By G. Tukash. Mount Marty College.

Further reading The concepts and methods used by such teachers are solidly based on well-researched anatomic and physi- 1 order 1 mg anastrozole with visa. Ligaments are rich in pain-sensitive fibers and Philadelphia cheap anastrozole 1mg on-line, was the first to use an injection to excessive stress on these tissues can create local and/ strengthen sacroiliac ligaments generic anastrozole 1mg without prescription. Dr George Hackett generic anastrozole 1 mg online, a or referred pain (Hackett et al 2002a, Magnuson 1941, surgeon, active in the late 1950s, correlated pain pat- Meisenbach 1911, Mengert 1943). He A simple diagnostic indicator for a ligamentous pain treated thousands of patients with ligament strength- pattern would be to consider whether the pain is ening injections which he named prolotherapy worse when standing still or sitting in one place for (Patterson 2004a). Once the patient gets up and There is historical evidence that a version of this moves around, there is relief. The same patient may technique was first used by Hippocrates on soldiers also describe pain upon waking in the morning that with dislocated, torn shoulder joints. When the patient a heated poker into the joint, to encourage normal is at rest, the muscles relax and the ligaments support healing (Adams 1946). Of course, we don’t use hot the structure; when the patient moves the muscles pokers today, but the principle is similar: get the body begin to hold the joints and there is relief. Reprinted by permission of Beulah Land Press 258 Naturopathic Physical Medicine they are susceptible to producing pain. During physi- cal examination, pain elicited by passive stretching of ligaments or firm pressure on ligament sites may also be indications for prolotherapy (Hackett et al 2002c). When tendon attachments onto bone (enthesis) are injured, the corresponding muscle groups react with hypertonicity and may develop trigger points. These muscles are commonly treated for spasm and tightness with trigger point therapies, stretching, massage or other methods. If the causative factor is the enthesopathy, then the focus of therapy on muscle may provide only temporary or partial relief. Often after prolotherapy injections, the trigger points will eventually disappear once the injured tendon attach- ment has remodeled. Frequently patients who are tight or stiff can gain a significant improvement in range of motion immediately after a treatment once the damaged tendon has been anesthetized and the hypertonic response reduced. Prolotherapy can be useful for most muscle and joint In studies, prolotherapy has not caused any serious pain problems. There is usually discomfort after each injection ligament in the body except where contraindicated, that lasts for a few minutes to several days, but this and be useful with chronic and acute pain as well as discomfort is seldom severe (Klein et al 1993). Research arthritides, disc degeneration and herniation, dis- articles on prolotherapy do not report any problems locations, whiplash, tendonosis and many other related to safety. It is recommended that anyone wishing to learn this technique obtain training from institutions Methodology that are able to provide cadavers for training pur- Once the injured tendons or ligaments have been poses. To avoid making mistakes it is prudent that the identified, they are usually treated by injection of a practitioner be trained by skilled experts who can 12. The tissue to be injected include: is first palpated and the skin is marked with a sterile • injury to nerves or blood vessels marking pen. The needle • piercing the dural membrane and producing a is injected until the tip is felt to touch bone. The patient spinal headache may often describe pain and/or a description of the referral pattern for that ligament or tendon. The solu- • injection into the spinal cord leading to tion is only injected while the needle is in contact with permanent paralysis or death bone. Chapter 7 • Modalities, Methods and Techniques 259 Validation of efficacy = 5 (see Table 7. Conclusion: ‘Dextrose prolotherapy appears to be a safe Animal studies and effective method for treating chronic spinal • Prolotherapy has been performed on animal pain’ (Hooper & Ding 2004). The ligament injury was treated with and randomized controlled trials’ (Rabago et al prolotherapy at 14 days and at 21 days. Results • A study in Pain Physician concluded: ‘This demonstrated that the mechanical properties of single blinded, randomized and cross-over the ligaments were of greater strengthening, study of prolotherapy was described as being a stiffening, enlargement and decrease of laxity. Alternatives Human studies Dry needle tissue irritation may be an effective alternative for stimulation of inflammation and new • A study at the University of Kansas (Reeves & growth. The acupuncture technique of ‘bone-pecking’ Hassanein 2003) concluded: ‘Dextrose injection or ‘osteopuncture’ involves needle irritation at bony prolotherapy at 2- to 3-month intervals resulted attachments of tendons and ligaments (Helms 1985, in elimination of laxity by machine measure in Lowenkopf 1976, Mann 1971). The use of taping, tensor bandages or devices injections, sustainable through 3 years with and splints to stabilize weakened ligaments may be periodic injection. Exercise for joints or core strengthening results in knees and finger joints (Reeves & for the spine are effective in reducing pain and are Hassanein 2000a, 2003). There are forms of electrotherapy (Harvard 60% sustained reduction in pain and disability Medical School 2006) and friction massage (Cyriax & after 12-month follow-up (Klein et al 1993, Coldham 1984) that strengthen ligaments. Surgery has been a standard for chronic groin pain in this group of elite medical practice and, more recently, growth factors rugby and soccer athletes. Many injuries and degenerative chronic spinal pain showed that 91% of processes do not fully heal on their own because of patients reported reduction in level of pain, the inhibition of the initial inflammation phase by the 84. The prolotherapy 260 Naturopathic Physical Medicine Inflammation Granulation tissue Matrix formation Box 7. To get a sense of the ligament diagnosis, find a patient with an unresolved sacroiliac pain. Consider that the problem may not be the restricted joint but perhaps a hypermobility in the other joint caused by ligament laxity. See if the symptom picture matches the indications outlined earlier in this section. This initi- ates a 3- to 5-day inflammatory cascade, followed by Hypothesis 2–4 weeks of fibroblast activity (Cockbill 2002, Reeves Form and force closure tests are also useful in & Hassanein 2000b). In the of localized inflammation and tissue repair is the basis Vleeming/Lee model the force closure problem is of how injuries self-repair. Prolotherapy, by irritating addressed by increasing articular compression through the injured site, initiates the natural inflammatory the strengthening of specific muscle groups (Lee cascade that allows the body to bring fibroblasts and 1997). These tests might also assist in prioritizing • Diffuse myofascial pain – prolotherapy is treatment strategies. The integration with the suboccipital region naturopathic methods may enhance the effectiveness • Areas that have been repaired by screws, plates of prolotherapy as a stand-alone therapy. By combin- or other hardware ing prolotherapy with manipulation, other manual • Needle phobic or high anxiety patient therapies and exercise the patient should receive a Chapter 7 • Modalities, Methods and Techniques 261 more comprehensive treatment approach. The nutri- Methodology tional, lifestyle, biochemical and energetic aspects of Lymphatic pump method description (Sleszynski & the naturopathic practice will ensure that all perspec- tives of joint and tissue healing are addressed. Kelso 1993) • The patient lies supine, knees and hips [Manual] pump techniques: lymphatics, flexed. Indications for the use of lymphatic pump techniques The arms should be more or less straight for include all conditions that involve congestion, lym- ease of transmission of force from the shoulder phatic stasis and infection (apart from those listed to the hands. Note: This is one example only; there are many other methods for enhancing lymphatic drainage, including direct ‘pumping’ of the lower thorax, exaggerated repetitive dorsiflexion during deep breathing by the Venous patient, etc.

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Western diagnoses that must be considered include social phobia (Ballenger 1mg anastrozole free shipping, 2004) and avoidant personality style or disorder cheap anastrozole 1mg without a prescription. Taijin kyoufusho (interpersonal fear) is probably the same syndrome (sufferers report that body parts/functions offend other people buy discount anastrozole 1mg line, e purchase 1 mg anastrozole with amex. Shame, which is a symptom of this syndrome, is very important in Japanese culture. Dhat (jiryan; also sukra prameha in Sri Lanka) is a ‘neurotic’ disorder common in India. The notion that semen possesses precious and life-preserving properties is deeply ingrained in Indian culture; therefore, its loss in any manner may be viewed as harmful. The dhat syndrome, originally described by Wigg, includes vague physical complaints, such as fatigue, anxiousness, anorexia, and guilt feelings. There may be sexual dysfunction, either impotence or premature ejaculation, which the patient attributes to loss of semen in urine due to excessive masturbation or sexual intercourse. An overvalued idea may form that the urine is foul smelling and less viscous than normal. Shenkui (or shen-k’uei) occurs in China and consists of anxiety, panic, and various physical complaints (including tiredness and sexual dysfunction). The author has certainly seen anxious Irish adolescents who imagined that they have semen in the urine due to ‘damage’ induced by masturbation, so the syndrome is more widespread than India. Frigophobia, found in East Asia, involves an excessive fear of the cold (wears far too many clothes). Hwa-byung (wool-hwa-byung; ‘fiery illness’ or ‘illness of anger’) is found in Korea, mainly in women. There are an epigastric mass sensation, anorexia, anxiety, dyspnoea, and epigastric pain. It seems to be reactive to social circumstances (a way to release anger or indignation), although partial improvement with antidepressant therapy has been recorded. There is usually awareness of the attack whilst it is happening and it can be recalled later. It may represent a way of expressing feelings without incurring adverse consequences. Koro (Malaysian for “head of turtle”; rok-joo in Thailand; jinjinia bemar in Assam; also called suk-yeong by Cantonese Chinese: shrinking penis) resembles panic in symptomatology. The victim, who usually has no history of psychopathology, believes that the secondary sexual organs (penis, female genitalia, breasts) are retracting (as does a turtle’s head) into the trunk. He, or she, may take active steps to maintain the externality of breasts, penis, and so on. It is probably a non-specific symptom, especially in the West, having been described in both schizophrenia and bipolar affective disorder. Qi-gong reaction is a transient neurotic or psychotic response to practicing qi-gong177 in China. Shenjing shuairuo (Mandarin Chinese: ‘weakness of the nervous syndrome’) is known to us as neurasthenia. Shinkeishitsu, found in Japan, consists of obsessions, perfectionism, ambivalence, social withdrawal, neurasthenia, and hypochondriasis. Shin-byung is found in Korea where it is attributed to ancestral spirits: initial anxiety and somatic complaints give way to convulsive movements and anorexia. Hsieh-ping in Taiwan is somewhat similar: short-lived trance state whilst possessed by ancestral spirit who may be attempting to communicate with the family through the possessed; auditory or visual hallucinations, delirium, and tremulousness. New Zealand Whakama (shame) is expressed by Maori people when they break social taboos. Whakamomori consists of low mood, sometimes with damage to 174 Person or voice that enters and controls a person (Zulu). It may involve movement, breathing regulation, or focusing on ‘energy centres’ in or around the body. Mate Maori (Maori sickness), which different forms, is due to the spirit world responding to the breaking of rules. Rules may be broken by the patient or by others (alive or deceased) in the whanau (extended family). Early studies of mental disorders shared problems of observer bias, sampling errors, and non-standardised measuring instruments. Initial reports of a lack of depressive guilt in developing countries may not have been entirely accurate, as it has been demonstrated to exist, especially in Uganda. It has been suggested that Afro-Caribbean’s are more likely to be detained as offender patients. Psychologists Li ea (2007) discuss common difficulties in assessing, diagnosing, and treating minorities: flawed approaches to assessment (e. Bhugra & Bhui, 2001) 178 Services for ethnic minorities need to be accessible, provide trained interpreters , employ members of the minority group, and supply patient advocates. Ireland and other countries are experiencing immigration in large numbers and provision remains inadequate. This contains a language identification card, a set of 20 translated phrasebooks and a user manual. The term disorder refers to ‘a clinically recognisable set of symptoms or behaviour associated in most cases with distress and with interference with personal functions’. Borderline personality disorder is hesitantly included and hyperkinetic disorder was broadened. Oppositional defiant disorder appears because of its predictiveness for later conduct disorder. In Neurasthenia, or nervous debility/exhaustion, the sufferer complains of tiredness, depression, irritability, 182 poor concentration, and anhedonia (also found in depression and schizophrenia), an inability to derive pleasure from anything. It commonly follows or is associated with exhaustion or an infection like influenza. It has been argued that most cases of neurasthenia are actually cases of anxiety or depression. Shenjing shuairuo, in China, and 183 shinkeishitsu, in Japan, are related concepts. Hedonic tone refers to the ability to experience pleasure, its absence 185 meriting the label anhedonia. Historically, Ernst Kretschmer and William Sheldon tried to associate so-called somatotypes, or body builds, with particular psychiatric conditions. There are three basic types, each one with overdevelopment of one of the primary embryonic layers: the endomorph with large visceral cavities and a tendency to bipolar affective disorder, the mesomorph with antisocial proclivities, and the ectomorph who has a tendency to develop schizophrenia. Dress and address Patients want doctors of both sexes to dress formally, the great majority prefer to address doctors by title, but they like to be called by their own first name or they may be undecided about this (Swift ea, 2000; Gallagher ea, 2008) – when in doubt, ask! In a study by Vinjamuri ea (2009) 91% of adult psychiatric 188 outpatients across all age wished to be greeted with their first name ; most wanted their hand to be shaken 184 A French physician described Briquet’s Syndrome (St Louis Hysteria; now called somatisation disorder), a term rarely applied in Europe, in 1859. Classically, it occurs in women, starts before their thirtieth birthday, the patient persistently complains of a variety of physical symptoms, she will not accept a psychological explanation - even if one is obvious, and it is said to affect at least one in a hundred females.

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