resourcesABOUT MT AUTHOR GUIDELINES CLASSIFIEDS EDITORIAL CALENDAR MEDIA GUIDE MASSAGE MART SCHOOLS & EDUCATION FEEDBACK
Sleepless nights, anxiety, mood swings, euphoric energy bursts, obsessive thinking, and a strange feeling in his chest. That is what Matt was experiencing when he first entered my practice. Rather than being concerned, he was loving every minute of it.
Streamline Your Front Desk
Your front office can be your greatest source of efficiency or it can be a constant bottleneck. Increasing the productivity of this area, while not sacrificing the quality of patient interaction, can be a little tricky. However, with some focused effort and intention, your front desk can keep your practice running smoothly.
Billing Timed Services
Q: I do not always use physical medicine services but in my state I do have a scope of practice that allows me to provide many of these services. I am trying to understand what "direct one-on-one patient contact" means in relation to physical medicine services.
Understanding Levels of Evidence
The concept of levels of evidence is a cornerstone of research literacy and a great starting point for understanding basic principles of how research works.
News in Brief
NYCC Aggregates Degree Programs in New School; Palmer Chancellor Receives Education Award From ICA; Oklahaven Announces "Have a Heart" Winners.
One of the most common trends to see in clinical medical practice and public health is the cycles of health "buzzwords." These come and go depending upon the current cultural zeitgeist. One year, "parasites" are causing all the issues, and the next year it's "candida."
In This Current Age of Anxiety
Anxiety, also referred to angst or hysteria, goes by many names. One, popularized by the sagacious Zhang Zhong Jing, who many practitioners of Chinese Medicine may be familiar with, is known as Restless Zang/Fu disorder.
Billing One-on-One, Direct Patient Contact
This is often misunderstood and leads to trepidation when documenting and subsequently billing timed services.
Low Fat vs. Low Carb & the Power of Protein
A science-based website recently posted a nice summary of 23 randomized, controlled trials from peer-reviewed journals pitting low-carb diets against low-fat diets.
A Different Way of Looking at It
The way you and your chiropractic colleagues access information has changed over the past decade. According to a recent survey conducted by Dynamic Chiropractic, almost half (48 percent) of DCs read online articles on their personal computer or laptop daily.
A Whole-Body Approach to Chronic Tension Headaches
Nearly every day in our practices, we see patients with chronic headaches that have not responded to traditional treatment. They present in our offices with a feeble hope that "maybe" a chiropractor can help.
How to Reach Your World With the Chiropractic Message
My latest effort to share chiropractic occurred in mid-May while I was sitting at an introductory parent information night for high schoolers. The IT instructor informed us that each student would be receiving a computer for all their studies.
Hip Flexor Contractures & LBP in Above-the-Knee Amputations
Patients with above-the-knee amputations (AK or AKA) are particularly prone to developing hip flexor contractures. Not to be confused with muscle tightness, contractures are a permanent shortening of tissues which cause deformity or distortion.
The Need for Standards
ISO-TC-249: You may look at these letters and numbers and wonder what they are and what they might mean. They turn into: International Standards Organization- Technical Committee – 249. There is a global organization called The International Organization for Standardization.
Transforming Las Vegas
On a warm spring day in Las Vegas, Sonia Kim, clinic front desk staff, is busy preparing for a full day of intern shifts at Wongu Health Center. She greets patients, makes sure documents are properly signed, and lets the interns know that their patients have arrived.
Holistic Skin Care and Modern Technology
Anti-aging is a concept that we hear in reference to skin rejuvenation and growing older on a daily basis. Aging begins as soon as we are born; therefore "pro-aging" is embracing all stages of life gracefully, with vitality, wisdom, joy, and gratitude as the goal.
Living Well: Lessons From Our Oldest Old
Aging is a significant public health problem, important to chiropractors in practice and important to DCs who teach students training to become chiropractors.
Building Bridges with Discipline
As practitioners of traditional Chinese herbal medicine, our role is to educate patients and medical practitioners about the various safety aspects of our medicine. Medical doctors that embrace Chinese medicine want to collaborate and include Chinese herbal medicine in more aspects of clinical care to support their patients.
Discovery: Finding Insights and Each Other in Different Disciplines
Recently I've been thinking about all sorts of things which are hidden from our daily direct experience. That general category is what links nearly everything that catches my attention and then demands some kind of investigation.
Finger (Pad) Pointing: Repetitive-Use Injury Waiting to Happen
"My wrist and hand hurt. I spend all day working on computers and then I come home and spend more time on a computer, usually playing video games."
Prostate Cancer Risk
A large study published in January 2016 in the American Journal of Clinical Nutrition showed that men who are vegans had a 35% lower risk of developing prostate cancer compared to non-vegan men. The study followed more than 26,346 men who are part of the Adventists Health Study-2.
With Low-Back Pain, Sometimes Little Things Matter
Typical treatments for low back pain involve large muscles like the quadratus lumborum, iliopsoas, and piriformis. However, there are situations when a very small muscle, the multifidus, can play a significant role in the diagnosis and treatment of low back muscular or spinal injury.
Keeping Malpractice Allegations at Bay
It has been suggested that in the litigious environment in which we live, the practice of chiropractic should be defensive and practitioners should constantly be watching their backs. An element of defensive practice is a good idea.
Distal Style Treatment of Neurogenic Pain
Treat locally or distally? This question has frequented my thoughts for the treatment of pain throughout my acupuncture career. Each style has strengths and weaknesses, thus the versatile practitioner would do well to forgo dogmatic adherence to any one style in deference to the needs of the individual patient.
Constructing Our Reality, Part 2
My last article discussed perception and its relationship to the primary channels. Before we get to the channels most commonly used to treat sensory disturbances, the small intestine and triple heater, we should first talk about the bladder channel.
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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