Treating Musculoskeletal Pain and Dysfunction Without Drugs and Surgery

Home , Counterstrain, Junk science, Lymphatic pump, Muscle energy technique

TREATING MUSCULOSKELETAL PAIN AND DYSFUNCTION WITHOUT DRUGS AND SURGERY

26th Annual Primary Health Care of Women Conference & Integrative Health in Primary Care University of Michigan Family Medicine Saturday 8, 2018 Weber’s Restaurant & Boutique Hotel Ann Arbor, Michigan

Presented by: Jay Sandweiss, D.O., C-NMM/OMM, F.A.A.M.A. 417 S. Fourth Ave. Ann Arbor, MI 48104 USA email: dr [email protected] website: www.doctorjaysandweiss.com Fax: (734) 668-6529 Telephone: (734) 995-1880 Integrating Manual Medicine and Nutritional Therapy with Acupuncture

Dear Friends and Colleagues… It is always a distinct honor and pleasure to present workshops. As many of you know, I have been treating patients for over thirty-nine years using a variety of modalities, including both complementary/ alternative therapies and conventional “standard of care” medicine. Buzz words like “evidence-based” and “standard of care” have undergone their own evolution in the past three decades. As a medical student, I was chastised for asking questions about the use of folic acid for the prevention of neural tube defects, magnesium for certain arrhythmias and migraine, fish oil for autoimmune disease and cardiovascular health, and the existence of Helicobacter Pylori(which my course instructor dismissed as “junk science” proposed by a misguided quack Australian). We laugh now as these examples have been integrated into mainstream medicine, but we must not forget that for better or worse, medical science is a very Jay Sandweiss, D.O., F.A.A.M.A. conservative, skeptical, critical entity that often dismisses truth with unfortunate consequences only to embrace these same facts later on down the road. Students of medical history are often appalled by what was the“standard of care” in those past times. Ridiculing and punishing hand-washing with soap, femur amputations for the treatment of pernicious anemia, and dismissing “stocking-glove” paresthesias and carpal tunnel syndrome as psychiatric illnesses or malingering were all part of a long-established history of blaming the patient whenever possible and punishing those that threatened the reigning paradigm. As acupuncturists, we have seen a growing acceptance and demand from the public at large to provide our services. “Evidence-based” studies have slowly infiltrated the mainstream medical establishment to the point where acupuncture is often included as a viable intervention for numerous conditions. Similar patterns of change have occurred in the fields of manual medicine and nutritional therapy. The burden of “evidence-based” studies helps prevent dubious therapies from being accepted but also limits many legitimate treatments because of the onerous time/money constraints placed on the investigators. This is particularly true in the field of nutritional therapy where money is not readily available unless the payoff is a drug patent for the pharmaceutical companies. Ironically, many drug companies are, indeed, trying to capitalize on the works of nutritional pioneers by patenting a slight variant of a readily available nutritional product. Prescription fish oil, time-released niacin, vitamin B-12/Folate and a recently approved strontium-hybrid are but a few examples. Fortunately, several of the top nutraceutical companies are sponsoring clinical trials with their products at major research centers around the world.

My knowledge of nutritionally based therapies represents a conflation of influences from many great teachers and innovators. A list of resources is included at the end of this introductory essay. My early teachers were Drs. George Goodheart Jr. and Walter Schmitt, who, along

1 with Harry Eidenier Jr. PhD, introduced me to the late and great genius, Royal Lee, DDS (the founder of Standard Process Laboratories. To this day, Dr. Lee’s work offers endless clinical pearls for effective patient care. Another huge leap of knowledge occurred studying the works of Jeffrey Bland, PhD. His seminars and publications are masterpieces that weave physiology, nutritional biochemistry, and clinical medicine into a vibrant working model. Many physicians have been transformed by courses offered by the Institute for Functional Medicine that teaches much of Dr. Bland’s life work. At the same time, Jonathan Wright, M.D. and Alan Gaby, M.D. were writing books and offering week-long courses to physicians. Their courses included applied nutritional therapies for almost every medical sub-specialty.

After attending their course at the Omega Institute in 1988, I became convinced that medical nutrition was destined to become an integral part of mainstream medicine. Melvyn Werbach, M.D from UCLA came along with his wonderful Third Line Press publications that documented the use of dietary, nutritional, and herbal interventions for nearly every medical condition. Finally, Kirk Hamilton P.A. offered comprehensive reporting on research in the field of medical nutrition with his Clinical Pearls services. My apologies to all the many other great contributors, leaders, and pioneers whose names have not been included in this brief presentation. This workshop pertains to the integration of nutritional medicine and manual medicine with acupuncture. As medical acupuncturists we appreciate those interventions that enhance a healthy physiology and homeostasis. Current theories about acupuncture propose mechanisms that involve cellular molecular biology in its varied forms including: neurotransmitters, cellular messengers, immune cells and modulators, endogenous opioids and cannabinoids, and numerous other components of immunology, neurology, and metabolism. Nutritional medicine shares many similar characteristics. It seems reasonable to postulate that acupuncture interventions and nutritional interventions are capable of achieving similar effects under certain circumstances and an enhanced synergistic result in yet others.

Often a pattern diagnosis in Chinese Medicine such as: Damp Heat in the Lower Jiao may represent in Western physiologic terms: intestinal dysbiosis involving an imbalanced microbial population in the bowel with overgrowth of candida albicans, the presence of parasites, and a deficiency of normal probiotic flora resulting in non-specific colitis or irritable bowel syndrome. An acupuncturist may choose to treat specific points that influence Damp Heat in the meridians: Spleen/Stomach, Large Intestine, Liver and Gall Bladder. Herbal formulas might be employed as well to resolve this issue. A functional medicine practitioner may order sophisticated stool studies, blood tests, and other tests before implementing a focused nutraceutical/pharmaceutical plan to resolve the abnormalities that appear in these investigations. Probiotics, prebiotics, antifungals, antimicrobials and nutrients that help heal and restore normal mucosal integrity may be utilized. Following treatment there will be a noticeable change in pulse and tongue findings from a Chinese Medicine standpoint in addition to the obvious clinical improvements. The question frequently arises as to whether or not acupuncture is necessary or sufficient to resolve these types of clinical disorders. During my internship year in medical school, I was completely cured by one acupuncture treatment for a refractory case of ulcerative proctitis that was confirmed by tissue biopsy and unresponsive to steroids. My physician friend, just back from China, diagnosed a severe Damp Heat invasion of my Lower Jiao by history, tongue and pulse diagnosis. This ”acupuncture healing” profoundly affected my life and viewpoint about illness and treatment. Nutritional modalities were not involved nor were manual treatments.

2 In my experience, acupuncture enhances the therapeutic effects of other modalities such as manual medicine or nutritional/pharmaceutical interventions. As physicians we appreciate the seriousness of pneumonia and will often prescribe an appropriate antibiotic. As medical acupuncturists, we would want to treat the Lung meridian and any additional corresponding meridian disturbances that were present during the illness and after the pneumonia had resolved. Furthermore, as healers we would seek out the inherent weaknesses or vulnerabilities that allowed our patient to acquire pneumonia in the first place. Acupuncture, nutritional medicine, and manual medicine can be pro-active and preventive in addition to being treatment responses for medical conditions. They are interventions that promote healing and homeostasis in addition to attacking pathology and dysfunction.

As an integrative medicine physician, I am frequently treating patients with multiple interventions simultaneously. It is not unusual for these patients to receive nutritional/herbal therapies, dietary manipulations, manual therapies, and acupuncture in their total treatment plans. Identifying the specific curative factor or factors is therefore rather difficult. Each therapeutic input is intended to address or resolve specific aspects of the troubling condition. Some refer to the “combination- lock theory “ of healing wherein all the numbers (factors) must be known and the specific sequence is needed to unlock the lock (heal the condition). A brief example might be useful here. Suppose the patient has chronic asthma as their chief complaint and is currently not facing an acute life-threatening crisis. In addition to, or as an alternative to the typically prescribed medications such as Albuterol, Flovent, Singulair, Zyrtec , etc. one could prescribe a food elimination diet, nutritional supplements such as: vitamin B-12, vitamin C, magnesium, n-acetylcysteine, and quercitin to name just a few. Acupuncture needles could be administered based on the specific etiology imbalances discovered during pulse, tongue, and history diagnostics. Herbal formulas could be added to support and enhance the acupuncture effect. Manual medicine techniques could be utilized to remove mechanical restrictions in the diaphragm, cranium and axial skeleton. Lymphatic drainage and respiratory-circulatory techniques could be used as well. Mind-body therapies could be taught to reduce “stress” and control triggers from a mental-emotional origin.

We can take advantage of the many readily available diagnostic tests for evaluating : nutritional deficiencies,toxicities, hormonal and metabolic disorders, food/chemical allergies and sensitivities, and bowel flora disturbances. Numerous studies have pointed out that nutritional deficiencies are common and often go unrecognized in our elderly population. As our “life energies” or “Jing” wanes with age there are often corresponding deficiencies seen with nutrients and hormones that if treated can markedly improve quality of life parameters.

I hope you will find useful, information in this presentation that can benefit your patients, your families and yourselves. Applied nutritional therapy is wonderfully synergistic with medical acupuncture. While you treat a Liver problem from an acupuncture perspective with needles, you can simultaneously identify specific dietary and nutraceutical interventions by history, examination, and diagnostic testing. One can also treat the liver organ itself with viscreal manipulation. Many useful charts, tables and clinical pearls are included for your review. A section is included in the slides that focuses on each principal meridian and how one can integrate specific nutraceutical interventions for that channel. Another section focuses on the treatment of Inflammation (Fire) which is very relevant for the treatment of inflammatory conditions involving the neuro-musculoskeletal system, cardiovascular system, respiratory system,gastrointestinal system, and the integument.

3 TRAUMA : AN INTEGRATIVE MODEL FOR DIAGNOSIS AND TREATMENT Caillet defines trauma as a: “wound or injury with implication of a force applied externally or internally causing a tissue reaction. Pain is the resultant which has varying degrees of intensity and effective interpretation with numerous avenues of transmission.” This lecture introduces a variety of treatment principles and modalities for patients who have suffered trauma in their past and are unable to move forward in their recovery. This presentation will not address the management of serious acute trauma that requires emergency interventions or acute hospital care. Rather, we will discuss approaches that can be utilized after the patient is medically stable but is “stuck” and unhappy with their current state of recovery. We often encounter these patients who have been told: “You’ll have to learn to live with it” (for the remainder of their lives). Be it chronic pain, loss of function, loss of motion, depression, or other sequelae to trauma: these patients could benefit from a variety of interventions that are not typically offered by traditional mainstream medicine. As acupuncturists we are quite familiar with these truths and most of us have already helped numerous patients with needles, moxa, and/or herbs. This session is meant to add to that growing list of possible complementary and alternative approaches for healing past trauma.

THE “LIST” Osteopathic Manipulative Medicine: Cranial Osteopathy, Visceral Manipulation, Strain- Counterstrain, Myofascial Release, Functional Release, Muscle Energy Technique, High Velocity Thrust, Facilitated Position Release, Balanced Ligamentous Tension, Percussion Hammer Special Attention to: Breathing( 3 Diaphragms), Visceral Mobility and Motility disorders, Sacrum-Coccyx(Holds fear/insecurity), Dural strains, Cranial/TMJ dysfunctions (often unexamined), Greenman’s “Dirty Half-dozen” (non-neutral facet joint restrictions, symphysis pubis shears, sacral posterior torsion or nutation, hip bone shear, short-leg/pelvic tilt syndrome, and muscle imbalance of the trunk and extremities), Nerve Restrictions, “Energy Sinks” (Robert Fulford’s Concept that is treated with the Percussion Vibrator) Chiropractic: Applied Kinesiology (Injury Recall Technique, Emotional Neurovascular Holding Points), Sacro-Occipital Technique (Suture Releases), Neuro-Emotional Technique Homeopathy: Arnica, Hypericum, Symphytum, Natrum Sulphuricum, Ruta Graveolens Bach Flower/ Other Flower Essences: Star of Bethlehem, Rescue Remedy, Revive All (FlorAlive Remedies) Aroma Therapy: Spruce, Rose, Lavender EMDR (Eye Movement Desensitization and Reprocessing): Psychotherapy Tool Redcord: A Revolutionary Rehab Device Gyrotonic and Pilates Prolotherapy: For hypermobilty unresponsive to other modalities or strengthening Nutritional/Metabolic: Evaluation of: Nutritional status (intracellular vs. other), Endocrine balance (blood, urine, saliva), Toxicity (hair, blood, urine, feces), Food and chemical sensitivities (ALCAT et al), Mitochondrial function (Cellular Energy Profile et al), Dysbiosis/”Leaky gut syndrome” (Comprehensive Stool Analysis), Immune panels with other traditional laboratory and diagnostic studies. Hypnotherapy, Biofeedback, Neurofeedback et al: Brain, behavior, and psyche Bioenergetics and other Mind-Body oriented therapies: Somato-emotional therapies Rolﬁng, Hellerwork, Soma Bodywork, Anatomy Trains: Core patterns Magnets, Crystals, Lasers, and other energy transfer devices: Energy fields Shamanic Healing and other forms of “Soul Retrieval”

4 Chinese Medicine: Seven Dragons, Chakra Acupuncture, Yintang, Shao Yin- Jue Yin groundingreleasing points: H-7, PC-6, LR-3, K-3, K-25, 26, 27, CV-17 Treat the “scattered” or “suspended” Qi, treat the loss of Heart Qi, Heart pulse is Fine and Tight, Complexion is bright-white or bluish tinged forehead. Pulse is rapid, short, shaped like a bean, vibrating Eyes may be dull without glitter** (from Giovanni Maciocia)

As an osteopathic physician I have been greatly influenced by my teachers, mentors, and the past masters of my profession. To better understand the osteopathic philosophy and treatment approaches to trauma, I can highly recommend the writings and methods of: Andrew Taylor Still M.D./D.O., Rollin Becker D.O., Robert Fulford D.O., William Johnston D.O., Viola Frymann D.O, Myron Beal D.O., William Sutherland D.O., Fred Mitchell Jr. D.O., Lawrence Jones D.O., Anne Wales D.O., Irwin Korr Ph.D., Philip Greenman D.O., Robert Ward D.O., Anthony Chila D.O., Edward Stiles D.O., John Upledger D.O. and Jean-Pierre Barral D.O. This is a partial list but certainly representative of the rich and prolific tradition of osteopathic healers and educators.

My first mentor, George Goodheart Jr., D.C., developed a unique system of diagnosis and treatment using manual muscle testing. His system, Applied Kinesiology, has been in a state of continual evolution for over 60 years. A central theme runs through his work known as the “Triad of Health”. This concept proposes that there is a continuous interaction between structure, chemistry, and emotional/energetic facets. When a patient presents with post- traumatic pain, there will undoubtedly be multiple somatic dysfunctions present. A careful history and thorough examination usually reveals biochemical and emotional- energetic problems as well. Food allergies, chemical sensitivities, toxicities, nutritional deficiencies, endocrine disturbances and subtle disorders of metabolism such as mitochondrial dysfunction are more common than one might imagine. “Post-Traumatic Stress Disorder” with its myriad of manifestations: Depression, Anxiety, OCD, ADHD, Paranoia, Phobias, Insomnia, Somatic Disorders, and Sexual Dysfunction, (just to name a few) is also quite common.

Perhaps a case example might illustrate the application of this “Triad of Health” paradigm. A 45 year old white female has had three years of pain in the cervical, mid-thoracic and lower back regions following a whiplash injury. Additionally, she complains of retro-orbital and temporal headaches, jaw tension with “clicking and popping,” insomnia, fatigue, depression, anxiety, irritable bowel syndrome, irregular periods, right carpal tunnel syndrome, left patella pain, and “foggy, dull thinking.” All of these complaints began after the accident. She was stopped at a red light and was rear-ended at approximately 35 mph. She hit her head on the driver’s window, hit her knee cap into the dashboard, and felt extreme strain to her wrist during the accident. A month after the accident she developed a thyroid nodule with goiter and became hyperthyroid requiring Tapazole medication. Patients with these scenarios are often treated as if their entire whiplash injury is strictly limited to their musculoskeletal system. Medications, injections, physical therapy, chiropractic, massage and other musculoskeletal modalities are often employed. The lucky patients recover with those interventions alone. Some are not so lucky. This patient requires deeper attention to the specific disruptions of her structure, chemistry, and energetic psychology. Osteopathic examination reveals: cranial somatic dysfunctions involving a petro-jugular dislocation, fronto-sphenoid compression, lateral sphenoid strain,

5 lowered cranial rhythmic impulse and impairment of venous sinus drainage. Physical examination reveals TMJ dysfunction which is supported by an MRI, documenting a dislocated/torn disc and capsule allowing for complete dislocation of the TMJ disc during opening and closing. Cervical MRI demonstrates atrophy of the rectus capitis superior minor muscle with resultant instability of the occipito-atlantal joint. Neural and myofascial tension is noted from the anterior cervical regions down the right arm into the wrist and hand. The diaphragmatic breathing pattern is markedly dysfunctional with dyskinesis of the thoracic, pelvic, and cranial diaphragms. Hypermobility of the cervical and thoracic ligaments is noted at multiple levels. The sacrum and coccyx are abnormally tight and intra-osseously compressed with a backward sacral torsion. A right pelvic shear is evidenced by the asymetrical positions of the ischial tuberosities. “Listening” reveals a restricted and mildly ptosed left kidney. The liver’s mobility and motility are also restricted.

The treatment of the above structural somatic dysfunctions would require skilled interventions with cranial manipulation, visceral manipulation, prolotherapy, neuro-fascial release, myofascial release, and temporomandibular joint treatment from a dentist familiar with cranial- mandibular mechanics (severe TMJ pathology may require surgery). Many of these patients benefit from the intelligent use of nutraceutical products including: vitamins, minerals, trace minerals, enzymes, amino acids, anti-oxidants, and herbs. Magnesium, zinc, vitamin C, proline, and a host of other nutrients are necessary for connective tissue integrity. Chronic inflammation can be treated with an anti-inflammatory diet (Mediterranean diet minus their food sensitivities) along with therapeutic levels of Omega-3 fatty acids, boswellia serrata, tumeric, bromelain, ginger, garlic, devil’s claw, MSM, CoQ10, and alpha lipoic acid. Several companies offer intra-cellular nutrient testing to specifically identify deficiencies.

The hypothalamic-pituitary-adrenal axis is universally stressed and often dysfunctional post-traumatically. Patients need a thorough examination of their endocrine system to determine the extent of abnormal hormonal involvement. The most common finding is adrenal dysfunction: either hyperactivity or exhaustion. Continuous stress on the adrenal system leads to fatigue, depression, idiopathic rashes, paradoxical wakefulness at night, sugar and stimulant cravings, gastrointestinal irritation, weakened ligaments, dilated pupils, orthostatic hypotension, susceptibility to infections, and marked susceptibility to joint injuries. B- complex vitamins, vitamin C, minerals, ginseng, gotu kola, saspirilla, rehmannia, adrenal glandular products, and selective Chinese herbal formulas can help restore energetic and metabolic balance to the gland. Occasionally, the patient will require physiologic doses of Cortisone (Cortef). Thyroid dysfunctions are very common and often present after severe stress or trauma particularly to the head and neck. In general, any gland may exhibit post- traumatic dysfunction. The pancreas may become hypo-functioning on an endocrine or exocrine basis. Menstrual irregularity may follow head or back injury. Each case is unique and needs to be evaluated for possible deleterious sequelae..Ideally, successful manipulation of “ key lesions”, dietary adjustments, individualized nutritional and herbal therapies and acupuncture can provide considerable relief and improvement to their former condition. One can not underestimate the importance of also treating the mental-emotional, psychic, etheric, and spiritual dimensions of trauma. As triune beings we resonate in accordance to the health and balance of our mind-body-spirit. Treating the subtler energy fields can at times produce the greatest changes in our patients. Many patients are stuck in their fixed attitude, posture, and energy resonance. EMDR, Bach Flower Remedies, Homeopathy, Hypnosis, Reiki, Hands of Light, Chinese Medicine, and other modalities on “The List” work with those

6 dimensions that are rarely acknowledged by conventional medical treatments. Dr. Fulford said that the goal of the healer is to help the patient find their destiny. To put the patient in touch with what their ultimate purpose was for being on this earth in this lifetime. Once a patient is doing what they were meant to do, everything else begins to fall in place. Sometimes trauma is a gift that leads to an awareness of what is important and what needs to be done.

Trauma can occur in “ one fell swoop” or as the “straw that breaks the camel’s back.” Repetition stress is commonplace and what I see in my practice is a body finally running out of adaptations. We see this often in children today playing sports or having a series of injuries where each one leads to an adaptive response that eventually can’t compensate. Too often, parents are told that their child athlete is fine and will ”get over it” because he’s just a kid. Soccer trauma, gymnastics injuries, and all the other trauma prone sports are creating a nation of “walking wounded child-athletes“ who are only given ice and ibuprofen for their aches and pains. Very little attention is paid to the specific, discrete nature of their injuries that can be treated by competent manual medicine practitioners and/or acupuncturists. A child might present with headaches or neck pain that is the result of untreated ankle or lower back strains from past injuries. The athlete will keep compensating for their previous injury with altered posture and motion mechanics which will ultimately take them down a path of new injuries. Gaining the skills to diagnose and treat somatic dysfunctions as they occur in the child or adult proves rewarding to the patient and doctor alike. “An ounce of prevention is worth a pound of cure” and treating and resolving trauma in a timely fashion can restore function and prevent a lot of unnecessary pain and suffering down the road.

Trauma: An Osteopathic Approach authored by Jean-Pierre Barral D.O. and Alain Croiber D.O. is an outstanding text for exploring the varied depths and multi-dimensional consequences of trauma. “Nothing is forgotten”, ”Nothing is isolated”, “Everything accumulates”, “Everything is recorded”, summarizes several critical concepts that are at the foundation of traditional osteopathic thought. All structures and tissues do not respond identically to the same given traumatic forces. The pre-existing state of the person’s mind/body/spirit influences the outcome of any traumatic event. Barral and Crobier describe in great detail the biomechanics and physics of trauma. Each system of the body is included in their analysis. Novel diagnosis and treatment procedures are presented for treating: cranial, dural, visceral, neural, vascular, and osteoarticular injuries. (Several of these modalities are presented in the powerpoint presentation).

Foundations for Integrative Musculoskeletal Medicine: An East-West Approach authored by Alon Marcus D.O.M., L.Ac., D.A.A.P.M. is certainly one of the most comprehensive texts I’ve ever read regarding the musculoskeletal system. Dr. Marcus has done an amazing job of merging orthopaedic, neurological, and osteopathic principles of diagnosis and treatment with that of Chinese Medicine; both acupuncture and herbal medicine. A wonderful reference text for almost any clinical presentation in musculoskeletal medicine.

Enjoy! Jay Sandweiss D.O., F.A.A.M.A.

7 MANUAL MEDICINE TECHNIQUES THAT TREAT CHANNEL RESTRICTIONS

CONCEPTION VESSEL: CV-17 COUNTERSTRAIN

GOVERNING VESSEL: GV-1 COUNTERSTRAIN, GV-20 CRANIAL

LUNG: LU- 1&2 COUNTERSTRAIN, LU-7-9 MYOFASCIAL RELEASE

LARGE INTESTINE: LI-4 UNWIND THUMB, LI-11 COUNTERSTRAIN/MFR

STOMACH: ST-41 MUSCLE ENERGY TECHNIQUE OR THRUST TECHNIQUE

SPLEEN: SP-2,3,4 MYOFASCIAL RELEASE OR MUSCLE ENERGY TECHNIQUE

HEART: HT-1 ACTIVATED RELEASE, HT-3 COUNTERSTRAIN OR THRUST

SMALL INTESTINE: SI-11,13,14 COUNTERSTRAIN , SI-19 TMJ RELEASES

BLADDER: ANY SPINAL LEVEL( e.g. BL-23) MET/ COUNTERSTRAIN

KIDNEY: KI-10 COUNTERSTRAIN, KI-27 MET

TRIPLE ENERGIZER: TE-10, 11, 12 DEEP MYOFASCIAL RELEASE

GALL BLADDER: GB-34,40 MET TO FIBULA, GB-20 MET OR COUNTERSTRAIN, GB-21 COUNTERSTRAIN OR MYOFASCIAL RELEASE

LIVER: LR-2,3 MFR OF TOE, LR-4 MFR OF ANKLE MORTISE, LR-14 VISCERAL

8 Upper Extremity Pearls

Upper extremity problems may be locally and/or distally induced and perpetuated

Always evaluate the whole patient/whole body for somatic dysfunctions of the spine, ribs, cranium, pelvis, sternum and lower extremities

Muscle testing helps identify the source of many problems. It helps to gauge the success of treatment by testing pre and post muscle response

Many upper extremity issues come from cervical and upper thoracic/rib somatic dysfunctions

Think brachial plexus trouble makers (cervical spine, T1, scalenes, upper ribs)

Multiple reflex systems affect the upper extremity from the opposite side of the body: Muscle Interlink Ligament Interlink Gait Reflexes/Brain Cortex Acupuncture Meridians: Inverse /Contrary pairings Shoulder = Opposite Hip Elbow = Opposite Knee Wrist = Opposite ankle Fingers = Opposite toes Upper Extremity = Opposite Cortex (80%)

Yang Meridians run from fingers to face (Large Intestine - Small Intestine - Triple Warmer)

Yin Meridians run from trunk to fingers (Heart – Lung – Pericardium)

Organ and meridian disturbances create upper extremity problems by referral through reflexes and channels

Poor posture/poor ergonomics are a form of repetitive stress on the upper extremity in addition to typical repetitive stressors

Stretching and strengthening is essential for total recovery

9 Worksite evaluations are very appropriate and helpful Occupational Therapy is invaluable with many tough cases

Ask patient about job, cell phones , keyboarding, mouse, one sided carrying habits

Often Cranial/TMJ involvement: Screen with Applied Kinesiology Protocols Breathing patterns– use upper extremity muscle group TMJ Protocol- use upper extremity muscle group

Specific Pearls:

Weak Adductor: Same side of chronic elbow problem (use neurolymphatic reflex ) * Goodheart

Medial ulna subluxation: causes chronic subscapularis weakness and perpetuates medial epicondylitis

Radial head restriction: causes or perpetuates wrist issues and lateral epicondyle problems, biceps tendonitis

T12-L1 spinal fixation: causes B/L lower trapezius weakness which disturbs scapular function and contributes to upper trapezius tension/trigger points

Latissiumus Dorsi: can come from cervical somatic dysfunctions (innervation) or thoracic, lumbar or sacral dysfunctions (origin of Latissimus)

Levator scapula: sensitive to calcium metabolism/parathyroid, torticollis. Use neurolymphatics aggressively consider nutrition

SCM/Upper Trapezius: Innervation CNXI (jugular foramen)/Cranial

Superior 1st rib dislocation: Pain/numbness down arm into hand

Persistent shoulder problems: Often undiagnosed visceral restriction of liver, lung, pleura, heart, pericardium or diaphragm. Consider when everything else has failed with traditional physical therapy

10 Carpal Tunnel Syndrome: Usually a continuum from C-spine/thoracic inlet Boggy lymphatics, B6 deficiency or thyroid problem Give patient the Dr. Sucher myofascial stretches for carpal tunnel Interosseous forearm strain: do indirect release

Pectoralis Minor: Often short tight or weak: important for lymphatic drainage

Retrograde lymphatic test and techniques

Must free diaphragm for all chronic shoulder problems

Subclavius often involved when patient can not put humerus next to their ear. Last part of frozen shoulder cases

Motion loss in minor movements cause loss of major movements (e.g. elbow flexion/extension affected by lateral glides and rotation of elbow)

*More will come spontaneously during the course get ready!

11 LOWER EXTREMITY PEARLS

- ALWAYS EXAMINE THE WHOLE PERSON FROM TOP TO BOTTOM AND FROM BOTTOM TO TOP. BRAIN, SPINE, AND PELVIS MUST BE CHECKED AS WELL AS LOCAL STRUCTURES (KNEE, ANKLE, FOOT)

- GAIT DYSFUNCTION CAUSES REPETITION STRESS INJURY. THE AVERAGE PERSON REPEATS A GAIT CYCLE ONE MILLION TIMES A YEAR

- FASCIAS ARE IMPORTANT TO TREAT BECAUSE THEY STORE AND RELEASE ENERGY DYNAMICALLY. FASCIAL DYSFUNCTIONS IN THE LOWER EXTREMITIES WILL GENERATE MULTIPLE PROBLEMS INTO THE TRUNK AND PELVIS

- THE KNEE IS A PLACE OF MANY MINOR MOVEMENTS (SLIPPING, EXTERNAL AND INTERNAL ROTATION OF THE TIBIA). VERY FREQUENTLY, A DECREASE IN A MAJOR MOVEMENT COMES FROM RESTRICTIONS OF MINOR MOVEMENTS.

- KNEE PAIN IS USUALLY CAUSED BY A PROBLEM ABOVE OR BELOW THE KNEE UNLESS THERE WAS DIRECT TRAUMA TO THE KNEE

- LONG BONES LIKE THE TIBIA AND FIBULA MUST BE EVALUATED AT BOTH ENDS AS THE TWO ENDS MOVE IN OPPOSITE DIRECTIONS. AN APPARENT ANTERIOR TIBIO-TALUS DISTALLY CAN ACTUALLY BE A POSTERIOR PROXIMAL TIBIA AT THE FEMUR

- AFTER TRAUMA, THE TISSUES WILL RETAIN THE INJURY PATTERN. INDIRECT SOFT TISSUE TECHNIQUES MUST BE USED TO RESTORE PROPER PROPRIOCEPTION AND FUNCTIONING. REST AND STRENGTHENING IS NEVER ADEQUATE TO RESTORE NORMAL FUNCTION.

- MOTION TEST ALL FOOT AND ANKLE BONES TO ASSURE THEY ARE DOING THEIR JOBS. PARTICULARLY CALCANEUS, NAVICULAR, CUBOID, TALUS, AND CUNEIFORMS

- CAREFULLY CHECK FOR “TRUE” SHORT LEGS VERSUS FUNCTIONAL SHORT LEGS

- MANY KNEE, CALF, ANKLE AND FOOT PROBLEMS ARE DUE TO ADRENAL GLAND STRESS OR OTHER VISCERAL-SOMATIC ISSUES

12 CERVICAL REGION PEARLS

- PROBLEMS OF THE CERVICAL SPINE REGION CAN COME FROM ANYWHERE! - - COMMON NEUROMUSCULOSKELETAL CAUSES OF THESE PROBLEMS INCLUDE: - CRANIAL FIELD SOMATIC DYSFUNCTIONS ( JUGULAR FORAMEN: CN9,10,11) - VISUAL DISORDERS - (OFTEN UNDIAGNOSED VERTICAL HETEROPHIA OR OTHER VISUAL PERCEPTUAL DEFECTS), TMJ AND HYOID BONE DYSFUNCTIONS. - THESE MUST BE IDENTIFIED AND TREATED TO ACHIEVE LASTING CORRECTIONS - LOVETT BROTHER REACTIVITY : - SACRUM=OCCIPUT, L5=C1, L4=-C2, L3=-C3, L2=C5, L1=-C6 - - SACROILIAC FIXATIONS= INHIBIT POSTERIOR CERVICAL EXTENSOR MUSCLES - - UPPER THORACIC VERTEBRA, RIBS, AND UPPER EXTREMITIES GREATLY INFLUENCE CERVICALS - - VISCERAL PTOSIS (USUALLY KIDNEY OR LIVER) OR VISCERAL RESTRICTIONS FROM THE THORAX(PLEURA/LUNG) CAN CREATE OR PERPETUATE CERVICAL SYNDROMES - - AFTER WHIPLASH INJURY NEED TO TREAT DIAPHRAGM, DURAL STRAINS, CRANIAL DYSFUNCTION ( OFTEN PETROJUGULAR DISLOCATION), LOCAL SOFT TISSUES: MUSCLE SPINDLE CELLS, FASCIA, MUSCLES, GOLGI TENDONS - - POSTURAL ERGONOMICS: “THE HEAD IS A HEAVY BOWLING BALL” - ALEXANDER TECHNIQUE, WORKSITE EVALUATION, POSTURAL TRAINING MAY ALL BE NECESSARY - - GAIT AND LOWER EXTREMITY INVOLVEMENTS: SHORT LEG, FOOT PRONATION, TIGHT TALOCRURAL MOTION, ASYMMETRICAL GAIT SWING, “WALKING GAIT” DISORDERS CAN ALL CAUSE OR PERPETUATE CERVICAL PROBLEMS - - -

13 - OTHER IDEAS TO CONSIDER: - - ALL ACUPUNCTURE CHANNELS AND POINTS IN THE HEAD AND NECK REGION ARE YANG EXCEPT FOR THE CONCEPTION VESSEL IN THE VENTRAL MIDLINE - - 4 OF THESE YANG CHANNELS ARE CONNECTED TO THE EYES ( BL, ST, TH AND GB) - - 4 OF THESE YANG CHANNELS ARE CONNECTED TO THE TMJ REGION (SI,ST,TH, AND GB) - - DISTURBANCES IN ANY OF THESE CHANNELS CAN BE A CAUSE OF CHRONIC CERVICAL COMPLAINTS. DISTURBANCES CAN INVOLVE ORGANS AND GLANDS ASSOCIATED WITH THOSE CHANNELS. ( EXAMPLE: GERD MAY BE CAUSED BY”REBELLIOUS STOMACH QI”. GERD MAY CAUSE SORE THROAT OR OTHER SYMPTOMS IN THE CERVICAL/TMJ AREA WHICH FOLLOW THE TRAJECTORY OF THE UPPER STOMACH MERIDIAN.) THIS IS ANOTHER WAY OF UNDERSTANDING VISCERO-SOMATIC PAIN PATTERNS. GALL BLADDER MERIDIAN PROBLEMS MAY PRESENT AS NECK OR SHOULDER PAIN - - THE NECK IS A VULNERABLE, SENSITIVE AREA: - CAROTID ARTERIES, THYROID, PARATHYROIDS, TRACHEA, SPINAL CORD VAGUS AND PHRENIC NERVES - - “BOTTLE NECK” : CONNECTOR BETWEEN THE HEAD (MIND) AND BODY (HEART) BECOMES SYMPTOMATIC WHEN THERE IS CONFLICT BETWEEN MIND AND EMOTION - - SADNESS AND GRIEF STORED THERE - - REPRESENTS THE INHERENT FLEXIBILITY TO SEE BOTH SIDES OF AN ISSUE - - - -

14 *These five printed pages are excerpt from Counterstrain Approaches In Osteopathic Manipulative Medicine reprinted with permission from author Jerel Glassman, D.O.

15 16 17 18 19 FUNCTIONAL RELEASE EXERCISE

STAND BEHIND YOUR STANDING PATIENT LIGHTLY HOLDING THEIR FOREHEAD

WITH YOUR OTHER HAND MAKE SOFT REPEATED POSTERIOR TO ANTERIOR ( P-A) GLIDES WITH YOUR THUMB AND FINGERS TOUCHING THE POSTERIOR FACET PLANES OF THE CERVICAL SPINE REGION

BEGIN BY SHEARING P-A AT THE OCCIPUT LEVEL AND THEN PROCEED ONE VERTEBRAL LEVEL AT A TIME UNTIL YOU HAVE INDIVIDUALLY APPRECIATED A P-A GLIDE AT EACH LEVEL C-0 THROUGH C-7

YOU MAY NOTE THAT ONE OR MORE LEVELS SEEM TO PRODUCE MORE RESISTANCE TO THE P-A GLIDE THAN THE LEVEL ABOVE AND BELOW THAT LEVEL

YOU MAY ALSO DO THIS PROCEDURE WITH YOUR PATIENT SEATED

ONCE YOU HAVE IDENTIFIED A PARTICULAR CERVICAL SPINE LEVEL THAT EXHIBITS MORE RESISTANCE TO P-A GLIDE THAN THE LEVELS ABOVE AND BELOW, YOU WILL FOCUS YOUR PALPATORY SKILLS AND ATTENTION TO COMPARE THE RELATIVE COMPLIANCE VS. RESISTANCE OF THOSE PARTICULAR TISSUES AS THEY RESPOND TO THE MOTIONS YOU WILL INDUCE PASSIVELY. YOU MUST ALSO NOTE HOW THE PATIENT’S TISSUES RESPOND TO INHALATION AND EXHALATION.

A KEY LESION IS CONSIDERED TO BE THAT MOBILE SEGMENT IN THE MIDDLE OF A 3 SEGMENT STACK OF VERTEBRAE THAT BEHAVES EXACTLY THE OPPOSITE OF THE SEGMENTS ABOVE AND BELOW IT. CAREFUL PALPATION WILL REVEAL THAT THE MOTIONS THAT INCREASE TENSION IN THE TISSUES SURROUNDING SEGMENTS ABOVE AND BELOW THE KEY LESION, WILL ACTUALLY DECREASE TENSION IN THE TISSUES ADJACENT TO THE KEY LESION. THIS WILL ALSO BE TRUE OF THE TISSUE RESPONSES TO INHALATION AND EXHALATION.

TREATMENT IS GENERALLY PERFORMED WITH THE PATIENT SUPINE. THE LEVEL OF THE KEY LESION IS TOUCHED BILATERALLY BY THE PRACTITIONER’S RELAXED FINGERTIPS AND THE ELBOWS ARE SUPPORTED IN SUCH A WAY AS TO SUPPORT THE PATIENT’S HEAD.

THE TREATING HEALTH PROFESSIONAL WILL PASSIVELY INDUCE THE 6 MONITORING MOTIONS WHILE NOTING WHICH DIRECTIONS PRODUCE GREATER OR LESSER TENSIONS IN THE PALPATED TISSUES. THE PATIENT IS ASKED TO INHALE AND EXHALE AS WELL.

20 AGAIN NOTING WHICH PHASE OF RESPIRATION PRODUCES THE GREATEST SOFTENING OF THE TISSUES.

ONCE ALL MOTIONS HAVE BEEN EVALUATED AND APPRECIATED FOR THOSE THAT PRODUCE THE GREATEST COMPLIANCE VS. RESISTANCE, THE TREATMENT IS PERFORMED BY “STACKING” ALL THE MOVEMENTS THAT INCREASE COMPLIANCE (EASE ) IN THE TISSUES WITH THE PHASE OF RESPIRATION THAT INCREASES COMPLIANCE (EASE)

THESE MOTIONS INCLUDE:

FLEXION/EXTENSION

SIDEBENDING

ROTATION

ANTERIOR/POSTERIOR GLIDE

LATERAL GLIDE

TRACTION/COMPRESSION

INHALE/EXHALE

A SENSE OF RELEASE AND SOFTENING OF THE PALPATED KEY LESION TISSUES WILL BE FELT UPON SUCCESSFUL PERFORMANCE OF THIS PROCEDURE.

RE-EXAMINATION OF THE PREVIOUS ASYMMETRICAL FINDINGS AND PATTERNS SHOULD DEMONSTRATE MARKED IMPROVEMENT THAT NO LONGER PRODUCES PARADOXICAL FINDINGS BETWEEN THE KEY LESION AND THE VERTEBRAL LEVELS THAT ARE ABOVE AND BELOW THAT SEGMENT.

21 TMJ PROTOCOL

1. Find strong muscle (e.g. TFL)

2. Have patient therapy localize the TMJ with thumb and 5th finger opposing each other, while 2nd, 3rd, and 4th fingers touch jaw joints.

3. Ask patient to: * Bite hard * Open a little * Open wide * Lateralize left * Lateralize right * Extrude jaw * Retrude jaw * Chew slowly (aerobic) * Chew fast (anaerobic) * Swallow * Talk

4. If any procedures described above weaken the patient, have them repeat the action while holding only the left side of jaw alone and then only the right side of jaw. Whichever side they were touching when their muscle weakened, is the involved side. (You may need to change their head position up/down or left/right for this problem to display itself.)

5. There is a specific treatment procedure for each specific pattern of weakness.

6. You may place paper or tongue depressors between their teeth and see if a specific change in vertical dimension changes their bite weakness. For example, if a person weakens when they clench their teeth forcefully, but they no longer weaken when two tongue depressors are placed between their teeth, then they probably need a bite splint that will approximate this correction. In other words, send them to a dentist who does TMJ work.

Final note: The above screening procedure helps confirm that there is a problem with the jaw that needs attention. The patient may have already shown signs and symptoms of TMJ problems in the initial history and physical.

22 TREATING MUSCULOSKELETAL Click to edit Master tle style PAIN AND DYSFUNCTION WITHOUT DRUGS AND SURGERY 26th Annual Primary Health Care of Women Click to edit Master text styles ______Conference & Integrave Health in Primary University of Michigan Family Medicine Second level ______Saturday 8, 2018 Weber’s Restaurant & Bouque Hotel ______Third level Ann Arbor, Michigan

______Fourth level Presented by: Jay Sandweiss, D.O., C-NMM/OMM, F.A.A.M.A. 417 S. Fourth Ave. Ann Arbor, MI 48104 USA email: ______dr Fih level [email protected] website: www.doctorjaysandweiss.com Fax: (734) 668-6529 ______• Telephone: (734) 995-1880

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40 Four Basic Principles of Osteopathic Medicine Click to edit Master tle style 1. The body is a unit.

2. The body is self-regulating Click to edit Master text styles ______and self-healing.

3. Structure Second level and ______function are reciprocally ______Third level related. 4. Rational treatment ______Fourth level is based on this philosophy and these principles. ______Fih level ______

Click to edit Master tle style Models of osteopathic care: Click to edit Master text styles ______Five models that articulate how an osteopathic practitionerSecond level ______seeks to inﬂuence a patient’s physiological ______Third level processes. ______Fourth level ______Fih level ______

41 Structural model

The goalClick to edit Master tle style of the structural model is biomechanical adjustment and the mobilization of joints. This model also Click to edit Master text styles seeks ______to address problems in the myofascial connective tissues, as well as in the bony and soft tissues to remove restrictiveSecond level forces______and enhance motion.

This is accomplished ______Third level by the use of a wide range of osteopathic manipulative techniques such as high velocity-low amplitude, ______Fourth level muscle energy, counterstrain, myofascial release, ______ligamentousFih level articular techniques, and functional techniques. ______

Respiratory-circulatory model

The goalClick to edit Master tle style of the respiratory-circulatory model is to improve all of the diaphragm restrictions in the body.

DiaphragmsClick to edit Master text styles ______are considered to be “transverse restrictors” of motion, venous Second level and______lymphatic drainage and cerebrospinal ﬂuid. ______Third level The techniques used in this model are osteopathy in the cranial ﬁeld, ligamentous ______Fourth level articular strain, myofascial release and lymphatic ______Fih level pump techniques. ______

42 Metabolic model

The goalClick to edit Master tle style of the metabolic model is to enhance the self- regulatory and self-healing mechanisms, to foster energy conservation by balancing the body’s energy expenditureClick to edit Master text styles ______and exchange, and to enhance immune system function and organ function. Second level ______The osteopathic considerations in this area are not manipulative in nature ______Third level except for the use of lymphatic pump techniques. ______Fourth level Nutritional counseling, diet and exercise advice are the most common approaches for balancing the body ______throughFih level this model. ______

Neurologic model

The goalClick to edit Master tle style of the neurologic model is to attain autonomic balance and address neural reﬂex activity, remove facilitated segments, decrease afferent nerve signals and relieveClick to edit Master text styles pain. ______

The osteopathic manipulativeSecond level ______techniques used to inﬂuence this area ______ofThird level patient health include counterstrain and Chapman ______Fourth level reﬂex points. ______Fih level ______

43 Behavioral model Click to edit Master tle style The goal of the behavioral model is to improve the biological, psychological and social components of the healthClick to edit Master text styles spectrum. ______

This includes emotionalSecond level ______balancing and compensatory mechanisms. ______Third level

Reproductive and behavioral ______Fourth level adaptation are also included under this ______model.Fih level ______

The goal of manipulation is to restore maximal pain-free movementClick to edit Master tle style of the musculo-skeletal system in postural balance. Click to edit Master text styles ______Second level ______Third level ______Fourth level ______Fih level ______

44 TightnessClick to edit Master tle style creates and weakness permits asymmetry.

Click to edit Master text styles ______Second level ______Third level Weakness creates and tightness maintains ______Fourth level asymmetry. ______Fih level ______

Osteopathic Manipulation Click to edit Master tle style Myofascial Release Muscle Energy Technique Click to edit Master text styles ______Strain-Counterstrain Functional Release CranialSecond level Osteopathy______High Velocity Technique Visceral ______Third level Manipulation Still Technique Facilitated ______Fourth level Position Release Balanced Ligamentous Tension Percussion ______Fih level Hammer ______

45 Somatic Dysfunction ImpairedClick to edit Master tle style or altered function of related components of the somatic (body framework) system: Skeletal, arthrodial, and myofascial structures, and related vascular, lymphatic, and neural elements; the positional and motion aspects of somaticClick to edit Master text styles ______dysfunction are best described using two parameters: 1. The positionSecond level of a______body part as determined by palpation and referenced to its adjacent defined structure ______Third level 2. The direction in which motion is freer and the directions in which ______Fourth level motion is restricted; In either instance the Cartesian, orthogonal or Euler coordinates are used ______Fih level as the reference axes of motion. ______

Monitoring Motions Click to edit Master tle style • Flexion/Extension • Side-Bending Click to edit Master text styles ______• Rotation • Anterior/PosteriorSecond level ______Translation • Lateral ______TranslationThird level • Cephalad/Caudad Translation (Distraction/Compaction) ______Fourth level

• Inhalation/Exhalation ______Fih level ______

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50 THE “LIST” . OsteopathicClick to edit Master tle style Manipulative Medicine . Chiropractic . Homeopathy . Bach Flower/ Other Flower Essences . AromaClick to edit Master text styles ______Therapy . EMDR (Eye Movement Desensitization and Reprocessing) . Gyrontonic and Redcord . Prolotherapy Second level ______. Nutritional/Metabolic: Toxicity, Food/Chemical Sensitivities Endocrine . Hypnotherapy, Biofeedback, Neurofeedback et al . Bioenergetics and other ______Third level Mind-Body oriented therapies . Rolfing, Hellerwork, Soma Bodywork, Anatomy Trains . Magnets, Crystals, Lasers, ______Fourth level and other energy transfer devices . Shamanic Healing and other forms of “Soul Retrieval” . Chinese Medicine . Reiki, Hands of Light, ______TherapeuticFih level Touch, Polarity Therapy et al ______

Special Attention to: • BreathingClick to edit Master tle style (3 Diaphragms) • Visceral Mobility and Motility disorders • Sacrum-Coccyx(Holds fear/insecurity) • DuralClick to edit Master text styles ______strains • Cranial/TMJ dysfunctions (often unexamined) • Greenman’s “DirtySecond level ______Half-dozen” (non-neutral facet joint restrictions, symphysis pubis shears, sacral posterior torsion ______Third level or nutation, hip bone shear, short- leg/pelvic tilt syndrome, and muscle imbalance of the trunk and extremities) ______Fourth level • Nerve Restrictions • “Energy Sinks ______” (RobertFih level Fulford’s Concept that is treated with the ______Percussion Vibrator)

51 Click to edit Master tle style Pelvic Diaphragm Click to edit Master text styles ______Second level ______Third level ______Fourth level ______Fih level ______

ThoracicClick to edit Master tle style Diaphragm Click to edit Master text styles ______Second level ______Third level ______Fourth level ______Fih level ______

52 Click to edit Master tle style Cranial Diaphragm Click to edit Master text styles ______Second level ______Third level ______Fourth level ______Fih level ______

Listening with traction on the Click to edit Master tle style Cylinder of the dura mater Click to edit Master text styles ______Second level ______Third level ______Fourth level ______Fih level ______

53 VisceralClick to edit Master tle style Manipulation for Liver MobilityClick to edit Master text styles ______(seated) Second level ______Third level ______Fourth level

Reproduced with permission ______fromFih level Visceral Manipulation Revised Edition, Eastland Press ______

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Reproduced from A MANUAL OF ACUPUNCTURE by Peter Deadman ______

55 Click to edit Master tle style Quadratus Lumborum Click to edit Master text styles ______Second level ______Third level ______Fourth level ______Fih level ______

Strain- CounterstrainClick to edit Master tle style

Treatment of PosteriorClick to edit Master text styles ______Lumbar TPs Second level ______Third level ______Fourth level ______Fih level ______

56 Strain- CounterstrainClick to edit Master tle style

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______Fourth level Treatment of Posterior Lumbar Spinous and Posterior Lumbar Transverse Medial TPs Process (TP) ______Fih level ______

Pearls of BL-23 Click to edit Master tle style COMMON ISSUES: Low Back Pain, Weak Back, Easily Chilled, Decreased Libido, Fear and Insecurity, Knee Problems, Dental Problems, Infertility, Erectile Dysfunction, Chronic Fatigue, Sore Throats, Chronic Illness, Ear Problems,Click to edit Master text styles ______Tinnitus, Genito-Urinary Issues

CHECK: Rehmannia, AdrenalSecond level ______Formulas, Ginseng, Tribulus, Astragalus, Vitamin A, Vitamin C, Uva Ursi, Cranberry Extracts, Licorice, Rhodiola, Withania ______Third level ______Fourth level ______Fih level ______

57 Concept of Barriers Click to edit Master tle style

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______NeutralFih level position ______

PhysicalClick to edit Master tle style Evaluation

Click to edit Master text styles ______• Listen • Observe Second level • Touch______•Third level Asymmetry • Tenderness ______Fourth level • Restriction of Motion ______• Fih level Tissue Change ______

58 MonitoringClick to edit Master tle style Motions

• Flexion/Extension Click to edit Master text styles ______• Side-Bending • RotationSecond level ______• Anterior/Posterior ______Third level Translation • Lateral Translation • Cephalad ______Fourth level /Caudad Translation (Distraction/Compaction) ______Fih level • Inhalation/Exhalation ______

SymmetricClick to edit Master tle style Response to Motion

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59 AsymmetricClick to edit Master tle style Response to Motion

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DiagnosticClick to edit Master tle style Approach

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______Fourth level *Positive Findings ______Fih level ______

60 Click to edit Master tle style Osteopathic Manipulation Myofascial Release Muscle Energy Technique Click to edit Master text styles ______Strain-Counterstrain Functional Release CranialSecond level ______Osteopathy High ______Third level Velocity Technique Visceral Manipulation Still ______Fourth level Technique Facilitated Position Release Balanced ______Fih level Ligamentous Tension Percussion ______Hammer

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61 Click to edit Master tle style Manual Medicine relies on visual observation of Click to edit Master text styles anatomical ______landmarks and their responseSecond level ______to induced motion, ______asThird level well as palpatory cues, to ______Fourth level arrive at a diagnosis of somatic dysfunction. ______Fih level ______

GENERAL LISTENING: Click to edit Master tle style From Barral Visceral Manipulaon Click to edit Master text styles ______Second level ______Third level ______Fourth level ______Fih level ______

62 PERCUSSION Click to edit Master tle style OF PARAVERTEBRAL TISSUES:

From Johnston Click to edit Master text styles ______Funconal Release Second level ______Third level ______Fourth level ______Fih level ______

SHEARING GENTLY Click to edit Master tle style FOR SKIN DRAG AND VALLEYS Click to edit Master text styles ______Second level ______Third level ______Fourth level ______Fih level ______

63 MONITORING TISSUE Click to edit Master tle style RESPONSE TO SIDEBENDING Click to edit Master text styles ______Second level ______Third level ______Fourth level ______Fih level ______

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Click to edit Master text styles ______Second level ______Third level ______Fourth level SIDEBENDING FOR BARRIER SENSE: ______Fih level RESISTANCE VS COMPLIANCE ______

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FUNCTIONAL RELEASE THORACIC: ______Fih level MONITORING 6 PLANES/BREATH ______

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Click to edit Master text styles ______Second level ______Third level ______Fourth level HOMING IN ON THE PRECISE ______Fih level VERTEBRAL LEVEL OF RESTRICTION ______

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Click to edit Master text styles ______Second level ______Third level ______Fourth level THERMAL SCANNING FOR INCREASED OR DECREASED HEAT ______Fih level ______

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HOMING IN ON THERMAL PROJECTION ______Fih level ______

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69 Click to edit Master tle style Manual Medicine relies on visual observation of Click to edit Master text styles anatomical ______landmarks and their responseSecond level ______to induced motion, ______asThird level well as palpatory cues, to ______Fourth level arrive at a diagnosis of somatic ______Fih level dysfunction. ______

Assessment of Lumbar TransverseClick to edit Master tle style Processes In Prone Extended Position.Click to edit Master text styles ______Second level ______If one TP is posterior, the ______Third level facet is stuck on the opposite side ______Fourth level (for finding FRS ______Fih level restrictions) ______

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71 Muscle Energy Click to edit Master tle style Finding An ERS LumbarClick to edit Master text styles ______By Having Patient Slump Into Second level ______Flexion ______Third level The posterior lumbar TP is ______Fourth level the facet side that ______Fih level will not open. ______

MuscleClick to edit Master tle style Energy Setting Up TreatmentClick to edit Master text styles ______Of An L2-ERSR

Patient’s rightSecond level ______hand on their ______Third level left shoulder, Practitioner’ ______sFourth level right arm under ______Fih level patient’s arm. ______

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72 MuscleClick to edit Master tle style Energy Position For TreatmentClick to edit Master text styles ______of An L2-ERSR

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AnteriorClick to edit Master tle style Lumbar and Pelvic Tender Points

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73 PosteriorClick to edit Master tle style Lumbar and Pelvic Tender Points Click to edit Master text styles ______Points for Counterstrain Second level ______Approaches ______Third level ______Fourth level ______Fih level ______

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Counterstrain

ConsidersClick to edit Master tle style the dysfunction to be a continuing, inappropriate strain reﬂex, which is inhibited by applyingClick to edit Master text styles ______a position of mild strain in the direction exactly opposite to that of the false strain reflex. Second level ______This is accomplished ______Third level by use of the specific point of tenderness related to this dysfunction, followed by specific directed ______positioningFourth level to therapeutic response. ______Fih level ______

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74 Counterstrain Procedure • IdentifyClick to edit Master tle style tender point • Find a passive patient position that markedly reduces the tenderness.

• Use flexion if on the front of body, extension if on the back, lateral bendingClick to edit Master text styles ______if on the side. Rotation, compression or distraction will vary with each case. Fine tune your position.

• Monitor the tissue overSecond level the tender______point without applying pressure for 90 seconds.

• Feel for a release in the ______tissueThird level (i.e., heat, softening, change in patient’s respiration) ______Fourth level • Retest by pressing into the original tender point. • Pain should be decreased ______Fih level and function improved. ______

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Strain- CounterstrainClick to edit Master tle style

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75 Strain- CounterstrainClick to edit Master tle style Treatment Of Lateral TP Tender Points Click to edit Master text styles ______Good for Quadratus Lumborum Second level ______Third level ______Fourth level ______Fih level ______

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78 Click to edit Master tle style

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Click to edit Master tle style COUNTERSTRAIN: RELEASE OF ANTERIOR Click to edit Master text styles ______TENDERPOINT STERNUM Second level ______Third level ______Fourth level ______Fih level ______

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79 Click to edit Master tle style

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COUNTERSTRAIN: ______Fih level RELEASE OF SUPERIOR 1ST RIB TENDERPOINT ______116

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80 Click to edit Master tle style

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COUNTERSTRAIN: ______Fih level RELEASE OF T4-T6 POSTERIOR TENDERPOINTS ______

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81 Click to edit Master tle style

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COUNTERSTRAIN: ______Fih level RELEASE FOR TRACHEA/ CHRONIC COUGH ______

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Myofascial Release Click to edit Master tle style Direct or Indirect ApproachClick to edit Master text styles ______To Thoraco- Lumbar Second level ______Area (Back of ______Third level Diaphragm) ______Fourth level ______Fih level ______

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82 Myofascial Release Click to edit Master tle style Direct or Indirect ReleaseClick to edit Master text styles ______of Lumbar Fascia Second level ______Third level ______Fourth level ______Fih level ______

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Completed: April 28, 2015 Received: April 14, 2015 Collected: April 08, 2015

ONE Results Overview

AntioxidantsClick to edit Master tle style Click to edit Master text styles ______ B-Vitamins Second level ______ ______Third level ______Fourth level Minerals ______Fih level ______

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Krebs Cycle At-A-Glance

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Metabolic Analysis Markers (Urine) Malabsorption and Dysbiosis Markers Neurotransmitter Metabolites

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Vitamin Markers

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Cellular Energy & Mitochondrial Metabolites

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Amino Acids (Urine FMV) Nutritionally Essential Amino Acids Intermediary Metabolites

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Dietary Peptide Related Markers

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Lab Comments 133

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Second level ______ ______Third level © Genova Diagnostics · A. L. Peace-Brewer, PhD, D(ABMLI), Lab Director · CLIA Lic. #34D0655571 · Medicare Lic. #34-8475 ______Fourth level ______Fih level ______

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91 “DIAGNOSE THE NEED, SUPPLY THE NEED, OBSERVE THE RESULTClick to edit Master tle style ” GEORGE GOODHEART JR., D.C. THE FOUNDER OF APPLIED KINESIOLOGY QUOTING ANDREW TAYLOR STILL Click to edit Master text styles ______M.D. THE FOUNDER OF Second level OSTEOPATHY ______Third level ______Fourth level ______Fih level ______

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TREATING THE BIOCHEMICAL SIDE OF THE TRIANGLE: Click to edit Master tle style 2 CASES OF PAIN RESOLVED WITH DIETARY/NUTRITION INTERVENTIONS

STORY OF B.S.: REFRACTORY THORACIC PAIN IN A 46 Y/O MARATHON RUNNER CAUSED BY Click to edit Master text styles UNDIAGNOSED CELIAC DISEASE AND NUTRITIONAL DEFICIENCIES ______

STORY OF M.T.: Second level ______PAINFUL , STIFF ARTHRITIC FINGERS IN AN EXECUTIVE BUSINESSWOMAN RESOLVED BY ELIMINATING GREEN BEANS AND CHOCOLATE ______Third level ______Fourth level ______Fih level ______

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92 PEARLS FOR CHRONIC PAIN: Click to edit Master tle style TREAT AND IMPROVE THE CHRONIC ACTIVITIES OF DAILY LIFE:

 SLEEP: SLEEP STUDY, JAW APPLIANCE, SLEEP HYGIENE, NUTRITION Click to edit Master text styles BREATHING: (3 DIAPHRAGMS, THORAX, INHALE/EXHALE RATIO ______ EATING: FOOD QUALITY, DIGESTION/ABSORPTION, LEAKY GUT, SENSITIVITIES/ALLERGIES, R/O CELIAC/GLUTEN INTOLERANCE Second level ______ EXERCISE/MOVEMENT: ERGONOMICS OF POSTURE/ GRAVITY  THINKING/FEELING: EDUCATION OF MIND-BODY CONNECTIONS ______Third level  FLOW OF BODY FLUIDS AND ENERGY: ACUPUNCTURE, YOGA, LYMPHATIC / VENOUS FLOW TECHNIQUES ______Fourth level ______Fih level ______

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Case Study Click to edit Master tle style . 27 year-old Peruvian female, former varsity lacrosse athlete at prominent university, referred for post-Click to edit Master text styles ______concussion syndrome. Second level ______Third level ______Fourth level ______Fih level ______

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Click to edit Master tle style CC: Constant headache, sensivity to noise and light, vesbular and vision problems, short term memory loss, irregular menses and sleep disturbance. Click to edit Master text styles ______

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Click to edit Master tle style Paent received standard mainstream treatment at prominent healthcare facility, which included Neurology, OT, PT, vesbular exercises, and 10 treatments from a licensed Click to edit Master text styles ______acupuncturist aﬃliated with the healthcare facility. Second level ______

______Third level Paent reported no appreciable improvement from all of ______Fourth level these intervenons. ______Fih level ______

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95 Inial visit, pernent ﬁndings Click to edit Master tle style

. Marked asymmetrical TMJ opening with popping, click and Rt. jaw deviaon Click to edit Master text styles ______Second level ______. Global muscle inhibion w. jaw clenching (AK) ______Third level . Markedly posive Vercal ______Fourth level Heterophoria Symptom Quesonnaire (VHSQ) and posive muscle test screening exam, (AK) ______Fih level ______

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. Click to edit Master tle style Petrojugular dislocaon of Rt. Temporal bone (Cranial Osteopathy) . Naso-maxillary suture Rt. compression (Cranial Click to edit Master text styles Osteopathy) ______. Posive anterior Second level cloacal______reﬂex dysfuncon, (AK) . Dysfunconal anterior gait test (AK) ______Third level ______Fourth level ______Fih level ______

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96 Click to edit Master tle style . C6 - FRSL (Flexed Rotated Side-bent Le) .Click to edit Master text styles Pulse diagnosis revealed: Deﬁcient Liver, Kidney, ______Spleen (TCM) . Tongue diagnosis: Spleen deﬁciency Second level ______w. retained heat (TCM) ______Third level ______Fourth level ______Fih level ______

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Paent aended her inial visit with her mother, a respected clinical psychologist. Aer her examinaon, a lengthy Click to edit Master tle style discussion ensued regarding a total recovery treatment program. Click to edit Master text styles ______In fact, it was suggested that both the paent and her mother read the book Total RecoverySecond level ______by Gary Kaplan, D.O., to beer understand the mulfaceted approach that we would be pursuing in her case. ______Third level ______Fourth level ______Fih level ______

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97 Click to edit Master tle style Referrals were made to:

. Funconal optometrist to conﬁrm Vercal Heterophoria and to prescribe correcve prismac lenses Click to edit Master text styles ______. Denst specializing in the treatment of TMJ disorders to Second level ______prescribe a therapeuc jaw appliance and to conﬁrm TMJ pathology with dedicated MRI study ______Third level

. A local Anatomy Trains manual therapist for a series of ______Fourth level deep ssue myofascial release treatments ______Fih level ______

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Click to edit Master tle style Diagnosis and Treatment

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98 Click to edit Master tle style Diagnosis and Treatment

Click to edit Master text styles Paent was treated in my oﬃce with a series of ______osteopathic manipulaons that inially addressed somac dysfuncons of her cranial and cervical Second level ______regions, in conjuncon with medical acupuncture treatments that ulized several disnct subsystems ______Third level within the acupuncture realm. ______Fourth level

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Laboratory tesng revealed mulple Click to edit Master tle style signiﬁcant abnormalies:

. Severely deﬁcient Vitamin D (25,OH)! < than 4 (Not measurable) Click to edit Master text styles ______

. Deﬁcient serum Zinc Second level ______

. Deﬁcient Coenzyme Q10 ______Third level

. Mulple low normal/borderline deﬁciencies of several ______Fourth level B Vitamins, as well as ______Fih level Manganese, Magnesium, Calcium, Copper, and L-Carnine

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99 Laboratory tesng revealed mulple Click to edit Master tle style signiﬁcant abnormalies (cont.)

.Click to edit Master text styles Stool tesng revealed disturbances in digeson and ______absorpon of fecal fats, as well as severe impairment of short-chain fay acids (SCFA). Also noted was an Second level ______absence of lactobacillus species, (a crically important probioc ______Third level in a healthy gut). ______Fourth level ______Fih level ______

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Laboratory tesng revealed mulple Click to edit Master tle style signiﬁcant abnormalies (cont.) . MRI of her TMJ revealed anterior displacements of her discs without recapture, and an incidental ﬁnding Click to edit Master text styles of an abnormal remodeling of bone in the area of the ______posterior pituitary. Second level ______Third level ______Fourth level ______Fih level ______

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100 Click to edit Master tle style

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GI Eﬀects Comprehensive Proﬁle - Stool Click to edit Master tle style . Stool tesng revealed Click to edit Master text styles ______disturbances in digeson and absorpon of fecal fats, as well as severe impairment of short-chain fay acids (SCFA). Second level ______

. Also noted was an ______Third level absence of lactobacillus species, (a crically important ______Fourth level probioc in a healthy gut). ______Fih level ______

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103 KZ Click to edit Master tle style 1987

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104 KZ

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Click to edit Master tle style Magnec Resonance Imaging Click to edit Master text styles ______. MRI of her TMJ revealed anterior displacements of her discs without recapture, and an incidental Second level ______ﬁnding of an abnormal remodeling of bone in the ______Third level area of the posterior pituitary. ______Fourth level ______Fih level ______

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MRI Impressions Click to edit Master tle style

Right TMJ Click to edit Master text styles Anterior displacement without recapture of the disc on open mouth ______views. Incidental ﬁnding of a bright T1 foci in the posterior sulcus signal with adjacent mild clivusSecond level remodeling. ______Clivus remodeling with scleroc borders was also present on CT from 8/23/2005. Given the long interval, this likely represents posterior pituitary with long-standing ______Third level remodeling of bone. This was read in conjuncon with neuroradiology faculty on 12/6/2014, 4:45 PM. ______Fourth level Incidental note is made of le greater than right T2 signal within the maxillary sinus also seen on previous MRI of the brain. ______Fih level ______

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107 Clinical Pharmacology Click to edit Master tle style

. Paent consulted a local clinical pharmacist for further suggesons regarding the treatment of her memory loss Click to edit Master text styles ______and cognive complaints. Second level ______. The pharmacist suggested hyperbaric oxygen treatments, ______Third level a trial of minocycline, curcumin, or low dose naltrexone to help shut down ______Fourth level neuro-inﬂammaon. . The pharmacist also felt that a trial of ______Fih level Piracetam might be helpful for her memory issues. ______

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Click to edit Master tle style Summary of Outcomes

. Click to edit Master text styles Aer receiving specially designed prism lens glasses, the ______Paent immediately experienced signiﬁcant Second level ______improvement with her headaches and dizziness. Also, her neck and shoulder tension was reduced. ______Third level

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108 Summary of Outcomes (cont.) Click to edit Master tle style . Her TMJ dental appliance further Click to edit Master text styles reduced her headaches signiﬁcantly and ______provided a stability factor to her treatments. Second level ______Third level . Therapeuc levels of vitamins, minerals, digesve enzymes, ______Fourth level probiocs and other nutraceucal ______Fih level agents led to marked improvement in her energy level and overall feeling of well being. ______

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Click to edit Master tle style Summary of Outcomes

Click to edit Master text styles ______Osteopathic manipulave medicine treatments with medical acupuncture provided signiﬁcant Second level ______improvement with all parameters of pain and ______Third level funcon. ______Fourth level

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109 Click to edit Master tle style Summary of Outcomes (cont.)

. In general, this Paent has experienced Click to edit Master text styles connual steady progress in all dimensions ______and was able to successfully return to graduate level courses this past year. Second level ______Third level . This case demonstrates the eﬃcacy of ______Fourth level applying an integrave medicine approach that is using new tools and following new ______Fih level rules. ______

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THE STORY OF LARRY H.: Click to edit Master tle style SEVERE SYMPTOMATIC LUMBAR SPINAL STENOSIS RESOLVED WITH A HEEL LIFT AND MANIPULATION Click to edit Master text styles ______Second level ______Third level ______Fourth level ______Fih level ______

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113 Biochemical Individuality Click to edit Master tle style Genetic and Environmental Uniqueness Toxic Chemical Radiaon Exposure

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Cells Immune Imbalance Poor Detoxification ______GenomicThird level Inflammation Poor Diet GI Problems ______Fourth level Instability Stress, Negave Expression of Inflammation Emoons Hormone Imbalance ______Fih level Emotional Stress and Preclinical ______symptoms Structural Stresses Lack of Trauma Chronic Disease Exercise 183 183 183

Biochemical Individuality Click to edit Master tle style Genetic and Environmental Uniqueness

Healthy Click to edit Master text styles Purpose ______Nutrition Body Energy Efficiency Second level ______Oxidative Protection

Balanced Cells Immune Regulation Detoxification Passion ______Third level Sleep Genetic Repair Relaxation ______Fourth level mRNA Healthy GI Tract & Stability Tolerance ______Fih level Hormones In Balance Emotional Tranquility Community Exercise Expression ______of Health Structural Strength 184184

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115 Click to edit Master tle style

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116 Dr.Click to edit Master tle style Fulford said that the goal of the healer is to help the patient find their destiny. To put the patient in touch with whatClick to edit Master text styles ______their ultimate purpose was for being on this earth in this lifetime. Once a patient is doingSecond level ______what they were meant to do, everything ______Third level else begins to fall in place. Sometimes trauma is a gift that leads to an awareness ______Fourth level of what is important and ______Fih level what needs to be done. ______

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117 AC1 Click to edit Master tle style Approach TP posteriorly. ______Treatment:Click to edit Master text styles Rotate away Second level ______markedly. Side bend away ______Third level slightly. Flexion/extension ______Fourth level minimal. ______Fih level ______

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Posterior Cervical TenderClick to edit Master tle style Points Posterior Cervical tender points are usually located at the lateral aspects of the tips ofClick to edit Master text styles the ______spinous processes. PC1 Inion is located 2 cm below inionSecond level at______the medial border of main muscle mass. ______Third level

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194 119 PC1 Click to edit Master tle style Inion Treatment: Flexion to barrier. SidebendClick to edit Master text styles ______slightly toward. Rotate slightly away. Second level ______Third level ______Fourth level ______Fih level ______

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PC3-7 Click to edit Master tle style Treatment: Patient’s head extended off table. ExtensionClick to edit Master text styles ______moderate to extreme. Sidebend away. Second level ______Rotate away. PC3 (rare) ______Third level

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196 120 Click to edit Master tle style

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THE “LIST” . OsteopathicClick to edit Master tle style Manipulative Medicine . Chiropractic . Homeopathy . Bach Flower/ Other Flower Essences . AromaClick to edit Master text styles ______Therapy . EMDR (Eye Movement Desensitization and Reprocessing) . Gyrontonic and Redcord . Prolotherapy Second level ______. Nutritional/Metabolic: Toxicity, Food/Chemical Sensitivities Endocrine . Hypnotherapy, Biofeedback, Neurofeedback et al . Bioenergetics and other ______Third level Mind-Body oriented therapies . Rolfing, Hellerwork, Soma Bodywork, Anatomy Trains . Magnets, Crystals, Lasers, ______Fourth level and other energy transfer devices . Shamanic Healing and other forms of “Soul Retrieval” . Chinese Medicine . Reiki, Hands of Light, ______TherapeuticFih level Touch, Polarity Therapy et al ______

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198 121 Special Attention to: • BreathingClick to edit Master tle style (3 Diaphragms) • Visceral Mobility and Motility disorders • Sacrum-Coccyx(Holds fear/insecurity) • DuralClick to edit Master text styles ______strains • Cranial/TMJ dysfunctions (often unexamined) • Greenman’s “DirtySecond level ______Half-dozen” (non-neutral facet joint restrictions, symphysis pubis shears, sacral posterior torsion ______Third level or nutation, hip bone shear, short- leg/pelvic tilt syndrome, and muscle imbalance of the trunk and extremities) ______Fourth level • Nerve Restrictions • “Energy Sinks ______” (RobertFih level Fulford’s Concept that is treated with the ______Percussion Vibrator)

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200 122 Test: Click to edit Master tle style Lassimus Click to edit Master text styles ______Dorsi Second level ______Third level ______Fourth level ______Fih level ______

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Lassimus Dorsi Click to edit Master tle style Weakness: Postural Distoron Click to edit Master text styles ______Second level ______Third level ______Fourth level ______Fih level ______

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202 123 Supraspinatus Click to edit Master tle style

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Infraspinatus Click to edit Master tle style

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204 124 Teres Minor Click to edit Master tle style

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Subscapularis Click to edit Master tle style

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