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Practice Policy (Gone Bad): The Sign
Every once in a while, you see something and think to yourself, That's a really bad idea. Case in point: I went to see my medical doctor the other day. Just after being "roomed," as they say, the nurse checked my vital signs. Then she left.
Acupuncture Rising: From Acupuncture Anesthesia to Assisted-IVF, Part 1
Acupuncture's cultural and historical roots go back to the emergence of Chinese civilization. For more than 2,000 years, acupuncture needling has been continuously practiced on the largest population in the world.
Harvard Health References Flawed AHA Position Paper
In its special health report, "Stroke: Diagnosing, Treating, and Recovering From a 'Brain Attack,'" Harvard Health Publications includes information from the American Heart Association's 2014 position statement on cervical manipulation and cervical dissection – a statement the American Chiropractic Association emphasized in a letter to Harvard Health mixes "scientific facts with half-truths."
News in Brief
Call for Abstracts Announced - Parker Las Vegas 2016; Logan Adds Doctorate Degree; New Role for Dr. James Edwards.
Help: A Need at Every Level
One of the great gifts of training in acupuncture is the ability to take good care of oneself. I recently had a bout of frozen shoulder — an inflammatory syndrome which can be debilitatingly painful and take years to resolve.
Improving Communication Between AOM and Biomedical Providers
How comfortable do you feel talking to Western medical providers? If you are like me, you may not feel as comfortable as you would like. Some of my interactions with MD's haven't been the fruitful steps toward integrative medicine for which I had hoped.
The Short Leg Dilemma
When evaluating a new patient, it is common to note a relative shortening of one leg to the other. Some patients will even tell you they have one, and then pull out the store-bought heel lift they read about online.
Do Some Good and Grow Your Business with Cause Marketing
Cause marketing is truly one of the best ways that you can promote your services as a acupuncture professional. Cause marketing refers to a type of marketing where a business partners with a non-profit organization to help bring awareness to a charitable cause.
An Acupuncturist's View of Medicinal Marijuana
The use of cannabis for medical purposes is very controversial. Use as a panacea by physicians uninitiated to the proper application of herbal medicine, as well as an excuse for recreational use have greatly confused the issue.
The Zen Art of "One Point"
We were always told in our Zen Shiatsu training (by Japanese and Japanese American instructors) that our ultimate aim was to to find that "One Point." To be so focused we could touch just one point to transform Qi throughout a client's body.
Practicing with Authenticity
To extrapolate from the above quote, patients love healthcare providers they can trust. One way to earn the trust of your patients is by practicing with authenticity. What does that mean, exactly?
Surprising Reasons for Orthotic Efficacy
Clinical outcome studies show orthotics are effective in the management of a wide range of injuries, including plantar fasciitis, Achilles tendinitis and patellofemoral pain syndrome.
Nuts Reduce Risk of Heart Disease, Cancer and Other Health Problems
Several recent studies suggest regular consumption of nuts may provide a significant degree of protection against certain types of cancer, heart disease, possibly type 2 diabetes and some neurodegenerative diseases.
Patient-Centered Care vs. Payer Restrictions: Your Ethical Obligation
Do you have an ethical obligation to evaluate your patients, make a diagnosis and provide evidence-based, patient-centered health care, irrelevant to the payer restrictions?
Getting a YES: An Effective Strategy for Overcoming Patient Objections
Patients make more excuses for declining care from an acupuncturist than perhaps any other type of doctor. Various reasons hold them back from making a commitment to care.
Modernization of Chinese Medicine
Language – written, spoken, signed, or otherwise is learned as a means to express our individualized perceptions about the world around us. Language is designed to communicate our personal experiences.
What's Chiropractic Research Worth to You?
The Palmer Center for Chiropractic Research (PCCR), in celebration of its 20th anniversary, has announced it is spearheading a fundraising campaign to support chiropractic research.
Dorsiflexion Dysfunction: Evaluation & Manipulation Techniques
Almost every condition from the foot to the hip can be attributed to the inability to dorsiflex the ankle mortice and other joints that participate in dorsiflexion. Let's start by understanding normal versus abnormal dorsiflexion.
Oriental Medicine on the World Stage
"Let me win. But if I cannot win, let me be brave in the attempt." This simple, yet powerful statement was lived out time and time again by so many of the athletes from around the world during the Special Olympics World Games in Los Angeles.
More Chiropractors Required
An intriguing study published in the Journal of the American Board of Family Medicine examines how "chiropractic care affects use of primary care physician (PCP) services."
Change Lives by Supporting Chiropractic Research: Are You In?
The Palmer Center for Chiropractic Research (PCCR), in celebration of its 20th anniversary, has announced it is spearheading a fund-raising campaign to support chiropractic research.
Fertility and Poly-Unsaturated Fatty Acids
Starting or expanding one's family is a major milestone. It's something that more and more people seek out health care advice and support for.
Healing Trauma: Cultivating Resilience and Presence Through Mindfulness, Part 2
In the last issue of Acupuncture Today, the first part of this article introduced the topic of trauma and resilience, and their relationship to the autonomic nervous system response and the concept of the spirit being grounded in the body, and suggested the importance of mindfulness as a tool for healing.
The Food Conversation: Nutrition and Your Practice
It's morning and your first patient rolls in with a triple espresso steaming in one hand and a frazzled, desperate look in her eye. "You gotta help me, doc, I am constipated unless I drink one of these, and I am exhausted and anxious all the time."
A Chiropractor's Guide to Yoga
"Doctor, can I continue to do yoga while undergoing your care?" "Is it OK for me to go back to yoga while I'm getting my back treated?" "It is safe to start my yoga classes again after my neck pain improves?"
Fish Oil: A Key Component of Positive Clinical Outcomes
Patients seem to be presenting with more complex problems, and many are responding to care more slowly or have completely unexpected results. Why?
The Sub-Scap Attack
Subscap-attack was fondly named by one of my clients who enjoys playing golf 4 to 5 days a week. As I was working on the subscapularis and she was laughing to ignore how uncomfortable this muscle is to be worked on, she gleefully named what I was doing "The Sub-Scap Attack." It is catchy and adds a bit of whimsy to a very important muscle and the absolute importance of understanding how to accomplish appropriate treatment applications to this muscle. I would like to focus on different treatment options of this muscle, the appropriate hand placement, how to know if it is in fact subscapularis causing the posterior pain and how to evaluate if you are making a difference. Let's revisit this often ignored and inadequately worked on muscle and look at a recent case history that was referred to my office in what the client called "his last resort."
This is an unusual but also typical case of subscapularis posterior pain syndrome. He, too, was a golfer but also has an additional challenge in the fact that he only has his right arm. Can you imagine doing everything in your life with just one arm? That alone should tell you how much stress is put onto the rotator cuff. And he loves to play golf, which is usually done with both arms.
"No one has been able to make the pain go away. I have been to several massage therapists and a top notch physical therapist, but no one has been able to make the pain go away," he told me. "I've been dealing with this for several years now, it comes and goes but is always there when I play golf. I took off three months and it only got worse instead of better. The therapist I have seen says it is subscapularis and infraspinatus along with teres minor," he continued.
As a therapist reading this story, what do think happened? If he can tell me and show me the source of the pain, why hasn't anything worked to get rid of the pain? What tests would you perform? What treatment do you think you would pull out of your bag? How would you know if you made it better? How many treatment modalities would you use? What are some other questions to ask in order for you to be the last therapist this client needs to see? Now, let's put two and two together.
First, he is a right-handed only golfer. On his intake form, he drew a small circle on the posterior side of the scapula close to the inferior edge just off center of the right scapula. His constant nagging pain is easy to pin point and correlate with Travell and Simons trigger point pain pattern of subscapularis from the Myofascial Pain and Dysfunction book. To help understand the function of subscapularis during the golf swing, we can look at some EMG studies that were done during the golf swing. Studies done by Dr. Jobe and Dr. Pink found that during the golf swing, supraspinatus and infraspinatus were relatively minimally active throughout the swing. The subscapularis was the most active rotator cuff muscle throughout the swing, especially on the dominant side.
In Travell and Simons, they showed the mean EMG activity of the right subscapularis muscle began at takeaway, with only 15% of the maximum activity elicited by manual muscle strength testing. The activity increased to 65% during acceleration, and subsided slightly thereafter. The left subscapularis muscle maintained a moderate amount of activity during the swing, ranging around 30% of maximum test activity. A similar study of men and women professional golfers reported a very similar pattern bilaterally for women golfers; however, the male subjects showed activity on the right side that started with mean takeaway activity at only 12% maximum test activity, increased to 80% by the time of the acceleration phase, and maintained the level of EMG activity throughout the remainder of the swing. The left subscapularis muscle in men, like both sides in women, maintained a mean of approximately 45% throughout all five phases of the golf swing.
Most of the time, I would say don't chase the pain, that 99% of the time there are other factors and it is part of a kinetic chain involvement, but this is one of those few cases that if we just relieve the abnormal pull coming from tight taunt bands in the subscapularis muscle and its synergistic teres major, along with the muscles that oppose arm-rotation infraspinatus and teres minor, it will cure the problem. You are trying to bring back a normal firing order to the muscles and help the rotator cuff control humeral movement in both the acceleration and deceleration phase of the golf swing.
The tests I performed literally took less than 60 seconds. I asked to see flexion and abduction range of motion. He had no loss, just complained of tightness. I performed manual muscle testing of internal rotation and external rotation. There was no loss of strength and no pain. I asked him to perform a scratch test. There was loss of internal range of motion. Throughout all the tests, you want to ask the same question: Does this cause any pain? None of the tests caused any pain. I asked him to adduct the arm across the body and he could feel the spot on the posterior side of the scapula. "That is where it always is," he told me.
How will you know if you make him better? Simple, there are two positive tests, loss of motion on internal rotation and tightness on adduction. Twenty minutes or less into the treatment, ask him to perform the scratch test again and see if there is more freedom of movement. Ask him to adduct the arm across and see if there is less tightness.
With the client in a side lying posture, I used a comfortable deep pressure across infraspinatus locating the spot he complained about. I used a small tool that is designed to help break up the fibrous bands of tissue. I followed that with cupping in all directions and specifically over the inferior portion of the scapula. I then abducted the arm out anteriorly as much as possible. This allows easier access to the scapula's anterior surface. I took the flat of four fingers on the inferior side of the scapula and compressed the tissue between my thumb on the posterior side. This was done slowly in a cross fiber friction fashion all along the border of the scapula until I reached the humerus. While still in contact with the muscle, I asked him to do internal and external rotation against my resistance of 25%. I added heat through the use of a hot stone. All of this took about 20 minutes of treatment. I asked him to sit up and perform the tests. The range had improved and he felt less posterior tightness. I just want to you think about how important it is to have the patient's subconscious mind hook up to the fact that there has been a change. This is where the true opportunity of healing can occur in the central nervous system.
Next, the treatment was performed in the supine position. I went under his body and pulled the scapula over to allow my hand to have as much surface area as possible to the inferior aspect of the scapula. I once again used the flat surface of four fingers sliding against the scapula. (Please note: I have not begun treatment yet, I am spending this time getting in the proper position for the treatment.) Then I asked him to medial rotate the arm against my resistance while my hand is still in contact with subscapularis. I once again abducted the scapula a little more and at this time my entire hand is easily softly against the inferior surface of the scapula. Then I began palpation of subscapularis and his felt like bands of steel with no pliability. "No one has ever isolated it like this before," he told me. I stayed in contact with the muscle and had him do internal and external rotation. I would change my position on subscapularis a quarter of an inch at a time and had him continue to perform internal and external rotation. My fingers are moving in a cross fiber friction fashion. I combined this with isometrics holding 6 seconds, 6 times through, followed by a stretch to the next barrier. This portion of the treatment probably took about 20 minutes.
The client sat up and he moved his arm all around, internal rotation was improved and no additional tightness on adduction. "This feels great!" I ended the treatment at 45 minutes and asked him to do another visit in one week, which he gladly signed up for.
Here is what Travell and Simons regard as factors of the clients that can end up with activated subscapularis TrPs:
And one I have noted is always following shoulder surgery. I have had the privilege to teach many therapists and of all the muscles that I find that is awkward and the therapist are lacking experience with is subscapularis. They have the most trouble in getting their hands to make appropriate contact with subscapularis. So let me leave you with this last thought for the Sub-scap Attack. Always test a muscles action with resistance and it will reveal itself to you. It will pop out and say hay here I am. Don't guess if you are in the right location with your hand placement, if you will just follow this simple rule throughout all of your therapy you will be the last therapist to see that client.