New Opportunities for DCs
For decades, the model chiropractic practice has been the single-doctor practice. Recent surveys have found that approximately two-thirds of U.S. doctors of chiropractic still practice this way, with another 20 percent practicing in multiple-chiropractor practices.
Acupuncture's Standard of Care
Both a concern and critique of acupuncture, frequently espoused by the bio-medical community is, "there is no standard of care in acupuncture." The following is why I believe this statement is disingenuous at best.
Catch the Workplace Wellness Wave
Do you offer workplace wellness services to local businesses? If not, you might want to consider this lucrative channel for expanding your practice. Workplace wellness programs and wellness-related benefits have grown in popularity over the past several decades.
Prevention: Stop Recurrent Urinary Tract Infections
The recurrent urinary tract infection (UTI) is one of those nuisance conditions that can play havoc with quality of life, and this particular infection is much more common than most people realize.
Practice Pearls: There's More to ROM Than Meets the Eye
As part of my neuromusculoskeletal examination, I perform range-of-motion (ROM) evaluations. I can "eyeball" the range and measure, I can use a goniometer and measure, I can use my phone app and measure, or I can use various other instruments to help determine degrees of motion.
NBCE to Reinstitute Computer-Based Exams
The National Board of Chiropractic Examiners (NBCE) has announced it will reinstate computer-based testing in January 2019 courtesy of a partnership with testing and assessment solutions provider Prometric.
Dropping Insurance: 4 Steps
My office manager just got off the phone with the secretary of a long-standing patient. I have treated this woman and 10 members of her family for more than a decade. She has, as have all of my patients, paid my fee at the time of service since I dropped insurance in 1997.
Diagnosing & Treating Aggressive Energy
Recently, there has been an article, and subsequent discussion, about the subject of Aggressive Energy (AKA "AE"), including ways to detect its presence and an alternative method of treating it.
First World Spine Care Graduate: Hildah Molate
Hildah Molate, the first World Spine Care (WSC) scholarship student, graduated from Palmer College of Chiropractic earlier this year and is now working at the WSC community spine clinic in Shoshong, Botswana.
Reducing Allostatic Load & Stress Through Heightened Awareness
Your contemporary mental health and psychotherapy colleagues may often approach the treatment of allostatic load as a mental health condition and use prescription psycho-pharmaceutical medicine to affect general and specific central nervous system (CNS) pathways and brain neuro-chemistry medicine to alleviate the associated symptoms.
Is Primary Spine Care the Answer for Chiropractic?
Recently, we sat down with Mark Studin, DC, FASBE(C), DAAPM, DAAMLP, to discuss the state of chiropractic and why primary spine care may hold the key to chiropractic's future. Read what he had to share in this exclusive interview.
Official NCCAOM Practice Tests
The National Certification Commission for Acupuncture and Oriental Medicine (NCCAOM) is excited to announce the launch of the new NCCAOM Exam Preparation Center.
Transforming Exam Delivery
The NBCE Board of Directors has never wavered on its promise to deliver an excellent, on-campus computerized testing experience to students. Likewise, there has never been a compromise to the delivery of fair, valid and legally defensible exams.
Bastyr University: On the Front Lines of the Pain Epidemic
At University of Washington's Harborview Medical Center, the Seattle region's only Level I Trauma and Burn Center, the demands for in-patient care are dramatically different from a private clinic environment.
TCM Codes for the World
I just received an email concerning the ICD-TM11 codes. The World Health Organization (WHO) will be presenting the new ICD-11 codes to World Health Assembly very soon.
It's Time for a Functional Approach to Chronic Illness
It seems one of the more modern buzzwords is chronic, referring to diseases – that is to say, "ongoing and incurable." However, we can take a different perspective and recognize that, although the body may have been traumatized and injured, healing should always be viewed in the realm of possibility.
Spring Allergies & The Spleen: Looking at Pattern Differentiation
As the season of Spring fades away and we shift into the warm summer months, many patients suffer from chronic allergies. This is by far one of the most common issues I see in the clinic as well as often mistreated and misdiagnosed.
Paving the Way to Integrative Health & Wellness
Jared Polis (D-Colorado) and Mike Coffman (R-Colorado) launched the integrative health and wellness (IHW) caucus in October, 2018.
Multi-Dimensional Acupuncture: 3D, 4D & 5D
Maggie is an intuitive healer and workshop leader who I met on a recent hike. While we were talking she told me how she had to take it easy because of her knees. She said that her doctor told her that she has the early signs of arthritis.
Cyber Threat Checklist: Defend Your Business With These 10 Steps
Living in an internet connected society brings many conveniences and benefits. The power of the internet to connect us with customers, store data, and find information has opened the door for many small business owners to grow and flourish.
Missed Causes of LBP: It's the Syndrome, Not the Subluxation
When I read the chart notes of other chiropractors, I am usually disappointed. They list what vertebrae are fixated or misaligned. They may describe the involved fascia and muscles.
Regenerative Medicine: How to Do It by the Books
The "lay of the land" for regenerative therapies, including but certainly not limited to adult stem-cell treatments, seems to change almost daily.
A Novel Way to Prevent Elderly Falls: Toe Strength
In any given year, nearly 40 percent of senior citizens ages 70 and older will fall at least once. Each fall significantly increases the risk of not only sprains, strains and contusions, but also fractures.
Chiropractic's Next Frontier: Adjusting the Microbiome
Restoring a healthy microbiome to help treat disease may be the next frontier in chiropractic offices around the country.
Old Trend, New Risks: Heavy Weight Training
With more opportunities to exercise than ever, a greater selection of exercise options, and the subsequent opinions supporting and challenging their merits, it's easy to be confused as to which approach is best.
Better With Chiropractic
While chiropractic care is receiving high levels of exposure these days, most pain patients who consult with a health provider still do so with their primary-care MD. And of course, that means in most cases, they're receiving standard medical care, not chiropractic.
News in Brief
Parker University Launches New Open-Access Research Journal for Chiropractic; Western States, Cleveland-KC Name New Deans of Chiropractic Colleges; Sherman College Goes Tobacco-Free; Life University Wins 11 Awards.
Prompting Memory: How to Stimulate Cognition
Recently I gave a talk titled, The Art of Memoir – Tapping the Past to Sharpen the Present at a senior lunch event in Austin, Texas.
State by State: Chiropractic Leads Changes in Health Care
Monumental legislative bills in support of the chiropractic profession were passed recently in Washington, West Virginia and Oregon. Here is a review of this important legislation, state by state...
The Acupuncturist and the Opioid Crisis: Conquering Pain & Addiction in the U.S.
The current opioid epidemic dominates the discussion among national health leaders, recovery advocates and families nationwide. Opioids include heroin as well as prescription pain relievers such as oxycodone, hydrocodone, codeine, morphine, fentanyl, and others.
March, 2009, Vol. 09, Issue 03
Prenatal Massage and Pre-Treatment Evaluations
By Elaine Stillerman, LMT
In addition to learning what to do to support your pregnant/postpartum clients and relieve their common discomforts, part of the prenatal professional training must include how to recognize when a massage should not be provided. And part of the dialogue that you have to establish with your clients is that when you feel a massage should be postponed until after they have been checked by their care providers, you mean it and stand behind your decision. It is not easy to tell a deserving client that her much-coveted massage is not going to happen, but if your pretreatment evaluations are positive, that is the only safe and responsible choice you can make.
But upon what standards or guidelines do you base your decision? The answer comes from understanding prenatal and postpartum anatomy and physiology. By the end of the pregnancy, most women have an increase of up to 40 percent more interstitial fluid. This excess fluid generally pools in her extremities, especially the legs and feet. In most cases, this "gravity" edema can be treated effectively with manual lymphatic drainage (MLD) and elevation of her legs. And although the swelling can be extensive due to poor posture, poor diet, excessive sodium in the foods she eats, standing a great deal during the day, weather conditions, and restrictive clothing to name a few contributing factors, it poses no health risk. Appropriate massage (MLD) will reduce the swelling by enhancing lymph absorption.
Assessing Serious Conditions
There are times, however, when the swelling is a symptom of a more serious condition - preeclampsia. This hypertensive condition is extremely dangerous for mother and her baby. Preeclampsia is a condition characterized by swelling of the face, hands, and feet, elevated blood pressure, excessive fluid retention, and protein in the urine. It is sometimes accompanied by severe headaches (or migranes) with or without optical "floaters." If preeclampsia is suspected or confirmed, all massage must be avoided until her blood pressure stabilizes and her care provider affirms that she and her baby are out of danger.
In order to test for the presence of this potentially life-threatening illness, we assess the swelling by pressing on the lowest part of each leg, just above the ankle. Press for a count of 5. If the indentation does not fill, or remains pitting, and the ischemic region does not appear red again within 10-30 seconds, massage is contraindicated and the client must see her care provider immediately. Some women develop preeclampsia during postpartum recovery, so the test for pitting edema must continue for the first six weeks, or during the puerperium recovery.
In order to protect against hemorrhaging during childbirth, pregnant women produce more blood clots. During the second trimester, there is an increase in the synthesis of plasma fibrinogen (coagulating factors VII, VIII, IX, X, and fibrinogen) that continues throughout the first few months (8-10 weeks) of postpartum. The potential in blood clot formation (thromboembolism) is five to sixfold during pregnancy and up to three months postpartum. These clots primarily appear in the deeper veins of the legs: the femoral, iliac, and saphenous veins. In order to prevent dislodging these clots, the safest and most effective modality to employ is, once again, MLD.
The risk factors for clots during pregnancy include a sedentary lifestyle, being confined to bed rest, a maternal age of 30 or older, being over-weight, having an autoimmune disease like lupus, and being pregnant with the fourth (or more) child. In addition, clots may develop because of the weight of the gravid uterus slowing iliac and femoral circulation, sluggish blood flow, venous stasis, increased blood volume, and higher levels of progesterone relaxing the smooth muscle fibers. (Although many of these changes reverse soon after childbirth, fibrinogenic activity doesn't normalize until 8-10 weeks postpartum.)
Illness and death from venous thromboembolism occur 1 in 1,000 to 1 in 2,000 pregnant and postpartum women. These figures do not reflect deaths which occur after the traditional 6-week recovery period.
Deep venous thrombosis (DVT), which occurs mostly in the left leg and its resultant pulmonary embolism are the leading causes of preventable in-hospital mortality in the United States. In general (not necessarily related to pregnancy and postpartum), the signs of DVT are commensurate with the degree of blockage in the vein and inflammation of the vessel wall. Many people, including those who are pregnant, are asymptomatic, but it is important to evaluate both legs before massaging your pregnant or postpartum mother for the signs that we can assess.
Surgeries, like Cesarean sections, increase the risk of thromboemboli and the sequelae of a pulmonary embolism. After surgery, most clots occur in the left leg, although both legs must be evaluated.
While lightly placing your hand(s) down the back of her leg (you can perform this before she gets on the treatment table or through the sheet with your client lying on her side), palpate for localized unilateral swelling, heat, pain (which occurs only 50 percent of the time), tenderness on the over-lying dermatome (50 percent of the time), muscle contraction, and possible redness. Keep in mind that the edematous leg will feel hot all over; remember that you are feeling for localized symptoms. In addition, her legs will feel hotter around the joints where the fluid tends to aggregate and in areas where the veins are superficial like the backs of her knees or her ankles.
The second test is specifically for the calf muscles and evaluates the presence of clots in the saphenous vein. However, this Homan sign or Homan check is present in less than one-third of patients with confirmed DVT and is positive in more than 50 percent of patients without DVT, so it is nonspecific. Still, it is a relatively fair barometer to use. With her leg extended, flex her knee to about 5 degrees. Dorsiflect (bend or flex backward) her foot. Any sharp pain in her calf may indicate a positive result. If you suspect that a blood clot is present, do not massage and refer her to her care provider immediately.
To effectively use these pretreatment evaluations, let your pregnant (postpartum) clients know that you will be doing them before each treatment. Once you become proficient, they will take less than one minute to do collectively. If you suspect pitting edema or the presence of a blood clot, explain this to your client in a calm manner and suggest that she seek immediate medical confirmation. I usually suggest that these evaluations are not absolute medical diagnoses but rather indicate that caution should be exercised, and massage should not take place. Instead, I offer my clients an opportunity to book another appointment, once the situation has been addressed, "on the house." However, it never fails that my clients return and pay, regardless of my offer.
Make these pretreatment evaluations a part of your prenatal/postpartum practice. You will feel more confident about giving the massage and your clients will be grateful that you are taking appropriate care of them and their babies.
Click here for previous articles by Elaine Stillerman, LMT.
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