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Three Tips to Help You Analyze the Acupuncture Case Studies of the NCCAOM Exam
Confirm the answer quickly by the elimination method. Case study:
After two treatments for back pain, a patient presents for a third
session complaining of rapid breathing and wheezing that is made worse
during cold weather.
Sit or Stand? Analyzing a Mixed Message
I'm more than a bit confused. At my age, that seems to be a rather common occurrence. However, today more than ever, I'm getting a mixed message.
What's New in Phytonutrition: Mangifera Indica, "The King of Fruits"
One hundred percent pure Indian green mango fruit (mangifera indica), harvested at a special degree of ripeness for efficacy and taste, can now be concentrated as a phytonutrient nutraceutical powder.
Kansas Achieves Licensing Law
Kansas Governor Sam Brownback signed House Bill 2615 into law on Friday, May 13, 2016. HB2615 includes provisions for the licensure of acupuncturists in the state of Kansas.
How to Stay Sane During the Elections: Understanding Through the Lens of Chinese Medicine
In Chinese Medicine philosophy, everything consists of Yin and Yang. The law of polar opposites – one cannot exist without its opposite.
Believe it or not, an estimated one-third of your patients have eaten some form of fast food within 24 hours of their appointment with you.
Chronic Pain: Become Part of the Solution
I have lectured to more than 7,000 chiropractic physicians over the past five years regarding the chronic pain and opioid epidemic in this country.
The Pertinent Negative
We all have to perform evaluations on patients. Most of us don't like doing it – exams take time, and worse it takes even more time after the evaluation to put together a narrative summary of the findings. Sometimes, this process becomes downright tedious.
Introducing the Acupuncture Today Digital Edition
In response to the changing habits of our readers, Acupuncture Today will introduce a digital edition of the publication (in addition to our print edition) beginning with the August 2016 issue.
Acupuncture Muscle Trigger Point and Oriental Medicine Sports Therapy
It is difficult to ascertain the internal condition of professional basketball player Lebron James during game one of the 2014 NBA finals, in which he developed debilitating muscle cramps that led to his premature removal from the game.
Tai Chi Documentary Premier
First Run Features recently announced the world theatrical premiere of Barry Strugatz's documentary The Professor: Tai Chi's Journey West, which premiered last month at the Laemmle Music Hall in Los Angeles.
Multivitamin Supplement May Reduce Breast Cancer Recurrence
There is a great deal of controversy regarding the value of multiple vitamin supplements in cancer prevention.
Adventures with the San Jiao
Those of us who have been in practice for several decades relish the way meridians and points reveal new diagnostic clues and new insights. I love to encourage my students to see this as an adventure that goes way beyond the textbooks.
AOM Hospital-Based Practice: A Future Reality?
The natural evolution of health care on the planet is integrative health. We may have some challenges ahead, but based on my research, all indicators are pointing in a positive direction. There seems to be an evolving consciousness among our patient population that is "getting it."
Insuring Quality Control in Herb Importation: An Interview with Wilson Lau
Wilson Lau is the vice president of Nuherbs, a Chinese herb importation company based in San Leandro, California. Before joining Nuherbs, he trained as a lawyer specializing in FDA law.
Treating Hip & Groin Pain With Abdominal Release of Upper Lumbar Nerve Impingements
Have you encountered patients with groin and hip pain you can't seem to solve? You know it's not a worn-out hip; you suspect the pain is somehow connected to the spine. But somehow, you just can't help them break through.
Acupuncture's Impact on the World
For several years, I have been hearing about the town of Rothenburg, Germany. It seemed just a dot on a map until I arrived. It is the home of the TCM Kongress which began in 1968. It has been held annually for 47 years and it has only missed one year.
Increasing the Value of Spine Care: CMS Approves New Low Back Pain Registry
The Centers for Medicare and Medicaid Services has approved the Spine IQ Low Back Pain Registry as a qualified clinical data registry for the Physician Quality Reporting System (PQRS) in 2016.
Beating the Odds: Interview With Para-Powerlifter Adeline Dumapong-Ancheta
Since October 2015, the FICS Foundation, the charitable organization affiliated with the International Federation of Sports Chiropractic (FICS), has been supporting disabled athletes internationally.
An MD Who Understands the Opioid Epidemic
Doctors of chiropractic have an important role to play in ending the opioid epidemic and dealing with chronic pain by conservative means (see our top story in this issue) – but who's to blame for opioid dependence and abuse in the first place?
A Long-Overdue Win for Oregon Medicaid Patients - and the Implications for Other States
Beginning July 1, 2016, Oregon Medicaid patients with spinal pain (cervical, thoracic, lumbar, pelvic) who are determined to be low risk based on a biopsychosocial assessment tool (STarT Back – Keele University) can receive four chiropractic visits per episode.
An Emerging Partnership Model
Maryland University of Integrative Health (MUIH) has educated integrative health and wellness practitioners for the last 40 years, originally as an acupuncture clinic and school. The institution's transformative, relationship-centered programs integrate traditional wisdom with contemporary science
Maybe That's Not Tennis Elbow
Lateral epicondylitis, commonly referred to as tennis elbow, is one of the most prevalent upper extremity overuse conditions. Originally perceived as an inflammatory condition of tendon fiber tearing, it is now recognized to result from non-inflammatory collagen degeneration within the tendon as a result of overuse. Massage can be very effective for addressing this problem because pressure and movement applied to the tendon is one of the most effective methods of encouraging fibroblast proliferation in helping to rebuild the damaged collagen.
However, lateral elbow and forearm pain may come from other causes and can easily be mistaken for lateral epicondylitis. In such a case, the standard treatment protocol for epicondylitis of deep friction massage applied to the lateral elbow region could aggravate the condition and make it worse. If the standard protocol for addressing lateral epicondylitis is ineffective, it could be because the primary dysfunction is something different.
Radial tunnel syndrome (RTS) is commonly mistaken for lateral epicondylitis. It is a nerve compression pathology affecting the radial nerve. RTS is also frequently referred to as "resistant tennis elbow" because the symptoms can be so similar to tennis elbow but resistant to the standard treatments.
The radial nerve courses around the posterior aspect of the upper arm along the spiral groove of the humerus. It then crosses the anterior aspect of the elbow, before continuing down the forearm. Just distal to the elbow the radial nerve divides into its two terminal branches, superficial and deep. The superficial radial nerve is sensory, while the deep branch, which comprises the posterior interosseous nerve (PIN), carries mostly motor fibers. It is the PIN that is involved in RTS.
The supinator muscle has two separate divisions. One comes off the lateral epicondyle of the humerus, and has fibers that also originate from the radial collateral and annular ligaments. The other supinator division originates on the supinator crest and the fossa of the ulna (Figure 1).
The posterior interosseous nerve passes between the two divisions of the supinator muscle as it enters the radial tunnel (Figure 2). The radial tunnel is bordered on one side by the tendons of the extensor carpi radialis brevis, the extensor carpi radialis longus, and brachioradialis. The tendons of the biceps brachii and brachialis make up the opposite wall of the tunnel. The capsule of the radiocapitular (radius and capitulum of humerus) joint makes up the floor of the tunnel.1
Compression of the posterior interosseous nerve in the radial tunnel is known as radial tunnel syndrome. There are several different factors that may cause radial nerve compression in this region. Trauma to the elbow causing displacement of bones in the elbow joint is a common cause. Small cysts or tumors can also compress the nerve in the tunnel. The most common cause of PIN entrapment in the radial tunnel is tendinous bands at the edge of the tunnel that press on the nerve.
The symptoms of other common upper extremity nerve compression pathologies such as carpal tunnel syndrome or cubital tunnel syndrome are dominated by sensory aberrations such as pins and needles, electrical sensations, or sharp stabbing pain. These strong sensory symptoms are predominantly the result of cutaneous sensory fibers within the nerve being aggravated.
Nerve compression in radial tunnel syndrome is a bit different because the posterior interosseous nerve is predominantly a motor nerve and carries very few sensory fibers. However, it does carry sensory fibers from the muscles it innervates and related joint areas so it is not completely devoid of sensory fibers. The pain felt from radial nerve compression is more likely to be perceived in the muscle belly as that is where the sensory fibers are coming from. This pain pattern in RTS is in contrast to that of epicondylitis where the primary tenderness is in the tendon fibers very close to the tendon attachments at the lateral epicondyle of the humerus.
Because the PIN is predominantly a motor nerve, muscle weakness or difficulties with upper extremity dexterity are common. The primary muscles affected are the extensors of the wrist and fingers. Forearm pain may accompany weakness when the extensor muscles are contracted significantly because the sensory fibers in the affected muscles are being stimulated. Keep in mind that motor or sensory symptoms may exist together or without the presence of the other.
The symptoms of RTS may develop suddenly or they may come on gradually. How they develop is mostly dependent on the primary cause of the nerve compression. For example, RTS will often occur as a result of some acute injury where there has been a fracture or dislocation of the elbow joint causing a change in positional alignment of the bones in the elbow. In this case a rapid onset of symptoms could be directly related to the traumatic injury in the region.
In other cases, the symptoms may arise more gradually. For example, when RTS is caused by tumors or tendinous bands in the nearby muscles, symptoms may occur more gradually. Repetitive activities involving supination and pronation of the forearm, especially when done from a position of elbow extension which stretches the nerve, are most likely to produce these symptoms.2
Several pain and symptom patterns that help in recognizing RTS have already been introduced. In addition, pain from RTS is likely to be aggravated with activities like handwriting that cause prolonged isometric muscle contractions in any of the forearm muscles. The pain sensations are also likely to be reproduced with palpation directly on the supinator muscle distal to the lateral epicondyle of the humerus. If fibers of the supinator muscle are compressing the posterior interosseous nerve, resisted supination of the forearm may also aggravate the symptoms.3
Weakness or palsy in the wrist and finger extensors is also a common finding. If the compression is only mild or moderate the client will often demonstrate an inability to extend the wrist or fingers against resistance because they will seem very weak. In addition to weakness, pain in the extensor muscles of the wrist may also be present with resisted wrist or finger extension.
Massage and soft-tissue therapy can play a beneficial role in treating RTS. The practitioner should address other regions of potential nerve entrapment such as the thoracic outlet region, axilla, or lateral neck region in case there is a multiple nerve crush or neural tension problem in some other region that is aggravating the nerve compression symptoms of RTS.
Particular attention should be paid to the wrist and finger extensor muscles in the forearm. Deep longitudinal stripping techniques on these muscles will help free any neural restrictions in the distal region of the radial nerve. Decreasing tension in the wrist extensor muscles may also reduce the symptoms. Deep broadening techniques for the wrist extensors will also be of benefit in this region.
Methods of reducing nerve compression in the interface between the posterior interosseous nerve and the radial tunnel will be helpful. Firm pressure on the proximal region of the supinator muscle while the forearm is being pronated will help encourage elongation in the supinator muscle and may reduce compression on the nerve. However, the practitioner should be careful not to aggravate the symptoms by putting additional pressure on the compressed nerve.
Watch for the symptoms of RTS if a suspected lateral epicondylitis problem is not resolving. Deep friction massage over the lateral epicondyle region is the primary treatment for epicondylitis, and this treatment could aggravate an existing radial nerve compression. Therefore, if a deep friction treatment near the epicondyle aggravates neurological symptoms or pain farther down in the forearm, it is wise to consider the possibility of radial nerve entrapment in this region and modify your treatment approach accordingly.
While radial tunnel syndrome is not a commonly occurring condition, it can certainly be a painful and debilitating problem, especially if it is not adequately recognized. Because its symptoms are so often mistaken for lateral epicondylitis it is wise to have a clear understanding of both problems in order to provide the most effective treatment for lateral elbow and forearm pain.