marie, and Howard Tooth. CMT is a genetically inherited disorder and does not result from overuse or mechanical nerve compression like many other common nerve problems. Although it is a genetically inherited disorder, generation skipping is not uncommon. It is a fairly common neurological disorder estimated to affect about 125,000 people in the U.S. alone. It is about as common as multiple sclerosis (MS) or amyotrophic lateral sclerosis (ALS or Lou Gehrig's disease). However, because CMT is not life-threatening, we don't hear about it as often.1
This pathology may sometimes go by other names as well. It is often called hereditary motor and sensory neuropathy. It is also referred to as peroneal muscle atrophy; however, this nomenclature can be a little misleading. Several of the sources that describe this condition as peroneal muscle atrophy cite a drop-foot gait as the most significant early indicator of the condition, and ascribe the drop-foot gait to peroneal muscle atrophy. However, a drop-foot gait occurs when there is inadequate nerve supply to the dorsiflexor muscles of the foot. Although the small and sometimes absent peroneus tertius muscle is a dorsiflexor, the primary peroneal muscles (peroneus longus and brevis) are plantar flexors, and therefore atrophy in these muscles does not produce the drop-foot gait.
CMT is usually divided into two predominant types, although recent clinicians have further divided these types into other subgroups. Type 1 is a neuropathy (pathological condition of the peripheral nerves) that occurs from demyelination of the nerve fiber. Nerve fibers in most of the peripheral nerves are covered by a myelin sheath, and it is the myelin sheath that is essential for proper transmission of the neurological signal (Figure 1). In type 1 CMT, there is a mutation in the myelin structure that causes it to become unstable and spontaneously break down. When the myelin breaks down, it is not able to transmit neurological signals properly.
Type 2 CMT is not a demyelinating disorder, but rather a neuropathy that occurs from what is called wallerian degeneration. The process of wallerian degeneration involves not only a breakdown in the myelin structure on the outer surface of the nerve fiber, but also destruction in the continuity of the axon. It is difficult to determine which type of CMT a client has without more specific laboratory evaluation procedures.
EVALUATION AND TREATMENT
One of the most problematic features for assessment of a condition such as CMT is the similarity of its symptoms to other peripheral nerve pathologies. For some reason, symptoms are usually perceived first in the distal lower extremities. It was mentioned earlier that the peroneal muscles are often affected. CMT appears to have the most significant effect on muscles innervated by the deep and superficial peroneal nerves. In this condition, the motor effects of nerve fiber disruption are much more significant than the sensory effects. Therefore, important symptoms to watch for include muscle weakness and lack of coordination rather than numbness or paresthesia. However, this may also be true for other compression neuropathies of the common peroneal nerve. Disruption of signals to the dorsiflexors of the foot is frequent, and that is the reason that foot drop is a common symptom.
Symptoms of CMT usually occur during the second decade of life and may initially present as a general awkwardness or clumsiness, especially in the lower extremities. This is commonly a period of awkwardness for many adolescents as they are growing, so detection is often not made early in development. Motor nerve damage resulting from CMT commonly progresses with age so the condition frequently gets worse as the person gets older.
It is common for clients to develop a pes cavus foot (excessively high arch, shown in Figure 2) as well as hammer toes. Observation of the leg will often indicate thin, "stork-like" legs due to visible muscle atrophy. The client is often able to walk on tip toes (primarily using the plantar flexor muscles), but will have great difficulty walking on his or her heels (primarily using the dorsiflexor muscles). The clinician should also take a detailed and thorough history because certain medications and even vitamins in high dosages may cause an aggravation of CMT symptoms.1
As mentioned earlier, most of these muscular symptoms appear in the lower extremity first, although some may appear in the upper extremity as well. When symptoms affect the upper extremity, the client primarily displays motor effects. S/he will usually report difficulty in operating zippers, buttons, or doing precise movements with the hand.
There is no current cure for CMT, although it is most commonly managed with conservative treatment that is aimed at stabilizing symptoms. Conservative treatments like physical therapy or orthotics are used to address the motor dysfunction in the lower extremities. In some cases, surgery is used to address more severe foot alignment problems like the severe pes cavus foot. However, because motor function may continually change with progressive degrees of nerve damage, surgical procedures may have limited effects. If the biomechanical alignment problem is changed with a surgical procedure and then motor function continues to alter with further nerve damage, the alignment in the foot may be changed rendering the surgical intervention less effective.
Due to the nature of this problem, it is not one that is likely to be corrected by massage therapy. Massage might be used to treat various distal extremity neuropathies and it may appear that there is some type of compression neuropathy occurring, when in fact the client has a hereditary neurological problem that cannot be corrected with physical intervention such as massage. There is no evidence that massage is harmful for CMT but, in the best interest of finding the true source of a client's complaint, it is valuable to know about this condition and consider it as a possible cause for the client's symptoms. If there is evidence that CMT may exist it is important to refer the client to a physician for evaluation.