What is Reflexive De-afferentation?

FITPRO and The developers of RDTs (Rapid-Reflexive De-afferention Techniques) are extending a hearty invite to Physical Therapists, Physiatrists, Orthopedic Medicine Practitioners, and Manual Medicine Specialists to join them for another "Sharing Session" / Workshop.

WHAT: Reflexive and Indirect Techniques in Manual Medicine 

For Pain Relief, Spinal Alignment, and Joint Freedom

            Workshop II

WHEN: August 29, 2010

TIME: 10 am to 3 pm

WHERE: The Holiday Inn Galleria Suites, Ortigas Center, Pasig, Philippines

EXPECT: To walk away with basic and intermediate tools for a working Integration of Muscle Energy, Reflexive Releases, and Articulatory Techniques that you can use the very next day at your clinics.

The study group will go over The Location and Uses of Reflexive Points.

REFUND POLICY: Try out the techniques and principles for 60 days. If, within that time, your clinical application of the technology has not (a) allowed you to turn off pain and (b) recovered your investment in the course, we will refund your money.

CE: The workshop counts as 6 coursework hours toward certification as an RDT practitioner. Certificates will be furnished. Participants may choose to test for certification as RDT Associate Practitioners or RDT Practitioners – Level I.

PREP: Please come in loose and repositionable clothing.

COST SHARING:

Late Reg: P2,000 if prepaid by Friday, August 06, 2010

On-Site Registration: P2,500

P500 waived from cost-shares for the following:

MMG Workshop participants (any workshop from 2007, just bring your certificate); 

SOMATIC members, Bowen Practitioners, and FITPRO members.

Credit card processing via Paypal is accepted.

Delayed or deferred sharing may be arranged. We just want to know who’s coming.

Early Course Outline may be requested via email.

Contact Rheysonn at +63 922 7914724 to confirm participation or request more info. 

Please furnish email addresses and return contact numbers.

What is the technology behind R.D.T.s?

Reflexive Antagonism is the phenomenon by which muscles with opposing functions tend to antagonistically inhibit each other. When one muscle is activated, its opposite muscle or muscle group or is reflexively inhibited or deactivated. By example, when the triceps brachii is stimulated, the biceps muscle on the same extremity is reflexively inhibited.

The phenomenon of Relfexive Antagonism is now known to be fleeting, incomplete, and weak. The incompleteness of the effect is related to postural and functional tone. Also, reflexes in vivo are polysynaptic, with entire muscle groups responding to noxious stimuli (Nociceptive Reflex or Nociceptive Withdrawal Reflex).

Reflexive antagonism is the basic original notion behind indirect muscle energy techniques. While this notion is now understood to be incomplete, the clinical mechanism of Reflexive Antagonism continues to be useful in widespread Osteopathic and OMT-derived practice. Reciprocal Inhibition is a synonym. (See Entry under Muscle Energy Techniques)

Techniques that utilize reflexive antagonism, (such as Rapid De-Afferentation Techniques) are manual medicine techniques and protocols that utilize reflexive pathways and the phenomenon of reciprocal inhibition as a means of switching off inflammation, pain, and protective spasm for entire synergistic muscle groups or singular muscles and soft tissue structures.

From http://www.amazines.com/Reflexive_Antagonism_related.html and http://en.wikipedia.org/wiki/Reflexive_antagonism

Suggested reading:

1.     Fryer G 2000 Muscle Energy Concepts –A Need for a Change. Journal of Osteopathic Medicine. 3(2): 54 – 59

2.     Fryer G 2006 MET: Efficacy & Research IN: Chaitow L (Ed) Muscle Energy Techniques (3rd edition) Elsevier, Edinburgh

3.     Ruddy T 1961 Osteopathic rhythmic resistive duction therapy. Yearbook of Academy of Applied Osteopathy 1961, Indianapolis, p 58

4.     Solomonow M 2009 Ligaments: A source of musculoskeletal disorders. J Bodywork & Movement Therapies 13(2): IN PRESS

5.     Smith, M., Fryer, G. 2008 A comparison of two muscle energy techniques for increasing flexibility of the hamstring muscle group Journal of Bodywork and Movement Therapies 12 (4), pp. 312-317

6.     McPartland, J.M. 2004 Travel trigger points - Molecular and osteopathic perspectives Journal of the American Osteopathic Association 104 (6), pp. 244-249

7.     Hamilton, L., Boswell, C., Fryer, G. 2007 The effects of high-velocity, low-amplitude manipulation and muscle energy technique on sub occipital tenderness International Journal of Osteopathic Medicine 10 (2-3), pp. 42-49

8.     McFarland, J.M. 2008 The endocannabinoid system: An osteopathic perspective Journal of the American Osteopathic Association 108 (10), pp. 586-600

9.     Magnusson M Simonsen E Aagaard P et al. 1996a Mechanical and physiological responses to stretching with and without pre-isometric contraction in human skeletal muscle Archives of Physical Medicine & Rehabilitation 77:373-377

10.   Magnusson M Simonsen E Aagaard P et al. 1996b A mechanism for altered flexibility in human skeletal muscle. Journal of Physiology 497(Part 1):293-298

What is Reflexive Antagonism?

Reflexive Antagonism is the phenomenon by which muscles with opposing functions tend to antagonistically inhibit each other. When one muscle is activated, its opposite muscle or muscle group or is reflexively inhibited or deactivated.

The phenomenon is now known to be fleeting, incomplete, and weak. By example, when the triceps brachii is stimulated, the biceps is reflexively inhibited. The incompleteness of the effect is related to postural and functional tone. Also, reflexes in vivo are polysynaptic, with entire muscle groups responding to noxius stimuli (Nociceptive Withdrawal Reflex).

Reflexive antagonism is the basic original notion behind indirect muscle energy techniques. While this notion is now understood to be incomplete, the clinical mechanism of Reflexive Antagonism continues to be useful in widespread Osteopathic and OMT-derived practice. Reciprocal Inhibition is a synonym. (See Entry under Muscle Energy Techniques)

Techiques that utilize reflexive antagonism, (such as Rapid De-Afferentation Techniques) are manual medicine techniques and protocols that utilize reflexive pathways and the phenomenon of reciprocal inhibition as a means of switching off inflammation, pain, and protective spasm for entire synergistic muscle groups or singular muscles and soft tissue structures.

Reciprocal inhibition describes muscles on one side of a joint relaxing to accommodate contraction on the other side of that joint.

Reciprocal Inhibition, however, can backfire by both muscles attempting to contract at the same time. Thus a common tear can occur at muscle level. The body handles this pretty well during physical activities like running, where muscles that oppose each other are engaged and disengaged sequentially to produce coordinated movement. This facilitates ease of movement and is a safeguard against injury. Sometimes, for example, a footballer running back can experience a "misfiring" of motor units and end up simultaneously contracting the quads and hamstrings during a hard sprint. If these muscles, which act opposite to each other are fired at the same time, at a high intensity, a tear can result. The stronger muscle, usually the quadriceps in this case, overpowers the hamstrings. This sometimes results in a common injury known as a pulled hamstring.

What are Visceral Organ Dysfunctions?

Visceral Organ Dysfunctions (VMDs ) are internal organ problems that arise from problems that affect the mobility and motility of these organs. As the treating physician or therapist, VMDs are something to consider when you’ve done what you can for musculo-skeletal problem resolution, and strangely still find yourself unable to deliver results that you are routinely happy with. You may have one of those “this should be fixed by now” moments. So, the question arises: have you found the primary dysfunction? Also, is the primary truly a framework problem? Is it possibly instead an internal organ dysfunction that is causing the constellation of abnormalities you have had problems correcting?

Visceral Organs may be limited in their natural motility or in their mobility in relation to the other organs. This is particularly true for when strong adhesions and scar tissues are present. The inciting history would include focal or generalized inflammation. Often, the first cause was trauma or surgery.

Somatic Dysfunction Recurrences are often due to Visceral Organ Primary Dysfunctions. Keep in mind, however, that the most common reasons for unresolved or recurrent somatic dysfunctions include (1) mis-diagnoses and (2) incorrect treatment. A mis-diagnosis almost always ensures that you then choose the wrong treatment approach. That is why we should always endeavor to treat what we see, and not what we expect. On the other hand, using a hammer where a screwdriver was needed will often make things worse a lot faster.

Other areas to look at would include proper identification of the true Primary Somatic Dysfunction. The “Primary” is the one area that most affects the other areas. By example, a recurrent Shoulder Somatic Dysfunction with multiple supposed primary tendinopathies and Tendinitides can in fact be the result of an incomplete diagnosis. Often, a subacromial bursitis is the inciting primary. In this example, this is the prime pathology that caused the entire rotator cuff weakness via reflexive inhibition. Think of it as the body trying to guard this area by turning off aggravating movements. Without addressing this primary, the involved tendons are kept in an inflammatory cycle, and the muscles are weakened.

Basically, pain begets inflammation, begets the inflammatory cascade, begets muscle spasm, and feeds back upon itself as more pain. In this light, the first rule of osteopathy may be more clearly understood: “the rule of the artery is supreme.” If we can improve circulation and lymphatic clearance, we can cut off inflammation and break the pain cycle.

May we fit in the prime rule of Reflexive De-afferentation Technology? “Turn off Pain first.” Turn off pain. Turn off reflexive guarding and protective modes. Improve circulation. Remind the body of how it functions when it functions best. Then let the body do what it does best: adapt and heal.

Keep in mind that Viscero-somatic reflexes are also a reverberating circuit. We can do all we can for the shoulder, but if the Gallbladder was the “Primary,” all our work would go nowhere.

Visceral mobilization techniques include mobilization techniques and motility enhancement techniques. Mobilization can be direct or indirect. Indirect techniques for mobilization include reflexive releases and long-levered techniques.

Direct techniques involve local contact, or at least contact that is transmitted directly through tissues adjacent to the organs we want to move around. When we break adhesions or scars this way, organs move more freely in relation to the other organs and structures they articulate with.

Long-levered visceral mobilization techniques utilize organ extensions or connections as handholds for transmission of therapeutically corrective forces. By example, the lungs may be moved via articulating the trachea. The stomach may be moved via an esophageal handhold. The heart may be articulated via a carotid handhold. The brain may be similarly articulated via a traction hold on the carotid vessels.

An Osteopath, a Naturopath, an Allopath, and an Oriental Medical Doctor meet at the nearby Starbucks

Alternative meets mainstream?

Treatments for Arthritis of the Hand

Capsulitis of the Thumb and Finger Joints

Diagnosis and Treatment

Prime cause: Overuse. Traumatic origin may also be recalled.

Capsular pattern or presentation:

Thumb: 

Pain and limited passive ranges of motion on:

adduction

extension

abduction

Other Digits:

Pain and limited passive ranges of motion on:

metacarpo-phalangeal joints:

extension with ulnar deviation

interphalangeal joints: painful and limited passive flexion

distal interpahlalangeal joints: painful and limited passive extension

Treatment Options may Include: 

Cold compresses on an off at five minutes each time would help deal with the acutely inflamed joint.

NAIDs have some benefit. Use must be weighed versus side-effects, and the probability that the pain cycle is properly cut.
DMARDs may be considered for chronic cases, as well as those with sub-acute components.
Standard TCM acupuncture has not been proven to be strongly beneficial.

Yamamoto new scalp acupuncture may be of some use if the Yamamoto points are distinctly identifiable.

Articulatory releases have proven benefit.

Instrument-assisted releases of associated soft tissue has proven benefit, and is among treatments that should first be considered. Prime candidates include the cases with longstanding low-grade inflammation and peri-lesional fascial adhesions.

Anatomy of Approach to Joint:

The first metacapal-trapezium joint is articulated at the apex of the anatomical snuff box. Keep in mind that the radial artery runs through the base of the snuff box. Taking the tractioned thumb into flexion-extension cycles delineates the joint.

Local steroid infiltration technique: mid-small guage needle (such as 25 G, 0.5 inch) is introduced at right angle to the skin surface at the joint line. A medial of lateral approach to the joint line may be used.

Illustration and Interventional Summary by Strix Toledo, M.D. (C)2010

Balance and Movement and The Effect of Chiropractic Care

Article Reposted for commentary. Send us feedback, will you?  

Balance and Movement and The Effect of Chiropractic Care Utilization with the Elderly, Cerebral Palsy, the Athlete and the General Population

Mark Studin DC, FASBE (C), DAAPM, DAAMLP

William J. Owens DC, DAAMLP

　

Sensorimotor is defined as our ability to feel and move. With infants, Piaget, the renowned researcher, categorized the first 2 years of an infant’s life as the sensorimotor stage. "During this period, infants are busy discovering relationships between their bodies and the environment. Researchers have discovered that infants have relatively well developed sensory abilities. The child relies on seeing, touching, sucking, feeling, and using their senses to learn things about themselves and the environment. Piaget calls this the sensorimotor stage because the early manifestations of intelligence appear from sensory perceptions and motor activities" (Anderson, n.d., http://facultyweb.cortland.edu/andersmd/PIAGET/sms.html).

As we develop and our nervous systems have acquainted us to our surroundings, we need the neurological "hookups" to remain intact to function optimally and pain free. In addition, our sensory and motor systems need to work in tandem in order for us to function normally.

To further break it down, our sensory system is part of the nervous system that consists of receptors that receive stimuli from both our internal and external environments. These receptors, such as the ones located in our fingertips, sense external stimuli, such as hot or cold, or what we feel. An internal receptor may be found in the tendons (connect your muscles to your bones) and lets you know what your joints are doing, such as are my fingers sensing if they are relaxed or in a fist. The sensory system is also controlled by the brain that processes what we feel.

Pain is part of the sensory nervous system and to the surprise of many, pain is an important component to protecting yourself. Without pain, you could get seriously hurt, such as by keeping your finger on a hot stove too long or touching a sharp object too heavily and cutting your hand. Internally, pain is a warning sign that an organ or system is "sick" and alerts you to seek medical care.

All pain receptors are free nerve endings, meaning they only bring information to your brain and function as the "pain receptors." There are three types of pain receptors; mechanical, thermal and chemical. They are found in skin and on internal surfaces such as the coverings of the bone and joint surfaces. "Deep internal surfaces are only weakly supplied with pain receptors and will propagate sensations of chronic, aching pain if tissue damage in these areas is experienced. Pain receptors do not adapt to stimulus. In some conditions, excitation of pain fibres becomes greater as the pain stimulus continues, leading to a condition called hyperalgesia [commonly known as, "WOW, that hurts a lot!"]" (Global Oneness, n.d.,http://www.experiencefestival.com/a/Pain_-_Physiology/id/597137).

Your motor system is what allows you to move, maintain your posture and control your muscles. The motor system is controlled through nerves similar to the sensory system and like the sensory system, has a controlling element in the brain.

Functional tasks are defined as those things we do in our lives. Answering a telephone, putting a key in a door lock or picking up a fork to eat are all examples of functions. These functions, just like Piaget described in infants, are how we have a relationship with our body and the environment and require an integrated motor and sensory nervous system. Every functional task that we do involves both the motor and sensory components of our nervous system and while performing these tasks, we are protected by our ability to perceive pain.

Due to the development and integrategration of the world around us necessary to complete every task in our lives, as we get older, postural disturbances can arise and negatively affect how we integrate the sensorimotor information we are receiving both internally and externally and lead to significant balance disorders. Lord and Ward (1994) reported that, "All of the sensory, motor and balance system measures showed significant age-associated differences"(http://ageing.oxfordjournals.org/cgi/content/abstract/23/6/452). This means that as one gets older, his/her sensorimotor system often fails to integrate the internal and external environment as it once could.

A research study by Taylor and Murphy (2008) concluded that chiropractic care reverses maladaptations in sensorimotor integration and improving motor control. The study suggests that spinal dysfunction may lead to muscle specific alterations of the brain’s ability to process motor control. The "real-life" implications of this finding affect every facet of our lives and every person. Whether it be an older person who is starting to exhibit balance disorders, or a cerebral palsy victim who struggles on a daily basis with the simple tasks of life or a world class athlete looking to increase his/her fine motor skills just 1/10 of 1%, the results of chiropractic care can be dramatic.

From the clinical observation of Dr. Mark Studin, a co-author of this article and practicing chiropractor for 30 years, "This now gives scientific evidence and validation to what patients have been sharing after receiving chiropractic care. The most common comment from patients post care is, 'I perceive my surroundings more acutely and feel straighter.'" Dr. Studin continues, "Although I have heard this from every age group, my first patient was a cerebral palsy patient who stated that without getting adjusted he could barely function. With care, he walked to and from the office, a distance of 3 miles."

These studies, along with many others conclude that a drug-free approach of chiropractic care is one of the best solutions to increase integration between the motor and sensory systems of your body. To find a qualified doctor of chiropractic near you, go to the US Chiropractic Directory at www.USChiroDirectory.comand search your state.

References:

1.  Anderson, M. (n.d.). Sensorimotor stage. Jean Piaget's Theory of Development. Retrieved from http://facultyweb.cortland.edu/andersmd/PIAGET/sms.html

2.  Global Oneness. (n.d.). Pain - Physiology. Retrieved from http://www.experiencefestival.com/a/Pain_-_Physiology/id/597137

3.  Lord, S. R. & Ward, J. A. (1994). Age-associated differences in sensori-motor function and balance in community dwelling women. Age and Ageing. Retrieved from http://ageing.oxfordjournals.org/cgi/content/ abstract/23/6/452

4.  Taylor, H. H. & Murphy, B. (2008). Altered sensorimotor integration with cervical spine manipulation.Journal of Manipulative and Physiological Therapeutics, 31(2), 115-126.

Other Mechanisms in Acupuncture Pain Control: Reduction of Dopa release and GABA Receptor regulation?

Acupuncture Suppresses Morphine Self-Administration Through the GABA Receptors

Yoon SS, et al. Department of Physiology, College of Oriental Medicine, 

Daegu Haany University, Daegu 706-828, South Korea.

Brain Res Bull. 2010 Jan 4. Prime Source: PubMed

The neurobiological substrate for morphine self-administration in animals is believed to involve the dopamine system of the nucleus accumbens. 

Our previous study has shown that acupuncture at the acupoint Shenmen (HT7) reduced dopamine release in the nucleus accumbens and behavioral hyperactivity induced by systemic administration of morphine. 

Here we investigated the effect of acupuncture on morphine self-administration and potential roles of GABA receptors in the mechanisms behind acupuncture. Male Sprague-Dawley rats were trained to self-administer morphine (0.1mg/kg per infusion) during daily 1-h session under fixed-ratio 1 schedule. Following the stable responding on morphine self-administration, acupuncture was applied to HT7 points bilaterally (1min) prior to the testing session. Another groups of rats were given the GABA(B) receptor antagonist SCH 50911 (3.0mg/kg, i.p.), the GABA(A) receptor antagonist bicuculline (1.0mg/kg, i.p.) or saline 30min prior to the acupuncture treatment. 

We have found that acupuncture at the acupoint HT7, but not at the control point Yangxi (LI5), significantly decreased morphine self-administration. 

Moreover, either SCH 50911 or bicuculline blocked the inhibitory effects of acupuncture on morphine self-administration. Taken together, the current results suggest that acupuncture at specific HT7 points regulates the reinforcing effects of morphine via regulation of GABA receptors.

Quantum 1 for Osteopathy Course

Quantum 1 for Osteopathy Course

Acupuncture Sedation Points and The Muscles they Reflexively Affect

Clink here to view original Article on postulated peripheral basis of acupuncture effects.

Acupuncture Sedation Points 

and The Muscles they Reflexively Affect

Small Intestine 8 - Rectus Abdominis
Stomach 45 - Pectoralis clavicular and sternal extent; Pectoralis Minor; SCM
Bladder 65 - Peronius tertius, longus, and brevis; Sacrospinalis
GB 38 - Popliteus
LU5 - Serratus anterior; Deltoids
LI2 - TFL, hamstrings
K1 - Ilipsoas, upper trapezius

The RDT Team of the Manual Medicine Group Philippines
can help you learn how profoundly useful these Reflexive Release Points are.

You may contact Rheysonn Cornilla for workshop registration.
He is at rheysonn_cornilla@yahoo.com
and (+639)22 791 4724 (Sun Cellular Philippines)

The Author nor the MMG can and will not be held responsible for unsupervised use of acupuncture and Relfexive De-afferentation Technology.

Assessing the Primary Subluxation Pattern

assesing the subluxation patterns:




general:

the rib cage tends to veer to the side of L3 rotation.

neck rotation ease tends to be oposite L3 rotation.



check L1

if L TP is posterior L,

SB L,

this is likely part of an L3 Rot R SB R pattern.



stand patient with feet aligned.

FB patient from the waist,

with arms hanging loosely on either side



if the rib cage shifts R

and shoulders rotate left,

you most probably have an L3 Rot R SB R pattern.



the right scrospinous and sacrotuberous ligaments will be tight

in supine, the patient will have left neck rotation ease.

lumbar SB ease is to the Left.





IN and L3 rot L, SB R pattern,

the rib cage veers left

and the shoulders rotate R

the left sacrospinous and sacrotuberous ligaments are tight

supine, the neck rotation ease is is to the R.

the neck in an L3 RR

with the L3 in Rot R, SB R,

the C1 and C4 are being pulled to the left, in FB, sidebent left, rotated L, with spinous protruding at R.

proximal plinth lowered to FB the neck mildly

sideshift to the R

operator on left

thumb on left,

fingers on R side of spinous.

tug at the spinous process toward operator to derotate the cervical segment to the R

testing which side to thrust into: for C1-occipital

hold occipital

concentrate forces against C1

backaward bend occiput gently

rotate head left versus right.

the side of rotation ease is the side to correct into

Bayliss Reduction of L2-5 rotated left, side-bent right:

caudad lowered, so FB lever the segments open

side-shifted to the R

operator on right

thenar push of spinous to the left


ADVANCED TECHNIQUE:
wedge derotates to the left
distal plinth side-bent to the right

standard logroll fine-tuning:

L3 SB R, Rot R:

right side exposed,

lumbar BB

engage pelvic de-rotation

thrust in de-side-bending to the left



L3 SB L, Rot R:

lumbar FB

setup de-sidebending to the right

thrust is a derotation thrust tableward (rotates segment to the left)



problem:

ceilingward SIJ is locked by ceilingward side-shift

Bayliss Reduction for Thoracic BB, Rotated R:

legs in slight extension,
plinth neutral

side-shift left

operator on left

pushes the left side of spinous process to the right

Bayliss Reduction for Thoracic rotated left, in FB

cephalad and caudad lowered to lever the segments open in FB

pelvis Side-shifted to the right

thenar operator push against right side of spinous process

check: if the segment does not derotate into reduction,

consider either a backward-bending lock

or a rib subluxation that prevents the derotation

Bayliss left posterior ilium

do this first, before other manips

raise distal 2 inches - mild BB of low back - this levers the sacral base posteriorly



support shins for knee flexion

side-shift right - makes left SIJ malleable

left asis floated on wedge braced against the left acetabulum and femoral head



operator on right of patient

operator hypothenar against medial PSIS

displace psis laterally toward contralateral side, thus gaping the posterior ilisacral joint

antero-superior push by operator, directed along the line of the iliac crest



this gives us a left posterior SIJ,

that can then be corrected by:

raised legs lever the iliac crest anteriorly

operator right hypothenar directed antero-inferior,

pushing the sacral base anteriorly into neutral

what's wrong with the STANDARD left posterior ilium logroll technique

side-roll with left PSIS exposed
PSIS rotated right

spine rotated left

logroll position

lumbar BB

accidental side-shift ceilingward

guidelines for Bayliss Reductions

non-weight-bearing
knees flexed

sideshift opposite the side that created the subluxation pattern

FB or BB or N opposite the direction that the patient was shifting to at the time of the subluxation

thrust direction opposite the causative force

subluxations must be reduced in the order of creation

muscles on opposite side the operator push will help spring back the segment into place



on analyzing pelvic lesions, patient must have ASIS equdistantly on plinth





standard order of adjustment for L3RR

SIJ

trauma ribs

anterior ribs

sternum

both clavicles

scapulae

left posterior ribs

left sacroiliac

left thoracic FB lesions

cervical lesions, left

right posterior ribs

right SIJ

right thoracic BB lesions

right cervical

right lumbar

left lumbar

both SIJs

fix byproducts of pelvic side-shift

thoracic unlock procedure:

T3 Rotated and side-bent to the left, subluxated in forward-bending

lower proximal and distal to engage thoracic forward-bending stretch to the spine

Operator on Right

side-shift left

reverse the posterior rotation - de-rotate T3 and T3 to the right, with a superior arc

side-shift to the right

left arm abducted, extended

"reverse the side-shift" - translate t4 t3 to the left

return to primary subluxation - translate T4 T3 inferiorly

against T2 spinous process on right, push the segment to the left

Bayliss Reduction Notes - Part One:

sidebending - rotation


note how side-shifting pelvis to one side slackens structures on the contralateral side

ES release

clavicular release

hip articulation

knee release

note how side-shifting to one side and standinng on that leg locks all thoracic lesions on that side

Neuromyofascial Trigger Point Infiltration

Description and Preamble for

Neuromyofascial Trigger Point Infiltration Protocols

Sandro Strix S. Toledo, M.D.

Neuromyofascial Trigger Points are small, discrete, hyper-irritable, hyperalgesic muscular foci within spastic or turgid muscles.

Frequent loci include the trapezius, the supraspinatus, the infraspinatus, the teres major, the rhomboids, the erector spinae group, and gluteal muscles. 


The upper body foci of these Trigger Points appear to be reflective of a Sympathetic predominance pattern for the ANS, and may be reflective of Dural Irritation or Inflammation.

The typical "Myofascial Pain Syndrome" is a regional clumping of Trigger Points.

Both dry needling and local infiltration with an anesthetic or steroid (or both) is an established clinical intervention.

Criterion for the justification or the medical necessity for intervention with needling for Trigger Points include:

• 
  
  A regional pain complaint
  
• 
  
  A proper neuro-orthopedic evaluation
  
• 
  
  The complete subjective record of pain
  

HMOs (Medical Insurance Services) often require proof that: 

(1) conservative therapy has failed or is not an option, and that 

(2) a return to previous levels of function and ADLs is possible. TP needling may also be justified as needed prior to more aggressive mobilization or manipulation.

Trigger Points are very often associated with exquisite point tenderness, with or without a referral pattern. Regional ROMs are usually compromised when TPs are present.

A "reproducible sign" or "exactly like that" or "duplication sign" pertains to the duplication of pain on palpation of a TP. 

A Local Twitch Response may be elicited with "snapping palpation" over a TP. Needling may evoke the same response.

The American College of Rheumatology diagnostic criteria for Fibromyalgia, when met, justify needling intervention for TPs. The Fibromyalgia Critera include:

• 
  
  Documented widespread pain for at least 3 months.  This means that manifestations are bilateral, with a cranial and caudad extent, plus axial skeletal pain
  
• 
  
  Tenderness must be present in at least 11 of the following 18 sites:
  
  • 
    
    Occiput: Bilateral, at the suboccipital muscle insertions;
    
  • 
    
    Low cervical: Bilateral, at the anterior aspects of the inter-transverse spaces at C5-C7;
    
  • 
    
    Trapezius: Bilateral, at the midpoint of the upper border;
    
  • 
    
    Supraspinatus: Bilateral, at origins, above the scapula spine near the medial border;
    
  • 
    
    Second rib: Bilateral, at the second costochondral junctions, just lateral to the junctions on upper surfaces;
    
  • 
    
    Lateral epicondyle: bilateral, 2 cm distal to the epicondyles;
    
  • 
    
    Gluteal: bilateral, in upper outer quadrants of buttocks in anterior fold of muscle;
    
  • 
    
    Greater trochanter: bilateral, posterior to the trochanteric prominence;
    
  • 
    
    Knee: bilateral, at the medial fat pad proximal to the joint line.
    

Medically justified schedules of intervention via needling for TPs include:


Diagnostic or stabilization phase: Two weeks apart, with a maximum of four times a year. The minimum period between interventions is often set at one week. 


TP needling is deemed useful when pain is reduced by at least 50%, with this therapeutic effect carrying over at least a six week period. This is the Therapeutic Phase or Treatment Phase. 


Persistence or recurrence of TP pain or MPS may warrant a repeat intervention.


Please note that most insurance carriers will not deem Dry Needling or Acupuncture as medically necessary. These then become an out-of-pocket expense for patients for whom this intervention is deemed useful.


ICD9 CM Diagnoses include:

723.1	Cervicalgia
725-728.9	Rheumatism, excluding the back
729.1	Myalgia and myositis, unspecified (fibromyalgia) Secondary Diagnoses: 338.0    Central pain syndrome 338.19    Other acute pain 338.29    Other chronic pain    724.00-724.9  Other and unspecified disorders of back The American Current Procedural Terminology Coding for TPs and MPSs includes:
20552	Injection(s); single or multiple trigger point(s), one or two muscle(s)
20553	Injection(s); single or multiple trigger point(s), three or more muscle(s)
	No specific code exists for dry needling
	TRICARE has drastically reduced the amount it will pay for Infiltration techniques in 2010.

www.manualmed.blogspot.com

Suggested Reading:

Alvarez DJ, Rockwell PG. Trigger points: diagnosis and management. Am Fam Physician. 2002; 15;65(4):653-660.

Cummings TM, White AR. Needling therapies in the management of myofascial trigger point pain: a systematic review. Arch Phys Med Rehabil. 2001; 82(7):986-992.

Huguenin L. Myofascial trigger points: the current evidence. Physical Therapy in Sport 5. 2004; 2-12.

Irnich D, Behrens N, Gleditsch JM, et al. Immediate effects of dry needling and acupuncture at distant points in chronic neck pain: results of a randomized, double-blind, sham-controlled crossover trial.  Pain. 2002; 99 (1-2):83-89

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RDT Preparatory Workshop

This invite was sourced from http://manualmed.blogspot.com/2010/08/manual-medicine-integration-workshop-in.html

The developers of RDTs (Rapid-Reflexive De-afferention Techniques) 

are extending a cordial invite to Physical Therapists, Physiatrists, Orthopedic Medicine Practitioners, and Manual Medicine Specialists 

to join them for a "Sharing Session" / Workshop.

WHAT: Workshop on Reflexive, Indirect, and Long-levered Techniques in Manual Medicine For Pain Relief and Spinal Alignment

WHEN: August 08, 2010

TIME: 10 am to 3 pm

WHERE: The Holiday Inn Galleria Suites, Ortigas Center, Pasig, Philippines

EXPECT: To walk away with the at least the basic tools for a working Integration of Muscle Energy, Reflexive Releases, and Articulatory Techniques that you can use the very next day at your clinics.

REFUND POLICY: Try out the techniques and principles for 60 days. If, within that time, your clinical application of the technology has not (a) allowed you to turn off pain and (b) recovered your investment in the course, we will refund your money.

CE: The workshop counts as 6 coursework hours toward certification as an RDT practitioner. Certificates will be furnished.

PREP: Please come in loose and repositionable clothing.

COST SHARING:

Early Reg: P:1,500 if prepaid by tuesday, August 03, 2010

Regular Reg: P2,000 if prepaid by Thursday, August 05, 2010

Late Reg: P2,300 if prepaid by Friday, August 06, 2010

On-Site Registration: P2,500

P500 waived from cost-shares for the following:

MMG Workshop participants (any workshop from 2007, just bring your certificate); 

SOMATIC members, Bowen Practitioners, and FITPRO members.

Early Course Outline may be requested via email.

Contact Rheysonn at +63 922 7914724 to confirm participation or request more info. 

Please furnish email addresses and return contact numbers.

Manual Medicine Integration Workshop in Philippines on August 08 2010

Sharing Session / Workshop: 

Reflexive, Indirect, and Long-levered Techniques 

For Pain Resolution in Manual Medicine

August 08 2010

Holiday Inn Galleria Suites Ortigas Center Pasig City Philippines

Call Time: 10 am to 3 pm

Cost-sharing: 

Early Reg: P:1,500 if prepaid by tuesday, August 03, 2010

Regular Reg: P2,000 if prepaid by Thursday, August 05, 2010

Late Reg: P2,300 if prepaid by Friday, August 06, 2010

On-Site Registration: P2,500

P500 waived from fees for the following:

MMG Workshop participants (any workshop from 2007, just bring your certificate); SOMATIC members, Bowen Practitioners, and FITPRO members.

Course outline may be requested via email. Spam will be destroyed, traced, and reported.

Contact Rheysonn at +63 922 7914724 to confirm participation or request more info. 

Please furnish email addresses and return contact numbers.

Confirmed attendance:
Bicol - 3
Baguio - 2
Physiatrist - 1
Teaching Staff - 1

(ALSO NOTE, however, that Special Advanced Classes may be appended by request. 

By example, August 7 2010 may be booked by request for preceptorships and advanced techniques instruction)