resourcesABOUT MT AUTHOR GUIDELINES CLASSIFIEDS EDITORIAL CALENDAR MEDIA GUIDE MASSAGE MART SCHOOLS & EDUCATION FEEDBACK
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.
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."
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
News in Brief
NYCC Aggregates Degree Programs in New School; Palmer Chancellor Receives Education Award From ICA; Oklahaven Announces "Have a Heart" Winners.
Parker University Embraces New Era
Change is in the air at Parker University, which recently announced the selection of both a new president and a new consultant for its seminar program.
Billing One-on-One, Direct Patient Contact
This is often misunderstood and leads to trepidation when documenting and subsequently billing timed services.
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.
August, 2014, Vol. 14, Issue 08
Searching for Trigger Points: Tips to Consistently Relieve Pain
By Valerie DeLaune, LAc
How much do you really know about trigger point therapy? Most likely you received 15 to 30 hours of training in trigger points in your massage school, or at least have purchased charts with referral patterns and books on trigger points.But did you learn a systematic approach to identifying likely culprits and resolving perpetuating factors – the things that cause and keep trigger points activated? Would you like to dramatically increase your success rate with resolving your client's pain? Since about 75% of pain is caused by trigger points, learning how to treat them is essential to a successful medical-massage practice.
Your Brain on Trigger Points
What you do with your brain is far more important than what you do with your hands. Massage therapists can successfully treat trigger points by applying pressure for eight to sixty seconds, by repeated stroking or with a combination of or variations on those techniques. But for any technique to work (whether manual therapy or needling), it must be applied in the correct place.
Trigger point therapy is like doing "detective work," you need to know how to use the "pain guides" to determine which muscles to search for trigger points. You also need to know how to assess your clients for perpetuating factors, the conditions that cause and keep trigger points activated. Teaching self-help techniques helps your clients participate in their healing process and provides them with tools they can use in the future.
Medical histories and pain mapping: get a comprehensive medical history from your client which at a minimum identifies all of the potential perpetuating factors that may be causing their trigger points. Go through the medical history at the beginning of the first treatment and ask questions to clarify the information they have given you; this should take about 1.5 hours for the first session. Continue to ask them questions as your treat them and spend a few minutes checking in with them and taking notes at the beginning of each subsequent treatment.
Have them mark their pain patterns on some kind of outline of the body before each treatment (known as "pain mapping") and ask them to rate the intensity and frequency of their symptoms so that you can track progress, or lack thereof. Try and get them to be as specific as possible so that you can match their referral patterns with common patterns on charts. Don't let them mark "x"'s or big circles, or color in large areas a solid color. Show them your trigger point referral pattern charts and explain to them that you are trying to match their pain patterns with some common patterns so that you will know where to start looking for the source of their pain.
Even if they are not improving, you can use that information to modify your treatment. Chances are you haven't located all of the trigger points that need treatment, there are perpetuating factors that still need to be addressed, or you need to refer them out for further evaluation since about 25% of pain is caused by conditions other than trigger points.
Use pain guides: about 74% of commonly found trigger points are not located within their area of referred pain. Unless you know where to search for trigger points, and you only work on the area where your client feels pain, they probably won't get relief. Familiarity with referral patterns gives us a starting point of where to look for the trigger points that are actually causing pain, but you must understand how to use the pain guides so that you will know which muscles to check.
For example, if your client has pain in their temple area, you need to know to check the temporalis, upper trapezius, sternocleidomastoid and some of the muscles in the posterior neck. Of these muscles, only the temporalis may contain trigger points which are located within the area of pain referral, so most of the time, unless you know which muscles to check, you won't come across the trigger point by accident.
It's not sufficient just to have a set of charts on your wall to look at and try to find referral patterns, since none of them have all of the potential referral patterns diagrammed. You also need to keep in mind that the books and chart sets only diagram the most common referral patterns and trigger point locations. Your client may have an uncommon referral pattern and trigger point locations. Pain guides and referral pattern diagrams are only a starting point.
Also, keep in mind that trigger point referral patterns from multiple trigger points can overlap, causing a composite referral pattern, as is often the case with migraines and other headaches. Buy at least one comprehensive trigger point book that includes pain guides so that you can see a list of muscles to check for any given part of the body, and buy a set of referral pattern charts to keep on your treatment room walls.
Often trigger points in different muscles can cause very similar referral patterns. For example, common referral patterns caused by trigger points in the supraspinatus, infraspinatus and scalenes are almost identical. One way to narrow down the culprit(s) is to know the symptoms and perpetuating factors for each muscle.
Spend some time reviewing your clients medical history form, pain mapping diagrams, and your chart notes and compare them with information for each muscle found in a comprehensive trigger point book. Trigger points can cause many non-pain symptoms which can help you narrow it down. For example, if your client comes to you with symptoms such as headaches in the frontal area and/or base of the skull, but also reports eye or ear symptoms such as tinnitus or eyelid twitching, that would be a clue to check the sternocleidomastoid muscle for trigger points. Trigger points can cause symptoms such as diarrhea, urinary frequency, menstrual cramps, dizziness and buckling or locking knees – symptoms most clients or health care providers wouldn't think to associate with trigger points.
You should decide which trigger points to treat first. Doctors Travell and Simons, who wrote the two-volume set of medical texts on trigger point treatments, listed muscles in their book's pain guides in the order they found were most likely to be causing the pain referral. In the previous example, they list the trapezius first and the posterior neck muscles last. But keep in mind, that depending on your geographic locale and practice specialty, you may find the order might be different for your practice; your clients will have different patterns depending on their work and hobbies and underlying medical conditions.
You also need to be familiar with primary trigger points and satellite trigger points. Once a trigger point has referred symptoms to any given area for any length of time, trigger points will form within the zone of referral, known as satellite trigger points. Then the satellite trigger points will cause their own symptom referral pattern, causing what I call a "trigger point chain-reaction." For example, there are at least eleven muscles that may contain trigger points which refer pain to the posterior portion of the deltoid muscle (the levator scapula, scalenes, supraspinatus, teres major, teres minor, subscapularis, serratus posterior, latissimus dorsi, triceps and iliocostalis thoracis). If you only treat the satellite trigger points in the deltoid, the deltoid pain will keep returning because you didn't treat the primary trigger points.
If your client has multiple symptomatic areas, don't try to treat everything in one session. Have your client prioritize their two areas of most concern, and focus on those. If you try to do too much, you likely won't treat any one area well. If your client has widespread pain, chances are they have some kind of systemic perpetuating factor that needs to be addressed and you will need to refer out to a practitioner who can order laboratory or other tests. During subsequent treatments, you may decide to continue working on the same area before moving onto another symptomatic area, or you may decide that other areas of pain are related and need to be addressed before the primary area of pain can be completely resolved.
Any decrease in intensity and/or frequency of symptoms, or decrease in size of the symptomatic area is an improvement that indicates that you treated at least some of the pertinent trigger points. Be sure to ask how they felt immediately after the last treatment. If they felt better even for awhile, ask what they were doing when their symptoms returned. Often that is a clue to at least one of their aggravating perpetuating factors and an indication that it needs to be addressed for lasting relief.
Next, identify and eliminate perpetuating factors. Trigger points may form after a sudden trauma or injury or they may develop gradually. Common initiating and perpetuating factors are mechanical stresses, injuries, nutritional problems, emotional factors, sleep problems, acute or chronic infections, and organ dysfunction and disease, though there are many more. If perpetuating factors aren't identified and treated, your client may improve temporarily, but their symptoms will keep returning. Most clients will have multiple perpetuating factors. When you buy a trigger point book, make sure it contains extensive sections on perpetuating factors and become very familiar with each factor and its symptoms.
Because resolving these factors are crucial for long-term relief, you need to be familiar with all of the potential perpetuating factors and the symptoms of each. For example, if your client is suffering from fatigue, depression and insomnia, you might suspect anemia or hypothyroidism, and you may need to refer your client to a health care provider who can order laboratory tests.
Even if it is not within your scope of practice to diagnose and treat many of these perpetuating factors, as a massage therapist, it is important that you have some ideas of whom you can refer your client to, who can diagnose and treat particular perpetuating factors that you suspect.
Learn self-help techniques so you can teach them to your clients, if it is within the scope of your practice. Refer them to books that reinforce self-help techniques for perpetuating factors, pressure techniques and stretches, especially if it is not within the scope of your practice. Clients who use self-help techniques and eliminate their perpetuating factors get better at least five times faster than those who just have you work on them.
Be careful not to overwhelm your client with too many suggestions; if you give them too many, they likely won't do anything. My recommendation is to recommend to clients no more than two self-help techniques per session, typically one pressure and stretch combination and one perpetuating factor to resolve. Help them find a way they can be successful so they will want to do more. For example, if you think walking would be beneficial for your client, suggesting an hour per day five days per week might be unrealistic for that client. Ask them if they could manage 20 minutes per day for three days per week. At their next visit, ask them how it went. If they weren't able to do it, find out why and problem-solve with them to see if you can find something they can/will do. Once they feel the benefits, they will likely want to do more. Above all, don't criticize them for failing to follow your suggestions. Keep a problem-solving dialogue going with them to try to find something they can achieve and feel successful.
A Protocol, Not a Technique
The trigger point protocol developed by Dr. Janet Travel and Dr. David G. Simons includes additional diagnostic techniques such as range-of-motion evaluation and gait analysis, but the treatment tips given here are the most easily integrated into your existing medical massage practice and most likely within the scope of your practice.
While there is a lot of information to learn about trigger points and how they develop in each muscle and manifest symptoms, fortunately there are now several good sets of charts and reference books to choose from. Trigger point continuing education classes are offered around the country, including several 100+ hour programs that teach the full protocol. Learning about trigger points will improve both your assessment skills and your success rate.
Valerie DeLaune is a licensed acupuncturist and certified neuromuscular therapist. DeLaune has authored eleven books on trigger point self-help techniques. Pain Relief with Trigger Point Self-Help, a book on CD ROM was released in 2004 and the print format was released in 2011. DeLaune teaches workshops in the U.S. and currently resides in Alaska. For more information, visit www.triggerpointrelief.com.
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