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Three for One: The Cervical Distraction Test
Taking the time to do an exam is important, but it is time spent. The exam serves as a way to physically validate your clinical impression following a history and clinical consultation.
Show Up and Show Respect
I was recently asked about my chiropractic philosophy. My answer surprised my questioner.
The App Advantage: Get More for Less
You may have noticed the list of "app-exclusive" articles in the directory on the front page of the print issue and in the Table of Contents on page 4. You can't find these articles in print or even in our online archives.
Helping to Create the Healthiest Generation
The imperative to create the "Healthiest Generation by 2030," envisioned by the American Public Health Association (APHA), was in full force at the APHA's 142nd Annual Meeting held in New Orleans from November 15-19, 2014.
Happy New Year 2015 Gong Hoy Fat Choi
Welcome to the year of the sheep! We begin a new year guided by the sign of a quietly and creatively organized animal.
Movement Assessments: The DC's Sphygmomanometer
I think back to when I was going through chiropractic school outpatient clinic. I was embarrassed to have my family and friends come in for treatment because initial evaluations took three hours to complete.
The Way of Zen Performance Enhancement
Working with elite athletes and implementing various techniques to keep athletes focused and at their optimal performance for a sustained period of time includes incorporating various meditation techniques that counterbalance their sport-specific physical and mental demands, which is an important element of success throughout the years.
Ringing in the Billing New Year
What are the new modifiers that replace modifier 59? Will they allow doctors of chiropractic to be paid for 97140, manual therapy, when done with chiropractic manipulation?
Environmental Toxins: Cause of Modern Illness, Part 2
In Part I of this article, we detailed the variety of environmental toxins assaulting our bodies. These include pesticides and herbicides; plastics; preservatives; cosmetics; gasoline additives, solvents and glues; and heavy metals.
Two for One: The Cervical Distraction Test
In today's healthcare system, diagnoses and treatment plans follow a western medical model - especially if you work with attorneys or insurance companies.
Age and Fertility: Why We Should Worry Less About Age and More About Overall Health
Recently, on one of the acupuncture alumni forums, the topic of age and fertility came up when a practitioner posted a question regarding a patient that was about to turn 40-years-old.
News in Brief
While indignation may be your immediate reaction to H.R. 5780, the Protecting the Integrity of Medicare Act of 2014, the American Chiropractic Association suggests the legislation is just what the chiropractic profession needs.
The Conscious Evolution of Healing: Importance of Opening the Sensory Portals in Classical Chinese Medicine
The Chinese medical classics are not just clinical guides. They give advice; ways we can awaken more fully into conscious awareness.
We Get Letters & Email
Rethinking Our Approach to Immunization; Coming Together for the Good of Our Patients.
How to Use Online Video as a Tool to Market Your Practice
Health care practitioners, including chiropractors, should consider online videos as a key element of their Internet marketing strategy. In the next three years, videos are expected to account for nearly 70 percent of all consumer online traffic, according to Cisco.
Right Back Where We Started?
More than 25 years after Judge Susan Getzendanner issued her historic opinion in the Wilk v AMA anti-trust case, evidence suggests that despite increasing collaboration between doctors of chiropractic and their allopathic medical counterparts, when it comes to organized medicine, we may be right back where we started.
Acupuncture and its Place in the Integrative Healthcare Practice: The Need to Move from Modality to Profession
Acupuncture and oriental medicine (AOM) has grown and flourished from its inception thousands of years ago in China. In surrounding regions of Asia, AOM developed as a response to differing cultural, pathological, health and wellness care needs.
I Felt it in My Fingers First
I'm not afraid to say it. Massage therapists make better acupuncturists. I'll tell you how I know, but first I have a question: What do a microcurrent device, a laser and a hippie massage therapist have in common?
Trouble Down Under: San Zhen Therapy for Lower Jiao Issues
In the last several columns, I have discussed many clinical options for utilizing San Zhen or Three Needle Therapy. In this installment, I will continue this trend and discuss several foundational patterns which can be found in several very common clinical presentations.
Animal Acupuncture Gaining in Popularity
We have just finished the year of the fire hoarse and now it is time to spend some time alone, daydreaming and thinking outside the box in terms of where our profession is headed. The sheep person is well organized and creative so this should not be difficult to do.
Chiropractic Research in Review
Occupational LBP in Primary- and High-School Teachers; Treating MVA Complications With Chiropractic Care; Neck Pain: Immediate Effects of Active Scapular Correction; Taping Benefits Stride, Step Length in Fatigued Runners.
Fight Colorectal Cancer With Folic Acid
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Professionalism and Evidence-Based Health Care
Today's chiropractors are facing a conundrum with the Affordable Care Act and its health care reform requirements, including evidence-based practice and health technology assessment.
Taking the Freeze Out of Adhesive Capsulitis
Adhesive capsulitis or "frozen shoulder" is a relatively common condition resulting in severe shoulder pain and global loss of glenohumeral joint range of motion. Incidence of the condition is approximately 3 percent in the general population.
The Static Postural Pelvic Exam
I include a static postural analysis in my evaluation routine whether you are a patient in pain or an elite-sport athlete in training. In my day-to-day practice, I require patients to stand still while I "just look" at them.
AWB Makes a Difference in the Yucatan
We are in the sleepy town of Izamal, located about an hour from the Merida airport where our group arrived last night. Later that morning, on a bus winding through the dusty roads of the Yucatan, fourteen acupuncturists, two facilitators from AWB and two tour guides make their way to the small rustic town of Popola.
July, 2014, Vol. 14, Issue 07
Exploring the Anterior Pelvic Tilt
By Whitney Lowe, LMT
Lumbopelvic pain is a common complaint that is not always remedied with many standard low back pain treatments. For many people, some treatments have been helpful, but the condition still persists.Frequently, the pain problem exists because an underlying postural or structural deviation has not been properly addressed. One such postural problem that might be considered is an anterior pelvic tilt, which can contribute to lumbopelvic pain in a number of ways.
The upright posture and locomotion of humans poses biomechanical balance challenges for the pelvis. The weight and force loads of the upper body are transmitted and distributed to the two lower extremities through the pelvis. When the pelvis is not aligned properly numerous biomechanical problems result, which can be painful and debilitating. Let's take a look at what constitutes an anterior pelvic tilt, some of its detrimental effects, and what role massage can play in helping to resolve it.
For the sake of this discussion, the pelvis will be addressed as a whole, even though it is composed of two separate halves, called innominates. The left and right innominate can move independent of each other, but most postural distortions occur when the left and right halves are both out of alignment in the same direction.
An anterior pelvic tilt occurs when the pelvis rotates anteriorly in the sagittal plane. The sacrum is tightly wedged between the two innominates so when the pelvis tilts anteriorly, the sacrum moves with it. The sacrum is tightly bound to the L5 vertebra, which is bound to adjoining vertebra. When the sacrum tips forward, the lower lumbar vertebrae are subsequently tilted forward, creating an increase in the lumbar lordosis at the same time.
There is a natural degree of anterior tilt in the pelvis that is necessary for proper movement and shock absorption. When the degree of tilt is too much, it is considered a dysfunctional anterior tilt. However, it is difficult to get an accurate determination of the exact degree of anterior tilt without a goniometer. Consequently, many clinicians use approximate alignment references to determine if the tilt is excessive.
However, just because it is challenging to define the anterior tilt, doesn't mean we should ignore it. Although massage therapists may not have the training to make accurate goniometer measurements, there are some simple tips for determining if a pelvic tilt could be a contributing factor to a clients pain. One way to evaluate the tilt with visual examination is to look at your client from the side. Place one finger on the posterior superior iliac spine (PSIS) and the other finger on the anterior superior iliac spine (ASIS). If the ASIS is more than a half inch lower (and slightly more in females), this would be considered a dysfunctional anterior tilt (Figure 1).
A degree of lordotic curvature in the lumbar region is necessary for proper shock absorption in the spine. However, too much lordosis causes multiple problems. As the lordosis is increased, there is increased pressure on the facet joints of the spine (Figure 2). The increased facet joint compression can lead to pain, irritation and even early arthritic changes in the spine.
An increased lordosis is frequently caused by excessive hypertonicity in the lumbar extensor muscles. Tightness in this muscle group is both a cause and an effect of the exaggerated anterior tilt. The lumbar extensor muscles are often tight in conjunction with the iliopsoas in a postural pattern known as the Lower Crossed Syndrome (Chaitow, Delany vol 1, 2000). A vicious cycle of muscle tightness and postural distortion ensues because muscle tightness contributes to the anterior tilt and is perpetually reinforced as a postural pattern. Myofascial trigger points in the lumbar extensors are also likely to develop as a result of the chronic tightness.
The increased lordosis may also decrease the opening of the intervertebral foramen which could lead to nerve root compression in the area. The risk of nerve root compression is increased if there are bone spurs or other obstructions along the edge of the foramen which encroach on the nerve with the exaggerated lordosis.
Another detrimental effect of the anterior tilt occurs at the Sacroiliac (SI) joint. There is only a slight degree of movement at the SI joint. For the most part, this joint is tightly bound so that the sacrum and ilia on both sides are almost locked into position with each other. The anterior pelvic tilt alters the force loads at the SI joint and is a frequent cause of SI joint pain and dysfunction.
Most of these potential effects are somewhat obvious, but another one that is not quite as clear is the increased risk of hamstring strains. When the pelvis tilts anteriorly, the ischial tuberosity rises in a superior direction, putting greater tensile stress on the hamstring muscle group. The elevated tensile load can lead to an increased incidence of hamstring strains, especially in active individuals.
So, is there a role for massage therapy in addressing this problem? There is a role for soft-tissue treatment, but there is also controversy and misunderstanding in constructing the most helpful treatment plan.
One of the biggest mistakes that clinicians make in attempting to treat the anterior pelvic tilt is to over-simplify the treatment strategy. For example, if you look at a person with an exaggerated anterior tilt from the side, it would appear that the lumbar extensors are tight and the abdominal muscles are weak and elongated, which is true. The mistake comes in attempting to address this distortion by strengthening the abdominal muscles with standard abdominal muscle exercises like sit-ups or crunches performed with the feet rigidly held in position.
When the feet are held rigidly in place for a sit-up exercise, it is called a closed-kinetic chain exercise. Unfortunately, performing a sit-up in a closed kinetic chain position strongly recruits the iliopsoas muscle. Since tightness in the iliopsoas is a contributing factor with this condition, further strengthening is counter to the intended treatment goal.
The key goal in a treatment strategy for the anterior pelvic tilt is to reduce tightness in the lumbar extensor muscles and iliopsoas. In many cases, the abdominal muscles, which appear weak and overstretched, are not weak because they lack sufficient exercise, but are instead weak because they are being neurologically inhibited by the tight lumbar extensors (their antagonists). Reducing tightness in the lumbar extensors will often allow the abdominal muscles to resume a normal level of tonus. A variety of massage techniques can be directly aimed at the lumbar extensors to reduce their hypertonicity.
One of the biggest mistakes that massage therapists make when attempting to address an anterior pelvic tilt is to focus just on the soft-tissue treatment with the idea being that reducing the muscle tightness will restore the proper pelvic position. Unfortunately, that rarely occurs. Postural distortions like the anterior pelvic tilt have developed from chronic habitual reinforcement. Even if you perform excellent massage work on these muscles, the person is likely to quickly slip back into the postural distortion if certain habitual patterns are not addressed.
Dysfunctional postural patterns need to be changed by constant reinforcement of new and more correct postural adaptations. Certain treatment systems like Alexander Technique, yoga or Feldenkrais are aimed at improving awareness of posture and position in order to make changes and reduce dysfunctional positions. However, it isn't always imperative that the client adopt one of these practices.
Sometimes, it can be as simple as teaching new postural positions and encouraging the client to be aware of his or her own postural positions and to reinforce that change as much as possible. Having the client explore the ergonomics of his or her home and work activities is also important. Does their work set up inspire a slumped position at a desk? Do they stand a lot, could they put one foot up on a small block? Can they take more breaks for stretching and be shown good stretching solutions?
As clinicians, our goal is to understand each individual's biomechanical stresses as best we can so we can craft a reliable treatment strategy most likely to achieve beneficial results. At the same time, keep in mind that the presence of an anterior pelvic tilt is not a guarantee of any of the above adverse outcomes. There are people who have an anterior tilt that do not develop any issues. That is why it takes a thinking practitioner to determine when the pelvic tilt might be a contributing factor to a client's pain.
Click here for more information about Whitney Lowe, LMT.
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