In orthopaedics, we typically focus on your complaints, physical findings, X-rays and MRIs. However, our bodies are adeptly designed to compensate for injuries. At times, our presenting complaint may be far from the true cause of the underlying injury. My goal is not only to heal your presenting problem, but to also diagnose and treat all underlying injuries in order to expedite a full recovery and prevent future injuries.
Autonomic Neuro-Muscular Reflex Testing (ANMRT) is a new exam used to identify the root cause of an injury through a systematic, neurological approach. Like the knee-jerk reflex, ANMRT is a collection of involuntary reflexes that confirms the health of the peripheral nervous system.
The light/dark test determines if there is any “dystrophy” or dysfunction in the peripheral nervous system. Your ability to stay rigid is first tested with your eyes open, and then with your eyes closed. When our nervous system is in distress, it reverts to an early infantile reflex, from which we all outgrow; i.e., when the lights go out, we go to sleep. If you are in dystrophy, when the lights go out – or if you even look at a dark object, you cannot maintain your rigidity. When I find a positive response, I know that one or several of your nerves are irritated. It is my job to find out which ones are irritated and correct them.
If the light/dark test is positive, you will go through a series of ANMRT reflex testing to determine the injured or irritated nerve(s) that caused this pathologic response. Again, it is based on an infantile reflex – the scratch/withdraw reflex. Adults like to be scratched, but infants withdraw from scratching. (At birth, the doctor scratches the baby’s foot to make the baby cry – not slap his/her bottom as we see in the old movies.) Similarly, if you are in dystrophy, your body will revert to this infantile reflex and withdraw from a scratch. If you are not in dystrophy, you will not withdraw from a scratch. If you are in dystrophy, and I rub the irritated body part, the reflex will reverse and you will not withdraw from the scratch test. (Remember when your mom rubbed an injury when you were little and the pain went away? It really works.) However, it only lasts a few seconds, and then the pain and/or the reflex returns.
Most of the time, you may be unaware of any nerve irritation until it is pointed out. Once it is pointed out, I often get responses like “It didn’t hurt until you poked me!” or “I feel it, but it doesn’t really hurt.” Nerve pain does not hurt as much as bone or joint pain. Nevertheless, the body feels it and compensates for it.
Whenever a nerve is irritated or injured, we are off balance. Most people are unaware that they have a balance problem – the younger we are, the more we can compensate for this imbalance. However, older patients do not compensate as well. They easily lose their balance, fall, fracture a limb, and then see me. On the other hand, an athlete with a nerve irritation, and subsequent imbalance, may misstep when making a cut or landing from a jump, thus spraining an ankle, twisting a knee, or worse. The wall test can demonstrate this imbalance and ensure balance is restored once the injured nerve(s) is (are) corrected.
I will have you stand away from the wall (or exam table), look straight ahead and remain rigid like a statue. If you are in dystrophy, I will be able to push you off balance and into the wall (or table) only with my fingers pushing on the radial nerve in your forearm. If you are not in dystrophy or once I reverse your nerve irritation, you will be able to remain stable when I try to push you off balance.
Next, I will also have you rotate your head, left, right, up, and down while re-testing your balance. If you do not have any problems with your neck or upper or lower back, you will remain stable. If you do have any problems with neck or back, whether you realize it or not, you will lose your balance. If you lose your balance, I will determine the cause and set you on a course to correct it. Your balance will improve.
There are eight described reflexes that detect nerve injuries. Recently, I found four more reflexes that tend to be associated with various musculoskeletal entities. The most common nerve injuries follow.
The temporal mandibular joint (TMJ) is your jaw joint which is located on either side of your cheek, just in front of your ear. It can be irritated by obstructive sleep apnea, grinding your teeth while sleeping, or trauma. Most of the time my patients are unaware of the pain, even when I point it out. When this joint is irritated, the trigeminal nerve, which lies just above the joint, can go into dystrophy, with the return of the light/dark response along with a decrease in balance. I have found that patients who present with knee injuries from non-contact sports or frequent falls tend to have TMJ syndrome.
Studies show that girls have more of a balance problem than boys do, resulting in girls having five to eight times more ACL tears from non-contact injuries. If girls undergo balance training, their rate of ACL tears is the same as boys. Unrelated studies show that girls are five to eight times more likely to have TMJ syndrome than boys are. I propose that if we find and treat TMJ syndrome in girls, their balance will improve automatically as will their ACL tear rate.
I have also found that TMJ syndrome can be associated with shoulder and back pain. These patients tend to complain that their pain is worse at nighttime and wakes them up from sleep. Since sleep apnea is associated with TMJ syndrome, sleep therapy may improve their symptoms.
Treating TMJ syndrome is difficult. Eating soft foods and avoid chewing gum can help, as well as physical therapy and jaw manipulation. Rubbing anti-inflammatory cream two to three times per day over one to two weeks will relieve the nerve pain and temporarily resolve the dystrophy; however, the underlying cause is still present and must be resolved.
If you tend to be a mouth breather, you may have some sort of nasal obstruction from allergies or a deviated septum. This, too, may aggravate your TMJ syndrome and needs to be addressed. I recommend that my patients see their dentist for evaluation and treatment, get a sleep study for sleep apnea, and/or see an ENT specialist for nasal or oral (tonsil) obstruction. I also recommend seeing Dr. Erin Macko, a dentist who specializes in sleep and TMJ disorders at Romano Orthopaedic Center.
Peroneal Nerve and Morton’s Neuroma:
Your peroneal nerve ends on the top of your foot between the 1st and 2nd toes. If irritated, you most likely will be sensitive in the 1st web space. Morton’s neuroma is the name given to a branch of the tibial nerve, which ends on the bottom of your foot, between the 3rd and 4th toes, causing pain in the 3rd web space. I often find patients with lower extremity complaints, i.e., knee injuries, arthritis, plantar fasciitis, ankle fractures, and hip fractures in the elderly, have peroneal nerve and/or Morton’s neuroma irritation in their feet.
Usually, the opposite limb of the presenting problem has the lesion. For instance, if your left peroneal nerve is irritated on your foot, your mind may ignore or even shut out the pain (you have to keep on walking). However, your body still feels the pain and will compensate for it. You will subconsciously put less weight on your left foot and more weight on your arthritic right knee, making it worse. With this compensation, you also might lose your balance, fall and tear the meniscus in your right knee or fracture your right ankle.
When you are walking or running, your ankle acts as a natural shock absorber for your lower extremity. If your calf muscles are tight, your ankle does not dorsiflex (move upwards) all the way. Consequently, your feet take a pounding. The tarsal bones (small bones in your feet) can sublux (go slightly out of place), thus irritating the nearby nerves and causing you to go into dystrophy. I recently have discovered that if I manipulate your foot, bringing the tarsal bones back into alignment, the nerves will stabilize, reversing the dystrophy.
Stretching your calves several times a day will lessen the pounding on your feet and prevent the tarsal bones from subluxing. Walking shoes with good arch supports will help, too. Remember to keep your foot flat on the ground when stretching. Excessive dorsi-flexion of the foot can cause the bones to sublux again and put you back into dystrophy. Stretching with your knees straight and then bent will stretch your upper and lower calf (gastrocnemius and soleus) muscles, respectively, without irritating your feet.
If your feet do come out of alignment over time, you can re-align them with aggressive plantar-flexion (downward movement) of your foot. Placing the top of your foot on a chair or step and then apply downward pressure on your foot will re-align your tarsal bones. If you do not have bad knees, kneeling down with the top of your feet flat on the floor and then sitting on your heels will also work. The Japanese call this seiza or “proper sitting”.
Carpal Tunnel Syndrome:
Carpal tunnel syndrome (CTS) is pain, numbness and weakness of the hand caused by entrapment of the median nerve at the wrist. Patients usually associate their symptoms with waking up from sleep, holding a steering wheel, or another object, for an extended period, or prolonged use of the hand, i.e., typing. Through ANMRT, I find that patients with the shoulder pain or vague arm/hand pain may have underlying CTS, which is often unrecognized. Diabetes, pregnancy, obesity, hypothyroidism, and heavy manual labor are some predisposing factors. Treatment involves wearing wrist splints while working and/or sleeping, proper ergonomics, and physical therapy.
I have found that if your carpal bones (small bones in your wrist) are out of alignment, your median nerve will be irritated. You will have a positive ANMRT reflex for CTS and be in dystrophy. Pulling your wrist, while forcefully palmar-flexing it, will bring your carpal bones back into alignment. Subsequently, your carpal tunnel reflex will reverse and your symptoms will improve. Doing this several times during the day and avoiding extreme wrist extension, i.e., doing pushups or pushing off a chair, can prevent further damage to the median nerve and allow healing. Occasionally, the nerve damage is too severe and surgery is necessary.
Breathing, Balance & Back Pain
Who would have thought that nasal breathing is so important? With the use of ANMRT, I have found that some neck and back pain, along with associated weakness and balance problems, can be improved with clear nasal breathing. As I stated in the beginning, the body has a great capacity to compensate for injuries and that the presenting symptoms are not the true source of the pain. Only by finding and treating the root cause of the pain can one truly be healed and avoid further injury.
By examining hundreds of patients, I have observed four patterns of neck and back pain that are associated with weakness elsewhere and aggravated by nasal blockage on the side of the pain. This has never been described before.
- Pain at the sacral-iliac (SI) joint (lower back, near the buttocks) is associated with weakness in extension of the opposite elbow. Therefore, when the right nasal passage is completely blocked, there is automatically irritation of the right SI joint with associated weakness in the left triceps (straightening out the elbow).
- Pain at the L2 level (lower back) is associated with same-sided weakness of hip flexion (raising the hip while seated, which is well known), and shoulder extension (raising the shoulder straight ahead, which is new).
- Pain in the mid-thoracic region (upper back) is associated with same-sided weakness of shoulder abduction (raising the shoulder to the side) with the palms parallel to the floor.
- Pain at the C5 level (mid neck) is associated with same-sided weakness of shoulder abduction with the thumbs pointing to the floor.
Although I routinely find this correlation, I can only find one Australian article that supports this finding: “Disorders of breathing and continence have a stronger association with back pain than obesity and physical activity.”
Complete nasal blockage, manually, will produce all four pain-patterns simultaneously; however, I never find this clinically. What I find routinely, but do not understand why, is that only one pain pattern is present at a time and it is associated with partial nasal obstruction. I also find that these pain patterns can fluctuate. I believe that this may be related to the nasal cycle. (The nasal cycle is the normal alternating partial congestion and decongestion of the nasal cavities produced by swelling of the nasal turbinates – bony projections covered by erectile tissue.) Normally this cycle goes unnoticed unless a deviated septum or excessive inflammation from diet, allergies and/or infection completely obstructs the nasal cavity.
So far, I have found the following five ways of reversing the above patterns, thus relieving pain, improving strength, and restoring balance.
Manipulation of your Si joint, lower back, posterior ribs or first rib by a chiropractor, an osteopathic physician, a trained therapist, or me will relieve your pain, improve your strength and restore your balance. If that is the only source of your pain, you will be cured. However, if nasal congestion is also present, your symptoms will return with mouth breathing and you will have to keep on coming back for repeat manipulations.
Below are simple stretching exercises that will help your back and neck pain.
- SI joint stretching. Lie flat on your back, grab your knee from the affected side and pull it toward the opposite shoulder. Hold it for a slow count of 10. Then, place your leg flat and relax. Repeat this two more times. On the third set, do a yoga stretch. Keep holding your knee with the opposite arm and bring it across your body. Release your other arm from your knee and bring it out to your side. Again, hold it for a slow count of 10. Do this before you get out of bed in the morning, several times during the day and when you go to bed at night.
- Lower back, L2, stretch. Stand behind a chair, holding its back for support. On the seat of another chair behind you, place the top of the foot on your affected side, and lean back until you feel a stretch on your thigh muscles and lower back. (If your knee hurts from bending, step forward a bit until it feels comfortable.) Next, bend your opposite knee to further stretch of your hip and lower back. Hold for a slow count of 10 and repeat two times. Repeat this stretch throughout the day.
- Upper back stretch. Stand in a doorway or corner of the room with your shoulders flexed 90 degrees away from your body and your forearms resting on the wall. Lean forward, feeling the stretch in your upper back. Hold for a slow count of 10 and repeat two times. Repeat this stretch throughout the day.
- Neck, C5, stretch. Looking straight ahead, stick your head straight out like a turtle. Now bring your head back and slowly lift our chin towards the ceiling as far back as you can go. Hold for a slow count of 10 and repeat two times. Repeat this stretch throughout the day.
Again, as long as you still have some nasal congestion, your symptoms will return with mouth breathing.
For reasons I do not yet understand, spinal rotational exercises will resolve the above patterns of pain, weakness, and imbalance for an extended period despite persistent nasal congestion. With your feet planted shoulder-width apart, rotate your body all the way to the right and then all the way to your left. Determine which way is easiest or which way you can go the furthest without pain and hold it in that direction for 40 seconds. Gently bounce at the end of your rotation to improve your stretch. Repeat this stretch three to five more times and then several times throughout the day.
Diaphragmatic, abdominal, belly, or deep breathing is breathing that is done by contracting the diaphragm, a muscle attached to the spine and lower rib cage and located horizontally between the chest and stomach cavities. During this type of breathing, air enters the lungs and the belly expands rather than the chest.
I have found that the above patterns of pain, weakness and imbalance will resolve with diaphragmatic breathing. Diaphragmatic breathing exercises are used in yoga, tai chi, and meditation. When practiced regularly, it may lead to the relief or prevention of symptoms commonly associated with stress, which may include high blood pressure, headaches, stomach conditions, depression, anxiety, and others.
We stress diaphragmatic breathing in our therapy program to stabilize the spine while improving posture and cardio-respiratory fitness. A good exercise to strengthen your diaphragm is to lie on your back, with your legs elevated, while blowing up a balloon.
Clearing the nasal passage:
Along with the above treatment options, clearing your nasal passage is the best way to relieve above pain patterns for an extended period. Methods include:
- Nasal strips. You see them advertised for snoring relief and worn by football players. These strips can be worn at nighttime and during exercise. They will open up your nasal passage, allowing you to sleep better, and may help relieve your lower back and upper arm pain.
- Nasal rinse/Neti pot. With this, you pour a saline mixture in one nostril, tilt your head and allow it to run out of your opposite nostril. This is best used at bedtime and/or after you wake up.
- Nasal sprays. Steroid (Flonase), anti-histamine and saline sprays can all open up your nasal passage and can be used as directed throughout your day, as needed.
If this does not improve your breathing and symptoms, you may need to see an ENT specialist and/or dental sleep specialist to help diagnose and correct your obstruction and relieve your pain.
N.B. The above work is based on the work of Dr. John Beck, an orthopaedic surgeon, who discovered the autonomic reflex testing through trial and error over decades of practice. My nephew, Dr. Daniel Klauer, a dentist, introduced me to this concept two years ago. He insisted that I learn ANMRT from Dr. Steven Olmos, a pioneering dentist with multiple TMJ and Sleep Apnea Centers around the world. He uses these techniques to make sure that his treatments for TMJ and sleep apnea are working.
Testing all of my patients in ANMRT over the last two years has completely changed the way I practice orthopaedics. I not only treat the presenting problem, but also now search for the root cause of each problem, facilitating a complete recovery and preventing future injuries. This is only the beginning. We have much more to learn.
Victor Romano, MD