It is almost humorous that one of the easiest home care methods is also one of the most controversial in its application. From the standard R.I.C.E. to “Ice is for dead people” there are a lot of opinions on whether or not the application of cold for pain and injury is beneficial or just bad advice. In my own education, my opinions have changed over the years (as they should when science says to). That being said, there is still a lot of misinformation out there. The goal here is to present evidence- based information to help you decide whether or not to reach for that ice pack. 

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It is very common for people to say that ice is useful for acute injuries, but not for chronic ones. A 2017 study by Singh et al., used rats to test the tissue response to ice application following acute injuries. Results showed that after 3 days, the rats that were using sham ice had healed more tissue than that of the rats that received ice. The conclusion of the authors however, was that icing delayed the infiltration of inflammatory cells, but did not necessarily decrease actual healing time or quality. They also noted further research was need to assess if icing the injury more frequently changed the outcome. These results do not necessarily bode well for icing, but does not entirely discredit it either. 

 

A 2012 A 2012 meta-analysis by Van den Bekerom et al, looked at the use of R.I.C.E. (rest, ice, compression, and elevation) in ankle sprains. Once again research showed to be inconclusive on the effects of ice. Authors reviewed 24 studies and noted that none of them sufficiently showed that ice was effective for the use of R.I.C.E. as a treatment for ankle sprain. Instead they found that the recommendation as a treatment should be made on a case by case basis by licensed professionals. That statement, while indecisive, does have validity in the sense that treating a patient as they come in is important.  

Another study on different icing protocols in acute ankle sprain was published in the British Journal of Sports Medicine. This study showed that the use of intermittent icing lead to a better decrease in pain over a ‘standard protocol’. The ‘standard protocol’ in the study was defined as icing for 20 mins, whereas the intermittent protocol involved icing for 10 minutes, not icing for 10 minutes, then 10 minutes icing again. Results showed there was still not a shortening of healing time from this treatment. So, what can we conclude from all of these studies together? 

Untitled design (1)The argument of ice effectiveness is an ongoing discussion that will take longer to truly identify. Will icing be harmful to an injury? It appears that is unlikely. It also appears that it is unlikely that ice will expedite healing time. Should ice be used at all? I tend to agree with the conclusions of Van Den Bekerom et al, that it all depends on the case. Many people want nothing to do with ice and I happily encourage them to avoid it. If a patient really leans towards icing injuries, perhaps the best advice is to use the intermittent protocol and note that it may help with pain.  

The next big question is, what about using contrast hydrotherapy or ice baths as preventative care? Recovery from exercise is perhaps as popular a topic as how to best treat injuries. So, what does research say about immersion? Check back next week to find out!  

 

References:

Singh et al https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5339266/ 

Van den Bekerom https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3396304/ 

BMJ https://bjsm.bmj.com/content/bjsports/40/8/700.full.pdf 

Frozen shoulder is a common shoulder pathology that can cause pain, decreased range of motion, disrupted sleep, and a decreased ability to perform basic daily activities. It is a frustrating complaint that has few treatment options from the standard care approach. As an acupuncturist focusing on shoulder pain, I have heard everything from “wait two years, it will just go away” to aggressive procedures that include anesthesia and manual manipulation of the shoulder to quickly reintroduce full range of motion. From my experience, people generally don’t like being told to sit around and do nothing and aren’t fans of unreliable aggressive and painful procedures. So, what can be done to help?

Unfortunately, there is no one shot cure all approach. There are however, options to try that may be very beneficial both at home, or with a professional. It is the health care professional’s duty to meet every patient where they are at when they walk through the door. Recognizing what works for one patient may worsen symptoms of another in regards to movement, is pivotal. That being said, we want to talk about home care options here and only briefly offer options for health care providers.

Frozen shoulder occurs in three stages: freezing, frozen, and thawing. Each of these stages comes with a separate focus. Generally speaking, the freezing stage is painful, the frozen stage is when the least mobility is available, and the thawing stage is the recovery period. Throughout each stage, tolerable movement is key. It is commonly thought that the frequency of tolerable range of motion is useful at increasing speed of healing. So, what are methods of tolerable range of motion?

Initially speaking, exercises to work on include both a wall walk and a pendulum exercise. These exercises don not require any special equipment and can be performed in a pain free manner by most people. The wall walk exercise can be performed in two separate directions, which makes it useful for range of motion. The video below discusses and demonstrates both of these exercises and how you can make them most effective.

 

If the above exercises worked well or are to easy, then it is time to test out the movements in the video below! You can use a dowel, broom stick, or perhaps a friend to try out these movements. In practice, these are often referred to as proprioceptive neuromuscular facilitation (PNF for short). If these can be performed correctly and pain free, you will note marked improvement in range of motion immediately. It is important to be consistent with the exercises to try and keep progressing. The video below demonstrates how to use this style of stretching with a stick. It is possible to use a home pulley system in a similar fashion as well.

Outside of these exercises, there are other methods of homecare that can be used. Self massage can be very helpful at decreasing pain and increasing range of motion temporarily. Good target muscles to “roll out” include the pectoral muscles and infraspinatus. The videos break down the details on how to perform these easy homecare options, but it is important to note that this should be done in a tolerable manner in regards to pain. These techniques can be performed before and after exercises, but do not go overboard on it beforehand. Utilize quick and light massage techniques to loosen the fascia up versus really working deep into those trigger points when doing before an exercise. Stronger and longer compressions can be used at the end of homecare exercises. If you find self massage to be really helpful, you can consider investing in a ‘Theragun’ or similar machine. They are not an inexpensive investment, but for the patient that really values trigger point work, ‘Theraguns’ provide easy homecare relief. Many local running stores have the option to test them out if your health care practitioner doesn’t have one.

Another excellent homecare option is taping. Taping takes a willing partner, but can be useful at mitigating related pain, aiding in muscle firing during exercise, and temporarily increasing range of motion. There are many different options when it comes to purchasing tapem, but my personal preference is Rock Tape. In the video below, I demonstrate a great approach to taping the shoulder that can be followed along at home!

If you decided to try any of these methods above,  let me know how they go by dropping a comment below. If you are inclined to try alternative treatments for your care, Trigger Point Acupuncture can be a very effective method of providing relief and increasing range of motion when combined with the other treatment options discussed above. Obviously, a blog post is not made to be a replacement for seeing professional that can identify your personal needs. Please discuss these options with a licensed health care professional before trying them on your own. Happy healing!

 

 

BY CELESTE HOUVENER LAC.

Here is a brief overview of a few key points for maintaining the immune system at an optimal level. The first three are ones you may already know, I have elaborated and provided some insight into these. The final point relates to my area of expertise and may be new or mysterious to most. There is great depth to each of these key immune boosting tips to be elaborated upon. Please enjoy this overview and do not hesitate to ask questions of book an online or in person consultation for your personal health concerns.

 

Daily stressors can accumulate . . . that weakens our body’s defenses over time

  1. Deep Breathing

You can help maintain and strengthen your immune system by taking full breaths from the belly. Daily stressors can accumulate and cause a tendency toward shallow and rapid breathing, that weakens our body’s defenses over time. The more we intentionally practice proper breathing techniques the more we maintain full breath throughout the day.

Try this technique for at least five minutes three times a day for a week. You will notice your breath, and therefore your life benefit. Keep mind and shoulders relaxed throughout exercise:

-Inhale slowly and evenly via the nose, aim for the inhale to last 7+ seconds

-Let your breath expand your belly and ribcage out in all directions

-Sip in a bit more breath into your belly than usual, feeling the oxygen reaching your entire body

-Hold breath in for as long as you comfortably can at max capacity, this may start at a second or two and build to between 5-7 seconds.

-Exhale slowly and evenly via nose, for 9+ seconds

-Completely empty lungs and again hold for as long as you comfortably can at minimum capacity in the same way you did at maximum capacity

-Repeat this at least 5minutes 3x a day

-After completing this exercise and throughout the day, notice your breath without judgment or effort to change. By bringing more awareness to your breath, regulate and bring you into a clearer state of being.

* Remember to keep your mind and shoulders relaxed throughout this exercise

If your nasal passage is blocked in anyway, don’t let it stop you from this practice. This exercise is especially helpful for you. You can start by breathing through your mouth and imagine your sinuses opening with each breath. Attempt partial mouth with partial nose inhales and exhales. Exhaling through the nose will help bring movement to stuck sinuses. Imagine all congestion draining downward bit by bit with each breath. You may need a few tissues during your exhale!

Stay tuned to my Celeste the Rose site for more in-depth breathing articles and breath exercise videos coming soon. Become a sponsor of more breathing education materials by clicking here: . Also feel free to submit your breathing technique video requests in the contact form.

2. Moderate Exercise

Physical exercise is key in maintaining general health. Moderate exercise is especially useful if your body is fighting any pathogens. Ideally, induce a light sweat for 20-40 minutes, 3-6 times a week with your favorite activities. You will raise your core temperature, encouraging healthy circulation throughout your body, and activate your body’s natural detoxification processes.

While I do have my preferred exercise modalities, its best to find something you personally enjoy. Any sweat-inducing physical activity that you have a good time doing will do wonders for your health. Pick something you can find enjoyment in over what you feel like you “should” do. This will keep you inspired and coming back for more movement each day. Enjoyable activities also help elevate your mood, and that will help regulate stress. Choosing exercises that you enjoy will also encourage you to actually get moving consistently, which is key.

Sometimes we get so caught up in what we should do that we forget what we actually like to do. So meet yourself where you are genuinely at and start exploring. Do not let excuses and old stories bog you down, everyone can pick up somewhere. Prioritize regular exercise in your schedule and you will see how you have the clarity and energy to actually do what is on your to do list.

Enjoyable exercise may look like a brisk jaunt through a beautiful park or participating in your favorite sport or fitness class. Some great activities to induce a light sweat are dancing, martial arts, mid to high-intensity yoga, Pilates, aerial arts, acrobatics, hiking, biking, swimming, cross-country skiing, rowing, vigorous yard work, stair climbing, jumping jacks, jump rope, and so many more! Your options are vast; you can choose a few to keep it fresh.

If you have decided at some point in your life that you hate exercise all together, there is still opportunity for you to get moving. You could tune out to your favorite TV show while you ride your stationary bike, treatmill, or better yet hula hoop! Get creative, make opportunity, &/or even trick yourself into getting a sweat on if you have to. Ideally, you can ditch the TV and bring mindfulness into your exercise. You know what you need to do to bring some movement into your day.

If you are suffering from pain or injury, listen to your body so that you help and do not hinder your condition. You can find ways to achieve an intense workout that does not cause acute pain to your condition. Find ways to keep moving even if you are injured. For instance, if you usually play tennis and broke your hand, try brisk walking or stair stepping while your hand repairs. Consult a professional if you need help with this. Injury repair and pain management is a major field treated within the scope of acupuncture, herbology, and qi gong. Don’t cover up your pain; use it as a guide to bring you into a more balanced state of strength!

If you have suffered extreme injury and are unable to find a suitable exercise to induce a light sweat for a time period, there is hope. Soak in an Epsom salt bath 30+ minutes throughout the week as need be. This will help with circulation, tissue repair, mood, and more. These baths can in this way provide some of these benefits until you are ready for therapeutic exercises and beyond.

If you are immune-compromised, make sure to wear light protective layers when exposed to cold and wind. Especially if you are sweating, the pores are more open for pathogenic invasion. This means covering your skin, especially around the neck, core, and joints. Give yourself time to cleanse and dry before going about your day after sweating.

Be on the lookout for more in-depth fitness articles and exercise videos my Celeste the Rose site. Become a sponsor of more physical fitness education materials by clicking here: . Also feel free to submit your fitness exercise video requests in the contact form.

  1. Proper Sleep

A good night sleep is key to maintaining a healthy immune system. Do not skip out on precious sleeping hours, as you need this time to help restore and replenish all of your mental and bodily capacities. Sleep is something you need each and every day, and not something that you can “catch up on” in the future. Amongst a society that idolizes an “all work, no sleep” mentality- you need to individually stand for you and your body’s need for proper rest.

Perhaps you have early mornings ahead? Setting a bedtime alarm for yourself can ensure you can get plenty of rest. Schedule at least 8-10 hours of intentional rest and relaxation. If you lead a high-intensity life, you may need a few hours of intentional winding down before you are able to fall asleep.

Get in touch with your circadian rhythm. Shut off artificial light sources and all stimulating mental, emotional, and physical triggers. Set your devices to filter out blue-light when the sun sets with night mode or apps like Flux for your computer. Set your phone to “do not disturb” mode. You will be more prepared to face the day’s issues if you allow yourself to fully refuel. For myself, this can be easier said than done with all of the fun things that start later in the evening. Yet when I align with the natural rhythms, my balanced and nourish mind and body thank me greatly! It is worth it to get my work and fun priorities in during the day so I am ready to sleep at night.

In Traditional Chinese Medicine (TCM) 11pm-1am are the hours where the Liver and Gallbladder do their best work. If you are out of balance you may feel this as a creative and productive surge coming to the surface. Yet in the long run following this urge to work or play late into the night will leave your body depleted. Aim to be winding down as the sunsets and in a deep sleep by the liver nourishing times. Your body will naturally cleanse and nourish your blood while you sleep.

Proper restoration takes time and intention. Allow yourself time to prepare yourself for sleep so you can truly relax. Perhaps this means tidying your space, preparing your things for the coming day, practicing meditation and yin yoga, taking a hot shower or bath, &/or whatever you need to get yourself in the right space to let go of the days concerns and rejuvenate. Leave the worries of the day behind and enjoy the calm inner state within yourself no matter what is going on around you.

Poor sleep can become a major issue that weakens the immune system. This can be inability to fall asleep, inability to sleep a full night into the morning, light sleep, dream-disturbed sleep, or even too much sleep with difficulty waking up. There are many things you can do to improve your sleep on your own. When in need of extra help, TCM provides many treatment options for various underlying causes of poor sleep. Feel free to book an online consultation or in-person session to seek treatment for poor sleep.

If there are aspects in your life that prevent you from sleeping, such as motherhood or graveyard shifts- do not panic. Realize a goal of sleeping at night for sometime in the near future. In the meantime find supplementary practices and treatments to help support your daily rest and restoration.

Educate yourself deeper on the fascinating importance of sleep and let me know what you discover!

  1. Acupuncture, Herbology, and Medical Qi Gong

Acupuncture, herbology, and medical qi gong are excellent ways to help build and maintain excellent immune functions. Treatments are effective preventatively as well as during and after acute immune dysfunction. You can receive treatments, learn exercises, and find herbal supplements customized to help your circumstance. Effective treatment to help clear head and nasal passageways, pacify fever, strengthen immune system, and much more!

Traditional Chinese Medicine offers preventative, acute, post-acute recovery, and ongoing care for pathogenic invasions. Treatments are aimed at balancing the body to its most natural state of wellbeing. When treating an illness, diagnosis of the pathogenic factor is taken into consideration to develop a balancing treatment. The external influences we face are broken into six encompassing categories: cold, heat, fire, damp, wind, and dryness. These become pathogenic factors when in excess, and are then considered to as the “Six Evils” or “Six Pathogenic Factors”.

The Six Pathogenic Factors can enter from the external environment into one’s body. The Six Pathogens have Six Levels of invasion into one’s body, as stated in the TCM classic text Shang Han Lun (220 CE). These are six levels to the depths of your body. They are can offer protection if the body is resilient, as well as invasion if the body’s immune system compromised. The pathogenic factors usually enter more superficially and can develop deeper into the body. This can look like a bacteria entering your lungs and developing an infection that spreads throughout your body. In some cases pathogenic factors can enter into the deeper layers from the get go, such as a toxic materials that enter through the digestion or bloodstream.

In TCM treatment, we aim to skillfully keep the body free of the invading pathogenic factor. Ideally, we can do so before a pathogen enters the body. If a pathogenic invasion is present, we aim to prevent it from developing deeper into the body. Whether the invasion is slowed, stopped, or reversed- there are many possibilities with proper treatment.

Our immune systems utilize mass amounts of energy when fighting off or pathogens to bring the body back into balance. The more we fortify our body and mind we become less vulnerable to pathogenic factors. Treating any physical, emotional, &/or mental condition with acupuncture will simultaneously increase your bodies resilience toward pathogens.

Onto some specifics about each TCM treatment modality:

Acupuncture treatments

There are individual and groups of acupuncture points in traditional Chinese medicine that can treat acute and chronic immune illnesses. If you have an acute cold, you can receive a series of treatment to help minimize and eliminate symptoms. For individuals with a systemic tendency towards sickness, you can build immune system resilience with regular acupuncture. If you are wishing regulate and strengthen immune and respiratory systems, find out more about how acupuncture can assist your efforts.

Herbal Prescriptions

Herbs can access your body internally, absorbing into your bloodstream to reach your organs and blood stream directly. They can treat specifically and are very useful to prevent, reduce, &/or eliminate pathogen invasions. Herbs can also build resilience to weak areas and systems within the body to increase your body’s resilience. You can take home herbal formulas to administer throughout the day depending on the prescription, which ensures you are receiving the treatment you need between sessions.

Medical Qi Gong

There are specific exercises in medical qi gong to help stimulate immune function in the body. You can increase your core energy and resilience through regular and proper practice of qi gong. Qi Gong essentially means “energy skill”. The practice utilizes breath, physical postures, and focus of the mind. The synergy of these pillars enables you to directly accomplish the objective of the various exercises. You can increase lung capacity, clear your respiratory channels, and build your core energy to stay your healthiest through any immune-compromising times.

Qi gong exercises are tangibly beneficial to all of your bodily systems. You can feel your inner power activating and bringing vitality to the various focus areas of each exercise. Depending on what issues you are experiencing, you will be prescribed specific exercises for your condition. Medical qi gong centralizes in exercises that build your core strength and defense systems. When your internal systems and external defenses are reinforced, no pathogen stands a chance against your fortress!

In life and in qi gong, “your energy goes where your mind goes”. This has huge implications in life, as what we focus on is what we will move towards. The mindfulness aspect of the qi gong exercises brings your focus to your breath and body. This in turn will increase your sense of bodily and energetic awareness. This means you will increase your abilities to access different areas of your body with your mind.

There are many types of qi gong, it is best to find one that works for you. Most qi gong does have medical benefit, yet specific qi gong exercises can be chosen for specific medical purposes. I prescribe specific exercises for my patients depending on their condition.

In closing, I hope these tips and bits of information are of help to you. Keep in mind, they are tips of an iceberg and up to your own discretion how you utilize them. Each of the individual suggestions could be elaborated on greatly and would benefit from professional consultation. If you would like to hear more, do not hesitate to ask questions or book an online or in person consultation. I am happy to help you integrate these tips into your life in the most effective way for you.

 

When it comes to trigger point needling in the shoulder one of the major muscles we have to address is subscapularis. It plays a unique role as the only rotator cuff muscle to perform internal rotation. It is also notoriously uncomfortable to access. In my days as a massage therapist, I found it was in a similar class to the psoas in the fact that even in seemingly healthy muscle, it is very sensitive. When it comes to needling, it takes significant skill to safely needle. Please see this video for how I like to needle subscapularis!

sub scap needling

In our advanced shoulder course, we teach how to treat subscapularis and the first aspect we discuss is risk to reward. The risk of needling any trigger point should not exceed the reward of it being released. With confident palpation, accurate needling skills and proper training, the risk of needling subscapularis decreases and the reward increases. If these skills are not present, the risks can include pneumothorax, nerve damage or artery puncture. If someone is untrained or uncomfortable with needling subscapularis, we encourage using manual therapy to treat the local trigger points. If you are interested in some of our favourite manual therapy techniques, check out last week’s blog!

Palpation

In my opinion the most important tool to confidently needling subscapularis is

Palpating subscapularis

Palpate where subscap is believed to be and resist internal rotation

manual muscle testing. As mentioned above, the subscapularis performs internal rotation. When palpating what is believed to be suscapularis, resisting internal rotation can help confidently identify the muscle. I like to ask the patient to push their wrist to belly button as a cue (check this out in my video). Another tip is to identify other easy to find landmarks such as intercostals, latissimus dorsi, and the lateral border of the scapula. Once the lateral border of the scapula is located it is simple to find the way to the subscapular fossa. If you know all your surroundings structures, it becomes much easier to find any muscle you attempting to palpate.

Trigger points

As shown in the picture below, the trigger points in subscapularis refer to the posterior shoulder and arm as well as the anterior and posterior wrist. Under palpation is often easy to illicit a clear referral pattern.

Subscap trp

When to treat

Deciding when to treat subscapularis is not always as straightforward as other trigger points acupuncturists treat. With a muscle like the upper trapezius, a trigger point can be palpated and safely released on a patient. In the case of subscapularis, many factors can get in the way. Frozen shoulder is a great example. It can be a major relieving factor to needle these trigger points for decreased range of motion, but the patient needs to have the range of motion to allow access. Manual therapy can help achieve access to this area. The axilla is also a common area for patient’s to be ticklish. This is usually easily overcome by the use of a glove and quick firm pressure. I would say comfortable patient placement with safe access is an absolute must. For me, I prefer to needle subscapularis in supine position with the patient in abduction as seen in the video.

Some common indications for needling the subscapularis can be:

  • Frozen shoulder
  • Decreased internal rotation
  • Posterior shoulder pain
  • Difficulty with putting a bra on (don’t forget Lats and Teres Major!)

Homecare for subscapularis

Homecare for subscapularis is dependent on movement and orthopedic assessment. Sometimes internal rotation with a resistance band is appropriate, but often there is more to it then that. For example, in the case of SICK Scapula, focusing on corrective exercises for the tipping of the scapula and it’s accompanying dyskinesis may prove more useful then direct strengthening to the subscapularis. Some of the most basic shoulder exercises I like can be found in the Trigger Point Acupuncture facebook group or in this video. Another great tool that can be incorporated is kinesiotape. To see an easy and effective taping method, check this video out! Just because we are using homecare to treat other muscles doesn’t mean that Subscapularis won’t be indicated for needling. It is simply that we have to treat the whole pattern, versus just a single muscle….however, that is nothing new to an acupuncturist, we always treat the pattern!

If you enjoyed this post please subscribe! And remember the above is for educational purposes only. Online reading and videos are not a substitute for in person training by a qualified professional. The author is not responsible for your actions should you use anything in the above article.

 

 

One of the most under-utilized techniques in the acupuncturist’s tool belt is manual therapy (Tui Na). This modality can be an extremely effective tool to decrease pain and increase range of motion immediately for a patient. Manual therapy is a modality every acupuncture practitioner spent a fair amount of time learning in school. Of course, like any other technique learned, it takes practice and clinical use to stay consistent with.

Often, we do not think there is time in a treatment for manual therapy, so this video shows how you can spend just a few minutes to get fast results. A few minutes before or after treatment can make a world of difference in patient outcome. Remember patients want the fastest results they can get!

When to use manual therapy

                Every practitioner will have their preference. I used to always perform manual therapy before needling, but have shifted into using the techniques more post treatment. The major exception to this is the needle sensitive patient or acute muscle spasm (i.e. torticollis). Using manual therapy before needling can decrease the discomfort of needling for a needle sensitive patient.IMG-0355 The reasoning is simple; manual therapy to MTrP will decrease the active response of the trigger point. If a patient is hypersensitive to needling, 30 seconds of manual therapy to oversensitive trigger points makes all the difference in the world.  After treatment it can quickly make a difference in pain and range of motion on top of what acupuncture had already achieved. This manual therapy can really be the icing on the cake of a great treatment.

Get immediate relief of symptoms

When performing manual therapy post treatment, it is pivotal that it provides immediate relief and increase ROM. When utilized on top of acupuncture it can accelerate the treatment effect. As discussed in this short video a combination of passive flexion and active flexion with compression on a MTrP can help to decrease the pain quickly. If the patient is sensitive to pressure passive flexion performed correctly should decrease pain in the point by approximately 60%. Hold pressure in the decreased pain state at least 30 seconds and up to 2 minutes then retest and the pain point should be less sensitive. This technique is often called positional release or strain counter-strain. If the patient is less sensitive to deeper techniques applying pressure through flexion of the muscle can create a quick decrease in trigger points. A combination of the two can be beneficial and quickly attained.

For quickly increasing ROM I add PNF (Proprioceptive Neuromuscular Facilitation) or Muscle Energy techniques along with the above techniques. My personal favourite version of these is a method of Contract-Relax technique which works through reciprocal inhibition. For example, when a patient has decreased lateral flexion in the cervical spine they are placed in passive flexion. Once a range where the muscle restricts movement is attained the patient restricts lateral flexion in the opposing direction for several seconds. After a few seconds the patient relaxes and passive range of motion increases. The results are instant and are phenomenal for increasing range of motion.

Create a well-rounded treatment

As acupuncturists we often fall into the trap of thinking our needles are a hammer and every problem is a nail. We have a complete scope of practice to treat a variety of conditions and should use the tools in our tool bag as efficiently as possible and to the best of our ability. When treating pain combining just a few minutes of manual techniques can be an excellent way to create a well-rounded approach to the patient’s symptoms. Please comment with your favourite manual therapy techniques to use on patients!

Information in the above contains statements related to the below:
Bron, Carel et al. “Treatment of Myofascial Trigger Points in Patients with Chronic Shoulder Pain: A Randomized, Controlled Trial.” BMC Medicine 9 (2011): 8. PMC. Web. 29 Mar. 2018.
https://www.jiscs.com/Article.aspx?a=11
Hindle, Kayla B. et al. “Proprioceptive Neuromuscular Facilitation (PNF): Its Mechanisms and Effects on Range of Motion and Muscular Function.” Journal of Human Kinetics 31 (2012): 105–113. PMC. Web. 13 Apr. 2018.

 

 

When patients receive trigger point needling for the first time it is often a significantly different experience then acupuncture treatments they have had in the past. The world of acupuncture is quite diverse with those practicing and favoring a variety of techniques based on their own clinical experience. Many patients that have experience with acupuncture are only familiar with distal needling practices so when they first experience local needling it can require adequate patient communication.

With distal needling, depending on style, the needling method may be pain free or focus on attaining “De Qi”. This can be very different than a twitch response elicited when a trigger point is directly needled. When I first see a patient, I always ask about previous needling experience. If they have had acupuncture before, I am sure to ask about the experience and whether they felt a twitch response. Often patients have also experienced needling from physical therapists, chiropractors, or physicians, which I also inquire more about as these providers treatment approaches can vary greatly as well.

I personally feel that the experience of Trigger Point Needling is separate enough from Distal or Constitutional styles that it even can have different home care recommendations and expectations. Not every practitioner may agree with this, but here is what I find most effective for my patients:

Move the day you are treated

This doesn’t mean have your most intense training session or compete right after needling. What this does mean however, is do not get a treatment and go rest all day. Taking a walk, going for a swim, doing a light work out or performing recommended exercises can all be beneficial movements. When we treat trigger points, we are increasing blood flow with needling and if the patient gets the blood moving it is even more beneficial.

Avoid NSAIDs

                This is a tricky one. I encourage patients to avoid NSAIDs as long as it does not counteract direct advice from their Physician. When we needle trigger points, we are somewhat reliant on micro trauma to create a positive healing cascade and NSAIDs are not going to help this process. In my opinion, if the patient can avoid anything that interferes with the healing cascade I recommend it. Movement, heat, and self massage can help instead. Ice is a topic onto its own. Qualified practitioners should be well educated on the topic to apply their knowledge to their patient’s specific needs.

Self massage is good in small doses

                Foam rolling, lacrosse balls and other methods of self massage are very common among well-informed patients these days. While I encourage my patients to utilize these techniques, I also give some time restrictions and try to limit overdoing it. A little bit can go a long way with these techniques. Use of these self care techniques for too long or too frequently can exacerbate symptoms and in my experience prolong the healing process.

Common occurrences

The other point I note to patients post treatment is common “side effects” and what to watch for. Obviously, the most common post treatment occurrences are bruising and temporary soreness. I think it is important to note that the bruises are not usually tender and the soreness should be brief but paid attention to (see the needle intensity blog for more). Fatigue can occur in some patients as well, but is not something I see often. Temporary exacerbation of symptoms also occurs occasionally enough to be called common, so being informative about this point can be very helpful to patients.

Want more tips and tricks for Trigger Point Acupuncture? Check out the Trigger Point Acupuncture facebook group!

 

When we think of treating shoulder, elbow, and hand pain, many practitioners do not often consider Brachialis, however it can be a very effective trigger point to treat. Considered a prime mover for elbow flexion, brachialis lays under the more commonly thought of biceps brachii. Brachialis originates from the lower half of the humerus (anterior aspect) and travels over the cubital fossa to attach to the coranoid process of the ulna and the ulnar tuberosity.  The trigger points in brachialis can be easily palpated and well accessed with acupuncture needles.

The common trigger points of brachialis are palpated when the patient is supine

Brachialis Trigger Pointd

with passive elbow flexion and the forearm is pronated. Palpate the bicep tendon and then travel superior and lateral to the bicep (essentially underneath) to note the taut bands of brachialis. When learning to find these trigger points, it is important to differentiate the biceps from brachialis. This can be easily done by manual muscle testing. While both muscles perform elbow flexion, the biceps also perform supination and shoulder flexion. If resisted supination is performed, the brachialis will not contract but the biceps will. This simple maneuver can help assure muscle identification between the two.

Once the practitioner has palpated the trigger points, needling the brachialis can be performed. My preferred method is to isolate the muscle between two fingers (compressing muscle and spreading skin), then insert the needle as shown in our YouTube video. The depth of insertion varies based on patient body habitus. To consider how much twitch may be needed see last week’s post!

Looking at the trigger point patterns, brachialis has referrals to the shoulder, elbow and hand, similar to that of biceps. The taut bands of brachialis can often be even more pronounced than biceps trigger points. More interesting is to consider what kind of patients may have certain active trigger points vs those that are present in others. For example, the athlete that performs a great deal of pulling motions (crossfit, gymnasts, grappling) is a definite candidate for the brachialis trigger points, as is the body builder. Occupational hazards may be landscapers or mail carriers as they both often work with prolonged elbow flexion. The only function of Brachialis is elbow flexion, so any activity that is reliant on sustained elbow flexion can create these trigger points.

Simple home care methods can include self massage and stretching. One of the most efficient methods  to perform self massage on brachialis is with a lacrosse ball (or I very much love “Rock Balls”). The patient can place the ball between the wall and their brachialis and apply tolerable pressure to the trigger point. When instructing patients on how to do this, I recommend demonstration and observation to make sure it can be performed correctly in a pain free manner. There are also several ways to stretch the brachilias (see photo below for two ways) depending on the mobility level of the patient. A combination of home care and Trigger Point Acupuncture can be very effective at dealing with Brachialis trigger points.

 

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The preceding is for educational purposes only and is not intended to treat or diagnose any disease. Trigger point needling should only be performed by those with adequate training and license to do so. The author is not responsible for your actions.

 

 

 

 

 

 

When we teach our courses one of the most common questions is about intensity of needling. Specifically, how much mechanical irritation is needed to relieve a trigger point. This is, of course, a loaded question. There is a great deal of research that is done to try to answer this. Research will also examine whether or not a twitch response is necessary for pain relief. However, in practice the amount of twitch response varies quite a bit not only from patient to patient, but often from location of the body.

The upper trapezius is an very common area to illicit a large twitch response multiple times. Depending on the severity of the patient’s pain level and their comfort Upper Trap Needlingwith trigger point needling, the amount of stimulation can greatly differ. If the patient is coming in after an MVA for example, less may very well be more. If the patient is a high-level athlete they may do better with a higher level of stimulation. This can only be assessed after building a relationship with the patient.

So how much stimulation should I use?

If it is the first time a patient is receiving trigger point acupuncture, I highly recommend starting with low to moderate levels of stimulation. It is very easy to increase the treatment intensity the second visit, but it is impossible to take back treatment intensity after the fact. Proper communication the patient can really help determine the treatment intensity. This does differ from the TCM tonification/sedation methods. We always have patients report back on how they felt afterwards and there are two questions that are key:

1.How long were you sore?

2.How long did you have a decrease in pain?

How long were you sore?

                Soreness is common after trigger point needling. Soreness is not pain! The soreness associated with trigger point needling should be likened to that of post work out. If a patient notes an increase in pain or lasting pain, then decreasing mechanical stimulation or utilizing more superficial fascial needling may be indicated. Manual therapy can also greatly help patients that have an increase in pain from needling.

How long did you have a decrease in pain?

                This question serves two purposes, and one of those is to see if an increase in stimulation is indicated. If the patient noted little to no soreness and only a brief or no relief, increasing stimulation can be indicated. This question can also can indicate treatment frequency for the patient. It is very common to have trigger point needling patients come in for shorter intervals at the beginning such as twice a week for two to four weeks depending on condition or whether or not they are seeking care with other providers.

One of the other major concepts to get across to patients is that less can be more. While we are going for a twitch response we don’t want the patient to be in pain. More often than not, a twitch response isn’t particularly painful, it is just a new sensation. If the patient is associating pain with a particular trigger point being needled it shouldn’t necessarily be a grin and bare it situation. That is why communication is key. In my opinion, communication during the needling process of trigger points is more interactive than that of needling acupuncture points with therapeutic properties. If we can communicate goals of needling with the patient, then needling intensity can be better attained creating more positive treatment outcomes.

Type “paleo diet” into google and you’ll find countless threads talking about it and most have a very strong opinion towards it. Some of these sites quite literally say it is the “healthiest way to eat,” while others talk as if it poison for every ounce of your being. Very few of these sites present pro’s and con’s and an informational approach. Hence my approach, an attempt at an unbiased review pointing out pros and cons so that the reader can decide and not be told the answer. Of course to do this, we have to first decide what the paleo diet is.

The concept of paleo from a branding standpoint is to mimic the diet of the caveman. Now of course, there is heavy branding going on and getting caught up in the specifics of this is missing the point. Essentially the diet is based on eliminating processed foods, grains, and dairy. It is a high protein, low carb diet attaining protein mostly from animal sources. Veggies, oils, nuts and some fruits are included in the diet. For the purpose of this article, we will leave it at that as getting too in depth with specifics will only cause arguments. Based off this definition, let us look further at some of the pros and cons.

Essentially the diet is based on eliminating processed foods, grains, and dairy.

Essentially the diet is based on eliminating processed foods, grains, and dairy.

Pros:

  1. Focusing on food- this diet gets you to pay attention to what you are putting in your body on a daily basis. It provides accountability and a map for eating. It encourages the avoidance of processed foods and aims for whole, organic foods. This is definitely a step up from the SAD (Standard American Diet) that is prevalent today. If everyone in the country took this step we would be a much healthier country.
  2. High Protein Low Carb- Want to cut weight? High protein low carbohydrate is the way to do it fast and effectively. Most athletes will follow that simple concept in sports nutrition at some point and be successful in certain ratios.
  3. Great Option for certain health conditions- Lactose intolerant? Celiac’s Disease? Gluten Sensitivity? Paleo has you covered as you are not eating Dairy or Gluten.
  4. Not your standard diet- I love that there is no calorie counting and Paleo is a sustainable dietary lifestyle versus a “diet”. It is something a person can embrace without having the likelihood of huge ebbs and flows due to difficulty of food choice availability.
  5. Group Mentality- The CrossFit community has really embraced Paleo. It practically comes packaged in some Boxes (CrossFit Gyms). Have a community supporting diet and lifestyle can be a very good thing and making it easier to stay on track.

Cons:

  1. Inflammation- High animal protein equals elevated inflammation in the body, period. There is no way around it, no arguing it. If you eat a diet that is high in animal protein you will increase inflammation via arachadonic acid pathways.
  2. Dehydration- With a high protein diet you will need more water. Drinking lots and lots of water can help with this, but more often than not, markers will show up on a blood panel such as an elevated ESR (inflammatory marker).
  3. Global Impact- High animal protein equals a heavy impact on the planet. It is estimated that about 18% of human caused green house gases come from live stock production. That is a huge global aspect to think about when you are considering eating meat with every meal.
  4. Not for everyone- There is the obvious, Vegans and Vegetarians will not be on board with this diet. There are also health conditions that would not benefit from a Paleo diet. People with inflammatory conditions such as arthritis, rheumatoid arthritis, lupus, ect or those with heart conditions. There are much better options for these individuals. This directly counteracts number 3 of the pros so I would say it is pretty balanced in this case.
  5. Excuse to indulge on meat- As a health care practitioner I have seen many patients that operate under the theory that Paleo means eat bacon all day, every day. They will look at paleo as a solid reason to offset any hope for a balanced diet. This can be argued for other diets as well (in fact I made a similar argument in a vegan diet blog). Balance is key with food.
  6. Elevated Cholesterol- Eating a diet where often every meal contains animal protein can have a negative effect on cholesterol. Many Paleo eaters find themselves on a high protein, high fat, low carb diet which can lead to an increase in LDL, decrease in HDL and increase in total cholesterol. In the event that an annual blood panel shows a negative increase in cholesterol, perhaps the Paleo diet should be reconsidered, especially in those with a genetic predisposition to elevated cholesterol. Interestingly, there are some studies performed that show people that switch to the Paleo diet actually have an improvement in Cholesterol levels. One study showed a decrease in LDL of up to 22%. The reason this is in the “con” section is it also shows the inconsistency of the diet standards. The Paleo diet can vary so much as to what is eaten, therefore sometimes having a positive effect and sometimes having a negative one. As mentioned in number 5, if the Paleo Diet is not well balanced, then is can be hazardous (as is the case with many other diets).

There is a brief synopsis of Paleo pros and cons. Part 2 coming soon will be a look at the Paleo diet from an East Asian Medical perspective. Don’t forget to subscribe if you want to check it out! What are your thoughts regarding the Paleo diet? Sound off below!

1)      Make a habit of not taking the easy route: Most people will wait for someone to pull out of that front spot in a a parking lot so they can take it and get into the store as quick as possible. Don’t be that person. Park further away and get a quick walk into your location. Same thing goes with elevators. There is no good reason (assuming capability) that you should take an elevator up one floor. Take the stairs! Another idea is, if you can use a hand basket instead of a cart while shopping, go for it!

The mind set of training over working out is highly beneficial.

The mind set of training over working out is highly beneficial.

2)     Don’t think exercise, think training: Mindset is extremely important. When someone asks me, “how often do you work out”, I say rarely, if ever. However, I do “train” about 6 days a week. Of course it is just a play on words, but there is some meaning behind it. People often think of “working out” as an activity done specifically to lose weight or get six pack abs and personally I never do that. I set goals and work daily to achieve them. The healthy management of weight and gain of lean muscle mass is just a cool side effect. For example, the goal I achieved to the right took a really long time to reach! Setting goals gives you something to focus on and create “work outs” around. Maybe you want to run a 5k? Or maybe you want to achieve a specific movement like a strict pull up? If you build your training schedule to achieve these specific goals, you will increase fitness levels while achieving these new skills.

3)      Get a partner or join a group: Some people love fitness groups to get motivated. For example, CrossFit or Yoga are large group fitness classes. Classes usually have around 10-40 people and this can create a great environment to encourage fitness.  A group or partner setting can easily be applied to any fitness situation. Training partners not only encourage you to reach fitness goals, but also can hold you responsible on those days where sleeping in or hitting the couch instead of training sounds good.

Go For a Hike4)      Find active activities you enjoy:  It’s no big surprise that not everyone enjoys the daily grind on a treadmill or hitting the weight room. In fact I’m that guy too! That is completely okay, but find something active you can enjoy. Don’t like a treadmill? What about hiking? Or golfing (walk the course!). Finding hobbies that are active will provide you exercise outside of hitting the gym. Who knows you may even find an activity that lets you look at gym time as training.

 

 

5)      Avoid negative reinforcements:  Becoming healthy is all about lifestyle changes and not temporary fitness and diet trends. Part of that can be making changes to habits that reinforce behaviors that won’t help you reach your goals. One example is “happy hour”.  Red wine in low amounts can be good for the heart and have antioxidant value, but more often than not, happy hour means cheap beer or high sugar beverages along with calorie laden appetizers. Hate to break it to you but they aren’t helping your heart or your fitness goals! Skip happy hour and grab a friend for a walk, run, or dance class instead!

6)      Don’t be afraid to get your hands dirty: Not many of us like chores but, they can be a good way to stay active. Mowing the lawn, tending the garden, and even doing laundry can play a part in your fitness. Yard work is hard work!

7)      Don’t sit all day: It is all too easy to get stuck at the desk staring at a computer for hours on end. We are all guilty of it. It is important to take time once an hour to get up and walk around. It is the perfect time to go to refill that water bottle you have been using to stay hydrated (see what I did there?). Another great idea is don’t have lunch at your desk. Take 30-60 minutes and go for a short walk. Eat outside if the weather allows. Getting that extra movement will also help recharge you for the second half of the work day without needing a pick me up.

8)      Create a routine: And stick to it! This can be huge for developing great fitness. You don’t have to go Type A about it, a broad routine is okay. For example, I make a point of going hiking at least once a week. Sometimes it is a whole day, sometimes it is just an hour or two but, I get out there for a good hike.  Even if I only have one day off that week, I carve the time out of that day to do this activity and make it a priority. You can do the same. You can also be more specific with a training plan and come up with an agenda that you want to go to the gym 5 days a week, three days cardio and two days strength training.  The routine is up to you, but make sure you can commit to it. Start with a realistic and attainable plan. It will feel better to be able to commit to your routine and even be able to surpass it rather than feel like you are falling short because it is too much.  Remember the importance of mind set!

9)      Cook at home: When you make meals at home you have total control about what is in them. When you eat out all the time you don’t always know what is snuck in there to get that rich flavor. Ever wonder why when you attempt to recreate a meal it doesn’t turn out the same as the restaurant? To be honest you may not want to know. Limit eating out and you may find success in the kitchen!

10)   Have your health team in line: Those who are really fit usually have a health team in order. Look at a professional athlete. These individuals have athletic trainers, coaches, physical therapists, acupuncturists, massage therapists, nutritionists, and chiropractors depending on what they find most useful. They do not just go to the doctor when something goes wrong, they see health care practitioners to prevent something from going wrong and to stay their best!

What kind of things do you do to keep active and fit? Leave a comment below! And don’t forget to subscribe to our blog and follow us on Facebook for lots of other great tips!

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