Multichannel Access: Software for a Better Customer Experience
It is no secret that today's consumer has high expectations when it comes to how and when they can contact a business. In fact, one of the reasons clinic management software has become so popular with acupuncture practitioners is they allows customers to book appointments and make payments online day or night.
The international standardization conference was held this year in Shanghai, China (June) - this was the ninth plenary session. Meetings for technical committees, or working groups also took place at the conference.
It's Time to Reward Yourself
An interesting study recently published in the Journal of the American Heart Association (JAHA) confirms what we all learned when we were children – and serves as food for thought as to how you can improve your practice and your personal life.
A Historic First for Chiropractic Assistants
The New Jersey State Board of Chiropractic Examiners will begin issuing licenses as early as Nov. 1, 2018 to chiropractic assistants who have undergone a 500-hour training course and passed a competency exam.
A New NCCIH Director ... One That Backs Acupuncture
The third time is a charm—the National Center for Complementary and Integrative Health (NCCIH), a division of the National Institutes of Health (NIH), announced it's newest director, Dr. Helene Langevin.
"Don't Crack My Neck": What Do You Do Next?
It's Monday morning and your first new patient of the day, a 35-year-old female, presents with chronic headaches and neck pain. The patient was referred by her primary care provider for evaluation and management without the use of cervical manipulation.
The Benefits of Going Paperless
The benefits of going paperless in your practice are profound. If you haven't done it yet, here's why you should.
Chiropractic Management of Patellofemoral Arthralgia
Patient reports with pain in the front part of her right knee, especially during and after her weekly Zumba class. She states there has been no injury of which she is aware. No outward sign of injury is observed.
That's a Wrap: Compression Bands for Contemporary DCs
Over the past decade, compression bands have been increasingly utilized in trainer and manual therapy offices. I was first introduced to the compression band by Kelley Starrett, author of Becoming a Supple Leopard, and have since been using it as a teaching tool.
Support Patients With Multi-Channel Customer Service
It's no secret that today's consumers have high expectations when it comes to how and when they can contact a business. In fact, one of the reasons clinic management software has become so popular is that they allow patients to book appointments and make payments online day or night.
Vaccine Injury? The Autism Debate (Part 2)
As suggested in my first article on this topic [August 2018],1 my impression is that the vaccine authoritarians and radicals have not helped to mold a proper social / political environment for addressing the issue of vaccine injury.
An Update From the Acupuncture Now Foundation
Since launching the Acupuncture Now Foundation (ANF), our volunteer leadership has continued to work to achieve our vision of "Creating a World Where the Benefits of Acupuncture are Known and Available to All.
The Origin of Blood
The Roman doctor, Galen, (2nd century AD) did pivotal work to prove that blood, which he thought was produced by the liver, and the cardio vascular system existed. He conceived that the arteries and veins were two separate networks.
Easy, Inexpensive Tools for a Successful Practice (I Promise)
Successful practitioners are the ones who know how to run a business, first and foremost. I became a licensed acupuncturist in 2006. After having worked in chiropractor's offices for nine years, I opened my own office in 2015: four treatment rooms, a back office and a waiting room.
Lead Patients to the Fountain (and Foundation) of Youth
We're all seeking the fountain of youth and marketers are capitalizing on it. (Global demand for anti-aging products, treatments and services was valued at 140.3 billion in 2015, according to Zion Market Research.)
Working for Someone Else: Know the Rules of the Game
Many of us decide to become acupuncturists because we are healers at heart and want to focus on treating patients, not because we want to own and operate a business. So we work for someone else, which can have great advantages, especially as a new graduate.
X-Ray: To Be or Not to Be - That Is the Question
For the past year, I have been asked by many practicing chiropractors, college presidents, faculty and others what my opinion is on the "Choosing Wisely" guidelines the American Chiropractic Association (ACA) recently adopted for its members.
Depression & The Secondary Vessels
As an acupuncturist I see many people suffering from depression. I often think depression is the major imbalance of our culture. I have a patient I've been working with for several years. Her major challenge is chronic stubborn depression.
Time-Saving Tips for Your Practice & Life
Of all the finite resources we possess, perhaps the most valuable one is time. There never seems to be enough time to accomplish everything that must be done, and all too often we sacrifice things in our personal life to meet the demands of our practice.
Your First Impression Always Deserves a Second Chance
Doctor, have you ever had a patient you just couldn't "warm up to"? You know, the kind of patient who "irks" you, who has a hidden agenda to get something you haven't anticipated, perhaps causing you to want to hide in a closet when they come in for treatment.
The Importance of the Scapulohumeral Rhythm
The shoulder has the greatest range of motion of any joint in the body. What is often overlooked in shoulder mechanics is that motion in the shoulder is not purely at the glenohumeral joint.
The Science Behind the Efficacy of Cosmetic Acupuncture
The beauty industry continues to boom and grow constantly, from topical creams, lotions and potions all the way to cutting edge cosmetic surgeries.
Neck Pain: Activation Exercises
In observing patients and studying rehab, I have learned that tight muscles are weak muscles and that stretching is sometimes less effective than muscular activation. There is a delicate balance between joints that move too little and joints that are hypermobile.
Travel-to-Treat Coverage Finally Becoming a Reality?
Long-awaited legislation poised to hit the president's desk extends liability insurance coverage from one state to another for DCs and other state-licensed health care professionals who care for athletes / athletic teams that cross state lines.
UHC Up to Its Old Tricks With Latest Headache Policy
A decade ago, UnitedHealthcare announced changes to its chiropractic services policy that declared manipulative therapy for headache unproven and ineligible for reimbursement.
More Access to Chiropractic Instead of Opioids: H.R. 5722
With the opioid epidemic both an ongoing public health crisis and a hot topic extending well beyond the health care industry, Congress continues stepping up to the plate.
Possession: Blocks to Healing
Before we can approach treatment of a patient's primary elemental imbalance (AKA "Causative Factor" or "CF"), a number of specific energetic blocks must be considered and, if present, removed in order for treatment to be effective. I cannot emphasize this enough.
Food for Thought: An Examination of Diet & Digestion
Even an acute poison can become an excellent drug if it is properly administered. On the other hand even a drug, if not properly administered, becomes an acute poison. — Charaka Samhita
March, 2010, Vol. 10, Issue 03
Evaluating Neurological Symptoms
By Whitney Lowe, LMT
In massage therapy, the tendency is to focus on the role of muscles in pain or injury, sometimes to the exclusion of other soft tissues. Nerves are one of these often forgotten tissues, yet they play a critical role in many pain complaints. Neglecting these tissues can lead to inadequate treatment and the development of chronic pain conditions.
With all the work we perform on soft tissues throughout the body, the absence of knowledge of nerve-tissue disorders is serious. Massage can be an exceptional treatment approach for numerous nerve pathologies because soft-tissue therapy can successfully address nerve compression and tension disorders. Effective treatment of these disorders must begin with accurate evaluation of the client's primary problem. When performed effectively, simple manual examination is one of the most effective tools for evaluating nerve system function.
One might be inclined to think evaluation of nerve-tissue disorders should be left to primary care professionals who have access to MRI, EMG and nerve-conduction testing. However, while high-tech diagnostic studies are effective in certain circumstances, they are not always accurate. For example, median nerve compression does not always show up in nerve-conduction tests for carpal tunnel syndrome.1,2 While no single testing method is always correct, manual neurological examination has a high degree of reliability and should always be a part of a comprehensive evaluation.3,4
Structure, Function and Pathology
The motor versus sensory fiber make-up of peripheral nerves is an important characteristic to note when evaluating neurological symptoms. Most major nerve pathologies affect the peripheral nerves. Peripheral nerves have a dorsal root that carries sensory information and a ventral root that carries motor signals (See Figure 1). The nerve roots blend together shortly after leaving the spinal cord, converging to create the major trunks of the peripheral nerves. These nerves then course through the upper and lower extremities as well as other regions of the body. Most peripheral nerves carry both motor and sensory fibers, but a few carry one or the other almost exclusively.
Compression pathologies are the most common type of nerve injury. Compression can occur anywhere along the length of the nerve from the nerve root all the way to the distal end of the nerve. Pressure on a nerve root is called a radiculopathy. Examples include herniated intervertebral discs, spinal tumors, bone spurs and spinal stenosis, which is a narrowing of the intervertebral foramen where the nerve root exits the spine (See Figure 2).
When pressure is applied to a nerve further along its length in the upper or lower extremity, it is called a peripheral neuropathy. Common examples of peripheral neuropathies include carpal tunnel, thoracic outlet and piriformis syndromes. In a peripheral neuropathy, the nerve can be compressed by muscle, fibrous bands, bone, tendon, local inflammation or other factors. Treatment focuses on reducing compression on the affected nerve, so the practitioner must distinguish where that adverse compression is occurring.
Evaluating for the location and type of nerve pathology is necessary for selecting the most appropriate treatment strategies. Evaluation seeks detailed information on the client's symptoms. Acquire as much detailed information from the client as possible through the history and physical evaluation.
Most of the large peripheral nerves carry both motor and sensory fibers, which have different symptom patterns. Consequently, when there is damage to the nerve, there may be motor and sensory symptoms. However, some nerves carry a much larger percentage of either motor or sensory fibers. In these cases, it is more common to see one type of symptom pattern than another.
For example, if the piriformis muscle is entrapping the posterior femoral cutaneous nerve in the gluteal region (See Figure 3), symptoms are most likely to be pain or paresthesia in the posterior thigh because this nerve is predominantly a sensory nerve innervating the posterior thigh. If the piriformis is compressing the superior gluteal nerve, the most common symptom is weakness in the hip abductor muscles because the superior gluteal nerve is mostly a motor nerve supplying the hip abductor muscles.
The most common sensory symptoms from nerve compression are pain, paresthesia (pins and needles), numbness, burning or electrical-type sensations. Sensory symptoms from nerve compression usually are felt distal to the site of compression. There are exceptions to this guideline, but it generally holds true.
The symptom pattern for compression on a nerve root usually is different from compression on a peripheral nerve. This distinction has important ramifications for treatment. When pressure is applied to a nerve root, the symptoms might be felt anywhere within a specific dermatome. A dermatome is an area of skin supplied by a single nerve root. Figure 4 shows the C8 dermatome, which is the area of skin supplied by fibers that originate from the C8 nerve root (between the C7 and T1 vertebrae). Dermatome maps such as the one in Figure 4 are common in anatomy books. However, these are not absolute, nor is every person exactly the same. There can be slight variations in the dermatome due to anatomical anomalies. In some cases, nerve-root compression symptoms are only felt in a portion of the dermatome, which makes it challenging to pinpoint the problem.
The symptom pattern for compression on a peripheral nerve occurs in regions that overlap the dermatome. Each peripheral nerve supplies sensory innervation to a particular area of skin in the extremity; this is called that nerve's cutaneous innervation. For example, the cutaneous innervation of the ulnar nerve is limited to the ulnar side of the hand as shown in Figure 5. Recognition of nerve symptom patterns requires knowledge of each peripheral nerve's cutaneous innervation or each nerve root's dermatome. Clearly there is overlap between the cutaneous innervation of the ulnar nerve in our example and the C8 dermatome. Such overlap makes clinical analysis more challenging. So, how do you figure out where the symptoms are originating?
The best way to determine the site of compression is through accurate assessment. In general though, if symptoms exist throughout a complete dermatome, then you likely have a nerve root issue (radiculopathy). Choosing tests that further evaluate that nerve root would be the next step. If the symptoms are confined to one nerve's cutaneous innervation, then a peripheral neuropathy is likely. However, because nerve-root compression symptoms can occur in only a portion of the dermatome, further testing would be warranted to rule out nerve-root involvement.
For instance, if a client presented symptoms along the medial side of the arm and forearm extending into the hand, involving the C8 dermatome, it would indicate a C8 nerve-root pathology. If the symptoms were felt only on the ulnar side of the hand, the problem would likely be due to pressure somewhere along the ulnar nerve distal to the nerve root. But, due to dermatome and cutaneous innervation overlap, further testing would be warranted. In addition, further testing would be needed to determine the location of that compression along the path of the ulnar nerve. Treatment could then be directed to the most appropriate location.
When evaluating neurological symptoms, do not assume there is always a mechanical compression or tension problem. Numerous systemic disorders such as multiple sclerosis, myasthenia gravis or diabetes can also produce peripheral neurological symptoms, as could myofascial trigger points from distant muscles. These other pathologies should always be considered as a possibility, and referral is suggested.
Nerve pathologies affect motor function when motor-nerve fibers are involved. The most common symptom from motor-nerve compression is weakness or atrophy in the muscle(s) supplied by the affected nerve. Numerous anatomical references show where motor branches depart from major nerve trunks to supply innervation to muscles. As with sensory symptoms, the affected muscles are distal to the site of compression. Consequently, the more distal the compression site, the fewer muscles will be affected. Figure 6 shows a schematic for compression at two different locations along a nerve and how it affects the muscles innervated by that nerve.
Muscle weakness and atrophy are the most apparent symptoms from motor-nerve compression. However, in some cases pathologies develop from altered biomechanical patterns resulting from muscle weakness induced by nerve injury. Most of our movements involve complex coordination patterns of multiple muscles to accomplish a task. Weakness or atrophy from nerve compression in one of these muscles can cause resultant problems that might not seem related.
Here's an example of motor weakness contributing to a different pathology. The long thoracic nerve innervates the serratus anterior muscle, which is crucial for moving the scapula properly during shoulder abduction. Tightness in the scalene muscles can compress the long thoracic nerve and cause weakness in the serratus anterior muscle. Carrying a backpack, book bag or other heavy item with a shoulder strap could also compress this nerve. When the serratus anterior is weak, the coordination of movement between the scapula and humerus in abduction no longer functions properly and can lead to shoulder impingement syndrome. You might not think of nerve compression as a primary cause in this condition, but muscle weakness from nerve compression is at the root of the problem.
More massage therapists today are working in clinical environments and with clients who have a wide variety of pain and injury conditions. It is crucial that practitioners understand how the symptoms of nerve conditions might present. In some cases, the client should be sent to another health professional for further evaluation, especially when the problem is out of the practitioner's scope of practice or experience level. In other situations, massage can be an extremely important part of the treatment process because few other approaches treat the soft tissues with the degree of specificity of massage therapy. In future columns we'll explore treatment strategies that can be used to address various nerve pathologies.
Any practitioner who wants to address the full gamut of soft-tissue disorders is strongly advised to learn more about function and pathology in the nervous system. Understanding nerve structure and function will aid in treating these conditions. Applying quality clinical reasoning and evaluation skills is part of this process and can greatly improve the outcomes for clients.
Click here for more information about Whitney Lowe, LMT.
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