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Going Shoeless: The Pros & Cons of Barefoot Running
With the subculture of barefoot runners and the products catering to them growing daily, just about every chiropractor has been asked at one point or another about their opinion regarding barefoot running.
Let's face it – patient evaluation takes time. Unless you are really into the diagnostic evaluation game, you probably have found the formal exam protocol tedious if not downright annoying.
Happenings in Our Evolving Profession
Good things seem to be happening for our profession and recent developments show we are all on board. Talking about being on board, this September The Veterans Express-Purple Heart Tour is expected to make its way out of the station.
There Are No Secrets: Treating Complicated Conditions with TCM
Including standardized extra points, there are just over 400 acupuncture points on the body. You get 400 and I get 400 - same. Yet, time and time again treatment protocols are coveted as if they were some secret formula only intended for the right and privileged.
A Building Block of Healthy Aging
Coenzyme Q10 has gained enormous attention in recent years, and with good reason —it's the Energizer Bunny of the cellular world.
We Get Letters & E-Mail
Patient Perception and the Farce of "Fast Relief"; A Fly in the Ointment; Persecuted for Choosing to Practice Chiropractic.
Helping Infertility Patients with the Spirit Essence
As many of you know, when it comes to treating infertility, we are dealing with a patient population that is, generally speaking, in emotional turmoil. These patients often experience fear, anxiety, despair, hopelessness, grief and anger.
SOAP Notes: It's Time for a Cleaning
I have been planning for some time to write an article about how traditional SOAP notes do not fit chiropractic practice, and the unfairness of holding DCs to a model clearly created for and primarily applicable to medical physicians.
Why You Should Get to Know the National Vaccine Information Center
Barbara Loe Fisher has been a diligent advocate for providing parents with the information necessary to make informed decisions regarding the usage of vaccinations for their children.
Side Effects From Big Pharma: Wellbutrin – Dangerous for You and Your Baby
Are some of your pregnant patients taking Wellbutrin? If so, it could be a danger to them and their baby. This drug is extremely popular, but it has a serious history.
Peer Points: Stories of Practice Success
When patients go see Arizona-based acupuncturist Jing Liu, it is to get top care from an practitioner well versed in all aspects of Traditional Chinese Medicine.
Remembering Joe Weider (1920-2013)
With the death of Joe Weider, the world's most famous body-building visionary, crusader, fitness magazine publisher and icon, on March 23, 2013, chiropractic has lost one of its greatest friends and supporters.
Research Abstracts From the Journal of Manipulative & Physiological Therapeutics
Effect of Pain Relief on Lumbar Muscle Function and Activation; Effects of Thrust Amplitude and Duration of HVLA Spinal Manipulation; Immediate Effects of Upper Thoracic Manipulation on Cardiovascular Response.
What They Don't Say Could Hurt You
I have written previously regarding the difficulties of drawing information from patients who are poor historians, forgetful or just plain uncooperative. The thought to revisit the topic occurred recently during preparation for an upcoming seminar.
Are They Finally Fixing Medicare Reimbursement?
Even with federal sequestration cuts taking effect in March, including a 2 percent reduction in Medicare reimbursement to health care providers, hope may be on the horizon in the form of a much-anticipated, perpetually suggested overhaul of Medicare's Sustainable Growth Rate formula, which serves as the basis for determining physician reimbursement.
News in Brief
Controversial Florida PIP Law Under Review; D'Youville Chiro. Students Learning Art of Co-Managing; And the Award Goes To...; F4CP Recognizes Major Contribution by ChiroTouch.
Chiropractic: The Right Choice for Relieving LBP
"Low back pain (LBP) is a common threat to medicine and a reasonable threat to all national health care systems. ... Reducing ineffective treatments is necessary to decrease the LBP associated costs."
What the Science Says About Magnesium Stearate
It's often been said that scientific studies can be used to support just about anything. But discoveries are never made one study at a time.
Economics of Complementary/Integrative Care
Although this column doesn't usually feature a book review, we're going outside of our usual public health format to discuss a new book written by Patricia Herman ND, PhD.
Medicine Presents: A Great Opportunity
The changing nature of health care presents both opportunities and challenges. While we tend to focus on our profession, we can sometimes forget the impact other health care professions can have on us.
Energy is a hot commodity. Society pays dearly for it and for the expertise of those who know how to cultivate it.
Herbal Medicine: Go Mainstream
When it comes to practicing herbal medicine in a mainstream setting, there are a number of important points to understand when it comes to prescribing formulas. Some important questions to ask are - what method of prescribing and dispensing is most effective in this setting?
Correcting Kid Logic in Health Care and Research Design
A recent broadcast on public radio described a fascinating phenomenon known as kid logic.
Helping Patients Through Pregnancy Loss
There is a lot of focus in the acupuncture world on fertility and helping women get pregnant. It's exhilarating to hear the news that a patient is expecting a baby. The other side of that is pregnancy loss. That includes abortion, miscarriage or stillbirth.
You are What You Eat Part II: Integrative Protocols
In the previous installment of this article I discussed important ideas concerning gastrointestinal health and foundational ideas from TCM, which can provide key insights into creating effective protocols for healing the gut.
Have a Heart: Say No to Soda
It's not enough that soft drinks and other sugar-sweetened beverages have been linked to cavities and weight gain, among other negative health consequences.
Some Thoughts on the TMJ
The temporomandibular joint is an interesting and dynamic articulation that can cause a lot of problems.
The Spirits of the Points: The Gall Bladder Official
The Gall Bladder is known as The Official of Decision Making and Judgment. In any given day, this Official makes countless decisions – conscious and unconscious, which influence every aspect of our being.
May, 2012, Vol. 12, Issue 05
Scalene Muscles: Playing Havoc with Your Clients
By Nicole Nelson
As a massage therapist, I am quite grateful to the scalene muscles as they have offered me a great deal of job security. Trigger points in the scalene muscles have been attributed a wide array of myofascial pain and motor disturbance, extending from head to toe.Trigger points in the scalene muscles are known to refer pain anteriorly, laterally, and/or posteriorly.1 Pain in the scalene muscles is routinely felt just about everywhere but in the scalenes themselves. How can these three (occasionally four, but for the sake of this article three) muscles wreak so much havoc and what strategies are most effective for clients suffering from laminated, matted down scalene muscles? It is important to understand the basic anatomy of the scalene muscles so therapists can utilize some basic treatment strategies to perform on clients that have scalene trigger points and brachial plexus entrapment syndrome.
Anatomy and Function
The three scalene muscles are located between the sternocleidomastoid and the anterior portion of the trapezius. Without getting too specific (most anatomy books will do a far better job at illustrating precise attachments), the scalene muscles attach to transverse and costal processes of C2 and attach onto the superior surfaces of the first two ribs. The brachial plexus and subclavian artery share passage around and sometimes through anterior and middle scalenes. Therefore, it is not uncommon for clients with tight scalene muscles to complain of paresthesia, anesthesia, coldness, claudication and lymphedema in the involved extremity.2
The scalene muscles when contracting bilaterally elevate the ribs during inhalation and flex the neck. Unilateral contraction (with the ribs fixed) laterally flex the neck to the same side, and rotate the head and neck to the opposite side. The scalene muscles also serve in a stabilizing role for the cervical spine against lateral movement. Additionally, the scalene muscles have been credited with being essential auxiliary muscles of respiration.3 Evidence goes so far as to support the scalene muscles as having a more primary role in respiration rather than just an accessory muscle of inspiration.4
What is clinically significant is understanding the mechanical advantage these muscles have on the upper ribs and cervical spine. The anterior and medial scalene, when chronically shortened, has the ability to elevate, rotate and fixate the first rib.5 An elevated first rib will certainly limit the space of the thoracic outlet, creating a strong potential for neurovascular and subclavian artery entrapment.
Bilaterally, contraction of these muscles flex the neck and pull the head forward. Like it or not, forward head posture is here to stay; driving, typing, gaming and empathetic listening all involve subjecting our bodies to this postural pitfall. Unilateral tightness in the scalene muscles typically expresses itself with an elevated shoulder. This unilateral shortening can result from leg length asymmetry, whiplash injuries, poor sleeping habits, heavy bouts of coughing, carrying awkwardly large objects or even swimming.6 To sum up, if your clients have ever slept, taken a labored breath, stood at a bar with reckless disregard of gravity, done any work on a computer, sat with crossed legs or had a cold, scalene work is necessary.
Any structural integrationist or alignment expert will tell you that a successful treatment plan addresses the entire body and that we as therapists must consider all deviations as relevant in coming up with our bodywork strategy. Some therapists start at the feet and credit them as the platform of all postural aberrations. Others would argue that the rotations and anomalous curvatures of the spine are the root of chronic pain. I believe they are all probably correct in some way. Regardless of your approach, consider the following strategies a piece of the puzzle in formulating a course of treatment for clients experiencing signs of brachial plexus entrapment or have pain patterns that correlate with the scalene muscles.
One of the first things that I establish with clients, regardless of their exercise history or yoga and pilates proficiency, is to assess how they breath. Paradoxical breathing is huge contributor to scalene trigger points. Clients should be able to breathe diaphragmatically in sitting, standing and supine positions. I strongly suggest evaluating their breathing in all positions. What you will find in practice is that a client might successfully diaphragmatically breath in a supine position, yet have difficulty doing so in a sitting or standing position. Depending on which position you have observed a breathing deficiency, you must have them retrain appropriate breathing in that position. The best technique I have found, courtesy of Travell, is to have the client place their right hand on their chest and left hand on their abdomen. With their eyes closed, instruct them to inhale through the nose to a four second count then exhale through the mouth (also to a four second count), allowing the abdomen to relax and retract to the starting position, extending their bellies into the left hand. Corrective exercise like this takes time for motor re-patterning to occur; therefore, the should be repeated for 30 to 60 seconds every hour throughout the day. Sixty seconds is adequate time to practice this without overly fatiguing the muscles. Diaphragmatic breathing certainly helps reduce the overworking of the scalene muscles and it is a very useful strategy in helping clients deal with scalene trigger points. But, those who have mastered good breathing practices are not out of the woods.
Postural strain patterns is next on our list. If a client is at their computer all day, or holding babies on a hiked hip or is attached to their cell phone, you can be assured body alignment will need addressing. Thomas Meyers suggests in his book, Anatomy Trains, to have your client observe their own posture in a mirror and ask them what they see. Take a picture of the client which is imposed on a postural grid and show it to them and get their impressions of their own alignment. I have found that when you take a more team approach in analyzing posture, the message is accepted fairly well and the client's awareness is heightened that much more. From here, postural alignment tips such as chin tucking exercises or discussing their workstation set up will not only be appreciated, but they will be far more compliant in applying these suggestions.
Now, as far as the actual act of bodywork. Basic compression and stripping of these muscles will do the trick. No muscle produces more amazed comments from clients. A useful tip when beginning this work is to communicate the possible referral patterns that can light up when working on these trigger points. Mentally, set your treatment pace at slow and then perform it even slower. I like to start with the scalene muscles in a slightly shortened position. The bit of slack will make the initial work far more tolerable and it better enables you to scoot under the SCM. With the client supine, laterally slightly flex (maybe 10 degrees) the neck to the side you are treating, and gently glide across the entire length of the tissue. Depending on the size of the neck, I either use my thumb or middle finger. Once you notice some softening to these structures, begin the same gently stripping process with the client's head in a more neutral cervical alignment, once softening occurs in this position, rotate the head away from the side you are treating and elevate it slightly off the table. In this position, place your thumb or index finger between the sternal and clavicular heads of the distal attachment of the SCM, have your client take a deep breath upon exhalation, and friction the scalene muscles underneath the clavicle. Finish with some pin and stretch anywhere you feel restriction.
Mobilizing the first rib is a key part in the success of scalene work. The scalene attachments can place the first rib in awkwardly fixated, elevated and/or rotated position.7 Take care of the rib if you want your scalene work to have lasting results. Don't let rib mobilization scare you, this is not a chiropractic adjustment, simply steady pressure. With your client supine, palpate the posterior aspect of the first rib in front of the upper trap with your thumb. It should feel like a flat surface; however, if rotated it will feel more like a sharp edge. Simply apply a steady downward pressure (in the direction of the client's heel) once you feel the surrounding tissue soften, have the client flex their shoulder, while you continue to pin the rib down. Additionally, flexing the clients head to the contra-lateral side while pinning the rib should also prove to be effective. Patience will prevail and remember to set your treatment pace at slow and then go slower.
Any client that breathes will benefit from scalene work. These entrappers are associated with a wide range of upper extremity issues ranging from carpal tunnel syndrome to tennis elbow. This article is hardly exhaustive in it's treatment suggestions, but will hopefully serve as a good starting point.
Nicole Nelson a licensed massage therapist in Jacksonville, Fla. She has a masters degree in Health Science from the University of North Florida and is a certified Advanced Health and Fitness Specialist through ACE.
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