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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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
News in Brief
NYCC Aggregates Degree Programs in New School; Palmer Chancellor Receives Education Award From ICA; Oklahaven Announces "Have a Heart" Winners.
Billing One-on-One, Direct Patient Contact
This is often misunderstood and leads to trepidation when documenting and subsequently billing timed services.
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."
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.
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.
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.
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.
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.
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.
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.
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."
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.