Always Focus On Growing

Physician, heal thyself. From its biblical origin to today’s modern interpretation, the proverb’s essence still rings true—and a 2013 study conducted at Duke University reinforces its message.

The study concludes that physicians often devalue self-care while prioritizing the care of others, resulting in possible burnout. On a positive note, the study suggests that increased self-awareness and self-care can reverse this negative pattern to benefit both physician and patient.1

As health care professionals devoted to their clients, massage therapists, too, can be at risk for burnout and injury if they don’t pay attention to developing—and maintaining—a solid self-care regimen. Self care is too often eclipsed by long hours, back-to-back sessions and the demands of lugging equipment to and from private sessions—all of which can trigger fatigue, physical imbalances, aches and pains, and potential burnout.

Defining the Problem

“It’s easy to get lost in your clients’ well-being and neglect your own self-care,” cautions Sarah Landicho, a yoga teacher based in Chicago. Maybe you repeatedly lean too hard and often to one side or you continually hunch over the client, causing some muscles to work harder and others to grow weaker. Repetitive movements can also take a toll on your strength and flexibility.

“All these examples can impact your physical health as well as your effectiveness as a massage therapist,” Landicho adds. “That’s why it’s so important to take care of yourself in order to take care of your clients.”

Although yoga has become known primarily as a set of postures (asanas), traditionally it is considered a state of mind, not just an exercise for the body. The primary text on yoga is The Yoga Sutras of Maharishi Patanjali. The classic definition of yoga is derived from the second sutra, which in Sanskrit reads: yogash chitta-vritti-nirodhah. In English, it is translated as “Yoga is the complete settling of the activity of the mind.”

A good place to begin is with various branches of hatha yoga, which rely on specific physical body postures, or asanas, to lengthen, stretch and relax muscles. In the West, yoga is primarily associated with physical postures, but traditionally breathing practices and simple meditation techniques that complement the postures are considered an integral part of the practice of yoga.

When done with consistent commitment, research points to yoga as an invaluable tool for self-care to help practitioners increase endurance, prevent physical stress, reduce inflammation, expand range of motion, build strength and ultimately extend career longevity.

Many massage therapists and yoga teachers alike agree that blending the two practices into one career naturally stretches their professional path and can help supplement their income.
Body of Knowledge

In addition to the literal self-caring physical benefits, like strength and endurance, Kaila Tatman, a yoga instructor and massage therapist in Sussex County, Delaware, credits yoga for encouraging a profound mental connection with her body. “During those 60 minutes in a yoga class, I’m focused on myself. That clears my mind to recognize, say, a tenderness in my forearm—maybe something I’ve been ignoring or accepting as part of the job.”

As you cultivate body awareness, it becomes easier to sense where you feel physically weak, uncomfortable or in downright pain. “Once you recognize the issues, a yoga instructor can guide you to what needs to be strengthened and what needs to be stretched,” explains Jeffrey Myers, yoga instructor, massage therapist, and owner of Healthways Wellness in the Boston area.

“Yoga is a similar but more balanced approach to strength training than lifting weights. The right level of hatha yoga, for example, conditions your body to perform daily activities, such as lifting, bending and all the repetitive moves associated with massage therapy,” Myers adds.

The complementary way that yoga and massage therapy sync up to promote physical well-being explains why it’s not uncommon for a massage therapist to also become a registered yoga teacher (RYT)—and vice versa. “Both careers engage your in-depth knowledge of the body’s anatomy and physiology,” Landicho adds.

As Myers says, “It’s a mutual dance between yoga and massage therapy. Both practices rely on being acutely aware of body mechanics, and this complementary overlap deepens what the massage therapist and yoga instructor can accomplish.”
Moving Forward

While historical evidence depicts an enduring respect for yoga’s innate benefits, recent studies put a modern scientific spin on yoga’s value. The National Center for Complementary and Integrative Health (NCCIH), the Federal Government’s lead agency for scientific research on complementary and integrative health approaches and part of the National Institutes of Health (NIH) within the U.S. Department of Health and Human Services, officially classifies yoga as a recognized form of Complementary and Alternative Medicine (CAM).

One meta-analysis, Exploring the therapeutic effects of yoga and its ability to increase quality of life2, details how the practice of yoga promotes strength, endurance and flexibility—while also facilitating characteristics of friendliness, compassion, greater self-control and a sense of well-being.

Specific to lower back pain, a common musculoskeletal injury among massage therapists, the NCCIH points to multiple recent studies:

An NCCIH-funded study of 90 people with chronic low-back pain found that participants who practiced Iyengar yoga (a form of hatha yoga) had significantly less disability, pain and depression after six months.3

In another NCCIH-funded study, researchers compared yoga with conventional stretching exercises or a self-care book in 228 adults with chronic low-back pain. Results showed that yoga and stretching were more effective than a self-care book for improving function and reducing symptoms due to chronic low-back pain.4

A review of published randomized clinical trials suggests that of 313 adults with chronic or recurring low-back pain, 12 weekly yoga classes, with a holistic combination of physical exercise, mental focus, self-awareness and relaxation, resulted in better function than receiving “usual medical care.”5
Where to Begin

Not all yoga classes are created equal, and for that reason Katherine Schaefer, a yoga instructor and massage therapist in Oakland County, Michigan, stresses that the type of yoga and the teacher you choose is essential for comprehensive and safe self-care. “Some yoga practices are more like gymnastics or a workout routine, which may be too fast or strenuous and consequently may put too much stress on the massage therapist’s body—especially the spine, hips, shoulders and wrists,” Schaefer says.

For example, Landicho adds, a level 2 or 3 vinyasa yoga class will focus on advanced postures, which would be too advanced for a new yoga student and could result in incorrectly positioned poses that can exacerbate shoulder, wrist and hand pain. “You want to start slowly and gently,” Landicho says. ” An introduction to yoga or a level 1 class is a great release for your wrists and back and especially for building core strength to support the spine.”

As for the right yoga teacher, look for someone who is trained in a more therapeutic approach and has a lot of experience, Schaefer says. “Many yoga teachers don’t know a great deal about anatomy and kinesiology, so the class may be more focused on achieving difficult poses or getting a workout,” she says. “Class size is also something to consider. Large classes may be fun and energetic, but if you want more individualized instruction, you are better off finding a smaller class or taking private lessons.”

Finding a class and teacher that fit you, Schaefer adds, is about getting out there, observing instructors in action and asking friends for recommendations. “Then, trust your instincts,” Schaefer stresses.
Stretching the Benefits of Yoga

It turns out that yoga is not only a good addition to a massage therapist’s self-care regimen, but can also provide a means of supplemental income. Because of overlapping knowledge and training, Myers describes the massage therapist and yoga instructor as “an almost seamless segue.”

Tatman also feels strongly that yoga and massage therapy go hand-in-hand. “When I attend a yoga training workshop, I pick up much more—because of the intense anatomy and physiology courses I took to become a massage therapist. I don’t need to start from the beginning. I have a strong base,” she explains.

Pursuing dual careers—as a massage therapist and yoga teacher—also builds trust between practitioner and client. “People here don’t touch each other much. So those with an adverse reaction to massage will likely feel the same about yoga—since both involve body manipulation,” Landicho explains. If someone goes to a massage therapist and grows comfortable with that person’s touch, Landicho suggests, it often follows that the client would translate that trust to all of the therapist’s practices. The next thing you know, the client will end up in the therapist’s yoga classes, too—or vice versa.

Schaefer explains how her expertise as a yoga instructor opens the door to more effective therapeutic massages. “As I watch someone do yoga, I learn about the way that client moves,” she explains. “So, for example, let’s say you sprain your ankle and your gait changes. But even after the ankle heals and the pain is gone, compensations may remain. If this yoga student comes to me for a therapeutic massage, I already know where they might be holding tension, not moving with ease or where they are weak, and I can adapt the massage accordingly.”

Yoga, according to Tatman, is a multifaceted approach to advancing your career. On a self-care level, it helps build strength, endurance and a deep awareness as to what your body needs to achieve peak professional performance. As for supplementing your income and increasing your professional value, adding “yoga instructor” to your résumé helps drive a fresh approach for every client. “By studying both professions, I see every one differently, and I know better what each body needs—from myself to my clients,” Tatman says. “And I definitely think yoga helps keep me young and energized about massage therapy. If that’s how you feel about your job, then you must be doing it right.”
Becoming A Yoga Instructor

If you’re interested in expanding your career by becoming a yoga instructor, here are five tips to get you started:

1. Consider your enthusiasm. “Really liking yoga makes a huge difference,” advises Sarah Landicho, a yoga teacher based in Chicago. Respected yoga training programs can cost upwards of $3,000, and they also require time, ranging from two months to two years, depending on how deeply you dive into the discipline. The financial and time commitment should feel like a positive means to expand and enhance your career.

2. Research … and then research some more. A good place to begin researching yoga training programs is with your own favorite yoga teacher. “This is the person who likely inspired you to teach,” Landicho says. “So, ask where he or she received training.” To research a specific program, visit the Yoga Alliance’s website, a nationally recognized organization. Only programs that meet certain standards—such as a specified number of hours studying asanas, teaching technique, anatomy and philosophy—can be registered with the Yoga Alliance.

3. Determine a goal. The Yoga Alliance recognizes two training certifications, both of which refer to program length. You can become a Registered Yoga Teacher (RYT) with the Yoga Alliance after completing a 200-hour or a 500-hour program. The Yoga Alliance recognizes RYTs who command significant teaching experience with an additional designation—Experienced Registered Yoga Teacher (E-RYT).

4. Study because you want to—not because you must. “In the U.S., there’s no law that you must go through a 200- or 500-hour training program,” Landicho adds, although she recommends formal study for two reasons: getting both insurance and a job. “If you want to teach at a yoga studio, you’ll more than likely need certification,” she says.

5. One final note! Even if teaching yoga is not your goal, a respected teacher-training program can deepen your own yoga practice and increase your knowledge of anatomy—two strengths that can enhance your career as a massage therapist.

Working With Clients Who Are Medically Fragile

About 15 percent of the current U.S. population is 65 years or older, and as the baby boomers continue to age, the size of this group will continue to grow. Combine this population with those who are chronically ill or have suffered a serious injury, and it’s easy to see how now and in the future you may have clients who are deemed medically fragile.

Although the benefits of massage therapy are likely similar for medically fragile clients, there are a wide array of things that will be different when working with these clients. Read on to learn more about what you can expect—and what’s expected of you—when working with medically fragile clients.
What Is Meant by Medically Fragile?

A medically fragile client can be loosely defined as someone with serious and complex medical conditions and a frail constitution. These clients will likely fall into one of three categories: chronic or terminal illness, suffering from severe injury or advanced age. Some other common terms that are used to describe the medically fragile are medically frail, medically complex or technology-dependent.

Because medically fragile spans such a large range of conditions and client demographics, massage therapists are going to need to be prepared to evaluate how the definition of medically fragile may vary across clients. Julie Goodwin, a massage therapist and educator, considers a wide array of variables when thinking of how a medically fragile status may apply to her clients. “To me, assignment of a medically fragile or medically frail status evolves from an interview, observation, assessments of medical treatment and medication side effects, physical and social risk, and a review of medical records or treatment transcripts,” says Goodwin. “This often represents multiple health conditions from which recovery or rehabilitation is unlikely, medical treatments and medications that create side effects that interfere with daily functioning, and impairments to mobility and cognition.”

Remember, there is really no “typical” medically fragile client, so you’re going to need to be able to adapt quickly and be flexible.
When Massage Is Beneficial

Even though the session for these clients will be different, the benefits they receive are similar to the benefits massage provides to all other clients. “All the reasons why a non-fragile person would want a massage would be applicable here, too,” says Susan Salvo, a massage therapist and author who specializes in the medically fragile. Goodwin echoes this sentiment. “In my practice, pain relief, relaxation and increased range of joint motion are typical reasons for seeking massage therapy,” she explains. “Most of my clients I have deemed medically fragile are elderly (over 65).”

While massage therapy is effective for many of the same reasons as it is with more typical clients, there are still some reasons medically fragile clients seek out massage therapy that are more common than others. The most common therapeutic reasons include pain and stress management, decreased swelling, improved range-of-motion, relief from nausea, fatigue, insomnia, and a feeling of calmness and improved mood. Massage can also be beneficial for clients who suffer from psychosocial issues such as isolation, hopelessness, depression and anxiety. “Massage can bring comfort to these clients and their caregivers,” says Salvo, “which can be especially important when spoken language is difficult or impossible.”
What You Need to Know

Space. When working with medically fragile clients, the location of the massage therapy session is going to depend in large part on the client, and can range from your practice location to the client’s home to a medical facility or nursing home. For each of these settings, massage therapy sessions will need to be adapted. For example, Salvo recommends scheduling all appointments at your practice during daylight hours.

Here, too, you need to think of how you can make the space easy for the client to negotiate, like making sure there is enough space between furniture and walls to accommodate wheelchairs and walkers. “Modifications in my location include lowering the table to ease access and assisting the client around the treatment space,” says Goodwin. “Working with the client only in a semi-reclining supine position, avoiding repositioning and working with the client clothed are other modifications I often make.” You should also consider using linens in contrasting colors for those clients who might be visually impaired.

Alternatively, if you see medically fragile clients on an outcall basis— either in their home or at a hospital or long-term care facility—different accommodations need to be made. Evening hours, for example, are sometimes better in these settings because there will likely be fewer disruptions. Space is limited in these settings, too, so don’t bring a portable table or massage chair. Instead, assume you’ll massage the client where they are, whether that’s in bed, in a wheelchair or while seated in a recliner. “If the client is in bed, the bed is often placed against a wall, limiting access to all sides of the body,” adds Ann Catlin, owner and director of the Center for Compassionate Touch.

Working with the care coordinator or nurses is a must. Ask for specific instructions, Salvo encourages, and when you go to the client’s room, obtain their permission before entering. Many times, these clients may have people in their room, too, whether medical staff or visiting family, so don’t be afraid to introduce yourself and explain why you’re there. A curtain pulled around your client often indicates a health care professional is performing care that requires privacy, says Salvo, so you should wait outside the room or in the hallway until they’re finished.

Other things Salvo suggests considering include:

Safety. Some medically fragile clients are going to be unsteady on their feet or experience dizziness, and so falling will be a big safety concern. You need to make sure you don’t allow a client to move without assistance from a member of their health care team, whether that’s from a chair or their bed. Also, if you need to step away from a client, make sure the bed rails are raised before doing so.

Accessibility. You aren’t going to want to move furniture from a client’s room, but you can try to make as clear a path as possible around the bed or chair to facilitate your work. If you need blankets or pillows or linens, however, ask someone to help you locate these items instead of looking for them yourself or bringing your own.

Emergency. Be sure you ask about the facility’s emergency protocol in advance so you can take proper measures. If an emergency occurs, Salvo recommends raising the bedrails to keep the client secure and then stepping out into the hallway to call for help instead of pushing the call button. Many times, you’ll get a quicker response this way.

Intake. Intake is always important, but especially so with medically fragile clients. The length of intake will differ based on the client, but make sure to have extra time allotted as most times you’ll need to talk with these clients longer. “Intake is extensive, and likely to comprise most of the client’s initial visit,” says Goodwin. “I prepare the client ahead of time by letting them (or the person making the appointment, who is often a family member) know what information to bring, including a list of health conditions, a list of all prescribed and over-the-counter medications, and the names of primary and specialist health care providers, to name a few.”

Remember, however, that when working in a hospital or other care facility, you won’t always have access to a client’s medical records. “It’s important to note that a massage therapist will only have access to the medical record if they have a formal relationship with the organization, either as an employee or a contracted service provider,” Catlin cautions.

Also, be sure the room is well lit and relatively quiet. Turn down the volume on the TV or radio, for example, or ask the nursing staff to hold calls while you’re conducting your intake. Salvo also suggests being systematic in your intake, asking how the client is feeling before moving on to more in-depth questions.
The Massage Session

Flexibility. As with most special populations, massage therapists need to be flexible when working with medically fragile clients. “Therapists are challenged to remain flexible and adaptive,” Catlin explains. “You’ll need to let go of preconceived ideas about how a session will unfold or how the client will respond.”

Positioning. Of all the differences you might notice when working with a medically fragile client, the massage therapy session itself may be where you see the biggest contrast, starting with how the client is positioned. “They’re rarely going to get disrobed,” says Salvo. “Depending on how medically fragile or how mobile they are, you’ll have to be willing to massage through clothing or just with what they have on, which might be a hospital gown or leisure clothing.” Before beginning, remind the client that they should let you know if anything hurts or causes discomfort so you can make the proper modifications.

When considering positioning, the client should be in a supine, semi-reclining, side-lying or seated position. If you’re working in a long-term care facility or hospital, many times the nursing staff will prefer to position these clients if they can’t manage on their own, so be aware of that before starting the massage. Prone positions, too, are not appropriate if there are any medical devices on the anterior surface of the chest or abdomen, like drain tubes or IV lines.

Catlin suggests thinking of ways you can work with the current location and position of the client to help with positioning. “For example, use the hospital bed controls to adjust the position, or use pillows to support the arms or raise the feet off the mattress,” she says.

Timing and Technique. Although the time you spend actually massaging these clients may be shorter than usual—typically from 15 to 45 minutes, according to Catlin—the length of the session when you include intake will still be an hour or more. Remember, too, that these clients are often going to need more time for activities such as using the restroom, drinking water or getting comfortable, and they may like to share personal stories, so you need to be patient.

“Technique modifications include shortening session duration to avoid overtiring the client, limiting or eliminating techniques that may stimulate systemic circulation, and decreasing pressure and increasing lubrication,” says Goodwin. “Also, choose a lubricant unlikely to trigger an allergic reaction, and take extra steps to preclude transmission of infectious pathogens.”

Salvo echoes this caution, advising massage therapists to use only unscented products or products that have a scent that is familiar to the client. Additionally, a different container should be used for each client whenever possible, or single-use lotion packs or the client’s own lotion could be used, with permission from the client, of course. Be sure to sanitize exterior surfaces both before and after use.

Whatever technique you use, making sure the level of pressure is appropriate is a must and requires you to continually check in with the client to ensure they are comfortable.
After the Massage Therapy Session

When the massage session is over, be sure to replace a client’s eyeglasses if you’ve removed them, as well as their socks or slippers. You might also ask the client if they need anything, Salvo suggests. After placing used linens in the hamper and sanitizing your hands, make sure to complete your session or SOAP notes. “Be sure to let the patient care coordinator know if you found unreported issues, such as swelling, redness or bruising,” Salvo adds.

Clients who are considered medically fragile often want—and need—the very real benefits offered by massage therapy, but you might have to modify your approach to accommodate the unique needs of the medically fragile client. Learning ahead of time what you’ll need to know when working with this population is a great place to start.

The M Technique for the Hand

When working with medically fragile clients, Susan Salvo recommends
a technique developed by Jane Buckle called the “M” Technique. This
technique uses a patterned sequence of three repetitions and light pressure
that remains unchanged, allowing the client’s body to become used
to the new stimuli and eventually relax. Following is the “M” Technique
sequence for the hand:

1. Alternate hand stroking to elbow
2. Lateral movements palm down
3. Joint circling
4. Scissor hold/pressure point/stroke
5. Turn hand over
6. Little finger links
7. Lateral movements, palm up
8. Handshake
9. One-hand stroking to elbow

Taking a Wrist Series: It’s About the Carpals

Routine radiographic examination of the wrist is not difficult, but does require some attention to positioning.

Keep in mind that to evaluate a joint on X-ray, one must be able to visualize the joint in two planes at 90 degrees to one other. The routine series for a wrist includes PA and lateral views. For further evaluation, oblique projection may also be necessary if trauma or arthritis is evident.

The PA View

The PA radiograph of the wrist is best obtained with the arm abducted 90 degrees from the trunk and the forearm flexed 90 degrees at the elbow. The wrist should lie flat on the cassette with the hand in a relaxed position, but with the fingers slightly cupped or flexed, or curled in a relaxed fist. A wedge also can be placed underneath the fingers to keep the wrist in contact with the cassette. The thumb should be extended parallel to the other fingers. (Figure 1)

PA wrist Figure 1: PA wrist The most common problem I’ve seen is that the PA projection is performed with the hand extended flat on the cassette, which elevates the wrist slightly, causing the carpals to appear jammed together. If the clinician instructs the patient to place their hand in a gentle fist position, this will help place the carpal bones of the wrist closer to the cassette. (Figure 2)

PA wrist Figure 2: PA wrist with hand in gentle fist Technical factors that are important to keep in mind include the following: 10 x 12 inch (24 x 30 cm) crosswise for two or more images on one cassette; for a digital screen, use lead masking to get more than one image one the cassette; for a detail screen, use the tabletop technique; 50-60 kVp range, mAs 4-5; and minimum SID of 100 cm.

PA wrist Figure 3: PA wrist When evaluating the PA view of the wrist (Figure 3), the joint spaces of the wrist have a width of 2 mm or less. Only the radiocarpal joint is slightly wider. The carpometacarpal joints are slightly narrower than the midcarpal joints. The capitolunate joint is considered the baseline joint width to which other joint spaces can be compared. Make sure to look at all of them: the radiocarpal, the proximal intercarpal, the midcarpal, the distal intercarpal and the carpometacarpal joint spaces.

The carpal arcs Figure 4: The carpal arcs The carpal joint spaces should be symmetrical. The cortical margins of the bones should be parallel. One excellent way of looking at the positioning of the carpals is by using three carpal arcs. (Figure 4) The first arc is a smooth curve outlining the proximal convexity of the scaphoid, lunate and triquetrum. The second arc traces the distal concave surfaces of the same bones, and the third arc follows the main proximal curvatures of the capitate and the hamate.

The carpal bones Figure 5: The carpal bones: scaphoid, lunate, triquetrum, pisiform, trapezium, trapezoid, capitate and hamate An arc is disrupted if it cannot be traced smoothly. A break in one of the arcs indicates a fracture or the disruption of a ligament leading to a subluxation or dislocation.

Here’s a common board question: What’s the most commonly fractured bone in the body? Ah, I’ll bet you thought it was the scaphoid. It’s actually the clavicle. But the most common region fractured is the wrist, with the scaphoid being the most commonly fractured wrist bone. (Trick question, matter of semantics, but what do you expect from a board exam?)

Lateral wrist positioning Figure 6: Lateral wrist positioning Can you remember the names of all the carpal bones? You’ve got the scaphoid, lunate, triquetrum, pisiform, trapezium, trapezoid, capitate and hamate. (Figure 5)

The Lateral View

Lateral view of the wrist Figure 7: Lateral view of the wrist The lateral radiograph of the wrist is obtained with the arm adducted with the ulnar side of the forearm on the cassette. The elbow is flexed to 90 degrees, adjusting the hand and wrist to make certain they are in a true lateral position. The same technical factors can be used for the lateral projection as for the PA projection. (Figure 6) If an X-ray table is not available, any sturdy table will do. This is a non-bucky technique.

pisiform Figure 8: Position of the pisiform for the true lateral wrist projection When evaluating the lateral view of the wrist (Figure 7), it is important to first determine if a true lateral view has been performed. A true lateral view is defined by the relationship between the pisiform, capitate and scaphoid bones. On a standard lateral view, the palmar cortex of the pisiform bone should overlie the central third of the interval between the palmar cortices of the distal scaphoid pole and the capitate head. (Figure 8)

Once it’s been determined that a true lateral projection has been obtained, the spatial relationships between the carpal bones can be evaluated. The most important axes are those through the scaphoid, the lunate and the capitate. The true axis of the scaphoid is difficult to appreciate since the midpoint of the proximal pole is often not visualized clearly, but a parallel line can be used to determine if the scaphoid is spatially aligned. Drawing a line along the most ventral points of the proximal and distal poles of the scaphoid will achieve the same spatial relationship. (Figure 9)

Axis of the scaphoid Figure 9: Axis of the scaphoid The axis of the lunate runs through the midpoints of the convex proximal and concave distal joint surfaces, and can best be drawn by finding the perpendicular to a line joining the distal palmar and dorsal borders of the bone. (Figure 10) The capitate axis joins the midportion of the proximal convexity of the third metacarpal and that of the proximal surface of the capitate. (Figure 11)

Axis of the lunate Figure 10: Axis of the lunate Since we are discussing the lateral view of the wrist, we can’t ignore the most commonly luxating/dislocating bone in the body, which is the lunate. Scapholunate instability can be assessed in the lateral view by measuring the scapholunate angle (30-60 degrees is normal – Figure 10) and the capitolunate angle (<30 degrees is normal – Figure 11). If the lunate is angulated dorsally, it is termed a DISI type of instability, which stands for dorsal intercalated segmental instability. Most agree that anything over 80 degrees for the scapholunate angle indicates instability. As far as VISI, volar intercalated segmental instability, or palmar flexion instability, when the lunate is tilted palmarly too much, most agree that VISI cases are most likely a normal variant, especially if the wrist is very lax.

Axis of the capitate Figure 11: Axis of the capitate The Oblique View

The other common view performed in a wrist series is the oblique view, which allows for visualization of the trapezio-trapezoidal joint. Again, this is a tabletop film. The patient is seated with the elbow flexed 90 degrees and the hand/wrist supinated. The fingers and hand should be slightly flexed to align the carpal bones. Rotate the wrist and hand internally 45 degrees toward the cassette; a 45 degree angle sponge can be used for support and stability. (Figure 12)

Oblique wrist Figure 12: Oblique wrist Other Considerations

trapezio-trapoidal joint Figure 13: Oblique wrist demonstrating the trapezio-trapoidal joint Functional views can also be performed if there is a question of ligamentous injury. Radial and ulnar deviation projections place stress on the intercarpal ligaments, which is used most often to evaluate the scaphoid bone. The clenched-fist PA wrist view can be also used to demonstrate a widening of the scapholunate distance.

Wrist injuries are common and may lead to degenerative joint disease, which can prove debilitating. A simple wrist series can be quite helpful in evaluating most acute wrist injuries.

Physical Activity Can Prevent Stroke

Silent brain infarcts (subclinical strokes) “have an increased risk of dementia and a steeper decline in cognitive function than those without such lesions” for older people. This study found that “engaging in moderate to heavy physical activities may be an important component of prevention strategies aimed at reducing subclinical brain infarcts.”

Abstract

BACKGROUND:

Silent brain infarcts are frequently seen on magnetic resonance imaging (MRI) in healthy elderly people and may be associated with dementia and cognitive decline.

METHODS:

We studied the association between silent brain infarcts and the risk of dementia and cognitive decline in 1015 participants of the prospective, population-based Rotterdam Scan Study, who were 60 to 90 years of age and free of dementia and stroke at base line. Participants underwent neuropsychological testing and cerebral MRI at base line in 1995 to 1996 and again in 1999 to 2000 and were monitored for dementia throughout the study period. We performed Cox proportional-hazards and multiple linear-regression analyses, adjusted for age, sex, and level of education and for the presence or absence of subcortical atrophy and white-matter lesions.

RESULTS:

During 3697 person-years of follow-up (mean per person, 3.6 years), dementia developed in 30 of the 1015 participants. The presence of silent brain infarcts at base line more than doubled the risk of dementia (hazard ratio, 2.26; 95 percent confidence interval, 1.09 to 4.70). The presence of silent brain infarcts on the base-line MRI was associated with worse performance on neuropsychological tests and a steeper decline in global cognitive function. Silent thalamic infarcts were associated with a decline in memory performance, and nonthalamic infarcts with a decline in psychomotor speed. When participants with silent brain infarcts at base line were subdivided into those with and those without additional infarcts at follow-up, the decline in cognitive function was restricted to those with additional silent infarcts.

CONCLUSIONS:

Elderly people with silent brain infarcts have an increased risk of dementia and a steeper decline in cognitive function than those without such lesions.

Copyright 2003 Massachusetts Medical Society

 

The Multidisciplinary Model: A Trend That Can’t Be Ignored

This past year was an eye-opening one for me, especially from an international perspective. It all started with the World Federation of Chiropractic’s biennial congress in Rio de Janeiro, Brazil, in April 2011.

More than 1,000 enthusiastic attendees participated, and what particularly impressed me was the representation from the World Congress of Chiropractic Students.

Students from all over the world traveled to the congress, led by WCCS President Dr. Stanton Hom from California. Dr. Hom is a West Point graduate and completed his chiropractic studies at the Southern California University for Health Sciences. His natural leadership skills helped bring a large body of energetic chiropractic students together, all of whom were hungry to learn about chiropractic and other health care disciplines that complement it.

Their energy was contagious. Sometimes I meet people who seem to have forgotten their passion for chiropractic, so I enjoyed meeting students from every corner of the world whose hearts are still full of love for the profession.

In October, I returned to Brazil to host a seminar in Sao Paulo at the Universidade Anhembi Morumbi, part of Laureate International Universities, a vast network of colleges with campuses in more than 70 locations around the world. The Sao Paulo location features a multidisciplinary health care facility that includes chiropractic, medicine, physical therapy, massage therapy, and other services. The facility itself has 47 treatment rooms, and all the disciplines collaborate with one another in their studies and in their delivery of care.

The common thread in my conversations with students at each of these stops was this: The multidisciplinary model of both learning and treating patients that I observed in Sao Paulo is spreading like wildfire around the world. Practitioners are accepting the model as an effective way to improve their own skills and to enhance the patient experience by creating a one-stop destination to manage all patient health concerns. International students are being exposed to this model without awareness of how things might have worked historically, which is accelerating its integration into the health care landscape.

We have been relatively slow to adopt this structure in the U.S., but we need to take note of the enthusiasm and satisfaction of students and practitioners who are following this model in their daily studies and practices. My international travels have demonstrated to me that this model is the one we should follow, and I hope that our U.S. chiropractic contingent will continue to experiment with a multidisciplinary approach to discover its true benefits.

In economies around the world, this model is working and chiropractors are thriving, which is why the student population continues to grow. Let’s learn from our colleagues in other nations and leverage those opportunities here in the U.S. to continue elevating our profession among all health care disciplines.

Conservative Care Beats Medication for Neck Pain

A study published in the Jan. 3, 2012 issue of the Annals of Internal Medicine and widely reported by mainstream media suggests conservative care consisting of either spinal manipulation or home exercise is more effective than over-the-counter and prescription medication for relieving acute and subacute neck pain.

Spinal manipulative therapy was more effective than medication in both the short and long term, as was home exercise in the form of self-mobilization of the neck and shoulder joints – a point media outlets were quick to emphasize in a classic attempt to downplay the value of the chiropractic intervention.

The study involved 272 adults ages 18-65 with nonspecific mechanical neck pain of two to 12 weeks’ duration. Participants were recruited from a university research center and a pain management clinic in Minnesota. Other inclusion criteria included pain equivalent to grade I or grade II according to the Bone and Joint Decade’s Task Force on Neck Pain and Its Associated Disorders; and neck pain score of 3 or greater on a 0-10 scale. Exclusion criteria included cervical spine instability, fracture, neck pain referred from peripheral joints or viscera, progressive neurologic deficits, diffuse idiopathic hyperostosis, inflammatory or destructive changes of the cervical spine, previous cervical spine surgery, and blood-clotting disorders, among other criteria.

neck pain Subjects were randomized at their second baseline appointment to one of three groups for 12 weeks:

  • A spinal manipulative therapy group, which received “manipulation of areas of the spine with segmental hypomobility by using diversified techniques, including low-amplitude spinal adjustments … and mobilization.” According to the study, six chiropractors, each with at least five years’ experience, provided treatment, with the specific spinal level to be treated and the number of treatments rendered left to the discretion of the individual chiropractor.
  • A home exercise advice group, “with advice provided [by six therapists] in two 1-hour sessions one to two weeks apart. Recommended mobilization exercises included “neck retraction, extension, flexion, rotation, lateral bending motions, and scapular retraction, with no resistance.” Participants received a booklet and laminated cards of prescribed exercises, and were advised to perform 5-10 repetitions of each exercise six to eight times daily.
  • A medication group monitored by a licensed medical physician, with nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen, or both serving as the first line of pharmacological therapy. With patients who did not respond to or could not tolerate these drugs, narcotic medications and muscle relaxants were prescribed. With each patient, the MD determined the type of medication administered and the number of patient visits.

Self-reported outcomes, including pain, were measured six times during the 12-week treatment period in all three groups: at both baseline appointments; two, four, eight and 12 weeks after randomization; and on two occasions post-treatment (weeks 26 and 52). Objective measures of cervical spine motion were measured at four and 12 weeks by seven trained examiners blinded to treatment assignment.

Of the 272 participants, essentially equally assigned to the three treatment groups (91 SMT, 91 home exercise and 90 medication), “improvement in participant-rated pain significantly differed with SMT compared with medication at 12 weeks … and in longitudinal analyses that incorporated pain ratings every two weeks from baseline to 12 weeks. At 12 weeks, a significantly higher proportion of the SMT group experienced reductions of pain of at least 50% [compared to the medication group]. Differences in participant-related pain improvement between the SMT and [home exercise] groups were smaller and not statistically significant.”

Specifically, at week 12, more than 82 percent of the SMT group reported a 50 percent or greater reduction in pain; 57 percent reported at least a 75 percent reduction and 32 percent reported a 100 percent reduction. By comparison, the home exercise group reported pain reductions of 77 percent, 48 percent and 30 percent, respectively, while the medication group reported reductions of only 69 percent, 33 percent and 13 percent.

In terms of long-term improvement, 75 percent of the SMT group reported at least a 50 percent reduction in pain after 26 weeks, while nearly 81 percent reported at least a 50 percent reduction at 52 weeks. At 26 and 52 weeks, 71 percent and 69 percent of the home exercise group, respectively, reported at least a 50 percent reduction in pain. In long-term follow-up, the medication group’s improvement fluctuated from 59 percent reporting pain reduction of 50 percent or more at 26 weeks to 69 percent reporting the same reduction at 52 weeks.

“Spinal manipulation therapy and [home exercise advice] led to similar short- and long-term outcomes,” stated the authors, “but participants who received medication seemed to fare worse, with a consistently higher use of pain medications for neck pain throughout the trial’s observational period.”

Meditation Promotes Mindfulness

The Default Mode Network (DMN) involves regions of the brain associated with mind-wandering – namely, the medial prefrontal cortex and the posterior cingulate corticies, that may cause lapses in attention and anxiety.   To assess whether mindfulness-based meditation can reduce activity along this brain axis, Judson Brewer, from Yale University School of Medicine (Connecticut, USA), and colleagues analyzed 12 experienced mindfulness meditation practitioners, and a group of 13 control subjects who never practiced the technique.

The researchers used functional MRI to assess brain activation during both a resting state and a meditation period in each subject.  Compared with novice meditators, experienced study participants had significant deactivation in parts of the brain associated with the DMN.  As well, the team found that practiced meditators reported less mind-wandering during meditation than did their less experienced counterparts.

The study authors conclude that: “Our findings demonstrate differences in the default-mode network that are consistent with decreased mind-wandering. As such, these provide a unique understanding of possible neural mechanisms of meditation.”

Aside from attention lapses and anxiety, the “default mode network,” or DMN, has also been associated with certain conditions, including ADHD and Alzheimer’s disease. Conversely, mindfulness training has been shown to benefit certain conditions, such as pain, substance use disorders, anxiety, and depression.

Action Points


  • Explain that this study found that meditation diminishes activity in areas of the brain associated with mind-wandering, the so-called default mode network in the medial prefrontal cortex and the posterior cingulate corticies.
  • Note that the study used functional MRI to assess brain activation during both a resting state and a meditation period in experienced mindfulness meditation practitioners and controls.

So to assess whether mindfulness-based meditation can reduce activity along this brain axis, the researchers analyzed both experienced meditators and controls who’d never practiced the technique. The researchers used functional MRI to assess brain activation during both a resting state and a meditation period in 12 experienced mindfulness meditation practitioners and 13 controls.

Groups attempted three different types of meditation: concentration, loving-kindness, and choiceless awareness. Concentration is intended to prevent practitioners from engaging with their preoccupations; loving-kindness focuses on fostering acceptance; and choiceless awareness allows for focusing on whatever arises in the conscious field of awareness at any moment.

Brewer and colleagues found that experienced meditators reported less mind-wandering during meditation than did controls, which was true across groups.

At the same time, they generally saw less activation in the main nodes of the DMN — the medial prefrontal cortex and the posterior cingulate corticies — in experienced meditators than in controls.

While there was significantly less activation in the posterior cingulate cortex/precuneus and in the superior, middle, and medial temporal gyri and uncus, the trend toward diminished activation in the medial prefrontal cortex was not significant, they noted.

With regard to the specific types of meditation, the researchers found less activation in experienced meditators than in controls in the following regions:

  • Concentration: posterior cingulate cortex, left angular gyrus
  • Loving-kindness: posterior cingulate cortex, inferior parietal lobule, and inferior temporal gyrus extending into hippocampal formations, amygdala, and uncus
  • Choiceless awareness: superior and medial temporal gyrus

When using the posterior cingulate cortex as a seed region, the researchers saw significant differences in connectivity patterns with several other brain regions, notably the dorsal anterior cingulate cortex, for experienced meditators compared with controls. And when using the medial prefrontal cortex as the seed region, they found increased connectivity with the fusiform gyrus, the inferior temporal and parahippocampal gyri, and the left posterior insula.

These patterns held during the resting-state baseline period as well, the researchers said, suggesting that meditation practice “may transform the resting-state experience into one that resembles a meditative state, and, as such, is a more present-centered default mode.”

The researchers concluded that the overall results “support the hypothesis that alterations in the DMN are related to reduction in mind-wandering.”

Though the study was limited by a small sample size, the researchers concluded that the findings may have a host of clinical implications, including treatment of conditions linked with dysfunction of these areas, such as ADHD or Alzheimer’s disease.

Is Soup Toxic to Your Health?

Bisphenol A (BPA) is a plasticizer that is regarded as an endocrine disruptor that may be linked to  cardiovascular disease, diabetes, and liver abnormalities.  Commonly used in food can linings, Karin B. Michels, from Harvard School of Public Health (Massachusetts, USA), and colleagues assessed the urinary bisphenol A (BPA) levels of 75 healthy men and women, ages 18 years and older, who consumed homemade soup for five consecutive days, and then ate canned soup for another five days in a row.

Urinary levels of BPA averaged 1.1 mcg/L during the homemade soup segment, but reached 20.8 mcg/L during the canned soup segment.   Observing that: “The effect of such intermittent elevations in urinary BPA concentrations is unknown,” the team urges that: “Even if not sustained, [it] may be important, especially in light of available or proposed alternatives to [BPA-containing] epoxy resin linings for most canned goods.”

Recent data from the National Health and Nutrition Examination Survey, for example, indicated that the 95th percentile for urinary BPA was 13.0 mcg/L, Michels and colleagues noted.

BPA is used in a wide range of consumer and medical products to soften plastics. Studies have shown that BPA can mimic the action of female reproductive hormones and may be linked to cardiovascular disease, diabetes, and liver abnormalities. Infants’ exposure is a particular concern because they may be more sensitive to these effects than adults.

Last month, researchers found that children whose mothers had high urine levels of BPA during pregnancy were more prone to behavioral problems.

The U.S. government, after initially dismissing concerns about BPA in baby bottles and other consumer products, reversed course in 2010 and promised a major research effort to pin down the health risks.

Because BPA is also used in food can linings, Michels and colleagues sought to examine whether canned soups would be a vehicle to increase human intake of the chemical.

They used five varieties of vegetarian Progresso soups, including tomato and minestrone, and five similar homemade soups. Participants were randomly assigned to start with the commercial or homemade soups, eating a serving of each variety at lunchtime daily for five days. After a two-day washout period, participants who first ate the canned products then had a week of the homemade soups, and vice versa.

Participants could otherwise eat what they pleased during the study.

Urine samples were collected in the late afternoon on the fourth and fifth days of each period. To minimize intraindividual variations, each person’s samples from consecutive days were mixed prior to analysis.

BPA levels in urine were adjusted for dilution, using a formula that included the samples’ specific gravity.

All the participants had detectable BPA in their urine after eating the canned soup, whereas 23% of samples in the homemade-soup phase were BPA-free.

The mean individual difference between mean adjusted urinary BPA levels following canned versus homemade soups, 22.5 mcg/L, was highly significant, with a 95% confidence interval of 19.6 to 25.5 mcg/L, Michels and colleagues reported.

Results were nearly identical for participants who started the trial with canned soup compared with those initially assigned to the homemade soups.

The researchers did list several limitations to the analysis. The study involved one institution (all participants were students or employees of the Harvard School of Public Health) and the canned soup came from a single manufacturer.

More important, Michels and colleagues indicated that “the increase in urinary BPA concentrations following canned soup consumption is likely a transient peak of yet uncertain duration. The effect of such intermittent elevations in urinary BPA concentrations is unknown.”

But they argued that the magnitude of the peaks seen in their study is great enough to cause concern.

“Even if not sustained, [it] may be important, especially in light of available or proposed alternatives to [BPA-containing] epoxy resin linings for most canned goods.”

Good for the Heart, Guard Against Cancer

As an American Heart Association Strategic 2020 Goal, “ideal” cardiovascular health is one of elements that aim to improve Americans’ heart health by 20% and reduce deaths from heart disease and stroke by 20%.  Laura J Rasmussen-Torvik, from Northwestern University (Illinois, USA), and colleagues followed more than 13,000 healthy individuals for 13 years, measuring seven “metrics” of heart health at the start and tracking any cancer that developed.

Those seven factors are: not smoking, normal BMI (a calculation based on weight and height), physical activity, healthy diet, and safe cholesterol, blood pressure and fasting blood glucose levels.  Between 1987 and 2006, the participants developed more than 1,800 new cancers, namely prostate, breast, lung and colon. But, the more “ideal” factors people had, the less likely they were to develop cancer. Compared to people who had none of the seven factors, having just one reduced the risk of cancer by 20%. Three factors lowered the risk of cancer by 22%, and five to seven pushed the risk down 38%.

The study authors conclude that: “Ideal cardiovascular health metrics are also collectively associated with lower cancer incidence.”

Individuals who don’t smoke and who maintain a healthy body-mass index (BMI), normal blood pressure and two to four other “ideal” measures of heart health have a 38% lower risk of developing cancer, according to research scheduled for presentation Wednesday at the annual meeting of the American Heart Association in Orlando, Fla.

The study authors hope the score they’ve developed will help doctors drive home the message that prevention is key to both cancer and heart disease.

“Physicians need motivation to really push the issue of prevention with patients,” said lead author Laura J. Rasmussen-Torvik, an assistant professor of preventive medicine at Northwestern University Feinberg School of Medicine in Chicago.

Other experts agreed.

“If we give patients a double whammy [message], in the ideal world, we might be preventing two of these biggest killers. It might be a stronger message,” said Dr. Tara Narula, a cardiologist with Lenox Hill Hospital in New York City.

“People generally know that healthy behaviors prevent heart disease and cancer, but to [relate risk factors such as cholesterol] to cancer is novel,” added Dr. Harmony Reynolds, associate director of the Cardiovascular Clinical Research Center at New York University Langone Medical Center in New York City. “It’s very nice to have that crossover in practice. Sometimes I talk to patients about lowering their cholesterol and exercising, and they get very fatalistic saying that, in my family, cancer is the problem. It’s very convenient to be able to say these things.”

“Ideal” cardiovascular health is one of the American Heart Association’s Strategic 2020 Goals, which aim to improve Americans’ heart health by 20% and reduce deaths from heart disease and stroke by 20%.

For this study, researchers followed more than 13,000 healthy individuals for 13 years, measuring seven “metrics” of heart health at the start and tracking any cancer that developed. Those seven factors are: not smoking, normal BMI (a calculation based on weight and height), physical activity, healthy diet, and safe cholesterol, blood pressure and fasting blood glucose levels.

Between 1987 and 2006, the participants developed more than 1,800 new cancers, namely prostate, breast, lung and colon. But, the more “ideal” factors people had, the less likely they were to develop cancer.

Compared to people who had none of the seven factors, having just one reduced the risk of cancer by 20%. Three factors lowered the risk of cancer by 22%, and five to seven pushed the risk down 38%.

“If you lower yourself by one point [risk factor], that’s a significant decrease in cancer risk and a lower risk of heart disease,” said Dr. Christopher Cove, assistant director of the cardiac catheterization lab at the University of Rochester Medical Center in New York. “That’s exciting.”

When the researchers looked at the same participants but removed smoking from the measure, the association was no longer significant but the trend was still in the right direction.

“This says that, yes, smoking is really important but we still see the trend when smoking is taken out, so adhering to a healthy diet and having a low BMI are still important for cancer risk,” said Rasmussen-Torvik.

The association might have been even clearer had the study had more participants and more cases of cancer, said Reynolds.

It’s not clear why these associations exist, but Narula hypothesized they could relate to overall inflammation, which drives both heart disease and cancer.

The study authors said they hope to see more collaboration between the American Heart Association and cancer advocacy groups.

“I think the American public is very confused about conflicting health messages,” said Rasmussen-Torvik. “If organizations like the American Heart Association, the American Cancer Society and the American Diabetes Association could work together to emphasize some core prevention goals, that could be beneficial to all groups.”

Research presented at meetings should be considered preliminary until published in a peer-reviewed medical journal.

Active Lifestyle Reduces Risk of Depression

Previous studies have reported an inverse association between physical activity and depression. Michel Lucas, from Harvard School of Public Health (Massachusetts, USA), and colleagues studied data co0llected on 49,821 US women enrolled in the Nurses’ Health Study, all of whom did not experience symptoms of depression in 1996.

Surveying for physical activity a total of five times during the study period, and following subjects for 10 years to assess for clinical depression, the team found that women who reported exercising the most in recent years were about 20% less likely to get depression, as compared to those who rarely exercised.As well, the more hours the subjects spent watching TV each week, the more their risk of depression rose.

The researchers warn that:  “Analyses simultaneously considering [physical activity] and television watching suggested that both contributed independently to depression risk.”

According to findings published in the American Journal of Epidemiology, researchers found that women who reported exercising the most in recent years were about 20 percent less likely to get depression than those who rarely exercised.

On the other hand, the more hours they spent watching TV each week, the more their risk of depression crept up.

“Higher levels of physical activity were associated with lower depression risk,” wrote study author Michel Lucas, from the Harvard School of Public Health in Boston.

More time spent being active might boost self-esteem and women’s sense of control, as well as the endorphins in their blood, although the study could not prove directly that watching too much television and avoiding exercise caused depression, she added.

The report included close to 50,000 women who filled out surveys every couple of years as part of the U.S. Nurses’ Health Study, and covered the years 1992 to 2006.

Participants recorded the amount of time they spent watching TV each week in 1992, and also answered questions about how often they walked, biked, ran and swam between 1992 and 2000.

On the same questionnaires, women reported any new diagnosis of clinical depression or medication taken to treat depression.

The analysis only included women who did not have depression in 1996. Over the next decade, there were 6,500 new cases of depression.

After the researchers accounted for aspects of health and lifestyle linked to depression, including weight, smoking and a range of diseases, exercising the most — 90 minutes or more each day — meant women were 20 percent less likely to be diagnosed with depression than those who exercised 10 minutes or less a day.

Women who watched three hours or more of television a day were 13 percent more likely to be diagnosed with depression than those who hardly ever tuned in, but Lucas said at least part of that link might be due to women replacing time they could be exercising with TV watching.

One alternative explanation the researchers brought up is that women might have been experiencing some symptoms of depression before they were diagnosed, leading them to exercise less. A formal diagnosis could have come later.

“Previous studies have suggested that physical activity is associated with a lower risk of depressive symptoms,” said Gillian Mead, who studies geriatric medicine at Edinburgh’s Royal Infirmary but was not involved in the study.