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A Letter to the Profession from the New President at AAAOM
Volunteering for a national, nonprofit organization brings with it such highs, lows, and accomplishments, as well as a steep learning curve.
Herbs for Digestion: The Power of Bitter
Many cultures (and indeed herbal clinicians) around the world have long respected the role of bitter herbs and foods for promoting digestion. For example, aperitifs – drinks consumed before a meal to stimulate appetite and digestion – were originally derived from bitter herbs.
End of an Era Looms at NYCC
New York Chiropractic College recently announced that Dr. Frank Nicchi will retire in August 2017 after 36 years with the college, the past 17 as president.
Can a Multivitamin Reduce Breast Cancer Recurrence?
There is a great deal of controversy regarding the value of multivitamin supplements in cancer prevention. However, with respect to preventing breast cancer recurrence, an important study was published in the Journal of Breast Cancer Research and Treatment in 2011 by Kwan ML, et al.
Molecular Motors: Tiny Machines Behind the Rhythm of Life
In the clinic, we aim to restore healthy patterns of movement for qi that has gotten trapped or misdirected, or may have even collapsed. We may be focused on freeing stagnation, releasing heat or redirecting counterflow qi, but it often comes down to helping re-establish a flow of sorts.
Meshing TCM With Environmental Pediatrics: Where's the Overlap?
Pediatrics has a long history within Chinese medicine dating back to the late Han dynasty (i.e., the late 200s CE), with the two primary areas of emphasis being herbal medicine and xiao er tui na (pediatric massage).
A Simple Protocol for Holiday Stress
It's winter, a time when we should be deep in reflection, eating warming foods and sleeping long hours. Following nature's rhythms, we restore our bodies and minds in preparation for the renewal of spring.
Branding: Set Your Practice Apart
Dr. Brad started his practice seven years ago on a shoestring budget. He created his generic logo in five minutes using a website because he didn't have the time to figure out how to make something special.
All Fiber Is Not Created Equal
Sometimes the best place to start is at the end. So, the conclusion of this article is that all fiber is good ... but some fiber is better. Let's break it down. There are two main types of fiber: soluble fiber and insoluble fiber.
Chiro School Reunion: Whatever Happened to...?
I opened the door to the closet slowly, carefully, since I knew it contained a large number of precariously stacked file boxes. It also held numerous outdated gizmos with electrical cords of various lengths that could trip or strangle a person.
Overuse Injuries in Young Athletes (Pt. 2)
Most overuse injuries are benign, but there are some high-risk injuries that, if unrecognized or inappropriately treated, can result in significant loss in time from the sport or even require leaving the sport.
DVT: Know the Signs and You Could Save a Life
I lost a friend several months ago. He died from a pulmonary embolism (PE) secondary to a deep-vein thrombosis (DVT) that originated in his lower leg. Bobby was in his mid-60s, soft-spoken and had a big heart.
Another Chance to Make a Difference
Just a few months ago, "the worst natural disaster to strike the United States since Hurricane Sandy" hit Louisiana. During this storm, one area experienced 31 inches of rain in 15 hours as almost 7 trillion gallons of water rained down in just one week across the state.
2016: A Year in the Life of Acupuncture
Happy Holidays, may you, your family and friends have peace, joy and blessings throughout this special time of year. As 2016 comes to a close, we can look back and celebrate the many events and accomplishments for the profession of acupuncture.
News in Brief
New President / CEO Takes Office at Yo San University. Electroacupuncture for Constipation?
Little Sticker, Big Impact
It's the end of an election year. Hilary Clinton and Donald Trump were the subject of conversation for everyone, everywhere for the entire 2016 calendar year. I don't think any of us can deny that this election affected us all very deeply on a personal level.
A First for the Profession: CCE Accredits First Chiropractic Residencies
The Council on Chiropractic Education (CCE) has awarded accreditation to all five chiropractic residency programs currently administered at Veterans Administration facilities, "the first residency programs in the nation ever to be awarded this distinction, a significant advancement in the evolution of chiropractic education," according to a VA press release announcing the milestone.
Southwest Acupuncture College Brings It to Division 1 Athletes
When Michael Phelps' photograph with the distinctive round marks left by cupping went viral, the Division 1 student athletes treated through the Dal Ward Athletic Center at the University of Colorado (CU) could relate.
6 Steps to Make 2017 Your Best Year Yet
People often ask me what defines success. Success, for me, is simple: doing exactly what you want to do in life. Whether it's the kind of practice you run, your life at home, your hobbies or something else, it's achieving anything you put your mind to.
What We Can Learn From Spine Surgery
Patients with lumbar stenosis presumably present for conservative care to improve their quality of life and avoid surgery. However, providing clear guidance to these patients can be difficult for a number of reasons.
A Q & A About Updated Codes
Yes, indeed there was an update to ICD-10 on Oct.1, 2016. This is a regular update to the diagnosis coding system and this type of update will occur every Oct. 1, just as it did when the ICD-9 system was in place.
Dedicated to Defending Chiropractic
Whether you're a veteran DC or a first-trimester student, the name George McAndrews should be part and parcel of your professional vernacular, as familiar as the word chiropractic.
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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