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Functional Medicine Training Program Page1 of 29 Insider’s Guide – Functional Approach to Neuromusculoskeletal Disorders

Copyright © 2008 Sequoia Education Systems, Inc

Functional Medicine University’s Functional Diagnostic Medicine

Training Program

INSIDER’S GUIDE

FUNCTIONAL APPROACH TO NEUROMUSCULOSKELETAL

DISORDERS By Ron Grisanti, D.C. & Dicken Weatherby, N.D.

http://www.FunctionalMedicineUniversity.com

Limits of Liability & Disclaimer of Warranty We have designed this book to provide information in regard to the subject matter covered. It is made available with the understanding that the authors are not liable for the misconception or misuse of information provided. The purpose of this book is to educate. It is not meant to be a comprehensive source for the topic covered, and is not intended as a substitute for medical diagnosis or treatment, or intended as a substitute for medical counseling. Information contained in this book should not be construed as a claim or representation that any treatment, process or interpretation mentioned constitutes a cure, palliative, or ameliorative. The information covered is intended to supplement the practitioner’s knowledge of their patient. It should be considered as adjunctive support to other diagnostic medical procedures.

This material contains elements protected under International and Federal Copyright laws and treaties. Any unauthorized reprint or use of this material is prohibited



Doctor or Glorified Technician? Neuromusculoskeletal Disorders (NMS) are epidemic.

There is this battle for the NMS patient among chiropractors, physical therapists, orthopedists, massage therapists and others claiming to have mastered some magic treatment.

Unfortunately, it is few and far between to see a healthcare practitioner who has mastered the science and art of taking any patient suffering with a specific NMS disorder and identified the functional bio-structural, biochemical and even the emotional/psychological glitches.

I am sad to say that the vast majority of healthcare practitioners who claim to treat NMS conditions focus on symptomatic relief without too much thought to the reason why the patient developed the problem.

This is the primary mode of treatment for most traditionally trained medical physicians.

The focus is finding the best prescriptive agent to temporarily suppress the symptom expression.

Even worse are the practitioners who sell long drawn out treatment plans without giving a nod to appropriate rehabilitation for XYZ conditions.

As past chairman for the South Carolina Chiropractic Peer Review and as a consultant for many insurance companies, I have consistently reviewed cases that had no end in sight.

Basically, the patient was on some dragged out treatment plan that consisted of the same identical treatment that was done on the 3rd visit, 10th visit, the 21st visit and in fact the 70th visit.

Here is my point, where is this treatment going? What are the unique qualities of each of the above visits? What makes visit 3 uniquely different from visit 21 and 70?

Or is the treating healthcare provider due to lack of knowledge in functional diagnosis uncertain what to do to return his/her patient to a pre-clinical status.

In the world of insurance and third party re-imbursement, the issue of maximum medical improvement (MMI) is one that healthcare practitioners need to understand and abide by or else they risk being audited for poor documentation to support long term care.

Now for the practitioner who decides to bow out of the insurance game and operate a 100% cash practice, he/she may believe that they are playing with different rules and do not have to abide to the MMI rule.

However, I am here to rock your boat and let you in on a little secret that will turn your practice into the most respected and most sought after clinic in your community and beyond.



However, before I divulge the most clinically accepted and most intelligent plan to achieve outstanding NMS success, I have to share the sad state of events that has created pseudo-confidence among practitioners of my profession (chiropractic).

You see, as you can see below, chiropractors have for as long as I have been in practice (28 years) been attracted to some technique in hopes of finding the holy grail of clinical success.

The following list makes up a good portion of the many techniques that are readily available for one to learn.

If you are chiropractic physician you are likely to see your specific technique listed above.

Unfortunately, way too many of my colleagues consider their technique to be the “be all and end all” of achieving clinical success.

I find it both sad and at the same time frustrating to see doctors of chiropractic hold firm to a belief that their specific technique is the best compared to their colleagues down the street.

Of course if you ask another chiropractor about their technique they too will recite a list of benefits that supposedly out-shines their fellow chiropractor down the road.



This battle of techniques has been going on forever and will likely continue as long as there are chiropractors who are looking for some magic bullet to achieving clinical success.

Sadly, most doctors of chiropractic appear to develop a huge boast of confidence when they buy into some technique.

Basically, the love of the technique becomes the identity of the chiropractor.

In addition to the folly of following some technique to establish one’s identity, I have to admit the concept of vertebral subluxation elimination has holes that has led to massive over-utilization and the stagnant acceptance of the field of chiropractic.

The following is a true story that brings all the above full circle and opened my eyes to the “real” benefit of my profession and to be quite honest a benefit only a few have had the joy to experience.

This benefit will be discussed in great detail and will not only position the chiropractic physician as the only choice for NMS disorders but for any healthcare practitioner who is licensed to do the clinical procedures I will be soon be outlining.

Now back to my story:

Approximately, 10 years ago I became ill and discovered the world of healthcare from a patient’s perspective. My illness lasted 2 years and for the sake of space and time, I will simply say that my illness just about put me out of business.

In my quest for help, I first sought out doctors within my profession.

First on the list was a doctor who was a devoted Gonstead practitioner and one that considered his technique to be the only technique doctors of chiropractic should be using.

My first visit consisted of a Gonstead instrument reading followed with x-rays and a Gonstead adjustment. I was told that my spine had a number of subluxations and that I needed a series of adjustment to fix my spine.

I was very compliant not missing an appointment and was told after a series of Gonstead adjustments that I was doing quite well and there were less subluxations.

Unfortunately, I was not doing well and in fact was much worse.

After being a good patient but not seeing any significant improvement in my declining health, I decided to seek the professional advice of another chiropractor who practiced a technique called Atlas Orthogonal. Again, I was x-rayed and told that I had some serious subluxations and needed a series of adjustments using Atlas Orthogonal Percussion Adjusting Instrument. Again, being a compliant patient I continued with treatment for months and was re-x-rayed on a number of occasions and told that my subluxations were improving.



After many months of being adjusted and still not improving, I sought out a chiropractor who was considered the best Activator practitioner in the upstate of South Carolina. Again, I was evaluated using the Activator evaluation and told that I had a significant number of subluxations and told that I needed a series of Activator adjustments.

As you probably already have figured out, not only was I super compliant but I was getting sicker by the day and was desperate for answers.

Without going into a lot more detail, I will simply say that I continued on the same path and consulted and was treated by chiropractors who practiced AK, Networking and Pettibon.

Each of these chiropractors were passionate about their specific technique and assured me that theirs was the best and the only choice a chiropractor should make when it came to deciding on a technique.

When my health finally turned around (yes, it was a chiropractor who practiced functional diagnostic medicine), it dawned on me that every chiropractor claimed to have discovered subluxations based on their specific technique.

I got to wondering about the inconsistencies and could not shake the fact that each of the chiropractors claimed to have discovered subluxations and in fact through their technique also claimed to have made dramatic improvements when it came to eliminating the subluxations.

However, there was one perplexing question that still resonates in my head as I think about it and that question was and still is:

If every chiropractor with their specific technique identified subluxations even after the prior technique discovered I was improving then how can one claim to treating and working on eliminating these subluxations?

Who was right and who was wrong?

Did it mean that one technique was superior and had the real pulse of identifying and eliminating subluxations?

Remember each of the chiropractors were convinced that their method of identifying subluxation was the best.

Sadly, that left me with many unanswered questions and to be quite honest made me do some soul searching to identify the common thread that allowed doctors of my profession to achieve good results.

From my humble perspective, all techniques have benefits, however, there is a major disconnect in the work of many doctors of chiropractic and it is my desire to present an intelligent clinical work of art that not only will take my profession to the next level but should allow other healthcare professionals the opportunity to gain an appreciation of the thinking



process of diagnosing and treating the NMS patient and ultimately consider working with chiropractic physicians trained in this clinical approach.

The Common Thread As I moved along in my profession and witnessed the variety of techniques and treatment modalities used for patients suffering with NMS disorders, I consistently asked myself what is this common thread that allows healthcare professionals this unique ability to help patient achieve some level of symptomatic improvement? It was obvious that each and every doctor of chiropractic, physical therapist, massage therapist and other professionals who were in the trenches treating NMS had their share of success stories but again what was that common thread that connected these professions. And more important, if this common thread could be identified would it be possible to expound on it to achieve a level of care that would mammoth the status quo. I must admit there is and it is the essence of this lesson and the following four lessons that will catapult you to a level of NMS excellence. This common thread among the many techniques is rooted in both biochemistry and physiology and has stood the test of time. Unfortunately, what I am about to present will likely be ridiculed and argued against by some of the most devoted and loyal followers of a specific technique. In addition, science will commonly take a back seat to one’s staunch belief in their practiced technique in place of philosophy. I am not a newbie in my profession and have seen many of my colleagues move from one technique to another in hopes that the next will be the winner. So again I say what is this common thread that I have been eluding too? The common thread returns us to the topic of total load. As we have discussed in the beginning of this training, the issue of total load and the impact it makes on the health expression of the human body is without a doubt the critical key to solving many of the most challenging health conditions. I firmly believe that the diagnosis and treatment of NMS disorders is to say the least a significant load on human physiology. Reducing that load may it be a structural dysfunction due to a fixated L5 facet joint or exposure to some toxic element is still a load and will always be load. With this thought in mind it begins to make sense why so many different techniques work. With each having their share of success stories, the common link is the reduction of a structural load. The structural load should not be overlooked or ignored or else the full expression of health may not be achieved. Now to piggy-back on our last module on stress, the following should be an eye-opener and one that is sure to creating some clinical excitement.



As you can see by reviewing the following diagram, cortisol/DHEA balance plays a critical role in the integrity and health of musculo-skeletal health and neural tissue health (neuronal conductivity).

Is it making sense? This common thread goes back to the impact of the total load and the physiology of stress. No single chiropractic technique or NMS treatment (massage, trigger point therapy, etc.) is the “end all and be all” of resolving the growing number of a chronically sick population. It takes an astute healthcare provider to carefully identify the many and varied loads impacting the human organism and develop a plan to reduce them. As part of your training, this lesson will have a profound impact on how you view most if not all NMS disorders. For this point on, it is important to not only provide the most effective NMS treatment for symptomatic relief but to consider the far reaching effects of the chronically unresolved NMS condition on other aspects of human physiology. In short, how much of a load does the NMS disorder place on the human organism and if this load is reduced what effect will it have on the patient’s recovery? All in all, these are questions that need to be considered when seeking to be an ACE practitioner.



Although this global explanation of structural dysfunction, total load and the physiology of stress is powerful it would behoove me to not discuss how one can diagnose and successfully treat NMS disorders.

Structural Integrity: A Closer Look Isolating the Lesion

Although it is beyond the context of this training to teach NMS anatomy and physiology, it is at least worthy to provide a simple overview on the compromised tissues one will need to identify when providing clinical care. When a new patient enters the office suffering with a NMS disorder the following sequence of clinical management should be adhered to in order to achieve the highest level of clinical success.

Medical History Taking: As a healthcare practitioner your consultation makes up 90%+ of your clinical investigation. Questions such as:

• How long have you had the pain? • What do you think caused the pain? • What aggravates the pain? • What makes decreases the pain? • What treatments have you had for this condition?

2. Past Medical History Review

3. Occupational Status

4. Social Status

5. Medication History

6. Surgical History

7. Identify non-NMS disorders the patient may be suffering with such as diabetes, fibromyalgia, rheumatoid arthritis, cancer

Clinical Examination of the area of pain The examination must be focused on the area of pain and the root source of the pain. Identify which tissue(s) has been compromised.



These would include: • Myofascial/Fascia pain (adhesions, scar tissue) • Neurological Pain/Discogenic Pain (recurrent meningeal nerve, foraminal stenosis,

piriformis syndrome) • Joint Pain/ Sclerotomal or sclerotogenous pain (synovial capsule, supporting

ligaments, zygapophyseal facet joint capsules,) • Vascular (thoracic outlet syndrome, intermittent claudication) • Visceral/Somatic Pain

The easiest theory to accept regarding referred pain is that the signals simply get mixed in your neurological wiring. Sensory inputs from several sources are known to converge into single neurons (nerve cells) at the spinal level, where they are integrated and modified before being transmitted to the brain. If only it was that simple. Again, in order to accurately diagnose and follow with a successful treatment it is imperative to identify the tissue that has been compromised Let’s say a patient presents with pain in the right shoulder radiating down into the hand. For the sake of this illustration no history will be given. My objective is to simply present the variety of similar referred pattern. The following represents neurological referred pain:



The following represents sclerotomal or sclerotogenous pain referred pain:



The following represents myofascial referred pain from an infraspinatus trigger point

As you can see from the illustrations above the referred pain may be due to a neurological compression/facilitated lesion, sclerotogenous pain or myofascial referred pain from a trigger point in the right infraspinatus. Kirkaldy-Willis reports that chiropractic adjustments, or an injection into the facet joints, can demonstrate if the facets are causing the pain. Both procedures alleviate the sclerotomal symptoms pain that derive from the facet capsules. Case in point: I recently consulted with a patient who was suffering with chronic right arm pain for a period of 3 months. Her history included seeing her family MD who prescribed anti-inflammatories and muscle relaxers. Unfortunately, the pain persisted.



My patient then decided to seek the services of a chiropractor who informed her that she had a subluxation of her cervical spine and needed a series of 37 adjustments. After approximately 15 sessions with the chiropractor, the pain persisted and she discontinued. Upon a referral from one of friends, she reluctantly scheduled an appointment to see me. Based on her history, examination and her occupational responsibilities (she worked in an attorney’s office doing filing), I concluded that her pain was coming from an active trigger point in the infraspinatus muscle. Treatment consisted of myofascial release of the infraspinatus TPs, improved mobilization of the scapular humeral rhythm, home rehab maneuvers to stretch and strengthen the infraspinatus muscle and finally instructions on proper ergonomics to lighten the load on the shoulder girdle/infraspinatus system. The patient’s chronic three month bout with pain was resolved in 5 treatments and she has not had a re-occurrence.

Perpetuating Factors Although most of us will see our share of NMS conditions, it is in the understanding of why and what caused the pain and more important what keeps the condition from being resolved. This is the essence of this very important next section. As the title states, I am referring to something called “Perpetuating Factors”. A month does not go by when I will commonly see a patient who was simply bending down to pick up a piece of paper when as they state “there back went out”. Case in point: I recently had a patient named Larry who entered my office in acute back pain. What made this case so interesting is the fact that Larry is a competitive bodybuilder and two days prior he was at the gym squatting close to 400 pounds and had no problems. When I asked Larry to tell me how he hurt his back all he could remember was the fact that he was at his desk at work and he dropped a pencil. In the process of bending down to pick up the pencil he felt this sharp, stabbing pain in the low back. Now was I to believe that a man just two days prior squatting close to 400 pounds would end up in my office in a right antalgic posture from simply bending down to pick up his pencil. Or was there something more going on below the surface that led to Larry’s low back episode. Another case you may find of interest involves a patient by the name of Judy. Judy was seen in my office three weeks ago suffering with an acute cervical pain. One look at Judy with tears rolling down her eyes would make anyone think she must had been involved in some serious traumatic event leading to her severe neck pain. When asked what thought caused her immediate cervical pain syndrome, all she remembered was taking a warm shower and washing her hair. It was soon following the adding of the conditioner to her hair that she began to experience increasing sharp pain in the cervical spine. By the time she was out of the



shower drying off her neck as Judy claimed was seized up and impossible to move without causing her to scream in pain. Now it would appear appropriate to have the patient be prescribed some anti-inflammatory meds when suffering with this degree of pain but the real issue is, what was at the root of both Larry and Judy’s severe pain syndrome and is it possible to prevent it from occurring again? To answer these questions it is important to do to gain an appreciation for identifying and mastering how to correct perpetrating factors.

Understanding Perpetrating Factors Perpetuating factors are any conditions or stressors (physical or otherwise) that cause a NMS disorders to remain or return in spite of appropriate treatment. Perpetuating factors may occur alone or with others. They may be behavioral, such as posture. They may be biochemical, such as nutritional inadequacy. They also may be mechanical, such as poorly fitting shoes. Some of these perpetuating factors are also aggravating and initiating factors.

The key to functioning better with as minimal a symptom load as possible is to identify as many of your perpetuating factors as possible and control them as thoroughly as possible. Frequently, one factor will initiate or aggravate the pain syndrome and another will perpetuate it. For example, a fall could activate a pain syndrome, and a repetitive action at work could perpetuate it.

Of all the factors in achieving outstanding clinical results the identification of perpetuating factors is the most important and unfortunately the most overlooked part of NMS management. The term perpetuating means to keep alive and/or to keep going. Another way to look at perpetuating factors are factors that predispose the patient to continued pain. The following is simple illustration of the importance of identifying perpetuating factors: A man is walking down 54th street in New York on his way to work when he accidently steps in a 3 foot hole in the sidewalk and breaks his right leg. After being rushed to the hospital he is examined and treated and told it will likely take two months for his leg to heal. Once healed this same man is back on his regular schedule and is again walking down 54th street when he steps in the same hole and breaks his right leg. Unfortunately no one patched the hole. The moral of this story is: if we continue to treat NMS disorders without patching the holes by not identifying and correcting the multiple perpetuating factors, the patient is doomed to endless cycle of treatments and undoubtedly continued relapses. For patients who have suffered NMS pain for many months or years, most physicians not privy of the multiple list of perpetuating factors will find themselves spending an unnecessary amount of time patching holes instead of getting to the root of their patient lack of long term improvement. Without identifying the factors that keep a condition perpetuating your degree of clinical success will suffer.



Quick Reference Guide of Perpetuating Factors Mechanical Stresses Key Points Short Leg Hemipelvis Long Second Metatarsal Short Uppers Arms Postural Stresses Misfitting Furniture Poor Posture Abuse of Muscles Immobility Nutritional Inadequacies B1 (Thiamine) Deficiency Will see high levels of the following

organic acids: Ketoisovalerate Ketoisocaproate, and Keto-ß-Methylvalerate

B6 (Pyridoxine) Deficiency Look for high levels of the following organic acids: Xanthurenate and Kynurenate

B12 (Cobalamin) Deficiency Look for high levels of the following organic acids: Methylmalonate

Folic acid Deficiency Look for high levels of the following organic acids: Formiminoglutamate

Ascorbic Acid (Vitamin C) Deficiency Look for high levels of the following organic acids: p-Hydroxyphenyllactate

Calcium RBC Erythrocyte Mineral Test Potassium RBC Erythrocyte Mineral Test Iron Order Ferritin Magnesium RBC Erythrocyte Mineral Test Metabolic/Endocrine Inadequacies Anemia Sub-clinical thyroid problems Hypoglycemia Psychological Stress Hopelessness Depression Anxiety Chronic Infections



Viral Infections Herpes simplex virus type 1 Bacterial Infections Abscessed/Impacted Tooth

Sinusitis Chronic Urinary Traction Infection

Parasitic Infections Tapeworm (Diphyllothrium latum) Giardia lamblia Entamoeba histolytica

Other Factors Allergies IgE and IgA/IgG testing Impaired Sleep Rule out Sleep Apnea/Sleep Study Nerve Impingement and/or Nerve Facilitation

Toxic Metals/Chemicals Paradoxial Breathing

Short Leg Syndrome

A short leg is a frequent and aggravating factor commonly overlooked by many healthcare practitioners. The short leg will commonly impose a biomechanical strain on the support muscle in their attempt to correct distortions of axial alignment.



Even a small leg length discrepancy of only .5 cm (3/16 inch) may be enough to compromise the axial balance. Axial deviation from a short leg will cause the pelvis to tilt down on the same side. In addition, a short leg will have a detrimental impact on the neck and upper back. It has been found that a short leg discrepancy of only 1 cm (3/8 inch) will cause the shoulder on the opposite side of the short leg to be lower contributing to myofascial compromise of the posterior cervical muscles, trapezius, levator scapular, SCM and other related muscles. Of interest is the finding that a short leg discrepancy of 1.3 cm (1/2 inch) will cause the shoulder on the same side of the short leg to be lower. The lumbar muscle that is commonly impacted by a short leg is the quadratus lumborum.

Compromise of the quadratus lumborum is far the most overlooked source of low back pain.

It is also important to remember that the tilted shoulder-girdle axis requires constant compensation by the neck muscles to maintain the head erect and eyes level. The muscles that primarily are overloaded and suffer are the scalene, levator scapular, sternocleidomastoid and the upper trapezius.

When Should a Short Leg Be Corrected?

To correct or not correct a short leg depends on first if the patient has pain due to myofascial trigger points which are being perpetuated by it and second whether the short leg discrepancy



is producing a tilt of the pelvis that is not compensated by a sacral tilt and/or angulation of the lumbar spine.

Best Method to Detect a Short Leg

The best and only method for identifying a short leg is via standing AP radiographs with the patients shoes removed. A lumbar-pelvis x-ray is taken at 40-inches through the pelvis with the feet directly under the femoral heads. Once taken, analyze the film by drawing a line across the superior femoral heads and then measure the millimeter shortness of the lower femoral head. Unfortunately, the amount of build-up (heel lift) seldom equals the exact difference in femoral head shortness. With this being said, it is recommended to use diagnostic build-up of heels and soles to determine the exact build-up needed to level the femoral heads. These build ups can be purchased from http://www.gwheellift.com and come in varying millimeters to help determine the exact heel lift to order. The procedure is as follows. Based on the first radiograph measurement select a build-up that you think would balance the femoral heads. It may take two radiographs to make that determination. Of course for patient protection use proper shielding and x-ray using the lowest possible mAs and the highest kVp. Because these x-rays are only being used to determine structural deviation, the same detail is not needed as would be for the first radiograph. Once you have identified the exact build-up that balances the femoral heads, that is the amount that should be purchased. Two commonly used techniques for measuring leg-length discrepancy are among the least reliable. The first includes the tape measure technique whereby a supine positioned patient is measured from the anterior superior iliac spine (ASIS) to the tip of the medial malleolus. The second which is the least reliable of the two is the simple observation of the level of medial malleolus while the patient is either in a prone or supine position. Although the leg check is considered the hallmark evaluation for many chiropractic techniques, it will not identify a structural short leg but instead a functional short leg. It is the latter that has been identified as a perpetrating factor and should be addressed.

Small Hemipelvis Small hemipelvis refers to a pelvis that is vertically smaller on one side than the other. Patients with a pelvis that is small in its vertical dimension on one side tend to sit crookedly and will commonly lean toward the small side. Unfortunately, a hemipelvis creates a see-saw effect causing the patient to often cross one knee over the other to balance up the low side. The impact of this see-saw pattern will ultimately compromise the myofascial integrity of the quadratus lumborum and have distal overloading effects on the scalene, sternocleidomastoid and other neck muscles. If the patient has symptoms (pain) when seated, a small hemipelvis is suspect. The ischial tuberosities, on which weight is borne during sitting, are only 10–12 cm (4–5 in) apart; any



difference in the size of the two sides of the pelvis is magnified farther up the torso because the spine is much longer than the distance between the ischial tuberosities.

How to Evaluate for a Hemipelvis

As you can see in the above diagram, the patient is in a supine position. Picture “A” reveals a right hemipelvis. The correction made under the right hemipelvis balances them out. On the other hand, placing the correction under the opposite ileum worsens it.

How to Correct a Hemipelvis

The restoration of skeletal symmetry is provided by placing an appropriate lift under the ischial tuberosity of the hemipelvis. The size of the ischial lift must be adjusted for the softness and the shape of the seat.



The above ischial pads can be purchased at http://gwheellift.com/ischial.html

Long, Second Metatarsal

This is characterized by having a relatively long second and a short first metatarsal bone. This has been found to perpetuate NMS pain in the low back, thigh, leg and dorsum of the foot. According to research done by Morton the first metatarsal head should carry half the bodyweight during normal weight bearing. When the first metatarsal is relatively short, the second metatarsal bears more weight. This then leads to the foot balancing on the second metatarsal as if rocking on a knife edge. Unfortunately, this has the potential to cause a postural distortion distally requiring support muscles in the low back and neck to have to work harder leading to pain and dysfunction.



It is recommended that the correction be made by inserting one or two thickness of a metatarsal support directly under the head of the first metatarsal bone. It has been found that releasing tension in the lower extremity via providing support for a short first metatarsal may at once increase a TP- restricted interincisal opening of the jaw by 20 to 30%

Short Upper Arms

Shortness of the upper arms is a commonly overlooked factor in perpetrating NMS disorders especially of the shoulder-girdle musculature. Basically, if the shoulder-elbow segment of the upper extremity is short in proportion to the rest of the body, the elbows will not reach the iliac crest. You will also notice the elbows not being able to reach the armrests of the usual chair when sitting.



Unfortunately, this places an overload stress on the shoulder-girdle region thus perpetuating trigger points in the upper trapezius and the levator scapular muscles.

Poor Ergonomics

Misfitting furniture, poor placement of computer monitor, improper usage of the telephone are just a few of the perpetuating factors related to poor ergonomics. Poor ergonomics will quickly tire and strain support muscles. The following checklist will aid you in helping patients identify poor ergonomics and making appropriate recommendations for correction.



Poor Posture

This is another common source of chronic NMS stress. Poor posture examples include unphysiologic positioning at a desk or work surface. The following are guidelines to minimize poor posture while sitting.



Head tilt resulting from poorly adjusted reading glasses can cause an unnecessary load on the posterior cervical muscles.

Reading material should be placed at eye level to avoid sustained forward tilting of the head and upper back overloading the posterior cervical and upper back muscles.



Head Forward Posture: This posture is indicated by a measurement of less than 6 cm curvature of the neck head should be balanced on the top of your spine. If it juts forward, it creates excessive strain on the neck muscles, which in turn create excessive strain on other muscles. It throws the whole body out of alignment trying to compensate for the weight of your head — which is considerable. This posture affects your lung capacity, causes pressure on your discs and affects the blood supply to your head.

Abuse of Muscles

People are notorious for abusing muscles via poor body mechanics. Sustained isometric contraction, immobility of muscles, repetitive motion, and excessively quick and jerky movements are all responsible for aggravating and perpetuating NMS conditions.



Abuse of Muscles Examples Sustained contraction Reaching up to a type-writer that is positioned too high

Painting a ceiling Hanging drapes Holding a chain saw

Immobility Casting of a fracture Falling asleep on a couch for an extended period of time Reading in one position for an extended period of time

Repetitive movement Using a mouse Writing with a pen Working on an assembly line and twisting repeated one way

Jerky Movements Lifting boxes at work Starting a lawn mower

Nutritional Inadequacies The following nutritional agents when inadequate have been well documented to be associated with chronic NMS disorders:

• Vitamin B1 (Thiamine) • Vitamin B6 (Pyridoxine) • Vitamin B12 • Folic Acid • Vitamin C • Calcium • Potassium • Iron • Magnesium

Vitamin B1 (Thiamine)

Thiamine is a critical ingredient in the energy metabolism chain and is essential for one of the steps required for pyruvate to enter the Krebs citric acid cycle. Research as shown that thiamine deficiency impairs central nervous system function. According to Travell and Simon, muscles of patients with low levels of thiamine have an increased susceptibility to myofascial trigger points that are resistant to therapy. A thiamine deficiency can accurately be determined by ordering an organic acid test. A thiamine deficiency will show elevated levels of the following organic acids: Ketoisovalerate Ketoisocaproate, and Keto-ß-Methylvalerate.



Vitamin B6 (Pyridoxine)

It is required for the production of the monoamine neurotransmitters serotonin, dopamine, noradrenaline and adrenaline, as it is the precursor to pyridoxal phosphate: cofactor for the enzyme aromatic amino acid decarboxylase. This enzyme is responsible for converting the precursors 5-hydroxytryptophan (5-HTP) into serotonin and levodopa (L-DOPA) into dopamine, noradrenaline and adrenaline. As such it has been implicated in the treatment of depression and anxiety.

According to Travell and Simon, muscles of patients with low levels of pyridoxine have an increased susceptibility to myofascial trigger points that are resistant to therapy. A thiamine deficiency can accurately be determined by ordering an organic acid test. A thiamine deficiency will show elevated levels of the following organic acids: Xanthurenate and Kynurenate

Vitamin B12 (Cobalamin)

Vitamin B-12 is normally involved in the metabolism of every cell of the body, especially affecting the DNA synthesis and regulation but also fatty acid synthesis and energy production. A cobalamin deficiency can accurately be determined by ordering an organic acid test. A thiamine deficiency will show elevated levels of the following organic acid: Methylmalonate.

Folic Acid & Vitamin C Deficiencies

Folic acid and Vitamin C Deficiencies have both been implicated in perpetuating NMS disorders and as such should be ruled out. A folic acid deficiency will show elevated levels of the following organic acid Formiminoglutamate, while a vitamin C deficiency will show an elevated p-Hydroxyphenyllactate organic acid

Mineral Deficiencies Long standing deficiencies of calcium, potassium, iron and magnesium may result in resistant resolution of chronic NMS conditions. The RBC Erythrocyte Mineral Test is an excellent advanced functional medicine test to identify which minerals need to be attended too. To identify low levels of iron, it is recommended to order a ferritin.

Metabolic Factors

Many possible co-existing conditions may be perpetuating factors such as:

• Anemia



• Imbalance of estrogens or testosterone • Hypometabolism or hypothyroidism • Reactive Hypoglycemia and Insulin Resistance

Psychological Issues

Recurrent or chronic NMS pain may be perpetuating from emotional/ psychological factors such as

• Depression • Hopelessness • Anxiety • Resentment

Chronic Infections Infections could be a hidden source of perpetuating factors and need to be considered when a NMS disorder is non-responsive to other forms of treatment.

Viral Infections: (Herpes simplex virus type 1)

Bacterial Infections: (Abscessed/Impacted Tooth, Sinusitis, Chronic Urinary Traction Infection)

Parasitic Infections: (Tapeworm (Diphyllothrium latum), Giardia lamblia & Entamoeba histolytica)

Environmental Factors

Toxic Metal/Chemical Overload: Newspapers and scientific papers are full of accounts on the chemicals now in our environment that are capable of producing illness. Chemical pollutants can be found in everyone. These chemicals place a total load on our patient’s recovery perpetuating NMS disorders.

Additional Perpetuating Factors to Consider:

• Allergic Conditions (IgE, IgG) • Smoking and Alcohol • Paradoxical Breathing • Impaired Sleep • Nerve Impingement and/or Nerve Facilitation

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