Techniques


The Most Effective Non-Surgical Treatment for Sports-Related Injuries
Techniques
Written by Ronald J. Grisanti, D.C.   
Tuesday, 26 July 2005 17:32

Transverse friction massage is a powerful, yet underutilized, treatment for tennis elbow, rotator cuff, ankle sprains and many common injuries to the muscles, tendons and ligaments. Cross-friction massage, as it is commonly called, is a technique popularized by the late British orthopedic physician, James Cyriax, one of the foremost specialists in the diagnosis and treatment of musculoskeletal injury and pain syndromes. The real value of friction massage is the opportunity for the treating chiropractic physician or therapist to get “immediate” feedback on the potential effectiveness of the treatment.

Real Case Review

Joe consulted with me for pain localized in his right shoulder. The problem resulted from performing overhead military press movements. Joe was unable to “abduct” his arm without significant pain. In addition to the traditional orthopedic shoulder tests, I also performed a functional shoulder examination. One test, in particular, was a simple “resisted” abduction shoulder test. Joe was unable to perform the test without experiencing pain. As part of my evaluation (and treatment), I performed transverse friction massage at the tendon of the supraspinatus muscle. This time, Joe was able to abduct his arm with minimal pain. Over the course of two weeks, Joe was treated every other day, using transverse friction massage, and achieved a 90 percent resolution of his shoulder pain.

How and Why It Works

When soft tissue structures (muscle, tendon and ligaments) are stressed beyond their biomechanical load, micro-tearing will occur. The normal physiological response to soft tissue micro-tearing is inflammation. Although, at first, a good thing, the end result of inflammation without intervention is a normal scar along the lines of stress.

Unfortunately, persistent and excessive overuse and/or immobilization of the healing soft-tissue will result in increased scar tissue. This increased scar tissue does not have the same characteristics as normal, healthy soft tissue.

This increased fibrous tissue has decreased mobility and a loss of soft tissue extensibility. This loss of elasticity results in a loss of optimal function. In turn, this loss of function results in a vicious cycle of micro-tearing, inflammation, scarring and the re-aggravating of the soft tissue, leading to a return of pain.

How Transverse Friction Helps

It has been hypothesized that friction has a local pain diminishing effect and results in better alignment of connective tissue fibers. Transverse massage is applied by the finger(s) directly to the lesion and transverse to the direction of the fibers. It can be used after an injury and for mechanical overuse in muscular, tendinous and ligamentous structures.

The technique is often used prior to and in conjunction with mobilization techniques. It is vital that transverse massage be performed only at the site of the lesion. The effect is so local that unless the finger is applied to the exact site and friction given in the right direction relief cannot be expected. Transverse friction massage imposes rhythmical stress transversely to the remodeling collagenous structures of the connective tissue and, thus, re-orients the collagen in a longitudinal fashion.

Basically, friction prevents adhesion formation and ruptures unwanted adhesions. Friction massage, applied correctly, will quickly result in an analgesic effect over the treated area, providing a noticeable improvement in common soft tissue injuries.

For a detailed review of the science and application of transverse friction massage, I highly recommend the book Functional Soft Tissue Examination and Treatment by Manual Methods, by Warren Hammer, D.C.

Ronald Grisanti DC, DABCO, MS, is a board certified chiropractic orthopedist with a master’s degree in nutritional science. He has created an innovative Web-based program in helping chiropractors develop a nutritional, functional medicine-based practice called Chiropractic Mentors. He can be reached by e-mail at This e-mail address is being protected from spambots. You need JavaScript enabled to view it or through his website, www.ChiropracticMentors.com.

 
The Benefits of Instrument-assisted Soft-tissue Mobilization
Techniques
Written by Warren Hammer, D.C.   
Tuesday, 26 July 2005 17:30

Experts agree that a crucial component of healing is soft-tissue treatment. Indeed, since the works of British orthopedist James Cyriax, clinicians have routinely employed cross-friction massage as a means of breaking up the web of adhesions and restrictions that normally form after injury. However, it is my contention that our profession is insufficiently informed about the advantages of soft-tissue methods in the healing process with regard to both the spine and extremities. Many doctors have steered clear of soft-tissue mobilization due to lack of exposure in their education or out of frustration—too many techniques from which to choose and there is minimal information available about most techniques. Others avoid soft-tissue mobilization because they fail to see the need—they are already successful at helping patients, so why abandon what works?

No matter the reason, this avoidance of soft-tissue mobilization in general is unfortunate, especially if one bears in mind that a principal goal of soft tissue healing is to improve the function of soft tissue by changing its quality.  Quality changes come about by enhancing the proliferate invasion of vascular elements and fibroblasts.1 Fibroblasts, of course, are essential in the inflammatory process necessary for repairing and healing tissue. These specialized cells produce needed collagen which—through deposition and ultimate maturation—supports and strengthens tissue, while also producing the surrounding proteoglycan gel.2

Thus, a primary criterion of any manual loading system is its ability to change the quality of the tissue by encouraging production of collagen and proteoglycan gel. The sad fact of the matter is that rubbing and stretching of tissue achieve only minimal quality changes, far below what is possible with an easier and more versatile method—an approach known as instrument-assisted soft-tissue mobilization.

Studies have conclusively demonstrated that ISTM causes fibroblast proliferation.3 Moreover, ISTM easily removes restrictive adhesions, those that prevent normal tissue motion. It also can be employed to create microvascular trauma and capillary hemorrhage in order to initiate a localized inflammatory response that stimulates the body’s healing cascade and immune/reparative system.4 Further, tissue restrictions and the direction of tissue barriers can be identified with heretofore unattainable precision. Take epicondylopathy (tennis elbow), for instance. After a clinician performs functional passive and resistive tests that localize the sites of pain, ISTM is used to confirm that these sites of pain require treatment. ISTM is also used to detect abnormal tissue tension throughout the kinetic chain (wrist, arm, shoulder) of which the patient may be totally unaware.

It would be extremely difficult to identify such problems in adjoining areas if the only diagnostic tool available to the chiropractor was his or her hands. The pads of the fingers simply cannot compete with instruments in a contest of sensitivity.

In my opinion, ISTM offers a near-universal method to evaluate and treat soft-tissue problems, both for the spine and the extremities. It supercedes many of the myofascial-release and muscle-manipulation methods and products currently on the market. And, for some 1,500 clinicians across the U.S. and Canada, me included, the ISTM application that has proven most efficacious in the role of injury resolution is the Graston Technique®.

I’ve been a proponent of hands-on methods for more than 40 years. Even so, I must say that, in less than the three years since its formal introduction to the chiropractic profession, it is nothing less than remarkable that Graston Technique has already found its way into the curriculum of seven chiropractic colleges.  To my knowledge, there hasn’t been another technique so widely embraced in so short a time in all of chiropractic history.

The Graston Technique system of instrument-assisted soft-tissue mobilization entails the use of six specially designed stainless steel instruments. However, to wield them properly, one must first be trained in their use. The company that owns the rights to GT provides such instruction, typically spread over two weekends.  However, there is a minimum of a two-month span between the 12-hour courses to allow the acquired basic skills to become second nature through daily usage before other, higher-level skills are taught.

In conclusion, soft-tissue mobilization should be looked upon for what it is—an important adjunctive to chiropractic care. And ISTM should be seen for what it is—a viable means of achieving greater success with the acute and chronically injured patient, faster and easier than ever before possible.

References

1. Nirschl RP, Ashman ES. Elbow tendinopathy: tennis elbow. Clin Sports Med 22(4);2003:813-836.

2. Davidson CJ, Ganion LR, Gehlsen GM, et al. Rat tendon morphologic and functional changes resulting from soft tissue changes  resulting from soft tissue mobilization. Med Sci Sports Exe;29(31997):313-319.

3. Gehlsen GM, Ganion LR, Helfst R. Fibroblast responses to variation in soft tissue mobilization pressure. Med Sci Sports Exer 1999;31(4):531-535.

4. Gross MT. Chronic tendonitis: Pathomechanics of injury factors affecting the healing response and treatment. J Orthop Sports Phys Ther 16(2):248-261.

Warren Hammer, DC, MS, DABCO, is the owner of Hands On Therapeutics in Norwalk, CT. He is the author of a widely used textbook, Functional Soft Tissue Examination and Treatment by Manual Methods, New Perspectives, soon to be released in its third edition.  For more information about ISTM and a GT training seminar near you, visit www.grastontechnique.com or call 866-926-2828.

 
Contact Reflex Analysis
Techniques
Written by Loren Marks, DC   
Wednesday, 22 June 2005 16:47

We are living in the midst of a “Wellness Revolution.”  Patients, primarily the baby boomers, are seeking greater levels of natural health care as they age. They are wealthier and more educated than their parents and are willing to spend more to attain a level of health that allows them to be stronger, healthier and more resistant to disease.

The insurance industry primarily limits reimbursement for the management of acute care services chiropractors provide. The model of patients depending upon their insurance to cover the rising costs for their health care has forced many of us to live within the paradigm of acute care management. This is contrary to the beliefs and benefits chiropractic has to offer, and undervalues its role. Fortunately, this does not have to occur. What does have to occur, in order to break the shackles of this bondage, is a broadening of our concept of healing and our willingness to study and learn many missing links to health. Many chiropractors feel that, if anyone is to take the rightful place as the leader in the Natural Healing movement in this country, it should be us. After all, we are the largest group of naturally oriented practitioners.

This demands that we, as chiropractors, step up to the plate and embrace the structural/neurological system as we know it, the chemistry or physiology and how it relates to nutritional and herbal intervention and the emotional or mental components of a patient.

Contact Reflex Analysis, developed by Dr. Dick Versendaal, is a technique that has stood the test of time and has been around for nearly 40 years. It has been utilized by thousands of doctors and has always been based on a triad of health. If we can perpetually balance the structure, chemistry and emotions of a patient, diminished disease and enhanced resistance must follow.

CRA is a muscle response system that enables you to navigate the status of a patient’s structure, chemistry and emotional state at any given time. It’s remarkable that you can define so many parameters of health accurately and correlate your findings with known diagnostic tests. In fact, once you have attained a commensurate level of skill, you are able to detect sub-clinical entities. This represents true preventative health care. Not only are you evaluating and treating your patient’s complaints more effectively, you are also treating the sub-clinical manifestations that may otherwise progress to enhanced disease.

CRA differs from many of the kinesiologic techniques being taught today. We have a unique monitoring system that allows the doctor to quantify a patient’s energy, pain, muscles, heart and chemistry. This is performed by “Pulsing and Scoring.” Doctors are taught how to rhythmically utilize the middle deltoid muscle or pulse, counting each depression numerically as the patient resists. This provides the doctor with a skill-set that analyzes the functional status of a particular organ, gland or tissue. We then teach you what the correct nutrient/herbal or homeopathic requirements are to assist the body in its need for restoration. This, also, is a process of quantification, allowing the dosage of any given therapeutic agent to be titrated to the exact requirements of the individual. It is a far cry from textbook or cookbook nutritional applications. We need to rise above the level of mediocrity that exists when doctors begin to employ nutrition in their practices.

The concepts of “just give them a multi-vitamin” and “I have covered all the bases” or “Just tell me what formula treats high cholesterol or diabetes,” leave us in the dust when making a comparative analysis of who should take the lead in providing a wellness model for health.

CRA does not favor one specific vertebra, but rather permits you to challenge where subluxations may exist, whether they are located in the axial or appendicular skeleton or both. You utilize the chiropractic technique you feel is best for your patient. We will teach you how to assess your validity and whether you have met the body’s needs.

There are some specific maneuvers that are genre to CRA, like an atlas wedge, a towers adjustment and a D4, but any means to resolve a subluxation complex that works, and you have mastery in, will more than suffice. Perhaps the real question is, “What is causing what?”

If a patient is suffering from a vertebral subluxation that is causing a significant pain pattern and we have not evaluated the inflammatory status or structural components that may be weak or degenerative due to faulty diet or nutritional insuffiencies, have we done our job? Think about what the world will say about chiropractors when we embody higher standards of care that are comprehensive and wellness-oriented, providing greater outcomes.

Dr. Loren Marks has been a clinical instructor with CRA for the past 13 years.  He teaches with Dr. Versendaal all over the country. For further information and seminar locations, visit www.crahealth.org.

 
Advanced BioStructural Correction™
Techniques
Written by Jesse Jutkowitz, D.C.   
Sunday, 22 May 2005 15:25

Advanced BioStructural Correction™ is exactly that; it is an advance in the correction of biostructural pathologies.

The most important advance is the identification of the most basic mechanical pathology that occurs in the human body. “Most basic mechanical pathology” has two meanings: It means the starting point of where structure becomes pathological, AND it means the fundamental pathology that keeps a structure pathological when it stays pathological.

This pathology is not a single thing, like an atlas subluxation or a sacral subluxation that some claim on the basis of all structural pathology, but a class of things that can all be described in one sentence.

A little history is in order here first.  One of the first things everyone learns coming out of schools of structural healing, such as chiropractic, and into private practice is that chiropractic and other structural healing methods can work to create the miracle results that we hear about in school. BUT, those results are not obtained consistently and predictably.  I discovered this very quickly in my own practice. Correcting headaches, back pain, neck pain, and many things you would not think that had a structural basis, was happening everyday, but not consistently and predictably.  Having a background in the physical sciences and engineering, I understood that, when one can create a given result but not do so consistently or predictably, there must be factors influencing the outcome that are unknown to the person trying to get the predictable result.

This means you must look further and measure more of the body on an objective basis to understand what is going on.  Lowell Ward provided some direction in this when he discovered the vast differences in spinal configuration on standing and sitting full spinal X-ray, so that is what I started doing—taking standing and sitting full spinal X-rays and measuring every vertebra and vertebral angle that I could think of.

At the time, in the early 1980s, this was contrary to the popular thought in structural healthcare and chiropractic, which was that X-ray was invalid because the changes seen on X-ray vary unpredictably and did not fit with the theories they had developed to explain the good results obtained.  Those theories conveniently left out an explanation of why various methods did not work and why sometimes damaging results were obtained.

In fact, since the results of treatment were unpredictable and the changes on the X-ray were unpredictable, the X-rays did correlate with what was physically happening, even if they did not correlate with the theory adopted to explain the good results that were often obtained in structural healthcare.  The next time you hear someone say that X-rays are not important in structural healthcare because they don’t show what’s actually happening, remember the above fact and understand that the person telling you that does not understand what is happening on the X-rays but that what is there is what is happening and is very important.

Measuring standing and sitting X-rays, I discovered that no theory of structural healthcare in chiropractic, in osteopathy, physical therapy or in any other system of structural healthcare could be true.  You can duplicate that discovery in your own office by taking standing and sitting full spine X-rays of your patients and noting the objectively measurable changes their bodies undergo from standing to sitting. You will discover for yourself that, if any of the theories which currently exist in structural healthcare were completely true, many of those patients could not exist.

I found I had to discard everything I had learned except basic anatomy.  It is a much longer story and there isn’t enough space to print it here, but the objective measurements and observations led to the following discoveries:

Axioms were developed.  (Keep in mind that an axiom is an established rule or principle or a self-evident truth.  “Self-evident truth” would be something that anyone could observe occurring in the physical universe.)

These are the axioms of structural healthcare:

1. The body is NOT a TOTALLY self-correcting thing or machine but it can self-correct many of its mechanical pathologies.  (This is self-evident by objective observation—mechanical things go wrong with bodies that they do correct, and that they do not self-correct.  Therefore, the body is partially self-correcting, but not totally.)

2. Health of the body is defined as a body working optimally on a mechanical basis. (Even chemistry comes down to mechanics, if you look at it from a small enough viewpoint—the shapes of the molecules fitting together are how drugs and nutrition work.)

3. To keep bodies healthy or get bodies healthy, one must make sure that the things the body cannot self-correct are corrected by some outside agency. (Observation of the correlation of Axioms 1 and 2)

4. Regarding what the body cannot self-correct: On the grossest scale, what the body cannot self-correct are bones out of optimal mechanical position in a direction the body has no muscle or combination of muscles that can pull in the direction needed to retrieve and replace the bone into its position of optimal mechanical advantage for the body. (Observation of anatomy/physiology—bones can go slightly out of position in a direction that adversely affects their ability to act as levers and exert the force needed for the body to work properly AND the body does not have muscles oriented to pull the bones and reposition them once they go out of place in some of those directions.  An example would be the case of radial head subluxation, or Nursemaid’s Elbow, which is just a bone out of place in a direction the body doesn’t have muscle or a combination of muscles that pull in the direction needed to self-correct the condition. Correction of that condition leads us to Axiom 5.)

5. Regarding treatment of a body: Doctors and others should only correct things the body cannot self-correct—as, by definition, the body will self-correct the rest.

One can readily see that these axioms are self-evident by objective physical observation; there is no theory or concept that must be learned or believed to understand or agree with them.

You can see more physical observations and explanations at the web site www.advbiostucturalcorr.com; but, just from the above physical observations, you can see that any system of mechanical treatment that includes pushing spinal bones from posterior to anterior, i.e., pushing down on a person’s back, is questionable, at best, since there are no muscles attaching from the vertebrae to something stable behind the vertebrae (since all that is back there is skin).

For those having difficulty with that statement, I invite you to the web site to examine the article, “Mechanisms That Others Have Not Seemed to Consider.” In that article are the full explanations of common misunderstandings of body mechanisms that most developers of structural healthcare methods or techniques have included in their techniques that limit their effectiveness.

Which are the bones that go out of place in directions the body cannot self-correct and how do you best correct them and in which order? These are all questions addressed in Advanced BioStructural Correction™.

Using the Advanced BioStructural Correction™ protocol for structural correction you will consistently and predictably correct every mechanical problem or pathology that walks in your door that is not caused by cancer, infections, fractures or the like. Ask the docs whose numbers are on the site. They did not believe it could be done consistently and predictably either—that is, until they learned and used Advanced BioStructural Correction™ for themselves and made their own discoveries. There is nothing to believe in ABC™.  You will discover for yourself that everything presented is an objective, physically measurable observation you can duplicate for yourself in your own office.

Advanced BioStructural Correction™ is most often learned with the at-home seminar that includes CD’s, DVD’s and Manuals and includes unlimited phone consultation time which doctors often use at the beginning while they are discovering for themselves that ABC™ does what we say, and use infrequently when they find out that they get the consistent and predictable results we promise.

For more information about Advanced BioStructural Correction, Dr. Jesse Jutkowitz, can be reached by calling 203-366-2746, by e-mail This e-mail address is being protected from spambots. You need JavaScript enabled to view it , or visit www.advbiostructuralcorr.com.

 
Somato Respiratory Integration™ Exercises: to Relieve Stress
Techniques
Written by Donald Epstein, DC   
Friday, 22 April 2005 13:23

A patient calls in the middle of your weekend feeling great distress about their experience under your care; what do you tell them?  You have a patient who seems to be so unresponsive to care, you feel lost.  You are looking for your practice members to take more responsibility for their health, wellness and healing processes.  If you have ever encountered any of these experiences, I am about to share with you something so powerful that it will absolutely transform your practice and patients.

The single most important exercise a patient or practice member should do to feel greater safety in his/her body, and take the “charge” off symptoms, consists of turning the attention within.  How do we get the patient to trust this innate healing ability enough when feeling stressed or in pain?  How do we recognize and promote a greater self-responsibility in care? 

We wear our stress response in our bodies as what I call  “defense postures.”  The structural distortion, tension patterns and subluxations are a testimony to, and physical anchor for, events that overwhelm our body-minds.

Somato Respiratory Integration™ (SRI) exercises (based on my book, The 12 Stages of Healing) are designed to help the brain reconnect with the body and its experience.  These exercises reconnect breathing with awareness of the body and its natural rhythms.  They help the individual experience his/her body more fully, instantly shift the individual’s state of consciousness to one that supports trust for the body-mind and healing process, as well as promote increased peace and ease.

These exercises appear to consistently reverse the process of defense physiology, spinal distortion and the disconnection that hinders the progression in chiropractic care. They can provide the acute patient with a tool to help dispel fear and encourage trust in the body or his/her experience of the body. The exercises can also be helpful to the practitioner in communicating the brain/body/emotion/stress connection.

Introducing Somato Respiratory Integration™ Exercises: Stage One

This exercise is recommended anytime an individual is overwhelmed by his body, experience or symptom, and also if he feels helpless, fearful of his body, is difficult to adjust, or just needs more internal connection and a greater degree of internal safety.  When an area of the spine does not adjust easily, or has recurring defense patterns, this exercise can be performed as a means of developing connection in the region directly anterior to the spinal tension pattern. It can be magical in its result.

Lie on your back or be seated.  Touch your upper chest at the top of the ribs with both hands, palms facing downward, and breathe slowly and gently in through your nose and out through your mouth.  Inhale just deeply enough to feel your breath meet the rhythm of your chest rising.  Exhale just enough to feel the rhythm of your chest falling. Localize the area of motion and breath to just the zone under your hands. Do not allow other areas of the body to recruit motion.  Repeat this process for a few respiration cycles.  Now, do the same exercise with your hands placed at the bottom of your breastbone and breathe the same way.  Then place your hands on your abdomen (near your navel) and repeat.  Remember to breathe gently just into the area where your hands are placed.

If this exercise is very difficult to do in one of these regions, move to a different region that feels more comfortable and at which you can focus the breath and movement with greater ease. Let the peace you experience there spread to the region where you felt discomfort.  Once the individual has found the “connection” in peace and can focus the breath and motion into just that area, then the practice member can alternate between this area and the area of distress. When he holds the area of distress, he should attempt to get breath as close to that area of the body as possible and moan or make the sound of that area—the sound that area would want to make if it could speak.  This technique requires the brain to hook up to the area again. 

After the sound is made in this area (no more than 30 seconds on this area of distress), have the practice member bring both hands back to the area of connection or peace of the SRI Stage One exercise.  At this point have the practice member sigh or make a sound of peace, ease, or relief at this area.  Alternate between the area of connection or peace and distress for a few minutes (usually up to 10 minutes).  Notice if there is more comfort, or if the practice member has greater wellness, or if the sounds between both areas seem to merge.

This is actually only the first of twelve exercises encompassed within the SRI exercises.  Each of the exercises in a series of twelve represents a unique state of awareness and different somatic-respiratory rhythm.  As an individual advances in his/her own healing journey, there are exercises to support that growth and development.  For those seeking evolutionary strategies for the future of their practices, look no further; Somato Respiratory Integration™ exercises lie waiting to serve you.

For more information on Somato Respiratory Integration™ exercises and on programs to learn these exercises, visit www.donaldepstein.com and www.wiseworldseminars.com.

 
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