ACA Rehab Council: Your #1 source for the latest in neuromuscular rehabilitation and state of the art doctors

July 2003

The Functional Approach

by K.D. Christensen DC, CCSP, DACRB

Selecting the ideal exercises for patients with back conditions requires judgment based on clinical experience and scientific evidence. There are several approaches to rehabilitation, and many different types of exercises are available; however, patients have a limited amount of time, willingness, and enthusiasm to exercise. Therefore, we must always try to give our patients the most effective exercises for their condition. But, what are the “best” exercises for Chiropractic patients?

Selection Criteria

The best exercises for a specific problem are those that will be rapidly effective, easy to learn and perform, and are safe; that is, they don’t worsen the current condition or aggravate other problems. The exercises must help the patient to regain normal alignment and easy, natural movement. And the end result should include a decreased chance of similar, recurring problems.

A successful and appropriate rehabilitative program for the back and/or neck can be designed without the use of expensive, joint-specific equipment. While rehab type machines can be very useful, current active care concepts consider such equipment not an absolute requirement. In fact, the low-tech approach can be very effective for the treatment of most spinal conditions. Additional personnel, fancy equipment, more office space, and extra time are not always necessary. With an understanding of normal spinal function, knowledge of the involved muscles, and some updating of exercise concepts, doctors of Chiropractic can effectively rehab their patients with timely in-office instruction and patient performance followed by simple home exercise procedures .

Specific Adaptation to Imposed Demands

The “SAID” concept is one of the underlying tenets of the strength and conditioning field. [1] It describes the observation that our bodies will predictably change in response to the demands that are placed on them. If we frequently perform aerobic activities, then our lungs, hearts, and muscles become more efficient at taking in and processing oxygen. When we spend more time in activities requiring force and providing resistance, our bodies become stronger. And, if we practice balance and coordination skills, we improve our ability to function easier on unstable surfaces (such as on an incline, rolling ship or a pair of skates). In fact, these improvements in our abilities are quite specific, and we become better at doing whatever it is that we do most often.

It has taken quite a while for those specialists in the treatment of spinal problems to incorporate the SAID concept into neck and back rehab programs. Recently, some of us have begun to use the same thought processes to design spinal exercises that we have used for decades to determine appropriate x-ray positions. As Chiropractors, we do recognize that the spine functions very differently when it is not weight-bearing. We now know that an ideal way to help our patients return to normal function is with exercises that imitate as closely as possible the real conditions under which the spine must function day after day. That certainly must include the specific stress of gravity in the upright position.

Kinetic Chain Exercises

When the spine is bearing weight it is part of a closed kinetic chain. This is the manner in which we use the joints and connective tissue of the spine during most daily and sports activities, and it requires the co-contraction of accessory and stabilizing muscles. Weaker or injured muscles can be quickly strengthened with the additional use of isotonic resistance to stimulate increases in strength. Isotonic resistance can come from a machine, from weights, from elastic tubing, or just using the weight of the body. Perhaps more important than the equipment used is whether the spinal support structures are also exercised in an open or a closed-chain position.

Open-chain exercises for the spine are done non-weight bearing, while either lying on the ground or immersed in water (which removes much of the effect of gravity). Both floor-based and water-based exercises have some specific usefulness, primarily during the acute stage.

A good example of this is a study comparing closed vs. open kinetic chain exercises for the training of the thigh muscles. Augustsson et al. wanted to improve their subjects’ vertical jump height. [2] Two groups exercised twice a week at maximal resistance – one group doing closed-chain exercises (barbell squats), and the other working on the knee extension and hip adduction weight machines (open-chain exercising). At the end of six weeks both groups had gained considerable strength, but the closed-chain exercisers were the only ones who improved significantly in the vertical jump. Since jumping is a closed-chain activity, the SAID concept tells us to expect that closed-chain exercising will likely be more effective.

Functional Position Exercise

We know that the functional origins and insertions of many muscles change when changing position from standing to lying down. Certainly the proprioceptive input from receptors in the muscles, connective tissues, and joint capsules is very different between the two positions. This is why it is also important to bring neck and back rehab exercises closer to real-life positions, and it explains why patients make rapid progress when they are taught to exercise in a functional (upright) position.

Patients initially may need to exercise when lying down. However, continual floor-based exercises do not train muscles and joints to function in upright functional postures. The neurological patterns that are developed on the floor or in a pool may not resolve problems encountered in upright activities. Generally, continually learning new skills and habits on the floor doesn’t translate to better functioning during upright activities And, some patients don’t like to get down onto the floor to exercise, anyway.

By staying up off the floor, exercising in a weight-bearing position is actually easier for most patients. In addition to being more focused and practical, upright exercising trains and strengthens the spine to perform better in everyday activities. Patients accept the idea of doing exercises that clearly prepare them for better function during normal activities of daily life.

How to Spot a “Sham” Exercise

When investigators want to test treatments, they always require a “control” group, which is given a treatment that is known to be ineffective. A 1998 study on back pain published in the respected journal Spine taught several popular low back exercises to the control group. As with other studies, the researchers found no improvement using these exercises. [3] The six exercises considered a “sham” treatment included: knee-to-chest stretches, partial sit-ups (“ab crunches”), pelvic tilts, hamstring stretches, “cat and camel”, and side leg lifts. The problem with these and most other commonly recommended back exercises is that the joints, discs, muscles, and connective tissues are not bearing weight during the exercise; therefore, the movements performed while exercising do not prepare or retrain these structures for daily activities. On the other hand, exercises performed with the spine upright (standing or sitting) against resistance specifically train and condition all involved structures to work together smoothly. Thus, effective exercises are ones that are performed upright, in a closed kinetic chain.

The Value of Balance Exercises

For many athletes (whether recreational or competitive), it is important to regain the fine neurological control necessary for accurate spinal and full body performance. This means that about five to ten minutes of each workout should be spent exercising while standing on one leg, with the eyes closed, while standing on a mini-tramp, or using a special rocker board. The advantage of these balance exercises is seen when athletic patients return to sports activities and can perform at high levels without consciously having to protect their backs. Back exercises done on a rocker board or while standing on one leg can be more useful than those done on a gym ball, since the entire body is in a closed-chain position during the exercises. The stabilizing muscles, the co-contractors, and the antagonist muscles all have to coordinate with the major movers during movements that are performed during closed-chain exercising. This makes these types of exercises very valuable in the long run, particularly for competitive athletes.

Functional Alignment

Many chronic spinal problems develop secondary to an imbalance in weight-bearing alignment of the lower extremities. In fact, lower extremity misalignments — such as leg length discrepancies and pronation problems — are frequently associated with chronic pelvis and low back symptoms. [4] Any of these that are present will need to be addressed in order to resolve the patient’s current symptoms and to prevent future back problems. The use of adjustments, exercises, and custom, flexible orthotics for the lower extremities is especially critical when a functional approach is taken. The effects of weight bearing and the alignment of the kinetic chain must be considered.

Conclusion

Selecting the best exercise approach for each patient’s back problem is important. A well-designed exercise program allows the doctor of Chiropractic to provide cost-efficient, yet very effective rehabilitative care. Exercises performed with the spine upright (standing or sitting) specifically train and condition all the involved structures to work together smoothly. The end result is a more effective rehab component and patients who make a rapid response to their Chiropractic care. Except for brief periods in patients who are acute, caution must be heeded for continual exercises that don’t place patients in real-life, functional positions. While this may require a change in standard procedures, it is consistent with Chiropractic philosophy and treatment approaches. When you persist with this, you will experience dramatic improvements in patient outcomes.

References

1. Fleck SJ, Kraemer WJ. Designing Resistance Training Programs. Champaign, IL: Human Kinetics, 1987.

2. Augustsson J et al. Weight training of the thigh muscles using closed vs. open kinetic chain exercises: a comparison of performance enhancement. J Orthop Sports Phys Therap 1998; 27:3-8.

3. Snook SJ et al. Reduction of chronic nonspecific low back pain through the control of early morning lumbar flexion — a randomized controlled trial. Spine 1998; 23:2601-2607.

4. Rothbart BA, Estabrook L. Excessive pronation: a major biomechanical determinant in the development of chondromalacia and pelvic lists. J Manip Physiol Therap 1988; 11:373-379.

Adjunctive Therapies to the Adjustment The Diabetic Patient and Improving Quality of Life

by K.D. Christensen DC, CCSP, DACRB

Type II diabetes or non-insulin dependant diabetes mellitus (NIDDM) affects millions of our patients. The condition usually develops after age forty, and many patients who present for treatment of musculoskeletal or neurological conditions may actually be experiencing complications from uncontrolled blood glucose levels. As potentially debilitating as this condition can be, it is unfortunate that as many as half of those with diabetes are unaware of their condition. (1) Being familiar with the disease process will allow the healthcare provider to function as an important member of any treatment team.

Signs, Causes, Complications

The classic signs of the Type II diabetic are:

  • Over weight
  • Hypertensive
  • Inactive

Type II diabetes usually results from decreasing tissue insulin sensitivity and degeneration of pancreatic Beta cells, related to a high carbohydrate diet and inactivity. The result is a chain of pathological processes involving mobilization and deposition of fat. The worst complication is vascular destruction because of atherosclerotic plaquing. As peripheral blood vessels become blocked, especially in those that supply nerves, characteristic changes occur in the feet and ankles.

Improving Quality of Life

The triad of peripheral neuropathy, neuropathic joint destruction (Charcot joint), and increased weight gain requires direct intervention by a structure-conscious healthcare provider. Although the chiropractor may not directly treat the diabetic condition, using some simple techniques will improve the quality of life for any diabetic patient:

• Increase patient activity level

• Monitor diet and supplements

• Protect and support the feet

Obviously, the number one goal is to control the blood sugar level. In Type II this may require oral hypoglycemic medications, but treatment will be far more effective if the patient is able to improve diet and increase activity, without adding additional stress to the feet and ankles.

Even patients without diabetes find it hard to exercise regularly when they are in pain. Chiropractic care increases the patient’s ability to establish an exercise regimen which is necessary to maintain healthy body weight. Furthermore, exercise is therapeutic. “During exercise, insulin need is diminished,” Souza observes. “This is due to the enhanced insulin binding at receptor sites, so that glucose uptake is increased without an increase in insulin (insulin demand reduced).” (2)

Excessive chronic hunger, thirst and urination (polyphagia, polydipsia, and polyuria) mean your patients will struggle with their diet. Despite the blood being full of ample fuel, the cells which need it don’t have access to it. The signals to eat and drink are truly false alarms. The function of insulin and its balance with other hormones that control glycemic metabolism depends on sufficient levels of chromium and potassium. Thiazide diuretics, used to control hypertension for example, decrease serum potassium and beta blockers may raise lipid levels. An attempt to correct hyperlipidemia with niacin can increase insulin resistance.

Foot Concerns

Any disease that impairs sensation of joint receptors predisposes the articulations to microtrauma and joint derangement, resulting in Charcot joints. Diabetic arthropathy affects the feet and ankles predominantly, and although diabetics may report tingling or burning in their feet, true sensation actually decreases. Especially for the diabetic, it is very important to ensure normal articulations in the feet.

First, subluxations are responsible for the severe joint destruction which occurs. Although destruction can happen anywhere, the tarsals and distal metatarsals are most susceptible. The arches of the feet should be supported to maintain proper alignment. Secondly, misalignments can cause pressure sores, which are slow to heal and are easily infected.

The American Orthopaedic Foot and Ankle Society (AOFAS) (3) makes the following foot-care recommendations:

  • Make frequent visual inspection to compensate for the loss of sensation.
  • Never walk barefoot.
  • Check inside shoes for foreign objects.

Orthotic Support

Use custom-made, flexible orthotics to help cushion the foot and provide shock protection to the joints. Avoid over-the-counter, rigid, and hard plastic insoles.

Research on magnetic inserts suggests a positive effect on diabetic-related distal neuropathy. Weintraub reports that despite “the uncertainty regarding the precise mechanism of this novel approach, the results are impressive and suggest that a legitimacy exits for magnetotherapy as a safe and unique therapy in neuropathic diabetic foot pain.” (4) Speculation as to how or why these positive changes occur currently centers around gradient changes in the Na-K-ATPase system of sensory nerve endings or the induction of a change in the C-fiber firing patterns which are known to be adaptive.

In response to demands from doctors who were already providing spinal/pelvic stabilization for their patients, there is now a line of flexible, custom-made orthotics which include magnet therapy. Not only do these scientifically designed orthotics help stabilize the body’s overall structure by providing a symmetrical foundation, enhancing shock-absorption capacity, and improving the sensory-motor responses, they also provide the potential positive benefits of magnetic therapy. Orthotics are a fundamental part of any treatment plan aimed at increasing the patient’s activity level and getting him or her back on their feet.

There are other specialty orthotics without magnets. These orthotics are specifically designed to support foot and ankle articulations in the diabetic, while providing a level foundation for the pelvis and spine. Built-in gentle orthotic correction protects the feet from possible pressure sores and provides a very high level of comfort.

So, even though you may not treat the diabetic condition directly, your efforts to minimize the damaging effects of this disease will add quality to the life of your patient, while you function as a vital member of the healthcare team.

References

1. Harris MI. Undiagnosed NIDDM: clinical and public health issues. Diabetes Care 1993; 16:642-652.

2. Souza TA. Differential Diagnosis for the Chiropractor: Protocols and Algorithms. Gaithersburg, MD: Aspen Publishers, Inc; 1997:705-710.

3. N.A. The diabetic foot. AOFAS Online. Revised March 24, 1999: www.aofas.org/diabetic.html.

4. Weintraub MI. Magnetic bio-stimulation in painful diabetic peripheral neuropathy: a novel intervention — a randomized, double-placebo crossover study. Am J Pain Mgmt 1999; 9(1):8-17.

Stiffness, Pain, and Sleep Following Exercise

by K.D. Christensen DC, CCSP, DACRB

Post-exercise Stiffness

It is to be expected that many rehab patients experience stiff, painful, slow-functioning leg muscles after an exercise, and myoglobinemia has been reported in many endurance activities. Hansen et al. determined the degree of leakage of myoglobin and other muscle proteins into the circulation during various types of muscular activity. 1 Sixteen highly-trained marathon runners, aged 19-44 years, were examined, along with nine nonrunners of similar age, and six rowers aged 15-24 years. All subjects were men. The runners trained for 100 km to 350 km per week, and had maximal oxygen uptake values of 72-90 ml oxygen per minute per kilogram of body weight. The nonrunners had maximal oxygen uptake values of about 40 ml, and the rowers’ values were at 60-75 ml. Four runners were examined after running 17-27 km on a hilly course at a mean rate of 17.4 km per hour. Six runners and six nonrunners were compared during and after a noncompetitive test run of 27 km or 12 km, respectively. Runners also participated in 15 km and 30 km events. The rowers were examined after hard rowing for 1 1/2 hours.

Runners returned from the 17 km to 27 km race with plasma-free hemoglobin values of 2.4-10 mole/L. High transferrin iron-binding capacity and low haptoglobin values also were noted. The runners received iron daily and had normal serum iron levels. All the runners had abnormally high serum myoglobin values immediately after the race. Minimal myoglobinuria was observed for 24 hours. No runner had significant proteinuria. Serum lactic dehydrogenase, creatinine kinase, and alkaline phosphatase values were increased. Nonrunners had a greater increase in serum myoglobin levels than did the runners. Most runners had increased values of serum creatinine kinase B after the competitive run, in contrast to those values after noncompetitive runs or rowing. The rowers had elevations of serum enzymes and serum myoglobin similar to those seen in the runners. Free plasma hemoglobin was present in all the rowers.

Both distance running and rowing damage skeletal muscle cells. The myopathic condition resolves within 24 hours except for soreness in leg muscles. The changes after competitive running are consistent with some leakage of muscle proteins from myocardial cells. Neither myoglobinemia nor hemoglobinemia appears to explain adequately the iron deficiency that occurs in athletes.

This study makes a careful comparison of the biochemical damage sustained by muscle in athletes and nonathletes after running, and in rowers after rowing. The fact that protein leaks from the muscles of rowers makes a traumatic explanation unlikely. This phenomenon is possible after endurance exercise within the clinic. Nutritional intervention is helpful.

Exercise-Induced Soreness

Acute soreness develops during exercise and is related by Abraham 2 to stress-induced ischemia. Pain occurs when exercise is intense enough to produce muscle ischemia and the muscle cannot remove metabolic waste products such as lactic acid and potassium quickly enough. Critical concentrations of these substances can stimulate pain, which continues until exercise intensity is reduced or work ceases, both of which result in increased blood flow.

Delayed muscle soreness develops 24-48 hours after exercise. It has been attributed to torn tissues, spasm and the strain placed on the elastic component of muscle by eccentric work. Increases in urinary myoglobin excretion have been associated with exercise-induced muscle soreness, but they may also follow exercise when soreness does not develop. The relationship between exercise-induced muscle soreness and urinary hydroxyproline excretion can be compared. Significant correlation is apparent between the time of maximum hydroxyproline excretion and the day when the most soreness is reported. Delayed soreness appears to be linked to an irritation of the connective tissue in muscles.

Exercise-Delayed Soreness

Exercise that uses untrained muscles results in delayed muscle soreness 3 and increased muscle enzyme activities in untrained individuals. 4 Tiidus 5 examined the time course of these effects and the importance of the intensity and duration of exercise in untrained individuals of both sexes, aged 20-45 years. All exercised less than once a week. A dynamic leg extension apparatus was used. Six persons performed sets of up to ten contractions to establish the time course of post-exercise serum enzyme changes and muscle soreness. Twenty-one subjects then performed exercise at various intensities and durations at ten-day intervals.

The most severe muscle soreness and the highest serum creatine phosphokinase (CPK), lactic dehydrogenase, and glutamic oxaloacetic transaminase activities occurred 48 hours and 8 to 24 hours after exercise, respectively, in the pilot study. Increasing intensities and durations of exercise resulted in corresponding increases in enzyme activities and muscle soreness. High-intensity, brief exercise led to greater enzyme activities and more muscle soreness than low-intensity exercise of long duration. The serum CPK activity correlated significantly with the change of degree of muscle soreness.

The findings suggest that exercise-induced muscle damage leads to leakage of muscle enzyme into the blood and physiologic reactions to the muscle damage that result in a sensation of muscle soreness. Studies in rate have shown myofibrillar disruption, macrophage and fibroblast accumulation, and necrosis in exercised muscles in association with serum enzyme elevations. The exercise-induced changes may be casually related to delayed muscle soreness. What is important is that the enzyme elevation and subjective symptoms of soreness are signals of profound cellular change, which includes cellular disruption, fibroblastic change, and necrosis.

Sleep and Exercise

Slow-wave sleep (SWS) has been suggested to be a restorative phase of sleep, and exercise has been hypothesized to create a demand for SWS proportional to energy expenditure. Bunnell 6 used a quantified submaximal exercise procedure, carried out to volitional exhaustion, to test the exercise-SWS hypothesis. Measures of total caloric expenditure permitted comparisons on individual energy costs and changes in SWS. Five women and four men, aged 21-30 years, participated in the study.

All were moderately active, but none engaged in vigorous physical training. Four patients typically exercised regularly. Recordings were made on adaptation and baseline nights and for two nights after an afternoon exercise bout in which the subjects walked on a treadmill for fifty-minute periods at 50% to 70% of maximal oxygen uptake to the point of volitional exhaustion.

The duration of SWS before the onset of rapid eye movement (REM) sleep increased markedly on the exercise night. Moderate increases in stage 4 sleep and total SWS were observed. An increased latency to first REM onset and decreased duration of the first REM period were also found. Initial REM cycle length decreased. The increases in SWS before the onset of REM sleep averaged twenty-four minutes in women and six minutes in men. In women, this increase correlated with total caloric expenditure during exercise with a coefficient of 0.85. Heart rate and cardiac output during sleep were significantly increased on the exercise night. A significant fall in nocturnal urinary cortisol excretion followed exercise.

The findings suggest that exhaustive exercise affects sleep primarily in the early part of the night. An increase in SWS pressure is observed, at the expense of REM sleep. The increase in SWS in the first non-REM period is consistently greater in women than in men. Any explanation of the increase in SWS after exhaustive exercise must take into account the apparently greater effect of exercise intensity, compared with caloric expenditure itself. An explanation that holds that SWS reflects primarily neural functioning seems to account for the changes in both SWS and REM sleep.

The metabolic and biochemical alterations induced by vigorous exercise have not been identified precisely. It is of some interest that in rats swum to exhaustion there is a 15% increase in whole brain serotonin and a 20% drop in norepinephrine levels. Whether this pattern is reduplicated or paralleled in the higher vertebrates remains to be seen. The main points are well documented: slow wave sleep is increased early on, REM sleep is decreased, and the effect is greater in women than in men.

References

1. Hansen KN, Bjerre-Knudsen J, Brodthagen U, Jordal R, Paulev PE. Muscle cell leakage due to long-distance training. Eur J Appl Physiol Occup Physiol 1982; 48(2):177-188.

2. Abraham WM. Physician Sportsmed 1979; 7(Oct):57-60.

3. Ernst E. Does post-exercise massage treatment reduce delayed onset muscle soreness? A systematic review. Br J Sports Med 1998; 32(3):212-214.

4. Vincent HK, Vincent KR. The effect of training status on the serum creatine kinase response, soreness and muscle function following resistance exercise. Int J Sports Med 1997; 18(6):431-437.

5. Tiidus PM, Ianuzzo CD. Effects of intensity and duration of muscular exercise on delayed soreness and serum enzyme activities. Sci Sports Exerc 1983; 15(6):461-465.

6. Bunnell DE, Bevier W, Horvath SM. Effects of exhaustive exercise on the sleep of men and women. Psychophysiology 1983; 20(1):50-58.

Managing Shoulder Sprain/Strain Injuries

by K.D. Christensen DC, CCSP, DACRB

The various shoulder problems seen by doctors of Chiropractic can be due to one or more of the manifestations of rotator cuff dysfunction. This is generally a biomechanical continuum which begins with dysfunction of the rotator cuff muscles and may progress to rotator cuff syndrome, supraspinatus tendinitis, impingement syndrome, subdeltoid and subacromial bursitis, calcific shoulder bursitis, and even cases of frozen shoulder and bicipital tendinitis. In most cases, there is no direct, acute injury.

Because it is a very mobile joint with little stability in certain positions, the soft tissues of the shoulder region can be injured during athletic and recreational activities, at work, or in a fall. Every acute sprain and strain injury to the shoulder needs an accurate evaluation, treatment and rehabilitation, if future problems are to be avoided. Chronic instability is a real possibility after an injury, since the surrounding muscles and connective tissues are the true source of shoulder joint stability.

Shoulder Function

The shoulder is made up of several joints that must function together smoothly to provide the extreme mobility which is possible, and is necessary for many activities. The shoulder joint complex includes the sternoclavicular joint, the acromioclavicular joint, the glenohumeral joint, and the scapulothoracic articulation (a pseudojoint). The upper thoracic spine should also be considered a major contributor to shoulder motion, especially during overhead reaching (when reach is extended as the spine tilts away from the shoulder), and during throwing. [1] The connective and muscular tissues that support and move these joints will need to be assessed, so that support can be provided for the healing of any injured tissues. Eventually, rehabilitation of all injured tissues will be necessary, in order to regain full function.

There are many connective tissues in these joints which can be injured, resulting in a shoulder sprain. The sternoclavicular joint is the only point at which the shoulder girdle is firmly attached to the axial skeleton. The ligaments involved there are the sternoclavicular and costoclavicular. The acromioclavicular (AC) joint is held in place by the coracoclavicular and acromioclavicular ligaments. A thick capsule composed of several ligaments secures the humerus into the labrum of the glenohumeral joint. The scapulothoracic “joint” has muscular connections only; there are no ligamentous attachments.

Any of the numerous muscles and tendons that contribute to the movement and coordinated stability of these joints can become strained in a shoulder injury. The main muscles associated with the shoulder include: the trapezius, latissimus dorsi, pectoralis major, deltoid, rotator cuff (SITS muscles), serratus anterior, and the biceps and triceps muscles. Manual testing can often quickly identify which of these muscles are weakened and painful upon contraction after an injury.

Mechanics of Shoulder Injury

While injuries can be quite individual and complex, several common shoulder injury patterns have been identified: [2]

  • Blow to the anterior shoulder – can cause ligamentous tears resulting in dislocation.
  • Fall onto top of shoulder – may cause a ligamentous tear resulting in AC joint separation.
  • Fall on an outstretched arm – can result in AC separation, posterior dislocation, labrum or rotator cuff tear.
  • Arm forced into external rotation and abduction – anterior dislocation and/or labrum tear.
  • Sudden traction to the arm – momentary subluxation or brachial plexus traction injury.
  • Sudden pain during activity or lifting – consider rupture of muscle/tendon or labrum tear.
  • Rehabilitation of Shoulder Sprain Injuries

Significant damage to one or more of the connective tissues of the shoulder can result in joint instability and chronic dislocations. Treatment of Grade 3 or moderate-to-severe Grade 2 sprains will include some external support (sling or taping) and restricted activities. Once the ligaments have undergone sufficient early repair, controlled passive motion to include PNF routines can help to prevent the formation of adhesions (scarring in areas of movement). Resistance exercises are introduced to stimulate a stronger repair and to assist in the remodeling process. Isometric patterns are progressed to various forms of resistance exercise, based on the patient’s tolerance for joint motion. For athletes, regaining full stability may require advanced forms of exercise in the functional phase of rehabilitation, such as proprioceptive training and plyometrics. These maneuvers help to re-coordinate the sensory receptors and motor controls at the spinal cord (non-thinking) levels. [3]

Rehabilitation of Shoulder Strain Injuries

Injured muscles and tendons of the shoulder girdle may need a brief period of support and restricted activity, but controlled re-strengthening should be initiated early. Elastic tubing is a safe and effective method of providing progressive resistance exercises. [4] A very easy and effective program starts with a consistent exercise routine using surgical tubing equipment in the basic forward-back-in-out directions (flexion, extension, abduction, adduction) making certain speed is pain free. This is initially performed within a limited, pain-free range of motion, building to full range as pain subsides. As tolerated, additional shoulder exercises should be performed as indicated, including internal / external rotation, horizontal abduction / adduction and the various complex PNF patterns. This inexpensive rehabilitative program should initially be practiced under supervision to ensure proper performance.

Once good exercise mechanics and control are demonstrated, a self-directed program of home exercises is appropriate. As with sprain injuries, shoulder strains in athletes may require more specific, sports-performance exercises, such as eccentrics and plyometrics. Specific sports skills (such as throwing) may also need to be retrained.

A factor that is too frequently overlooked is the influence of posture on shoulder girdle function. Reports by Hertling and Kessler [5] and Hammer [6] support the need to evaluate the patient for specific postural distortions, such as thoracic kyphosis and cervical anterior translation (causing a “forward head”). An additional complicating postural factor can be the alignment of the scapula on the thoracic cage – when the shoulder is “rolled forward” (protracted). Correction of these chronic alignment faults will significantly reduce the biomechanical stress on muscular support for the shoulder.

Outcome Management

Outcomes assessment is the collection and recording of information relative to health processe, whereas, outcomes management uses outcome information in a way that enhances patient care. With the dawning, of the “era of accountability,” there are new social mandates directed toward health care providers and health-related facilities. Measurements of quality, satisfaction, efficacy, and effectiveness now serve as essential elements for health care decisions and matters of health policy. The two common outcome assessments in regards to shoulder management available to chiropractors include:

Shoulder Injury Self-Assessment of Function Questionnaire

This is a 15 item ADL tool from American Shoulder and Elbow . The patient fills out the questionnaire. A score of 0 is considered normal whereas scores approaching 60 represent disability.

Shoulder pain and Disability Index (SPADI)

This is a 13 point questionnaire measuring pain and disability. The Scale has been
shown responsive to improved and worsened change over time and treatment.

Both of these questionnaires require permission from the copyright owners to utilize which has been obtained and available. (See OutcomesAssessment.org).

Conclusion

An appropriate and progressive active rehab program should be started early in the treatment of patients with shoulder sprain and strain injuries, generally after ligaments and connective tissues have repaired sufficiently. Simple, yet effective rehab techniques are available, none of which require expensive equipment or great time commitments. A closely monitored home exercise program using exercise tubing is recommended, since this allows the doctor of Chiropractic to provide cost-efficient, yet very effective and specific rehabilitative care. Outcome assessment monitoring is a simple way to document curative progress and treatment during recovery.

The most important aspect is to recognize and address the biomechanical alignment problems and postural factors that are frequently associated with shoulder injuries. This entails screening the patient for forward head and flexed (kyphotic) torso postures. In addition, protracted (forward) shoulders change the angle of the scapula and compress the rotator cuff further. Failure to recognize these complicating factors will result in a patient with recurring shoulder complaints. When the shoulder girdle is properly aligned on the torso, the complex mechanism of the shoulder will be more likely to function optimally.

References

1. Nordin M, Frankel VH. Basic Biomechanics of the Musculoskeletal System, 2nd. ed. Philadelphia: Lea & Febiger; 1989. 235.

2. Souza TA. Differential Diagnosis for the Chiropractor. Gaithersburg: Aspen Pubs; 1997. 145.

3. Kibler WB, et al. Functional Rehabilitation of Sports and Musculoskeletal Injuries. Gaithersburg: Aspen Pubs; 1998. 157.

4. Roy S, Irvin R. Sports Medicine: Prevention, Evaluation, Management, and Rehabilitation. Englewood Cliffs: Prentice-Hall; 1983. 195.

5. Hertling D, Kessler RM. Management of Common Musculoskeletal Disorders, 2nd. ed. Philadelphia: JB Lippincott; 1990. 177.

6. Hammer WI. Functional Soft Tissue Examination and Treatment by Manual Methods. Gaithersburg: Aspen Pubs; 1991. 31.

Adjunctive Therapies to the Adjustment Preventing Leg Injuries

by K.D. Christensen DC, CCSP, DACRB

Leg injuries (to the ankles, lower leg, knees, and hip and thigh) affect many athletes, both competitive and recreational. These injuries can interfere significantly with sports enjoyment and performance levels, and they occasionally will end participation completely. Excessive pronation and poor shock absorption have been found to be an underlying cause or a contributing factor for many leg injuries. (1) Custom-fitted orthotics can help to improve pedal biomechanics, reduce the extent of pronation, and prevent many activity-related leg injuries.

One recent study looked at the foot biomechanics of athletes who reported a recent foot or leg injury (iliotibial band syndrome, Achilles tendinitis, stress fracture of the tibia, tibial periostitis, or plantar fascitis), and compared them to an uninjured control group. (2) The researchers determined that those athletes with more foot pronation had a much greater statistical probability of sustaining one of these five leg injuries. This helps us understand how providing appropriate orthotic support to patients who are involved in sport or recreational activities can lower their likelihood of developing leg injuries.

Hip and Thigh Injuries

Many injuries experienced at the hip and thigh develop from poor biomechanics and gait asymmetry, especially when running. Smooth coordination of the muscles that provide balance and support for the pelvis is needed for optimum performance. This includes the hamstring muscles and the hip adductor muscles (groin strains), in addition to the iliotibial band. When there is a biomechanical deficit from the feet and ankles, abnormal motions (such as excessive internal rotation of the entire leg) will predispose to pulls and strains of these support muscles. The hamstrings (comprised of the biceps femoris, semimembranosus, and semitendinosus muscles) are a good example.

Hamstring muscles. During running, the hamstrings are most active during the last 25% of the swing phase, and the first 50% of the stance phase. (3) This initial 50% of stance phase consists of heel strike and maximum pronation. The hamstring muscles function to control the knee and ankle at heel strike and to help absorb some of the impact. A recent study has shown a significant decrease in electromyographic activity in the hamstrings when wearing orthotics. (4) In fact, these investigators found that the biceps femoris (which is the most frequently injured of the three hamstring muscles) (5) had the greatest decrease in activity of all muscles tested, including the tibialis anterior, the medial gastrocnemius, and the medial and lateral vastus muscles. The scientists in this study theorized that the additional support from the orthotics helped the hamstrings to control the position of the calcaneus and knee, and to absorb some of the shock of heel strike.

Knee Injuries

Except for direct injuries from contact or forced overstretch, most knee problems develop from poor biomechanics and overuse of muscles and tendons. Many of these injuries are associated with foot pronation and can be prevented by using orthotics during sports activities.

Anterior cruciate ligament (ACL). Epidemiology and frequency studies have now demonstrated that the vast majority of acute tears of the ACL occur without any contact or direct trauma to the athlete’s knee. (6) Eighty-one percent of athletes with injury to the ACL recalled the moment of injury as having their tibia in internal rotation. (7) It is the torque, or twisting forces imposed on the knee joint that cause some ACLs to rupture. Some athletes have knee joints that are more susceptible to these torque forces, and excessively pronating feet transmit more rotational force into the knee joints.

A recent study by Beckett et al. retrospectively reviewed a group of athletes with acute, non-traumatic ACL ruptures (arthroscopically-proven), and compared them to a matched control group. These researchers found excessive pronation of the foot and collapse of the arch during weight-bearing in the injured subjects, and they proposed this finding as the mechanism of injury. (8)

In their study, Beckett et al. reviewed the biomechanics of the foot and ankle, and described how arch collapse and excessive pronation cause abnormal internal (medial) tibial rotation that “pre-loads” the anterior cruciate ligament. Normally, subtalar joint pronation and internal rotation of the tibia occur only during the initial, contact phase of gait. If pronation continues beyond the contact phase, the tibia remains internally rotated. This abnormal tibial rotation transmits excessive forces upward in the kinetic chain to the knee joint. This theory is supported by Copland’s work, which found that passive tibial rotation was statistically greater in hyperpronators than in nonpronators. (9) Another study found that ruptures of the ACL in female athletes (many of whom are at a high risk for ACL rupture) were directly correlated with the amount of arch collapse and hyperpronation. (10)

Patellofemoral pain. Pain and injury at the front of the knee can be due to patellar tendinitis and/or rubbing of the patella in the femoral groove. Both of these conditions can be caused by poor foot biomechanics and are easily prevented with the use of orthotics that reduce pronation. Prolonged time in pronation causes excessive internal rotation of the tibia, impeding its normal external rotation during gait progression in the stance phase. (11) This excessive internal tibial rotation transmits abnormal forces upward in the kinetic chain and produces medial knee stresses, force vector changes of the quadriceps mechanism, and lateral tracking of the patella. (12) One study found that the use of soft corrective orthotics was very effective in reducing patellofemoral pain, and preventing recurrence. (13)

Lower Leg Injuries

Excessive movements of the tibia can cause injury to many of the structures in the lower leg. The muscles and tendons in the shin, the Achilles tendon, and even the bones of the lower leg are all at risk from excessive pronation. Studies have demonstrated a significant decrease in tibial internal rotation (14) and on pronation velocity (15) when using orthotics, which will help to prevent injuries to this area.

Shin splints. A chronic tendinitis affecting either the anterior or posterior tibialis muscle can present as “shin splints.” (16) The anterior tibialis tendon is stressed when the foot is unable to adequately absorb the forces of foot deceleration at or after foot strike, while the posterior tibialis tendon develops micro-tears from attempting to stabilize excessive foot pronation. (17) Therefore, orthotics can reduce the likelihood of developing shin splint injuries.

Stress fractures. Repetitive biomechanical stresses are often accentuated by inherent imbalances or asymmetries, such as hyperpronation. An example is the increased frequency of stress fractures found in the feet and lower legs of military recruits with low arches and flat feet. (18) The hyperpronating foot tends to develop stress fractures more frequently in the collapsed metatarsals and in the tibia. (19, 20) Orthotic support for the arches that includes pronation correction at the heel (a medial or “varus” wedge) will decrease the torque forces on the bones of the foot and leg and prevent the development of stress reactions. And, of course the additional shock absorption found in modern orthotics is an additional preventive factor.

Foot and Ankle Injuries

Orthotic support is most obviously able to help prevent leg injuries that affect the foot and ankle. Many injuries of this region have been found to be caused by hyperpronation, and orthotics are recommended for the associated poor shock absorption and arch collapse. These include injuries such as ankle inversion sprains (21), heel spurs and plantar fascitis, metatarsalgia, and even sesamoiditis (which can become a frank fracture). (22)

Conclusion

Excessive pronation and/or poor shock absorption have been shown to be an associated or causative factor in many leg injuries — from the foot itself, up the lower leg to the knee, thigh, and hip. Many of these conditions can be prevented with custom-fitted orthotics. The investigation of foot biomechanics is a good idea in all patients, especially for those who are recreationally active. Competitive athletes must have regular evaluations of the alignment and function of their feet, in order to avoid potentially disabling injuries. Additional preventive measures include wearing well-designed and constructed shoes. Recommending orthotics may help prevent not just arch breakdown and biomechanical foot problems, but numerous other injuries to the lower extremities as well.

References

1. Dahle LK et al. Visual assessment of foot type and relationship of foot type to lower extremity injury. J Orthop Sports Phys Ther 1991; 14:70-74.

2. Busseuil C et al. Rearfoot-forefoot orientation and traumatic risk for runners. Foot Ankle Intl 1998; 19:32-37.

3. Mack RP. AAOS Symposium on the Foot and Leg in Running Sports. St. Louis: Mosby; 1982.

4. Nawoczenski DA, Ludewig PM. Electromyographic effects of foot orthotics on selected lower extremity muscles during running. Arch Phys Med Rehabil 1999; 80:540-544.

5. Garrett WE. Muscle strain injuries. Am J Sports Med 1996; 24:S2-8.

6. McNair PJ, Marshall RN, Matheson JA. Important features associated with acute anterior cruciate ligament injury. NZ Medical Journal 1990; 14:537-539.

7. Arnold HA et al. Natural history of the anterior cruciate ligament. Am J Sports Med 1979; 7:305-313.

8. Beckett ME et al. Incidence of hyperpronation in the ACL injured knee: a clinical perspective. J Athl Train 1992; 27:58-62.

9. Copland JA. Rotation motion of the knee: a comparison of normal and pronating subjects. J Orthop Sports Phys Ther 1989; 10:366-369.

10. Loudon JK. The relationship between static posture and ACL injury in female athletes. J Orthop Sports Phys Ther 1996; 24:91-97.

11. Zappala GG, Taffel CB, Scuderi GR. Rehabilitation of patellofemoral joint disorders. Orthop Clin North Am 1992; 23:555-566.

12. Tiberio D. The effect of excessive subtalar joint pronation on patellofemoral mechanics: a theoretical model. J Ortho Sports Phys Therap 1987; 9:160-165.

13. Eng JJ, Pierrynowski MR. Evaluation of soft foot orthotics in the treatment of patellofemoral pain syndrome. Phys Ther 1993; 73:62-70.

14. Nawoczenski DA, Cook TM, Saltzman CL. The effect of foot orthotics on three-dimensional kinematics of the leg and rearfoot during running. J Orthop Sports Phys Ther 1995; 21:317-327.

15. Eng JJ, Pierrynowski MR. The effect of soft orthotics on three-dimensional lower limb kinematics during walking and running. Phys Ther 1994; 74:836-844.

16. Souza TA. Differential Diagnosis for the Chiropractor. Gaithersburg: Aspen Pubs; 1998. 313.

17. Roy S, Irvin R. Sports Medicine: Prevention, Evaluation, Management, and Rehabilitation. Englewood Cliffs: Prentice-Hall; 1983. 434, 438.

18. Simkin A, et al. Combined effect of foot arch structure and an orthotic device on stress fractures. Foot Ankle 1989; 10:25-29.

19. Subotnick SI, ed. Sports Medicine of the Lower Extremity. New York: Churchill Livingstone; 1989. 164.

20. Michaud TC. Recurrent lower tibial stress fracture in a long-distance runner: a case report. Chirop Sports Med 1988; 2:78-87.

21. Heiser JR. Rehabilitation of lower extremity athletic injuries. Contemp Podiat Phys 1992; Aug:20-27.

22. Hartley A. Practical Joint Assessment: A Sports Medicine Manual. St. Louis: Mosby Yearbook; 1991. 571.

Osteoporosis and Spinal Exercise

by K.D. Christensen DC, CCSP, DACRB

With an aging and sedentary population, osteoporosis and its complications are affecting greater numbers of our patients. Initially, there is a reduction in bone mass (osteopenia), which is considered a universal phenomenon of aging. However, when the condition progresses to osteoporosis, bone strength is compromised, and fractures develop with trivial (or no) trauma. These fractures may affect the extremities, the hip, and the spine. While calcium intake and diet are very important, and hormone status is a major contributing factor, physical activity and exercise have been shown to provide significant protection from osteoporosis [1] and fractures. [2] As doctors of chiropractic, we have a duty to identify those patients who are at risk of fracture, and to provide exercise recommendations that will decrease that risk. And, very importantly, we can tailor their exercises to prevent the spinal complications of osteoporosis, such as kyphosis, vertebral wedging, and compression fractures.

Benefits of Exercise to Bone

As recalled from the principle known as Wolff’s Law, bone density and strength are a function of the magnitude and direction of the mechanical stresses that act on bone. Assuming the availability of necessary nutrients, stimulus to the osteoblasts results in a net gain in bone mass. Exercise is a form of repetitive loading that facilitates osteoblastic activity, thereby helping to maintain a positive balance between bone formation and bone resorption. [3] Even the very moderate amount of exercise that is recommended for general wellness (a minimum of 30 minutes on most days) is helpful in preventing osteoporosis. [4]

Exercise Types

Aerobic/endurance. Two of the most commonly recommended forms of exercise for the elderly are walking and swimming. While improved aerobic capacity is good for the cardiopulmonary system and is generally beneficial for most older patients, we mustn’t expect any skeletal improvement. Bone mineral density can be increased by walking, but only when it is done above the anaerobic threshold. [5] It is unlikely that most older women will be willing to walk at this intensity, especially those who have been sedentary. Women who participate in a regular swimming program have no significant difference in bone mass from women who don’t swim. [6] This is also true of a standard “weightbearing, water-based exercise program” (aquacise). [7]

Impact/weightbearing. In order to create sufficient stimulus to increase bone density, exercise needs to be weightbearing and have some impact. This doesn’t mean jumping off of chairs, but can be as simple as step-training (10 minutes stepping up and down from an 8 inch high step). [8] Caution should be used when recommending impact exercise to elderly patients, and orthotics with good support and shock absorption may need to be considered. Certainly, excellent shoewear is important.

In general, exercises are effective when done in an upright, weight-bearing position, since the entire body is in a closed-chain position during the training. The stabilizing muscles, the co-contractors, and the antagonist muscles all learn to coordinate with the major movers during movements that are performed during closed chain exercising (Fig. 1). This makes these types of exercises very valuable for the elderly — not just for increasing bone density, but also for preventing stumbles and falls.

Resistance/strength. Resistance training has been found to be safe and quite effective in increasing strength and function in the elderly. [9] Older patients make similar relative, but smaller absolute, strength gains when compared with younger adults. Weight training in a submaximal controlled, supervised situation can also preserve [10] and even increase [11] bone deposition. Strength training recommendations should be an integral part of chiropractic treatment for older and osteoporotic patients. Exercise tubing is an excellent tool for strength training of the elderly, since the risks of injury are minimized, and a spotter or expensive equipment is not needed (Fig. 2).

Spinal Osteoporosis

As doctors of chiropractic, we often encounter osteopenia and osteoporosis on our patients’ spinal x-rays. Of course, by the time changes are visible on x-ray, substantial bone loss has already occurred. The most common fractures due to osteoporosis are vertebral fractures, and yet less than a third of all vertebral fractures are clinically diagnosed. [12] Needless to say, these skeletal changes can have a significant impact on posture and our ability to handle subluxation complexes. Specific, corrective exercises should be recommended in order to relieve the postural strain on the spine and to prevent further wedging and compression fractures. Avoiding exercise is the worst approach to an aging patient with osteoporosis. Back strengthening exercise constitutes a powerful intervention for reducing pain and increasing functional capacity.

An important caveat must be addressed when designing an exercise program for patients with osteoporosis. Most importantly, the exercises should not worsen a patient’s condition. And this is certainly possible, since some of the commonly used back exercises may cause more fractures. For patients with spinal osteoporosis, the most harmful activity is that which places an anterior load on the vertebral bodies. Patient education must emphasize the dangers of lifting in flexion, and of performing flexion exercises. In fact, one exercise study [13] found an increase in new vertebral deformities when postmenopausal women performed flexion exercises (such as forward stretches and abdominal curls), while those who performed only spinal extension exercises had a significant reduction in the number of vertebral compressions.

Corrective Spinal Exercises

Spinal osteoporosis is often associated with poor postural support, specifically an increase in the thoracic kyphosis. This posture is secondary to many decades of flexed activities, and may be compounded by poor posture habits and tendencies to “slump.” One important factor in chiropractic treatment is the correction of any loss of the normal upright alignment of the pelvis and spine. In addition to general strengthening and coordination exercises, all patients (and especially the elderly) should be shown corrective exercises that are specific for the postural imbalances they have developed. The thoracic kyphosis of estrogen-deficient women has been found to be directly correlated with weakness of the back extensor muscles, [14] and increasing the back extensor strength has been shown to decrease the kyphosis. [15] In this instance, when the torso is carried flexed forward, the patient will need to retrain the extensor muscles of the spine with isotonic resistance exercises. As stated previously, this is most effective when done in an upright, weightbearing position.

Conclusion

A well-designed exercise program can improve posture, help to reduce bone loss, and prevent fractures, while also reducing symptoms. Exercises performed with the spine upright (standing or sitting) can specifically train and condition all the involved structures to work together smoothly. For some elderly patients, orthotic support will be necessary to reduce shock and ensure correct alignment of the lower extremities during weightbearing exercises such as walking. The end result is an effective rehab component for osteoporosis and aging patients who will make a rapid response to their chiropractic care. Now we understand how important it is for our exercise recommendations to provide for strengthening of the spinal support mechanisms to prevent kyphosis and compression fractures in our elderly patients.

References

1. Chien MY, Wu YT, Hsu AT et al. Efficacy of a 24-week aerobic exercise program for osteopenic postmenopausal women. Calcif Tissue Int. 2000; 67:443-448.

2. Campbell AJ, Robertson MC, Gardner MM et al. Randomised controlled trial of a general practice programme of home based exercise to prevent falls in elderly women. Br Med J. 1997; 315:1065-1069.

3. Pirnay FM. Bone mineral content and physical activity. Int J Sports Med. 1987; 8:331-335.

4. US Dept. of Health and Human Services. Physical Activity and Health: A Report of the Surgeon General. Atlanta: 1996.

5. Hatori M, Hasegawa A, Adachi H et al. The effects of walking at the anaerobic threshold level on vertebral bone loss in postmenopausal women. Calcif Tissue Int. 1993; 52:411-414.

6. Orwoll ES, Ferar J, Oviatt SK et al. The relationship of swimming exercise to bone mass in men and women. Arch Intern Med. 1989; 149:2197-2200.

7. Bravo G, Gauthier P, Roy PM et al. A weight-bearing, water-based exercise program for osteopenic women: its impact on bone, functional fitness, and well-being. Arch Phys Med Rehabil. 1997; 78:1375-1380.

8. Chien MY, Wu YT, Hsu AT et al. Efficacy of a 24-week aerobic exercise program for osteopenic postmenopausal women. Calcif Tissue Int. 2000; 67:443-448.

9. Fiatarone MA, Marks EC, Ryan ND et al. High-intensity strength training in nonagenarians: effects on skeletal muscle. JAMA. 1990; 263:3029-3034.

10. Nelson ME, Fiatarone MA, Morganti CM et al. Effects of high-intensity strength training on multiple risk factors for osteoporotic fractures. JAMA. 1994; 272:1909-1914.

11. Kerr D, Ackland T, Maslen B et al. Resistance training over 2 years increases bone mass in calcium-replete postmenopausal women. J Bone Miner Res. 2001; 16:175-181.

12. Ross PD. Clinical consequences of vertebral fractures. Am J Med. 1997; 103:30S-43S.

13. Sinaki M, Mikkelsen BA. Postmenopausal spinal osteoporosis: flexion versus extension exercises. Arch Phys Med Rehabil. 1984; 65:593-596.

14. Sinaki M, Itoi E, Rogers JW et al. Correlation of back extensor strength with thoracic kyphosis and lumbar lordosis in estrogen-deficient women. Am J Phys Med Rehabil. 1996; 75:370-374.

15. Itoi E, Sinake M. Effect of back-strengthening exercise on posture in healthy women 49 to 65 years of age. Mayo Clin Proc. 1994; 69:1054-1059.

About The Author

Kim D. Christensen, DC, CCSP, DACRB, is codirector of the SportsMedicine & Rehab Clinics of Washington, and current president of the American Chiropractic Association Rehab Council. He can be reached at Chiropractic Rehabilitation Association, 18604 NW 64th Avenue, Ridgefield, WA 98642 or via email: kimdchristensen@hotmail.com.

[captions for illustrations]

Fig. 1. Hip extension exercise

Fig. 2. Exercise tubing: an ideal tool for elderly/osteoporotic patients

Lower Extremity Rehab for the Elderly

by K.D. Christensen DC, CCSP, DACRB

When a patient over the age of sixty needs to regain strength in an injured lower extremity, or when an elderly woman needs to build bone mass to prevent hip fractures, a question arises. What exercises are appropriate, safe, and effective? Won’t exercising this older patient make the problem worse? As caring doctors of Chiropractic, the last thing we want to do for our older patients is to increase their pain or add to their disability.

While there are very important special considerations when planning exercises for a patient over sixty, the benefits far outweigh the risks. In fact, it would be a distinct advantage for every person over the age of sixty to be under the care of a Chiropractor who can advise and provide guidance regarding the most effective forms of exercising. What follows is a review of the concerns we must address, and some solutions when we need to start an elderly patient on a lower extremity rehab program.

Rehab Concerns in the Elderly

Because the lower extremities bear the weight of the entire body, eventually some imbalance or mis-step will result in the need for a rehab program. There are several areas where older patients differ from the younger population, however. These special concerns include weaker bones, problems with blood flow, joint degeneration, and age-related weakness. Let’s look at each of these problem areas, and then we’ll see what the experts say.

Osteoporosis. With aging comes a loss of bone mass in many people, especially post-menopausal women. We don’t want to place an elderly patient in a situation that could cause a hip or leg fracture, or a vertebral compression fracture. Even recommending a walking program may expose elderly patients to a higher risk of ankle fractures, since what is normally a simple ankle sprain becomes a comminuted fracture when the bones are osteoporotic. A well-organized study of elderly women found a much higher incidence of thoracic compression fracture after five years of performing exercises that placed the spine in flexion. [1] This means that many of the standard exercises we use, such as knees to chest, and abdominal crunches should be modified or possibly even eliminated in the elderly population.

Hypertension/atherosclerosis. Hardening and constriction of the arteries cause a decrease in blood flow, especially to the extremities. The heart responds by increasing the blood pressure, trying to force the blood through the restricted areas. When resting measurements are consistently above 140 mmHg (systolic) and/or 90 mmHg (diastolic), the person has hypertension. Elderly patients entering the office may already be on medication to control their high blood pressure, especially in the higher age ranges. While the drugs do decrease the likelihood of strokes and heart attacks, many patients are still hesitant to exercise, and they become even more sedentary. There is now good evidence that exercise is not contra-indicated, and is actually beneficial for patients taking blood pressure medications. [2] We’ve got to consider what type of exercising is least likely to further increase blood pressure, since we don’t want to cause a heart attack or stroke.

Osteoarthrosis. Degenerative arthritis is one of the most common musculoskeletal disorders in older adults, causing significant amounts of physical disability. Osteoarthrosis afflicts an estimated 20 million Americans, with the knee being the most commonly affected weightbearing joint. [3] In addition to pain with movement, the involved joint(s) lose flexibility and strength. Also found is a loss of proprioception, which may be a contributor to impaired balance. [4] Exercises for the elderly must avoid increasing painful movements, yet improve flexibility, strength, and balance. Contrary to what is commonly believed, moderate exercise does not increase the risk for osteoarthrosis or exacerbate it; rather, it has been found to improve function and reduce pain. [5]

Deconditioning/low muscle mass. As we age, we become more sedentary. National surveys reveal that 70% or more of older adults do not engage in any regular exercise. [6] This compounds the previously identified loss of strength and muscle mass, and increase in body fat that is normally seen in aging. In fact, this change in body composition is tied to many factors, including poor nutrition, decreased physical activity, increased disability and disuse, type II muscle fiber atrophy, and drug side effects.

Benefits of Elder Exercise

The American Geriatrics Society recently reviewed the literature that demonstrates the wide range of benefits that are obtained when older patients exercise. [7] There is now a wealth of data that supports the value of resistance exercise in the geriatric population. Improvements are seen in weight and body composition, decreased falls, improved balance, better psychological health, less frailty and improved function. With exercise, the resting blood pressure lowers, and there is a reduction in the risk of all-cause mortality. [8] Studies have shown that the stronger the back and leg muscles are, the higher the bone density is in the region. [9] These benefits are so widespread, they overwhelm the few detrimental concerns, and encourage us to recommend resistance exercise to older patients who need lower extremity rehab.

Solutions

First, flexion exercises may have to be avoided, in order to decrease the likelihood of compression fractures in the spine for some elderly patients. In fact, exercises that strengthen the back extensor muscles can decrease the thoracic kyphosis seen in many older women. [10] Repetitive impact stresses needs to be reduced without sacrificing the benefits of repetitive motion for the cardiovascular system. Swimming or water exercise is perhaps one of the ideal repetitive exercise options. Distance walking can cause repetitive overuse complaints. These can be minimized with the use of shoe inserts or custom orthotics made of viscoelastic materials. [11] If a lower extremity joint or muscle is acutely inflamed (with joint effusion), an initial period of relative rest with cryotherapy may be needed. During this period, though, exercise of the opposite leg should be encouraged. Vigorous exercise of the uninvolved contralateral leg muscles will produce a neurological stimulus in the injured side (called the “cross-over effect”), and helps to prevent atrophy. [12]

Isometric exercises may increase the systolic blood pressure; therefore, isotonic or “dynamic” exercises are the better choice. [13] Elastic resistance tubing is an excellent method to provide dynamic exercise strengthening without the need for machines or heavy weights. Older adults may have difficulty getting to and figuring out complex machines. They may not be able to handle heavy weights and barbells. Studies have shown that a home-based program using elastic tubing can provide significant gains in lower extremity strength and improvements in gait. [14] These exercises can be done standing or sitting.

ACSM/NSCA Guidelines

Two major organizations – the American College of Sports Medicine (ACSM) [15] and the National Strength and Conditioning Association (NSCA) [16] have both published recommendations to be followed when advising older adults to exercise. Both state that aerobic and resistance exercise for older populations is generally safe and can be very effective, both for treating specific problems as well as avoiding general disability. These guidelines encourage the use of regular physical activity, along with specific exercising to improve endurance, strength, and proprioception. Current research has found that even high-intensity training of frail men and women in their 90s is safe and leads to significant gains in muscle strength and functional mobility. [17]

Conclusion

An appropriate and progressive rehab program should be started early in the treatment of all patients with lower extremity injuries and problems. [18] Selecting the best exercise approach for an older patient is not difficult, but does require some special considerations. A review of the patient’s health history is necessary, in order to identify any complicating or restricting factors. Using the factors described above, an effective lower extremity rehab program can be easily designed for an elderly patient. A closely monitored home exercise program allows the doctor of Chiropractic to provide cost-efficient, yet very effective, rehabilitation care for patients of all ages.

References

1. Sinaki M, Mikkelsen BA. Postmenopausal spinal osteoporosis: flexion vs. extension exercises. Arch Phys Med Rehabil 1984; 65:593-596.

2. LaFontaine T. Resistance training for patients with hypertension. Strength & Conditioning 1997; 19:5-7.

3. Lawrence RC et al. Estimates of the prevalence of arthritis and selected musculoskeletal disorders in the United States. Arthritis Rheum 1998; 41:778-799.

4. Wegener L, Kisner C, Nichols D. Static and dynamic balance responses in persons with bilateral knee osteoarthritis. J Orthop Sports Phys Ther 1997; 25:13-18.

5. Casper J, Berg K. Effects of exercise on osteoarthritis: a review. J Strength Condition Res 1998; 12:120-125.

6. Clark DO. Racial and educational differences in physical activity among older adults. Gerontologist 1995; 35:472-480.

7. Christmas C, Andersen RA. Exercise and older patients: guidelines for the clinician. J Am Geriatr Soc 2000; 48:318-324.

8. Blair SN et al. Influences of cardiorespiratory fitness and other precursors on cardiovascular disease and all-cause mortality in men and women. JAMA 1996; 276:205-210.

9. Sinaki M, Offord KP. Physical activity in postmenopausal women: effect on back muscle strength and bone mineral density. Arch Phys Med Rehabil 1988; 69:277-80.

10. Itoi E, Sinaki M. Effect of back-strengthening exercise on posture in healthy women 49 to 65 years of age. Mayo Clin Proc 1994; 69:1054-1059.

11. Schwellnus MP et al. Prevention of common overuse injuries by the use of shock absorbing insoles. Am J Sports Med 1990; 18:636-641.

12. Hertling D, Kessler RM. Management of Common Musculoskeletal Disorders. 2nd ed. Philadelphia: JB Lippincott; 1990. 334.

13. American College of Sports Medicine. Exercise prescription for special populations. In: Guidelines for Exercise Testing and Prescription. 1991. 166.

14. Jette AM et al. Exercise- it’s never too late: the strong-for-life program. Am J Publ Health 1999; 89:66-71.

15. American College of Sports Medicine. Exercise and physical activity for older adults. Med Sci Sports Exerc 1998; 30:992-1008.

16. Pearson D et al. The national strength and conditioning association’s basic guidelines for the resistance training of athletes. Strength & Conditioning J 2000; 22(4):14-27.

17. Fiatarone MA et al. High-intensity strength training in nonagenarians: effects on skeletal muscle. JAMA 1990; 263(22):3029-3034.

18. Kibler WB et al. Functional Rehabilitation of Sports and Musculoskeletal Injuries. Gaithersburg, MD: Aspen Publishers; 1998. 252.

Warm-Up and Stretching Procedures

by K.D. Christensen DC, CCSP, DACRB

A majority of patients involved in rehabilitation — athletes and non-athletes alike — perform some type of preliminary physical activity or warm-up procedure, especially if a strenuous workout is expected. Warming up provides numerous benefits. An accelerated metabolic rate promotes the efficient use of substrates needed to provide energy for physical activity. A rise in muscle temperature reduces the internal viscosity of muscle protoplasm, enhancing the mechanical efficiency of moving muscles. Recent research indicates that mild warm-up exercise could inhibit the development of intracellular acidosis during subsequent intense exercise. 1 Muscle contraction is more rapid and forceful when muscle temperature is slightly higher than body temperature. An elevated body temperature stimulates vasodilation, increasing blood flow through the vascular bed of muscle tissue and increasing substrate delivery.

An adequate warm-up appears to minimize the risk of injury to the muscles, tendons, ligaments, and other connective tissues, possibly because of improved elasticity from blood saturation. 2 Therefore, the most common static stretch procedures before warming up must be reconsidered. A warm-up may also reduce the incidence of subendocardial ischemia and improve blood pressure response to exercise. It is clear that a warm-up should precede participation in any type of vigorous rehab activity.

Types of Warm-Up

Any effective type of warm-up should produce increased muscle temperature. Passive warm-up raises the body temperature by some external means a hot shower, for example). A general or nonspecific warm-up involves active motion of major muscle groups, as in simple calisthenics. Specific warm-up focuses on the neuromuscular regions to be used in the anticipated exercise (a rehearsal of the exercise event taking place), making this method the most effective for rehab patients. The intensity and duration of warm-up should be individualized according to the patient’s physical capabilities. A rectal temperature rise of 1° to 2° C seems adequate and is usually accompanied by the onset of sweating in normal environmental conditions. Too intense a warm-up should not be done too far in advance of exercise, as the body temperature returns to normal after about 45 minutes of rest. Some believe that the benefits of warming up may be related in part to psychologic factors.

Warm-up before exercise is a generally accepted practice. 3 Genovely et al. 4 examined the effects of prolonged warm-up exercise at 40% and 68% of maximal aerobic capacity (below and above anaerobic threshold, respectively) on maximal performance in five men who were active regularly but were not highly trained. Maximal performance, consisting of two 40-second bouts of maximal pedaling against a 5.5-kg resistance, was tested without warm-up exercise.

The two bouts of maximal exercise, separated by a five-minute rest period, were found to be reproducible for work output and peak blood lactate level. Below anaerobic threshold, warm-up exercise significantly increased core temperature with no rise in the steady-state blood lactate level. It did not contribute to improved maximal performance. Above anaerobic threshold, warm-up exercise led to significant increases in both core temperature and steady-state blood lactate level; work output and peak blood lactate concentration on maximal exercise were significantly reduced.

Task-specific, prolonged warm-up exercise below anaerobic threshold does not contribute to improved maximal performance, while warm-up exercise above the anaerobic threshold impairs maximal performance. This probably is due to glycogen depletion in fat-twitch muscle fibers, which in turn may have contributed to decreased lactate production. These findings apply to short-term maximal exercise in a setting in which the psychologic aspects of testing are rigidly controlled.

In recent years more flexibility exercises are included in most warm-ups. The warm-up should be exercise specific, and the type of drills used should prepare the patient for the skills they will use. The warming up should not be exhausting and should prepare the patient both physically and mentally for their rehabilitative events.

Static Stretching Exercise

The 1999 study by Johansson et al. suggests that pre-exercise static stretching “has no preventive effect on the muscular soreness, tenderness and force loss that follows heavy eccentric exercise.” 5 Shrier 6 and Pope et al. 7 conclude that stretching before exercise does not reduce the risk of exercise-related injury. Dominguez 8 believes that stretching, particularly static stretching, is itself a significant cause of injuries. The hurdler’s stretch and the plow, in which the patient is supine with the legs raised up and over the head so the feet touch the ground behind the shoulders, are specific examples of static stretching exercises deemed to be harmful. He does favor a 15 minute warm-up of gentle range-of-motion exercises (ROM) for individuals who perform explosive activities, but advises most to merely start slowly and finish with a gentle cool-down, bending and rotating the hips, knees, ankles, and shoulders. The benefits associated with stretching are attributed to active, controlled exercises, not static stretching itself.

Dominguez 9 also believes that, rather than seeking flexibility, most should attempt to develop dynamic ranges of motion. The ability to actively control joints through the full range of motion can be promoted by a combination of gentle flexing, extending, sideways bending, and rotation. A good overall program should develop range of motion, strength, power, endurance, balance, and motor control. Nothing more than oversized rubber bands (rehab tubing), balls, teeterboards, and balance beams is needed. Dominguez feels there is much room for creativity as clinicians apply general techniques to individual needs.

Flexibility Exercise

In the past few years static flexibility exercises have gained a great deal of popularity. However, many clinicians have gone beyond this and are using proprioceptive neuromuscular facilitation (PNF) techniques to increase flexibility. Warnings began to appear in the literature that some of the exercises may actually be harmful. “Bouncing could tear a muscle.” “Stretch the muscle and not the tendon.” “Hurdler’s stretch can damage the medial aspect of the knee.” “The plow is bad for the cervical spine.” “The ballet stretch is dangerous.” However, most believe that flexibility done in moderation, when the muscles are warmed up, can be beneficial. There are obviously some exercises that should be avoided. Attempts should be made in general to stretch muscle bellies and not tendons. This can be done by slightly relaxing the joints which the stretched muscles pass over. Never stretch a cold muscle. Most of the flexibility program should be done at the end of a rehab program.

Surberg 10 points out that there is an optimal level of flexibility that allows efficient movement while reducing the risk of certain types of injury. Attainment of this level of flexibility usually is a goal of rehab conditioning programs. The first step after certain injuries is achievement of normal ROM. Flexibility or ROM can be increased by reducing the resistance of agonist muscle groups, or by increasing the strength of opposing muscles. Decreasing the resistance of an agonist muscle group can be accomplished by lengthening connective tissues or by relaxing the myotatic reflex. Certain PNF methods may increase the strength of opposing muscles, whereas others influence agonist muscle groups. Flexibility or ROM exercises include passive or active, and combined active and passive, movements. Passive movements involve guiding a body part through an ROM with or without a prolonged stretch at the end of the movement. Active ROM involves the slow movement of an extremity of body part until resistance precludes further movement. Several variations in these methods exist.

References

1. Kato Y, Ikata T et al. Effects of specific warm-up at various intensities on energy metabolism during subsequent exercise. J Sports Med Phys Fitness 2000; 40(2):126-130.

2. Shellock FG. Physician Sportsmed 1983; 11(Oct):134-139.

3. American College of Sports Medicine position stand. The recommended quantity and quality of exercise for developing and maintaining cardiorespiratory and muscular fitness, and flexibility in healthy adults. Med Sci Sports Exerc 1998; 30(6):975-991.

4. Genovely H, Stamford BA. Effects of prolonged warm-up exercise above and below anaerobic threshold on maximal performance. Eur J Applied Physiol 1982; 48(Apr):323-330.

5. Johansson PH, Lindstrom L et al. The effects of preexercise stretching on muscular soreness, tenderness and force loss following heavy eccentric exercise. Scand J Med Sci Sports 1999; 9(4):219-225.

6. Shrier I. Stretching before exercise does not reduce the risk of local muscle injury: a critical review of the clinical and basic science literature. Clin J Sport Med 1999; 9(4):221-227.

7. Pope RP, Herbert RD, et al. A randomized trial of preexercise stretching for prevention of lower-limb injury. Med Sci Sports Exerc 2000; 32(2):271-277.

8. Shyne K. Physician Sportsmed 1982; 10(Sept):137-140.

9. CRA. Chiropractic Rehabilitation Standards Manual. Chiropractic Rehabilitation Association, 1989.

10. Surberg PR. Athletic Training 1983; 18(Spr):37-40.

Adjunctive Therapies to the Adjustment High-Heeled Shoes and Musculoskeletal Problems

by K.D. Christensen DC, CCSP, DACRB

Looking good is what counts most! At least, that is what one might conclude, faced with the popularity of high-heeled fashion footwear. Ironically, a recent survey of 620 women established that the majority were dissatisfied with their dress shoes because they hurt their feet, even though most had paid between $50 and $200 per pair. Furthermore, women have about 90% of the nearly 800,000 annual surgeries for neuromas, bunions, and hammer toes. (1) There is a clear link between the types of shoes worn and the development of abnormal foot conditions.

Spotting a high heel is an easy task; convincing patients not to wear them is another story. This information should help you make a strong and logical appeal. Additionally, custom-made shoes — which combine fit, fashion, and the postural support of custom orthotics — are now available, so you can offer a sensible solution.

Forefoot Compression Injuries

A neuroma, also called interdigital neuritis, results from compression of a plantar nerve or a bursa between two metatarsals. The resulting inflammation and fibrosis can diminish both nerve and vascular flow, resulting in a burning sensation that extends into the toes. The most common area involved is between the third and fourth metatarsals but may occur at any site of compression. “A three-inch heel creates seven times more stress on the forefoot than a one-inch heel.” (1)

Brantingham et al. reported the results of a clinical trial involving twenty-nine patients suffering from Morton’s neuroma. The average pre-treatment history of foot pain was nineteen months. All patients received a series of foot manipulations, with the number of treatments ranging from three to twenty-six. The manipulations included mobilization of the metatarsal and MTP joints, forefoot mobilization relative to the rearfoot, ankle mobilization, and specific adjustments of the cuboid and cuneiforms. Additionally, twenty-three (80%) of the patients were fitted with orthotics to control excessive movements and hyperpronation. A follow up, three months after treatment, established that 83% reported moderate to excellent relief of their pain. (2) Adjustments that restore the articulations, combined with flexible orthotics that maintain the corrections, provide a true long-term solution in many cases, but high heels (higher than two inches) are nearly impossible to properly fit with orthotics.

Shoe Styles and Biomechanics

Although the Brantingham et al. study did not comment on modifying footwear, a long history of studies have attempted to link shoe style with altered biomechanics, necessary for the development of these common conditions among women. (3-5) Some of the earliest studies that compared gait in low-heel and high-heel shoes were performed by Schwartz et al. They reported changes in the distribution of weight in the forefoot with a shift away from the fifth metatarsal head in high-heel shoes. (6) Increased weight distribution over the third and fourth metatarsals, combined with the compressive toe box common to most high-heel shoes, is a logical mechanism for the development of a neuroma. Considering that 59% of women surveyed report wearing high-heel shoes at least one to eight hours a day, unless the underlying stress is removed by changing shoe styles, the symptoms associated with neuromas are likely to return. (7)

Loss of Arch Integrity

The same biomechanical derangement responsible for neuroma can cause a hallux valgus and bunion formation. In this condition, one or more of the foot’s three arches has often collapsed or lost integrity, which changes normal toeing off and weight transfer in the forefoot. Lateral deviation of the proximal first phalanx changes the direction of muscle attachments on the great toe. Contraction of these muscles leads to abnormal abduction of the phalanx and the cycle of deviation continues.

An early clue that the patient is losing integrity of the transverse arch is excessive callus formation directly under any of the metatarsal heads, but especially two through four. This is the body’s attempt to lift and pad the fallen structures. Metatarsal corrections built into flexible, custom orthotics can lift the metatarsals from the bases and remove the pressure from the metatarsal heads.

Rearfoot Conditions

Wearing heels also concentrates abnormal forces on the ankle and rearfoot, relative to the forefoot. The tibiotalar joint “is a tightly interlocked joint exposed to extreme mechanical conditions during single limb support” and is susceptible to repetitive, traumatic forces. (8) Anyone who has seen an inexperienced high-heel walker knows exactly what repetitive microtrauma is. The integrity of this joint is ensured by tension produced as the wedge-shaped talus is secured between the malleoli. However, the forced plantarflexion associated with high-heel use decreases the degree of tension, because of the shape of the wedge (wider anteriorly).

Although slight, this loss of tension decreases the optimal biomechanical relationship. According to Kapandji, “there is only a single position of articular congruence for the subtalar joint, i.e. the median position. The foot is then straight without any inversion or eversion and it is the position adopted by a normal foot lying flat on a horizontal plane…” He continues, “this neutral position, where the articular surfaces are kept together by the force of gravity, and not by the ligaments, is stable and can be maintained for a long time owing to the congruence of the articular surfaces. All other positions are unstable and are associated with a variable degree of articular incongruence.” (8)

In extreme cases, the plantarflexion associated with heels may be responsible for injuries as serious as inversion sprains. Remember also, that because of the lack of muscular attachments, the talus is nourished only by a weak blood supply, accompanying ligaments. “Thus it has a barely adequate arterial supply under normal conditions.” (8) This is an unfortunate situation for a bone faced with remodeling in response to repetitive microtraumas.

Conclusion

Whether or not your patient turns an ankle, heels disrupt gait and posture for the entire body. In their study of varying heel heights, Gastwirth et al. make the following observation: “Proximal symptomatology associated with wearing high heels, such as knee, hip and back problems, may in part be related to [a] restriction of subtalar joint pronation. The subtalar joint pronation that normally occurs at heel strike aids in shock absorption. If this pronation is limited, an increased shock wave must be absorbed by the joints proximal to the foot.” (9)

If your female patients continue to wear their high-heeled shoes, despite your best recommendations, it isn’t your fault if you cannot “cure” their every ache and pain,. However, because fashion is still in fashion, your patients will want an alternative to high heels. According to at least one study, it is not necessary to wear completely flat shoes. Only heel heights greater than 5 cm (2 inches) significantly influenced lower extremity mechanics and gait. (10) That may be a compromise that many of your fashion-conscious patients could live with.

References

1. The low down on high heels. AOFAS Online (www.aofas.org/highheels.htm).

2. Brantingham JW et al. Chiropractic management of Morton’s metatarsalgia (Morton’s neuroma): a review of 29 patients. Chiropractic Technique 1994; 6(2):61-66.

3. Craigmile DA. Incidence, origin and prevention of certain foot defects. Br Med J 1953; 2:749.

4. Feinberg H. Women’s fashion shoes. JAPA 1969; 59:360.

5. Gorecki GA. Shoe related foot problems and public health. JAPA 1978; 68:245.

6. Schwartz RP, Heath AL, Misiek W. The influence of the shoe on gait. J Bone Joint Surg 1935; 17:406.

7. The Gallup Organization, Inc. Women’s Attitudes and Usage of High Heel Shoes. August, 1986.

8. Kapandji IA. The Physiology of the Joints (5th ed.). New York: Churchill Livingstone Inc. 1989:148-206.

9. Gastwirth BW, et al. An electrodynographic study of foot function in shoes of varying heel heights. J Am Podiatric Med Assoc 1991; 81:463-472.

10. Ebbeling CJ, et al. Lower extremity mechanics and energy cost of walking in high-heeled shoes. JOSPT 1994; 19:190-196.

Rehabilitation of Running Injuries

by K.D. Christensen DC, CCSP, DACRB

As the number of participants in recreational and competitive running continues to increase, so does the number of Chiropractic patients who need treatment for running-associated injuries. Some researchers have estimated that up to 60% of runners will experience an injury that will limit their activities. [1] While some of these injuries are due to actual trauma, the vast majority fall into the category of overuse syndromes. In these cases, the runner pushed beyond the capabilities of the musculoskeletal system.

Overuse/Microtrauma

Most running injuries are not due to a recent acute injury, but have developed gradually, over a period of weeks or months. These “overuse” or “misuse” conditions are due to excessive and/or repetitive motion. The end result is a microtrauma injury – the body is unable to keep up with the repair and re-strengthening needs, so the tissue begins to fail and becomes symptomatic. If it is not very painful (or if the pain is eliminated by pain-killing drugs), the runner continues to run; eventually complete failure, such as a stress fracture or ligament tear, will result. The causes of these types of injuries are often categorized into extrinsic and intrinsic sources (Table 1). [2]

Extrinsic factors. Causes of microtrauma injuries that are outside of the runner are often the easiest to modify, and should be addressed immediately in treatment. Extrinsic factors include: the training program (such as mileage per week, number of speed or hill workouts, recent mileage increases, and amount of rest time); running surfaces (such as asphalt, artificial track, or natural trails); and equipment (design and materials of running shoes). Modifications in the running routine (such as less mileage on more forgiving surfaces) and newer, better shoes should be introduced at the start of the rehab program for any running injury. One extrinsic source of problems that is often overlooked is the forced pronation and “environmental” leg length discrepancy due to repetitive running on a banked surface, such as along the sides of roads that have with a pronounced slant for water run-off. [3]

Intrinsic factors. The individual variables associated with overuse injuries are either muscle imbalances or structural alignment problems. These factors are more difficult to modify, but a good rehab program should be able to make significant progress once the problem has been identified. In fact, this is actually the most difficult part – recognizing the intrinsic source of the runner’s symptoms. A well-designed examination is necessary to investigate the structural, biomechanical, and dynamic aspects, searching for evidence of muscle imbalances, misalignments, and dysfunctions. Often there are several intrinsic factors that combine to interfere with a runner’s musculoskeletal efficiency and to limit performance. When the runner tries to push harder, the system breaks down and becomes symptomatic.

This type of categorization, however, is overly simplified. When a runner has good alignment and muscle balance, even a strenuous training program is well tolerated. Runners with biomechanical problems, however, can’t withstand even a moderate training program without developing various types of overuse injuries. A change in running surface or shoes may bring out the fact that a runner has an underlying foot or leg alignment problem that had previously gone unrecognized. In other words, the intrinsic and extrinsic factors are closely intertwined, and both contribute significantly to most running injuries.

Implementing Rehab for Runners

First the extrinsic factors must be addressed. This entails changing the training program to decrease stress, selecting different running surfaces, and upgrading the runner’s shoes. Then, all involved intrinsic factors need to be evaluated, and any problem areas are treated. This will often include support for structural alignment and biomechanical improprieties.

Muscle imbalance. Muscle imbalance inhibits normal joint function and limits the functional range of motion. Improving the flexibility of shortened and tight muscles from many miles of running is often necessary. Slow, sustained stretching must be performed regularly. Stretching is possibly most effective when the muscles are warm (at the end of a run). Stretching and gentle, passive movement of involved joints should also be initiated soon after an injury, in order to improve flexibility and prevent adhesions. If an injury is very acute, an initial period of relative rest with cryotherapy may be needed. During this period, though, exercise of the opposite leg should be encouraged. Vigorous exercise of the uninvolved contralateral leg muscles produces a neurological stimulus in the injured muscles (called the “cross-over effect”), and helps to prevent atrophy. [4]

Weaker or injured muscles can be safely strengthened with the use of controlled isotonic resistance exercises. The resistance can come from a machine, from weights, from elastic tubing, or just using the weight of the body. Possibly more important than the equipment used is whether the exercise is done in an open or a closed chain position. The muscles and joints of the leg form part of a closed kinetic chain when the foot is fixed (usually on the ground). Exercises performed in this position mimic the way we use the leg during most daily and sports activities, as they require the co-contraction of accessory and stabilizing muscles.

Alignment problems. Knees, hips, ankles and feet all must be in proper alignment during the repetitive striding performed during running. The arches of the foot are particularly important for providing a combined strength and flexibility to support the stress of body weight during running. Interestingly, the arches are seldom symptomatic in the earlier stages of biomechanical stress, and they are capable of tolerating extreme stresses for long periods before breaking down and failing. This strength is also a weakness, since many foot failures seem to come on suddenly, when they actually have been developing for a long time.

Biomechanics. The structures and the functioning of the foot, ankle, and knee are all exposed to greater stresses during running. The most important biomechanical action during running is the timing and amount of pronation at the foot and ankle. If there is too much pronation, or if the foot stays in pronation too long (prolonged pronation), the biomechanics of gait are altered, and running is less efficient. [5] Excessive pronation also increases the internal rotation of the tibia, placing additional stress on the knee. [6] When running is a dominant component of the recreational choices of an individual, the natural biomechanics must be able to sustain these higher forces.

Current Research

A recent retrospective study looked back at the foot biomechanics of running athletes who reported recent foot and leg overuse problems, and compared them to a control group of uninjured runners. [7] The researchers (three M.D.s and a Ph.D. who work with many athletes and runners) wanted to determine whether excessive pronation (measured while weightbearing) correlated with the likelihood of developing various types of “overload” sports injuries. Specifically, the researchers looked at runners who had needed treatment for iliotibial band syndrome, Achilles tendinitis, stress fracture of the tibia, tibial periostitis, and plantar fascitis.

The amount of pronation during standing and while running at “regular speed” was determined by measuring the angles of the footprints of sixty six injured runners and 216 matched, uninjured control runners. The results are consistent with several other studies that have taken a slightly different approach, but have arrived at similar conclusions. The investigators found a significant correlation: Those athletes with more pronation had a much greater likelihood of having sustained one of the overuse athletic injuries. And they found that the amount of pronation seen in the static weightbearing footprint was more predictive than the footprint obtained during running. This reinforces the value of checking the alignment of our running patients’ feet in the standing position.

Shoe Inserts and Orthotics for Runners

A shoe insert made of viscoelastic material will help decrease the amount of stress on the feet, legs, and back during running. [8] If there is either excessive pronation or a high-arched foot, additional calcaneal and medial arch support will often need to be supplied by an orthotic.

Biomechanical efficiency. Orthotics have been found to be very useful in the long-term improvement of running biomechanics. [9] While there is still controversy regarding exactly how and why orthotics are so useful, [10,11] there is solid empirical evidence of their benefits to runners, for both treatment and prevention of overuse injuries. [12]

Shock absorption. Running exposes the joints, muscles, and connective tissues to high levels of repetitive stress. For patients with any tendency to develop overuse injuries, additional dispersion of these ground reaction forces is an important part of their treatment and rehabilitation. Even healthy young athletes who expose their knees to frequent pounding (runners, ball players, etc.) should be supplied with shock-absorbing insoles to decrease the stress transmitted from the feet into their knee and hip joints.

Conclusion

Overuse injuries in runners are a good example of the individual interacting strenuously with the environment. Problems can arise from either the environment (extrinsic factors) or the individual’s biomechanics (intrinsic factors). Rehabilitation needs to consider both sources of structural stress and strain, and then apply cost-effective treatments. Immediate treatment will include modifications of training and improvements in muscle balance – stretching of tight muscles and strengthening of weakened areas. For long-term improvement, biomechanical alignment problems will need to be addressed – often with the addition of custom-fitted sport orthotics. Failure to recognize these intrinsic complicating factors will result in a patient with recurring, and possibly variable complaints. A comprehensive approach to rehabilitation of running injuries provides the best hope for many years of recreational enjoyment.

References

1. Jacobs SJ, Berson BL. Injuries to runners: a study of entrants to a 10,000 meter race. Am J Sports Med 1986; 14:151-155.

2. Lysholm J, Wiklander J. Injuries in runners. Am J Sports Med 1987; 15:168-171.

3. Subotnick SI. ed. Sports Medicine of the Lower Extremity. New York: Churchill Livingstone, 1989:193.

4. Hertling D, Kessler RM. Management of Common Musculoskeletal Disorders (2nd ed.) Philadelphia: JB Lippincott, 1990:334.

5. Martin PE, Morgan DW. Biomechanical considerations for economical walking and running. Med Sci Sports Exerc 1992; 24:467-474.

6. Coplan JA. Rotational motion of the knee: a comparison of normal and pronating subjects. J Orthop Sports Phys Ther 1989; 11:366-369.

7. Busseuil C. et al. Rearfoot-forefoot orientation and traumatic risk for runners. Foot & Ankle Intl 1998; 19:32-37.

8. Schwellnus MP, Jordaan G, Noakes TD. Prevention of common overuse injuries by the use of shock absorbing insoles. Am J Sports Med 1990, 18:636-641.

9. Gross ML, Napoli RC. Treatment of lower extremity injuries with orthotic shoe inserts. Sports Med 1993; 15:66-70.

10. Nigg BM, Nurse MA, Stefanyshyn DJ. Shoe inserts and orthotics for sport and physical activities. Med Sci Sports Exerc 1999; 31:S421-428.

11. Nawoczenski DA, Ludewig PM. Electromyographic effects of foot orthotics on selected lower extremity muscles during running. Arch Phys Med Rehabil 1999; 80:540-544.

12. Gross NL, Davlin LB, Evanski PM. Effectiveness of orthotic shoe inserts in the long-distance runner. Am J Sports Med 1991; 19:409-412.

CAUSES OF MICROTRAUMA INJURIES
Extrinsic Factors Intrinsic Factors
training program muscle imbalance
running surfaces structural alignment
equipment (shoes) biomechanical function

Rehabilitation of the Hip

by K.D. Christensen DC, CCSP, DACRB

By virtue of its deep-socketed bony anatomy, the hip is a very stable joint. The intrinsic stability of the hip joint is further enhanced by a very thick joint capsule reinforced by strong spiral ligaments, and several powerful groups of muscles. [1] It is injured much less commonly than joints such as the shoulder, knee, and ankle; [2] however, since hip problems can be very disabling, it is vital to have a treatment and rehabilitation program which can return patients to full function. Simple daily activities such as walking down stairs, getting to the bathroom, and even turning in bed can be difficult for a patient with a hip problem. Athletes, both the highly competitive and the recreational, can be put out of commission by pain in or around the hip joint. This is because the hip forms a vital link in the lower extremity kinetic chain — transferring ground-reaction forces from the legs to the trunk during gait. While some hip problems are due to trauma, many conditions are secondary to overuse or misuse. Osteoarthritis of the hip joint is often an end-result, following years of improper biomechanics and dysfunction.

Most hip problems seen by doctors of Chiropractic have developed gradually, over a period of weeks, months, or even years. Common examples include: trochanteric bursitis, recurrent muscle strains (hamstrings, adductors), piriformis syndrome, snapping hip, and chronic degenerative changes (hip joint DJD). A successful and appropriate exercise program for the hip does not require expensive, joint-specific equipment. In fact, the low-tech approach can be very effective for the treatment of most hip conditions. With an understanding of normal hip joint function, knowledge of the involved muscles, and simple home exercise equipment, doctors of Chiropractic can readily help their patients with hip complaints.

How to Rehab the Hip

Stretching and passive motion. For some hip problems, improving the flexibility of short and tight muscles is necessary. Muscle imbalance inhibits normal joint function and limits the functional range of motion. Frequent, gentle and sustained stretching of specific muscle groups should be demonstrated to the patient, who can usually start the stretching immediately, even in the early stages after an injury. Slow, passive movements of the joint should also be initiated soon after an injury, in order to prevent the formation of adhesions. If an injury is very acute (with muscle swelling), an initial period of relative rest with cryotherapy may be needed. During this period, though, exercise of the opposite leg should be encouraged. Vigorous exercise of the contralateral leg muscles produces a neurological stimulus in the injured muscles (called the “cross-over effect”), which helps to prevent atrophy. [3] This is most easily done by “single-leg cycling” on a stationary bike or water exercise using the non-injured leg.

Piriformis syndrome and trochanteric bursitis are the two hip conditions which benefit from specific stretching exercises. In both of these, tight muscles contribute to an overuse condition which irritates sensitive tissues. Piriformis syndrome develops when a tight piriformis muscle inflames the sciatic nerve, causing posterior hip aching along with paresthesiae down the back of the leg, in the sciatic distribution. Since the piriformis is an external rotator of the hip, treatment must include inward rotation stretches for the piriformis muscle. Complete Chiropractic care will also encompass corrections of subluxations and biomechanical faults of the pelvis, as well as predisposing factors — such as an anatomically short leg and/or foot pronation. [4] Trochanteric bursitis causes pain at the lateral aspect of the hip, where a shortened iliotibial band crosses over the greater trochanter, irritating the protective bursa. Localized pain in this area, along with a positive Ober’s test, indicates the need for stretches to lengthen this long segment of connective tissue. Again, correction of abnormal biomechanics, such as leg length discrepancies, must be part of the treatment [5], and foot orthotics may be needed. [6]

Isotonic resistance exercise. Weaker or injured muscles can be quickly strengthened with the use of isotonic resistance exercises. The resistance can come from a machine, from weights, from elastic tubing, or just using the weight of the body. Since the hip functions as part of a closed kinetic chain during most daily and sports activities, weight-bearing exercises which require the co-contraction of accessory and stabilizing muscles can be most effective. Open-chain exercising (done with the foot and lower leg freely moving) are most helpful in the early stages of hip rehab, to reduce the stress on the surrounding muscles.

Open chain exercising can be started very early with a symptomatic hip, since it doesn’t require the musculoskeletal structures to bear the weight of the body. The easiest method is to extend the entire leg against the resistance of elastic tubing. This can also be accomplished with the knee bent and in a sitting or recumbent position with the tubing attached around the thigh. Initial exercising should be done with a limited amount of movement — within a “pain-free” range of motion. These exercises are particularly useful for patients who have an injured muscle, or a chronic muscle imbalance, which can develop into a “snapping hip” syndrome. Surprisingly, strengthening of the muscle and tendon involved in a “snapping” hip (such as the tensor fascia lata, iliopsoas, or biceps femoris muscles) is reported as more useful than stretching for resolving the snapping. [7] Rehab for degenerative arthritis of the hip should also start with open chain exercising, since the joint is more safely exercised when the damaged cartilage is not bearing weight directly. As the patient progresses, additional resistance can safely be supplied with heavier tubing.

Weight-bearing strengthening exercises, with the foot on the floor, should be included when an athlete is preparing to return to sports activities. Examples of closed chain exercises include partial squats, lunges (forward, back, and to the side), and step-ups or stair-climbing. Initially, body weight will be sufficient. Resistance can be gradually and progressively increased with the use of hand weights or a weight bar. A closed chain exercise which is available at many gyms is the leg press machine; however, this machine does not re-train the co-contraction of accessory hip support muscles as fully as weight-bearing exercises do.

Proprioception and coordination. It is important for athletes (whether recreational or competitive), to regain the fine neurological control necessary for accurate hip and lower extremity movements. Stimuli from articular and muscle mechanoreceptors must be modulated with efferent responses to maintain “dynamic joint stability.” [8] This means that some time (five to ten minutes each day) should be spent exercising while standing on one leg, with the eyes closed, while standing on a mini-tramp, or using a rocker board. The advantage of these balance exercises is seen when patients return to sports activities and can perform at high levels without consciously having to protect their hip or leg. Rocker board exercises are especially necessary for injuries, but can also help patients who have degenerative arthritis of the hip to gain improved function.

Plyometric exercise. Advanced exercises designed to develop explosive power and eccentric responses of the hip muscles are needed to re-establish the rapid responses necessary for good performance in many sports. Building strength during the eccentric (lengthening) phase of contraction and overloading the stretch response with plyometric exercises are often the missing component in recurrent hip muscle strains. Plyometric exercises include jumping with rapid returns, “bounding” style of running, and dropping off a box and quickly jumping up as high as possible. These types of exercises are part of the final phase of rehab for all athletes who hope to return to full function after a hip injury. Sedentary patients and those who do not need to develop this level of specialized muscle contractions usually do not need to progress into this part of hip rehab.

Functional alignment. Many of the chronic and overuse hip problems seen by doctors of Chiropractic develop secondary to an imbalance in weight-bearing alignment of the lower extremities. Alignment problems will need to be addressed in order to resolve the patient’s current symptoms and to prevent hip arthritis. Leg length discrepancies and foot pronation problems are frequently found in association with trochanteric bursitis, iliotibial band syndrome, and piriformis syndrome. Studies have found that osteoarthritis is much more common in the hip joint of a longer leg. [9] Recurrent muscle strains, especially hamstring and groin pulls, often occur secondary to an asymmetry in structural alignment. The use of custom-fitted orthotics and/or heel lifts is frequently a necessary part of a comprehensive hip rehab program.

Shock absorption. Asymmetrical loss of joint space is evidence of degenerative change at the joint surfaces and erosion of cartilage. In addition to proper nutrient support, additional dispersion of ground reaction forces will be necessary by providing shock-absorbing insoles. Many recreational athletes can avoid developing hip problems when they are fitted with orthotics which support the feet and ankles, and limit the forces on the hip joints. Shock absorbing orthotic supports provide almost immediate symptom relief for many patients with chronic, degenerative hip symptoms.

Conclusion

An appropriate and progressive rehab program should be started early in the treatment of patients with hip complaints and sports injuries. [10] Several rehab techniques are available, none of which require expensive equipment or great time commitments. Selecting the best exercise approach for each patient’s hip problem is not difficult. A closely monitored home exercise program allows the doctor of Chiropractic to provide cost-efficient, yet very effective rehabilitation care.

Since biomechanical alignment problems are frequently found in association with chronic hip complaints, patients must be screened for excessive pronation and/or leg length discrepancies. Failure to recognize these complicating factors will result in patients with recurring hip complaints, or symptoms that vary in location due to the effects of the underlying biomechanical stress. When the lower extremities are properly aligned, the muscles are strengthened and lengthened, and the hip joints work smoothly, patients will be able to enjoy the benefits of independent mobility well into their elder years.

References

1. Hertling D, Kessler RM. Management of Common Musculoskeletal Disorders (2nd ed.). Philadelphia: JB Lippincott, 1990:280.

2. Geraci MC. Rehabilitation of the hip, pelvis, and thigh. In: Kibler WB, ed. Functional Rehabilitation of Sports and Musculoskeletal Injuries. Gaithersburg, MD: Aspen Publishers, 1998:216.

3. Hertling D, Kessler RM. Management of Common Musculoskeletal Disorders (2nd ed.). Philadelphia: JB Lippincott, 1990:334.

4. Souza TA. Differential Diagnosis for the Chiropractor: Protocols and Algorithms. Gaithersburg: Aspen Publishers, 1998:134.

5. Souza TA. Differential Diagnosis for the Chiropractor: Protocols and Algorithms. Gaithersburg: Aspen Publishers, 1998:263.

6. Subotnick SI. Sports Medicine of the Lower Extremity. New York: Churchill Livingstone 1989:312.

7. Souza TA. Differential Diagnosis for the Chiropractor: Protocols and Algorithms. Gaithersburg: Aspen Publishers, 1998:265.

8. Laskowski ER, Newcomer-Aney K, Smith J. Refining rehabilitation with proprioception training. Phys Sports Med 1997; 25:89-102.

9. Friberg O. Clinical symptoms and biomechanics of lumbar spine and hip joint in leg length inequality. Spine 1983; 8:643-645.

10. Heiser JR. Rehabilitation of lower extremity athletic injuries. Contemp Podiat Phys 1992; Aug:20-27.

Adjunctive Therapies to the Adjustment Functional Re-Training and Spinal Support

by K.D. Christensen DC, CCSP, DACRB

Choosing the best exercises for patients with back problems requires judgment based on clinical experience and scientific evidence. There are many approaches to rehabilitation, and lots of different types of exercises are available, but patients have a limited amount of time (and willingness) to exercise. Therefore, we must always try to give our patients the most effective exercises for their condition. But, what are the “best” exercises for chiropractic patients?

Exercise Selection

The best exercises for a specific patient are those that will be rapidly effective, are easy to learn and perform, and are safe (they don’t worsen the current condition or aggravate other problems). The exercises must help the patient to regain normal alignment and easy, natural movement. And the end result should include a decreased chance of similar, recurring problems.

A successful and appropriate exercise program for the back and/or neck may not require expensive, joint-specific equipment. While high-tech machines are very useful and helpful particularly in the research lab, current rehab concepts recognizes the value of the low-tech approach. In fact, the low-tech approach can be very effective for the treatment of most spinal conditions. Additional personnel, high-tech equipment, more office space are usually not essential for general results but may be helpful in various situations. With an understanding of normal spinal function, knowledge of the involved muscles, and some updating of exercise concepts, doctors of chiropractic can effectively rehab their patients with simple exercise equipment.

Specific Adaptation to Imposed Demands

This concept (sometimes shortened to the acronym SAID) is one of the basic tenets of the strength and conditioning field. (1) It describes the observation that our bodies will predictably change in response to the demands that are placed on them. If we frequently perform aerobic activities, then our lungs, hearts, and muscles become more efficient at taking in and processing oxygen. When we spend more time in activities requiring force and providing resistance, our bodies develop more muscle mass, and we become stronger. And, if we practice our balance and coordination, we improve our ability to function easier on an unstable surface (such as on a rolling ship or a pair of skates). In fact, these improvements in our abilities are quite specific, and we become better at doing whatever it is that we do most often.

It has taken quite a while for those who specialize in the treatment of the spine to incorporate this idea into neck and back rehab programs. Recently, some of us have begun to use the same thought processes to design spinal exercises that we have used for decades to determine appropriate x-ray positions. As chiropractors, we do recognize that the spine functions very differently when it is not weight-bearing. We now know that a method to help our patients return to normal function is with exercises that mimic as closely as possible the real conditions under which the spine must function day after day. That generally will include the specific stress of gravity in the upright position or functional posture.

Closed Kinetic Chain

The spine is part of a closed kinetic chain when it is bearing weight. This is the manner in which we use the joints and connective tissue of the spine during most daily and sports activities, and it requires the co-contraction of accessory and stabilizing muscles. Weaker or injured muscles can be quickly strengthened with the additional use of isotonic resistance to stimulate increases in strength. Isotonic resistance can come from a machine, from weights, from elastic tubing, or just using the weight of the body. Also important is whether the spinal support structures are exercised in an open or a closed chain position. Open-chain exercises for the spine are done non-weight bearing, while either lying on the ground or immersed in water (which removes much of the effect of gravity). Both floor-based and water-based exercises have usefulness, especially during the acute stage. However, there may be a difference in functional end results.

A good example of this is a study comparing closed vs. open kinetic chain exercises for the training of the thigh muscles. The investigators wanted to improve the subjects’ vertical jump height. Two groups exercised twice a week at maximal resistance – one group doing closed chain exercises (barbell squats), and the other working on the knee extension and hip adduction weight machines (open chain exercising). At the end of six weeks both groups had gained considerable strength, but the closed chain exercisers were the only ones who improved significantly in the vertical jump. (2) Since jumping is a closed chain activity, the SAID concept tells us to expect that closed chain exercising generally will be more effective.

Exercising the Spine in a Functional Position

We know that the origins and insertions of many muscles change when going from standing to lying down. Certainly the proprioceptive input from receptors in the muscles, connective tissues, and joint capsules is very different between the two positions. This is why it is so important to also bring neck and back rehab exercises closer to real-life positions, and it explains why patients make rapid progress when they are taught to exercise in a functional position.

Patients may need during the acute phase of recovery to exercise when lying down. Floor-based exercises train muscles and joints to begin to accept function in normal posture. The neurological patterns that are developed on the floor or in a pool assist in improving upright activities. However, learning new skills and habits on the floor may not translate to better functioning during all upright activities. The time and effort patients spend on open chain exercises is prepatory to more functional patterns and generally is not all that should be provided.

Exercising in a weight-bearing position is generally accepted by most patients. In addition to being focused and practical, upright exercising trains and strengthens the spine to perform in everyday activities. Patients recognized the value of doing exercises that clearly prepare them for better function during normal activities of daily life.

Exercises for Back Pain

When investigators want to test treatments, they always need to have a “control” group, which is given a treatment that is known to be ineffective. A recent study on back pain published in the respected journal Spine taught several popular low back exercises to the control group. As with other studies, the researchers reported no improvement using these exercises. (3) The six exercises considered a “sham” treatment included: knee-to-chest stretches, partial sit-ups (“ab crunches”), pelvic tilts, hamstring stretches, “cat and camel”, and side leg lifts. The problem with these back exercises if they are the exercises only ones performed is that the joints, discs, muscles, and connective tissues are not bearing weight during the exercise; therefore, the movements performed while exercising do not prepare or retrain these structures for daily activities. On the other hand, if exercises are also prescribed and performed with the spine upright (standing or sitting) against resistance specifically train and condition all involved structures to work together smoothly. Thus, effective exercises given are those that are performed upright or functional.

Proprioception and Balance

For many athletes (whether recreational or competitive), it is important to regain the fine neurological control necessary for accurate spinal and full body performance. This means that about five to ten minutes of each workout can be spent exercising while standing on one leg, with the eyes closed, while standing on a mini-tramp, or using a special rocker board. The advantage of these balance exercises is seen when patients return to sports activities and can perform at high levels without consciously having to protect their back. Back exercises done on a rocker board or while standing on one leg are useful since the entire body is in a dynamic position during the exercises. The stabilizing muscles, the co-contractors, and the antagonist muscles all have to coordinate with the major movers during movements that are performed. This makes these types of exercises very valuable in the long run, particularly for competitive athletes.

Functional Alignment

Many chronic spinal problems develop secondary to an imbalance in weight-bearing alignment of the lower extremities. In fact, lower extremity misalignments such as leg length discrepancies and pronation problems are frequently associated with chronic pelvis and low back symptoms. (4) Any of these that are present will need to be addressed in order to resolve the patient’s current symptoms and to prevent future back problems. The use of adjustments, exercises, and custom orthotics for the lower extremities is especially critical when a functional approach is taken. The effects of weight bearing and the alignment of the kinetic chain must be considered.

Conclusion

Selecting the best exercise approach for each patient’s back problem is important. A well-designed exercise program allows the doctor of chiropractic to provide cost-efficient, yet very effective rehabilitation care. Exercises performed with the spine functional will ultimately specifically train and condition all the involved structures to work together smoothly. The end result is a more effective rehab component and patients who make a rapid response to their chiropractic care. When you persist with this, you will experience dramatic improvements in patient outcomes.

References

1. Fleck SJ, Kraemer WJ. Designing Resistance Training Programs. Champaign, IL: Human Kinetics, 1987.

2. Augustsson J et al. Weight training of the thigh muscles using closed vs. open kinetic chain exercises: a comparison of performance enhancement. J Orthop Sports Phys Therap 1998; 27:3-8.

3. Snook SJ et al. Reduction of chronic nonspecific low back pain through the control of early morning lumbar flexion — a randomized controlled trial. Spine 1998; 23:2601-2607.

4. Rothbart BA, Estabrook L. Excessive pronation: a major biomechanical determinant in the development of chondromalacia and pelvic lists. J Manip Physiol Therap 1988; 11:373-379.

Adjunctive Therapies to the Adjustment Pelvic Unleveling

by K.D. Christensen DC, CCSP, DACRB

The most useful method for determining pelvic unleveling is to examine the patient in normal, upright posture. Much of the confusion surrounding this topic is then eliminated, and treatment decisions are simplified. Whenever we check a patient on the treatment table, whether prone or supine, errors of positioning are introduced (and are very difficult to exclude). Measurements of pelvic balance obtained in the non-weight bearing position have been found to be very unreliable. (1) In a relaxed, upright posture, these confounding factors are no longer a factor. Accurate clinical and radiographic determinations are then possible, (2) and effective chiropractic care can proceed.

Determining Anatomical Source

When evidence of pelvic unleveling has been identified in the standing position, efficient treatment depends on the anatomical source of the misalignment. Either the pelvis or the lower extremities must be the cause of the biomechanical imbalance. If the pelvis is the source, then treatment will need to be directed to this region. When the cause is in the lower extremities, successful care can be expected only with evaluation and correct treatment of the foot, ankle, or leg asymmetry. Since the lower extremities provide the foundation and support for the pelvis during standing and walking, it is not surprising that they can have a profound effect on the alignment of the pelvis (and the spine, as well).

Determination of Causal Factors

Whether the pelvic unleveling originates in the pelvis or in the lower extremities, there are only two possibilities — the cause must be an anatomical asymmetry, or a functional imbalance. Anatomical sources include growth asymmetries, anomalies, and post-fracture discrepancies. Functional problems encompass subluxations and biomechanical imbalances. Since these two categories are treated very differently, they must be separately identified. Here are the details of these two causes in the two regions:

In the Pelvis

Anatomical asymmetry. A very small percentage of patients will demonstrate pelvic unleveling due to a growth asymmetry or an old fracture of an ilium. The innominate bones can develop with a substantial difference in height, although this is rare. Luckily, it also is the least likely of the categories under discussion to cause symptoms. For sedentary patients, an ischial lift (a wedge under the “sit-bone” of the smaller side) can prevent problems from developing when seated for long periods of time. For most patients, standard chiropractic care of biomechanical problems in the spine and pelvis is sufficient.

Functional imbalance. Much more common in the pelvis is a biomechanical source of pelvic unleveling, with sacroiliac joint subluxations. This condition can be caused by work postures, recreational habits, or just a broken-down chair at home. Muscle imbalances are frequently part of this syndrome, with weakness of the hip extensor muscles being most common. Tightness of a psoas muscle, or shortening of the hamstrings from excessive sitting can also contribute to pelvic unleveling. An “antalgic” posture in response to acute pain and inflammation of the lower spinal joints often results in a difference in height of the iliac crests.

Treatment should include specific stretches targeted to shortened muscles, with strengthening and stabilizing exercises for weak or poorly coordinated muscles. Careful, specific adjustments of the pelvis and lumbar spine are necessary, in order to regain normal pelvic biomechanics and full function of the region.

In the Lower Extremities

Anatomical asymmetry. Some patients have a difference in the anatomical components of the lower extremities that results in pelvic unleveling. This may be due to a fracture of the tibia or femur, which healed with persisting shortness. Much more likely is a simple growth asymmetry. In fact, it is quite amazing that most of us have no significant difference in the length of our legs. Somehow, most legs grow to an equal length at adulthood. Those that end up with a difference in length over 9 mm. (measured while standing) have a higher incidence of low back pain. (3) Athletes and those who spend a lot of time on their feet may develop chronic symptoms with 5 mm. or just 3 mm. of discrepancy. (4)

Functional imbalance. The most commonly seen cause of pelvic unleveling is loss of support from the lower extremity — from the foot, in particular, due to collapse of the medial arch. When the arch drops (excessive pronation), the leg rotates medially, and the femur head drops, causing an unlevel pelvis. Excessive pronation may occur from a young age, through lack of development of the arch; but most commonly it occurs in later years, when the ligaments that support the arches undergo plastic deformation. Since this process usually happens gradually, over many years, there is often no significant foot pain. The patient with this condition begins to develop chronic low back and pelvis problems, but doesn’t describe any foot symptoms. Therefore, the doctor of chiropractic must always have an index of suspicion, and include a lower extremity postural exam in the evaluation of most new patients. Whenever there is evidence of pelvic unleveling, investigation of the feet and ankles, along with inspection of shoe wear patterns, is necessary.

Lift vs. Orthotic

It is very important to recognize the functional short leg, since providing a lift instead of an orthotic is likely to perpetuate the associated sacroiliac subluxations. (5) And there is no reliable information on the radiographs to differentiate these conditions. A pelvic tilt, a lower sacral base, and a femur head discrepancy indicate a lower extremity source, but not whether it is an anatomical or a functional short leg. The clinical postural exam with lower extremity screening is the only way to make this determination. If there is any doubt, the safest approach is to fit the patient with flexible, custom-made orthotics, initially. If there is a persisting pelvic tilt after wearing the orthotics for several weeks and receiving chiropractic adjustments, a heel lift can then easily be added to the orthotic for complete correction.

Conclusion

Once pelvic unleveling has been found in a patient, effective treatment can be planned. The first step is to differentiate whether the source of the imbalance is in the pelvis or the lower extremities. This may require accurate, standing radiographs taken without projectional distortion. Then, a determination of anatomical asymmetry or functional imbalance will help guide treatment. Most commonly, the lower extremities are not providing the necessary support for the pelvis. In many cases, orthotic support for foot pronation, knee rotation, or femur angulation is needed. Those few patients with a true anatomical leg length discrepancy will need to be supplied with the appropriate lift. The additional time required to determine the source of the pelvic unleveling will be repaid in more effective chiropractic care, and adjustments that last. The gratitude of patients who have finally found a doctor who is interested enough to individualize their treatment will help build a tremendous practice. This level of service ensures a great future for chiropractic, no matter what the insurance companies say or do.

References

1. Woerman AL, Binder-MacLeod SA. Leg length discrepancy assessment: accuracy and precision in five clinical methods of evaluation. J Orthop Sports Phys Therap 1984; 5:230-238.

2. Friberg O et al. Accuracy and precision of clinical estimation of leg length inequality and lumbar scoliosis: comparison of clinical and radiological measurements. Int Disabil Studies 1988; 10:49-53.

3. Giles LGF, Taylor JR. Low back pain associated with leg length inequality. Spine 1981; 6:510-511.

4. Subotnick SI. Limb length discrepancies of the lower extremity; the short leg syndrome. J Orthop Sports Phys Therap 1981; 3:11-16.

5. Rothbart BA, Estabrook L. Excessive pronation: a major biomechanical determinant in the development of chondromalacia and pelvic lists. J Manip Physiol Therap 1988; 11:373-379.

Adjunctive Therapies to the Adjustment Ligament and Muscle Stress

by K.D. Christensen DC, CCSP, DACRB

Muscles and ligaments are normally exposed to stress throughout life. Their structure is such that they respond and adapt to the usual amount of stress exposure. Damage occurs when the muscle or connective tissue is exposed to higher than usual stress levels. This can be a single, sudden excessive stress, or the result of repetitive stress to the muscle or ligament. In either case, the doctor of chiropractic must determine how the damage occurred, and then make appropriate recommendations to help the body heal the injury and to prevent a recurrence.

Problems can also develop when these tissues are not exposed to sufficient regular stress to maintain functional health. It’s important to recognize that there is a “continuum,” or spectrum of usual stress to the tissues in the body, and that categorizing a patient’s level of use helps in the planning of treatment and exercise regimens.

The Continuum of Use

What we usually consider to be normal use is in the mid-range of the use continuum. At one far end is paralysis, when the skeletal muscles and ligaments are completely unused. Close to paralysis is immobilization, such as in a cast or with bedrest. The difference between these is that paralysis lacks a neurological stimulus, called “tone,” which is present in immobilized (yet still neurologically intact) muscles and skeletal ligaments. (1) Next is sedentarism, when the ligaments and muscles are used only minimally. Unfortunately, this condition is becoming more common in all age groups in our rich, advanced society, which has so many labor-saving devices. Normal use can vary widely, but requires the intermittent and regular exercise and use of all muscles and ligaments. Those who are employed in active (usually blue-collar) jobs and people who engage in regular, active recreational pursuits fall into the strenuous use category. And then there are the athletes, who are always trying to improve and push their limits by specifically building and strengthening their muscular and skeletal ligament tissues. They are at the far end of the continuum, demonstrating the body’s response to progressive overload.

Paralysis. When the muscles and ligaments are not used at all, their functional properties rapidly diminish. The combination of muscle atrophy and ligament stiffening produces joints which do not function smoothly or easily. In some cases, the complete lack of use causes calcium to infiltrate into the soft tissues, resulting in heterotopic ossification. (2)

Immobilization. When a joint or extremity has been immobilized, atrophy sets in rapidly. The muscles shrink and the ligaments get stiffer and weaker. In fact, within a month, an immobilized muscle will lose up to one half its normal size. (3) After just one week of immobilization, a 20% decline in muscle strength has been measured! (4) Ligaments which have been immobilized for two months have been found to have only about half of their functional strength and resistance to stretch and injury. (5)

Sedentarism. In today’s society, we are able to avoid most physical efforts which were previously necessary to put food on the table and keep our homes warm. As a matter of fact, most of our patients no longer have to perform any significant physical labor. The result is several problems: overweight, de-conditioning, hypertension, and poor fitness in general. One in three Americans is clinically obese (defined as 20% or more above normal weight), and more than half are overweight. (6) This new reality causes problems for doctors of chiropractic who attempt to return patients to all capabilities; they find that many of their patients are too out of shape to maintain normal spinal function. Among other terms, this condition has very appropriately been called the “disuse syndrome.” (7)

Normal use. Throughout most of our existence, humans have needed to perform a variety of physical activities every day. Some strength was needed, as was a certain amount of flexibility and endurance. This began to change when the Industrial Revolution required certain repetitive movements, and now has been modified by our labor-saving inventions over the past century.

Strenuous use. By exercising regularly and participating in recreational sports, some of our patients work their ligaments and muscles harder than most. Some occupations place more than the usual stress on the feet, legs, and spine of some patients. This is beneficial, so long as the use does not exceed the body’s response to the stress. However, these are the patients who are susceptible to repetitive injuries, due to ongoing, stressful use which eventually overcomes the ability to strengthen muscle and ligaments.

Progressive overload. Athletes who push their bodies to continuously improve their performance take advantage of our innate ability to respond to stress by building strength. In response to gradually increasing loads, the muscles and ligaments strengthen and improve their function. (8) Many factors must be considered when designing and implementing these types of programs, so that injury can be avoided. (9)

Overuse and Damage

The muscles and ligaments in any of the above categories can be overused and damaged. Less stress is needed to cause injury to tissues in the lower use end of the continuum. After several days of immobilization, or when someone has been on bedrest or is a couch potato, even mildly strenuous effort can be too much. Fitness protects from some injuries, especially overuse conditions of the spine. Athletes who are regularly pushing their muscles and ligaments are most likely to end up with either overuse or acute injuries. There are two major categories of excessive stress to ligaments and muscles — repetitive use (chronic, over time), and sudden injury (strain or sprain) with tissue tearing.

Repetitive overwhelm. As discussed above, when the muscles and ligaments are stressed, they respond by repairing and strengthening. In some cases, however, the physical stress occurs so frequently that this process is overcome, resulting in damage. Examples include: runners who quickly increase their mileage, workers who are placed in a new position which requires repetitive movement or bending, and athletes who practice throwing to the point that they injure their shoulders. Even someone taking up walking after years of standing on rigid flooring can quickly overwhelm the foot’s ability to strengthen, developing plastic deformation of the plantar fascia with arch collapse.

Acute injury. Of course, trauma to a ligament or muscle is a single episode of stress which causes damage. When a muscle or ligament is torn, there is immediate pain, followed by swelling and loss of function. Around the spine, this is often a complex injury, since it is inevitable that several layers of both muscles and connective tissues will have been damaged (a “strain/sprain” injury). Understanding of the healing response is necessary for good management of acute injuries to muscles and ligaments, wherever their location.

Healing Response

Whether damaged by repetitive overuse or by acute injury, muscles and ligaments will heal most rapidly and completely when they are treated properly. A brief period of “relative rest” is important; the amount depending on the extent of injury. This may require one to four days of immobilization of the damaged region, followed by gradual reintroduction of movement and activity. (10) Then reactivation is necessary; this usually requires specific exercise instruction and expert guidance. The patient should be encouraged to return to the level of pre-injury, and then advised on preventing further injury, either by providing additional response time or by improving muscle strength and balance (or both). Occasionally, ligaments become damaged and deformed to the point that full repair is not possible. In these cases modification of stress may be necessary, either through changes in activities or through the use of supports, such as knee braces or custom foot orthotics.

Conclusion

It is vitally important to understand the status of a patient’s muscle and ligament tissues prior to injury. And then it’s also necessary to realize how these tissues became overwhelmed: Was it an acute injury, or can a history of repetitive insult be elicited? Once the doctor of chiropractic has the information for the “start point” and an understanding of the method of stress damage, the treatment can proceed rapidly. This is what separates caring doctors of chiropractic from those providers who prescribe drugs or bedrest for ligament and muscle injuries.

References

1. Schafer RC. Clinical Biomechanics: Musculoskeletal Action and Reactions, 2nd ed. Baltimore: Williams & Wilkins; 1987.163.

2. Resnick D, Niwayama G. Diagnosis of Bone and Joint Disorders, 2nd ed. Philadelphia: WB Saunders; 1988.3127.

3. Guyton AC. Textbook of Medical Physiology, 5th ed. Philadelphia: WB Saunders; 1976.145.

4. Noonan TJ, Garrett WE. Muscle strain injury: diagnosis and treatment. J Am Acad Orthop Surg 1999; 7:262-269.

5. Noyes FR. Functional properties of knee ligaments and alterations induced by immobilization. Clin Ortho Rel Res 1977; 123:210-242.

6. [NA]. Update: prevalence of overweight among children, adolescents, and adults — United States, 1988-1994. MMWR Morbid Mortal Wkly Rep 1997; 46:199-202.

7. Bortz WM II. The disuse syndrome. West J Med 1984; 141:691-694.

8. Frank C, Amiel D, et al. Normal ligament properties and ligament healing. Clin Ortho Rel Res 1985; 196:15-25.

9. Baechle TR. Essentials of Strength Training and Conditioning. Champaign: Human Kinetics, 1994.

10. Jarvinen MJ, Lehto MUK. The effects of early mobilisation and immobilisation on the healing process following muscle injuries. Sports Med 1993; 15:78-89.

Adjunctive Therapies to the Adjustment Improving Proprioceptive Balance with Orthotic Support

by K.D. Christensen DC, CCSP, DACRB

Recently published research has shown that custom orthotic support can help improve structural alignment (1), balance (2), gait (3), and athletic performance. (4) This is quite an extensive list of benefits. How can all of these claims be justified from the use of a single adjunctive therapy?

There is a reason so many changes (both in physical function and in symptoms) are reported with the use of custom-fitted orthotics. This large universe of improvements is due primarily to the sense of proprioception — one of the most important neurological systems of the body. A quick review of the mechanisms and components of proprioception will help us comprehend how patients can demonstrate such a large variety of improvements. Being able to explain this to patients (using simpler terms, of course) will help them understand the reasons you are recommending they wear in-shoe orthotics.

Specialized Sensory Organs

Proprioception is defined as “sensing the motion and position of the body”. (5) Specialized nerve endings are present throughout the soft tissues of the musculoskeletal system which interact with the central nervous system and coordinate our body movements, our postural alignment, and our balance. Athletic activities, in particular, rely on this delicately controlled and finely-tuned system of receptors and feedback loops, as well as the validity of the information which is sent into the spinal cord. This coordination normally allows for appropriate motor responses — and in some special cases, artistic physical performances.

Proprioceptive sensory organs are found in two distinct groups which are located in either muscles and tendons, or within the connective tissues (ligaments and capsules) of joints (Table 1). These specialized nerve fibers provide information regarding the status and function of the musculoskeletal system with a constant flow of information to the spinal cord, the cerebellum, and the brain.

When there is a communications breakdown, or when improper information is supplied by one or more of these sensors, efficiency of movement decreases. This is harmful and possibly injurious to the muscles and joints, and results in problems with postural coordination and/or joint alignment. Beyond being just an annoyance, faulty coordination or misalignments can also be the source of chronic, unresolving pain.

Location of Nerve Endings

The most important sensory nerve endings for controlling the muscular system are the muscle spindle fibers and the Golgi tendon organs. Muscle spindle fibers are found interspersed within the contractile fibers of all skeletal muscles, with the highest concentration in the central portion (belly) of each muscle. Muscle spindles respond to changes in the length of muscles. A complex circuitry of these nerve endings, with interconnections in the dorsal horn of the spinal cord, maintains muscle tone and, most importantly, the appropriate tension in the muscles on opposite sides of each joint. Without this basic “wiring”, proper joint alignment can’t be maintained, and relaxed, upright posture is almost impossible.

Golgi tendon organs are located in the junctions of muscles and their tendons. These protective nerve endings exert a powerful inhibitory effect on contraction of the muscle fibers. They are stimulated by strong stretching of the muscle/tendon junction (as when the muscle fibers are contracting too strongly). Golgi tendon organs transmit their information to the spinal cord and cerebellum through large, rapidly conducting nerve fibers, and they can rapidly inhibit a muscle contraction in order to protect the tendon.

Joint Mechanoreceptors

Surrounding and protecting all joints are tough, fibrous tissues which contain a variety of sensory nerve endings. The input from these specialized sensors keeps the nervous system informed as to the location of the joint, and also the degree of stretch, compression, tension, acceleration, and rotation. (6) These joint mechanoreceptors are classified by their anatomy and their neurological function. (7) Type I mechanoreceptors are found in higher densities in the proximal joints. They sense the position of a joint by signaling the joint angle through normal ranges of motion. These help determine postural (tonic) muscle contractions. Type II nerve endings adapt to changes in position, and are most active at onset and termination of movement. These are more densely distributed though the distal joints, and affect phasic muscle actions. Type III mechanoreceptors are high threshold, which means they require considerable joint stress at end ranges before firing. These receptors serve a protective function similar to the Golgi tendon organs. Type IV receptors are free nerve endings located in the ligaments, joint capsules, and articular fat pads which respond to pain stimulus. They can generate intense, non-adapting motor responses in all muscles related to a joint, resulting in the protective muscle contractions that restrict joint movement.

Foot Involvement

These six specialized nerve sensors are found throughout the musculoskeletal system, in all skeletal muscles and in every ligament, joint capsule, and articular connective tissue. With many small joints, lots of connective and articular tissues, and both intrinsic and extrinsic muscles, the feet are particularly well-supplied with proprioceptive nerve endings. Mechanoreceptors in the joints along with the muscle spindles of the foot muscles are responsible for the positive support reflexes and a variety of automatic reflexive reactions. (8) These include the flexor/extensor reflex, which converts the lower limb into a firm, yet compliant pillar. Weightbearing compresses the joints and muscles, evoking reflexive activity in the extensors and inhibition of the flexor muscles. (9)

The first research to demonstrate how altered proprioceptive input predisposes to recurring injuries was performed on patients with chronically sprained ankles. (10) Freeman et al. called this phenomenon “articular de-afferentiation” to recognize the importance of inappropriate afferent signals from injured ankle and foot proprioceptors. They pointed out that, “Since articular nerve fibers lie in ligaments and capsules, and since these fibers have a lower tensile strength than collagen fibers, it seems inevitable that a traction injury to a ligament or capsule will lead to the rupture of nerve fibers as well as collagen fibers”. (11)

Conclusion

Except for the spine, the foot is the anatomical region which contains the most proprioceptive sensory receptors, and the foot has very distinctive nerve circuits which must be considered. Because of the magnitude of sensory input, the feet are frequently involved in clinical conditions which will respond to specific treatment approaches that include the proprioceptors — such as custom orthotics. Structural support and shock absorption for the musculoskeletal system is provided by the corrective orthotics, thereby reducing physical stressors on the muscles and joints of the feet, legs, and pelvis.

Greater understanding of the proprioceptive system of sensory receptors in the muscles and joints has enabled us to more accurately assess and treat many complex musculoskeletal problems. When custom-fitted orthotics are included, treatments can be more effective and responses will be more comprehensive and longer-lasting.

Table 1.

SENSORY ORGANS FOR PROPRIOCEPTION
Muscles and Tendons Muscle spindle fibers

Golgi tendon organs

Joint Ligaments and Capsules

(Mechanoreceptors)

Type I – low threshold, slow-adapting

Type II – low threshold, fast-adapting

Type III – high threshold, slow-adapting

Type IV – nociceptive (pain endings)

References

1. Kuhn DR, Shibley NJ, Austin WM, Yochum TR. Radiographic evaluation of weight bearing orthotics and their effect on flexible pes planus. J Manip Physiol Ther 1999; 22(4):221-226.

2. Stude DE, Brink DK. Effects of nine holes of simulated golf and orthotic intervention on balance and proprioception in experienced golfers. J Manip Physiol Ther 1997; 20:590-601.

3. Stude D, Gullickson J. Effects of orthotic intervention and nine holes of simulated golf on gait in experienced golfers. J Manip Physiol Ther 2001; 24(4):279-287.

4. Stude D, Gullickson J. Effects of orthotic intervention and nine holes of simulated golf on club-head velocity in experienced golfers. J Manip Physiol Ther 2000; 23(3):168-174.

5. Gatterman MI, ed. Chiropractic Management of Spine-Related Disorders. Baltimore: Williams & Wilkins, 1990:413.

6. Slosberg M. Effects of altered afferent articular input on sensation, proprioception, muscle tone and sympathetic reflex responses. J Manip Physiol Ther 1988; 11:400-408.

7. Wyke BD. The neurology of joints. Ann R Coll Surg Engl 1967; 41:25.

8. Freeman MAR, Wyke BD. Articular contributions to limb muscle reflexes. J Physiol 1964; 171:20.

9. Panzer DM, Fechtel SG, Gatterman MI. Postural complex. In: Gatterman MI, ed. Chiropractic Management of Spine-Related Disorders. Baltimore: Williams & Wilkins, 1990:263.

10. Bosien WR, Staples OS, Russell SW. Residual disability following acute ankle sprains. J Bone Joint Surg Am 1955; 37:1237.

11. Freeman MAR, Dean MRE, Hanham IWF. The etiology and prevention of functional instability of the foot. J Bone Joint Surg Br 1965; 47:678-685.

Hyperpronation: Treating Secondary Conditions

by K.D. Christensen DC, CCSP, DACRB

Patients seldom present with the complaint of “hyperpronation” or “excessive pronation.” It is usually left to the doctor to realize that the reported problem is due to pronation. Unfortunately, too many times the patient undergoes unnecessary or excessive examinations and treatment procedures, when the underlying problem is actually a hyperpronated foot (or feet).

What follows is a listing of commonly seen patient complaints that are frequently caused by (secondary to) excessive pronation, and which indicate the need for custom-fitted foot orthotics. Patients with an obvious need should be fitted with orthotics early in their chiropractic care. This will produce a good response to spinal and extremity adjustments, and will prevent frustration in both doctor and patient.

In the History

Back problems are worse with standing, walking, running. When a patient reports a history of upright locomotor activities and spinal symptoms, a close evaluation of the feet will often identify excessive and/or asymmetrical pronation. A brief gait evaluation should look for abnormalities such as foot flare or poor toe-off. This clearly calls for orthotics to minimize the stress being transmitted from the lower extremities to the spine.

Recurrent ankle sprains. A history of previous sprain injuries to one or both ankles indicates biomechanical instability and probable permanent ligament damage. The important ligaments that support the arches of the foot are often injured during an ankle sprain, and arch collapse and/or unilateral hyperpronation can result. Orthotics will provide the proprioceptive stimulus and mechanical advantage needed to prevent re-injury.

Family history of foot problems or surgery. Since we inherit many health tendencies, a patient who has family members with foot problems and/or surgery has a much higher probability of the same. Excessive calcaneal mobility, hallux valgus, plantar fascitis, and poor arch development are all associated with hyperpronation and appear to have a familial tendency. Fitting for orthotics may prevent these problems from developing, and could avoid surgery.

Strenuous athletic activities. Those who regularly engage in weight-bearing sports need both shock absorption and foot/ankle stability. Patients who present with athletic injuries associated with their sport activities often demonstrate excessive pronation as a complicating and inhibiting factor. (1) Orthotic support can increase performance and prevent injuries in a long list of individual and team sports — such as running, tennis, skiing, skating, soccer, baseball, football, and basketball.

History of lower extremity stress fractures, tendinitis, shin splints, hamstring strains. Whenever an athlete, whether recreational or competitive, reports symptoms of overuse injury (microtrauma) in the lower extremities, excessive pronation must be considered. These conditions have been closely correlated with biomechanical asymmetries (such as hyperpronation) and require better support and shock absorption. (2)

Chronic knee pain, patellofemoral arthralgia, ACL injury. The knee joint is a sensitive indicator of abnormal biomechanical stress, and many knee problems have been found to indicate the need for orthotics. Controlling pronation decreases the rotational forces, which improves patellar tracking and protects the anterior cruciate ligament. (3)

During the Exam

Postural imbalances (pelvic tilt, scoliosis, forward head). When a standing structural evaluation discloses a pelvic tilt (whether forward, backward, or low on one side), a lower extremity asymmetry due to unilateral or bilateral hyperpronation is likely. Both functional and idiopathic types of spinal curvatures can be associated with pronation, and will benefit from the foot stabilization and neurological stimulus provided by orthotics. Many postural complexes (forward head is one of the most common) are secondary to excessive pronation, with poor standing balance and proprioception from the feet.

Gait asymmetry, calcaneal eversion, foot flare. Watching a patient walk, and looking for indicators of biomechanical asymmetry, will often demonstrate the need for orthotics. Whenever there is excessive pronation, the foot and ankle complex does not function correctly during the stance phase of gait, and this stress is transmitted to the pelvis and spine with every step.

Foot calluses, bunions, hallux valgus. A careful examination of foot problems will often show evidence of hyperpronation and arch collapse. Heavy callusing, bunion development, and abnormal alignment all indicate the need for improved biomechanics and orthotics. (4)

Lack of an arch (especially unilateral). This is easily seen during the weight-bearing portion of the exam, when a foot collapses under the weight of the body. An even better method is the Navicular Drop Test, which measures the change in height of the medial longitudinal arch at the navicular prominence from sitting to standing. (5) A foot without an arch will pronate excessively, and needs orthotic support. (6)

Knee instability, high Q-angle, poor patellar tracking. When the knee does not align properly or track correctly, degenerative wear-and-tear and chronic symptoms will follow. Orthotic alignment is required to reduce the abnormal pronation forces on this complex joint, which must be able to sustain frequent high forces during walking and running. (7)

On the X-rays

Scoliosis (functional or idiopathic), widespread disc degeneration. The spine responds to poor support from one of the lower extremities by developing a lateral curvature. Some studies indicate that gait disturbances (during the stance phase, in particular) may be one of the causative factors for idiopathic scoliosis. (8) Significant intervertebral disc degeneration is made worse when the foot pronates, and transmits heel strike shock upwards into the spine. In this case, orthotics with viscoelastic properties will often reduce chronic symptoms dramatically.

Unlevel sacral base, sacroiliac joint degeneration. The pelvis shows evidence of inadequate support by the appearance of a tilted sacral base when standing. This is often due to a functional short leg secondary to hyperpronation, which requires orthotic support. (9) Sacroiliac degeneration may be due to chronic SI joint dysfunction, which may be secondary to hyperpronation.

Low femur head, coxafemoral DJD. These conditions are due to either an anatomical or a functional short leg, which are often associated with asymmetrical and/or excessive pronation. Degenerative changes in the hip joint have been correlated with the stress of a longer leg. Both will benefit from the improved balance and support provided by orthotics.

Heel spurs, DJD in knees, metatarsals. X-rays of the feet and knees may reveal evidence of long-standing regional stress, such as degenerative changes in weight-bearing joints, and connective tissue calcification. Calcium deposited in the calcaneal attachment of the plantar fascia specifically indicates the need for support of the arches of the foot.

Response to Care

Recurrent subluxations, symptom flare-ups. Making the same adjustment to a patient’s spine again and again suggests poor structural support for the region. Excessive pronation is often the underlying lack of proper support. Orthotics have been used for decades by chiropractors who don’t want to continue adjusting the same area, and want to see the adjustment “hold” better.

Conclusion

Chiropractic care is based on the concept of the treating the cause, and not just decreasing the symptoms. Our goal is to achieve long-term health, and not just short-term relief of pain. As can be seen by the above list, excessive foot pronation can be the source of many of our patients presenting symptoms. In fact, the feet are seldom painful in most of the conditions that are clear indicators of the need for orthotics. All doctors of chiropractic must be alert for signs of lower extremity involvement in spinal conditions and musculoskeletal problems.

References

1. Freychat P et al. Relationship between rearfoot and forefoot orientation and ground reaction forces during running. Med Sci Sports Exerc 1996; 28:225-232.

2. Busseuil C et al. Rearfoot-forefoot orientation and traumatic risk for runners. Foot & Ankle Intl 1998; 19:32-37.

3. Beckett ME et al. Incidence of hyperpronation in the ACL injured knee: a clinical perspective. J Athl Train 1992; 27:58-62.

4. Eustace S et al. Hallux valgus, first metatarsal pronation and collapse of the medial longitudinal arch — a radiological correlation. Skeletal Radiol 1994; 23:191-194.

5. McPoil TG, Cornwall MW. The relationship between static lower extremity measurements and rearfoot motion during walking. J Orthop Sports Phys Ther 1996; 24:309-314.

6. Dahle LK et al. Visual assessment of foot type and relationship of foot type to lower extremity injury. J Orthop Sports Phys Ther 1991; 14:70-74.

7. Eng JJ, Pierrynowski MR. Evaluation of soft foot orthotics in the treatment of patellofemoral pain syndrome. Phys Ther 1993; 73:62-70.

8. Giakas G et al. Comparison of gait patterns between healthy and scoliotic patients using time and frequency domain analysis of ground reaction forces. Spine 1996; 19:2235-2242.

9. Rothbart BA, Estabrook L. Excessive pronation: a major biomechanical determinant in the development of chondromalacia and pelvic lists. J Manip Physiol Therap 1988; 11:373-379.

Flexibility Training and Rehabilitation

by K.D. Christensen DC, CCSP, DACRB

Flexibility exercises are used to facilitate rehabilitation, prevent injury or reinjury, and provide a warm-up regimen. In rehabilitation regimens, flexibility or range-of-motion (ROM) exercises are used to establish a functional range of motion before proceeding to resistive exercises. Prescribed motions are emphasized with ROM exercises for certain conditions, e.g., calcific tendinitis and bursitis. The patient must execute the correct protocol in a consistent manner to avoid problems.

Is PNF Superior to Static Stretching?

A flexibility program is designed to improve the range of motion at a given joint by altering the extensibility of the musculotendinous units. Static stretching, once recommended, is now considered by many out of favor. 1, 2, 3 Proprioceptive neuromuscular facilitation (PNF) techniques by others are preferred. Both methods are based on alteration of the myotatic stretch reflex. Prentice 4 compared static stretching with PNF stretching by the slow-reversal-hold method for improving the range of hip joint motions in 46 subjects of both sexes, aged 18-34 years, who participated in a 10-week general fitness program emphasizing flexibility and cardiovascular endurance. Flexibility measures were applied three days a week under direct supervision. Only the right hamstrings were stretched, and goniometric measurements were repeated after the 10-week training period. The slow-reversal-hold PNF technique was superior to static stretching. The slight gain in range of motion in the control extremity suggested that some training effect took place to improve flexibility.

The efficacy of various stretching methods in improving flexibility may be explained by autogenic inhibition, based on inhibition that is mediated by afferent fibers and that acts on the alpha motor neurons supplying a muscle, and also by reciprocal inhibition. The PNF approach denotes any method in which input from peripheral receptors is used for either facilitation or inhibition. Static stretching relies on autogenic inhibition, as does the slow-reversal-hold technique. In the latter method, the sustained isotonic contraction by the antagonist muscle increases tension in the muscle, again exciting the inhibitory Golgi tendon organs. The isometric contraction of the agonist is based on reciprocal inhibition. The PNF method is superior to static stretching in improving in general range of motion of most subjects.

Adequate flexibility is necessary for rehabilitation from injury as well as for prevention of injuries and superior performance. Sady et al. 5 compared the effects of static and PNF stretching techniques for shoulder, trunk, and hamstring muscles on the flexibility of 65 male college students. Forty-eight subjects (three groups of 16) used the techniques; 17 served as controls. Results were available in 43 subjects. A Leighton flexometer was used to measure the range of motion at the joints traversed by the tested muscle groups. Exercises were performed three days a week for six consecutive weeks.

Only the PNF group had an increase in flexibility greater than the control group (10.6 vs. 3.4 degrees). The hamstrings improved by 9.4 degrees and the trunk by 5.2 degrees. Reliability generally was higher for post-training scores. Variability between test days was lower for post-training scores of the shoulder and hamstrings. Significant between-day changes in flexibility were observed before training.

These findings again indicate that PNF is a preferred method of improving flexibility. Flexibility training appears to result in more consistent flexibility scores. PNF techniques can be integrated into any rehabilitation setting and provide increased flexibility relatively rapidly. Further studies are needed to learn which combination of repetitions, sets, duration, and frequency will result in maximal gains in flexibility.

The proprioceptive neuromuscular facilitation mobilization techniques of contract-relax (C-R) and hold-relax (H-R) are commonly applied at the point of limitation of motion and require active, resisted contractions of the range-limiting antagonistic pattern. Range of motion may increase contralaterally when these methods are used on an uninvolved extremity. Markos 6 compared the effectiveness of H-R and C-R in increasing range of hip flexion bilaterally during straight-leg raising. Studies were done in 30 normal women with a mean age of 22 years.

Maneuvers were applied to the right leg in two diagonal patterns while electrical activity was monitored in the contralateral rectus femoris, vastus medialis, semimembranosus and biceps femoris. The increase in range of motion of the right leg in subjects in the C-R group was significantly greater than that in the H-R and control groups. For the unexercised limb, the increase in motion in the C-R group was significantly greater than that in the control group. All but one of the 30 subjects exhibited electrical activity in the contralateral limb when the right leg contracted against resistance.

Both H-R and resistance toward the non-painful range deserve consideration when a treatment program is being planned. Contract-relax appears to be of most benefit in increasing the range of motion of tight musculature in both the involved and uninvolved limb.

Cryostretch

Many musculoskeletal injuries cause some degree of muscle spasm or tightness. Cryostretch therapy 7 combines ice application with the hold-relax technique of proprioceptive neuromuscular facilitation, involving static and isometric stretching of the affected muscle. A brief neuromuscular training session is conducted before the first exercise session to help the patient so that the joint moves through as great a range of motion as possible without resistance. The motion is repeated two or three times.

Each exercise bout consists of a 65-second set of static stretches and isometric contractions, a 20 second rest, and another set of exercises. Three bouts are performed during each treatment session, with two or three sessions each day. The muscle is numbed with a large cold pack or by massage with an ice cone. Initially the extremity or body part is moved until tightness or pain is felt. After holding the part in a pain-free position for 20 seconds, the patient is told to contract the muscle and try to perform the practiced motion while the therapist resists. Rapid contraction is avoided; contraction should last about five seconds and be as strong as possible. After this, the part is again moved to the point of pain for 10 seconds. The sequence is repeated, ending with a 10 second stretch, and the 65-second set of exercises is repeated after the limb has rested in the anatomical position for 20 seconds.

Combined cryokinetic and cryostretch therapy is instituted when the spasm is partially relieved, often within two-three days. Cryokinetic exercises begin with manually resisted muscle contraction through a functional range of motion, and should proceed through graded activity exercises. Full activity must be resumed gradually to avoid reinjury.

In order to assess the effectiveness of a PNF treatment plan, both objective and subjective data on patient results on outcomes must be collected and documented. The data typically focus upon the physical changes noted at the time of consultation and in subsequent visits (eg, range of motion). Ongoing outcome assessment data with comparative graphs over treatment time (available at www.outcomesassessment.org) documents the longterm results and effectiveness of the technique.

References

1. Pope RP, Herbert RD, et al. A randomized trial of preexercise stretching for prevention of lower-limb injury. Med Sci Sports Exerc 2000; 32(2):271-277.

2. Johansson PH, Lindstrom L et al. The effects of preexercise stretching on muscular soreness, tenderness and force loss following heavy eccentric exercise. Scand J Med Sci Sports 1999; 9(4):219-225.

3. Shrier I. Stretching before exercise does not reduce the risk of local muscle injury: a critical review of the clinical and basic science literature. Clin J Sport Med 1999; 9(4):221-227.

4. Prentice WE. Athletic Training 1983; 18(Spring):56-59.

5. Sady SP, Wortman M, Blanke D. Flexibility training: ballistic, static or proprioceptive neuromuscular facilitation? Arch Phys Med Rehabil 1982; 63(6):261-263.

6. Markos PD. Ipsilateral and contralateral effects of proprioceptive neuromuscular facilitation techniques on hip motion and electromyographic activity. Phys Ther 1979; 59(11):1366-1373.

7. Knight KL. Physician Sportsmed 1980; 8(Apr):129.

Adjunctive Therapies to the Adjustment Flat Feet in Adults

by K.D. Christensen DC, CCSP, DACRB

Flatfoot is defined as a lack of the medial longitudinal arch of the foot. Adults with flat feet demonstrate several biomechanical inefficiencies in the foot and ankle, as well as a variety of gait abnormalities. The development of clinical problems is dependent on the levels of activity and the amount of repetitive stress the feet must endure. The average person spends four hours each day on their feet, and takes between 8,000 and 10,000 steps every day. In some jobs and many sports, these amounts are more than doubled. During an average day, the feet support a combined force equivalent to several hundred tons. In addition to carrying the weight of the body, each foot acts as a shock absorber and a lever to propel the leg and body forward, and it serves to balance and adjust the body to uneven surfaces. The various problems associated with flatfoot can interfere significantly with normal daily activities, as well as limiting participation in recreational and competitive sports. Flat feet are due to either a loss of the normal arch due to breakdown of the supportive collagen structures, or a lack of development of a normal arch in the first place.

Congenital Flatfoot

Until about the age of 2 years, infants have flat feet, due to the presence of a large medial fat pad, and incomplete development of the foot structures. (1) As children begin to walk and spend more time on their feet, this fat pad slowly decreases, resulting in a noticeable medial longitudinal arch. (2) A study of the developing arch in children has confirmed that 28 to 35% of school children have an apparent flatfoot deformity, but 80% of those are classified as “mild.” (3) Follow-up evaluations have determined that 90% of these children will have normal arches by the age of 10 years. (4) The remainder never develop an arch, and are considered to have a “congenital flatfoot.”

Acquired Flatfoot

As adults, some of those who did develop a normal arch gradually lose it. This occurs secondary to a breakdown of the normally strong and dense connective tissues of the foot. It is the ligaments and connective tissues that support the medial longitudinal arch, (5) and not muscular strength. (6) In fact, normal alignment depends on a complex arrangement of dense collagenous fibers, and no single structure provides all of the support. (7) Problems with this arch will develop when these supportive tissues are put under excessive stress. This can be either from high loads for sudden, brief periods, or from more moderate, but repetitive stresses over longer periods, resulting in an “acquired flatfoot.”

Rigid Flatfoot

The overwhelming majority of flat feet are considered “flexible,” and will respond well to external support. In some cases, however, the arch never develops due to a bony abnormality (most commonly a tarsal coalition). This results in a “rigid” flatfoot, which will can be greatly aggravated by attempts to provide external support with inserts and orthotics. Differentiation is important, but can be easily done during the examination. If an arch is present when the patient is sitting with the foot dangling, or when standing up on the toes (toe-raise test), then the flatfoot is “supple and is correctable with an arch support.” (8) If the foot remains flat and rigid during this test, any attempt to lift up or support the arch can be painful, and corrective orthotics generally are avoided. Evaluation by a foot specialist is usually necessary to determine the underlying cause of a rigid flatfoot. Treatment may consist of accommodative orthotics and/or surgery.

Associated Terminology

Two descriptive terms are often used interchangeably with flatfoot, and can contribute to confusion. Pes planus is the more technical term that represents a flattening of the longitudinal arch; the arch is lower than established normal parameters when standing, especially on radiographic evaluation. (9) Hyperpronation (or excessive pronation) refers to excessive medial deviation of the talus during gait, primarily during the stance phase of gait. (10) Both of these problems are found in patients with flexible flatfoot, and will interfere with lower extremity biomechanics. An extensive list of the varied symptom complexes and health problems caused by flexible flatfeet has been compiled by Dr. Yale (Table 1). (11)

Energy Cost / Athletic Performance

An interesting study assessed the effects of arch supports on oxygen consumption in 20 subjects with flat feet who complained of fatigue and “weariness.” (12) The participants were between 18 and 38 years old, and had no specific foot symptoms. Their heart rates, blood pressures, and walking oxygen consumption were measured on a treadmill – first without, and then with arch-supporting orthotics. The results demonstrated that use of the orthotics significantly improved their gait efficiency, and decreased their oxygen consumption during normal walking. These responses can be extrapolated to athletic performance. In fact, it has long been observed that a flat foot, and hyperpronation, in particular, can interfere with performance in a number of sports. (13)

Support From Orthotics

In order to improve the biomechanics of the foot and provide permanent support for the medial longitudinal arch, most patients will need custom-fitted orthotics. Active patients generally benefit from flexible orthotics which are most beneficial for athletes and workers who must be on their feet for many hours each day. A recently published study found that custom-made flexible orthotics cast in a weight-bearing position significantly improved the alignment of the foot and increased the medial longitudinal arch when standing. (14) The materials and fit of an orthotic are critical, since support is needed for all three arches of the foot, along with cushioning and shock absorption in a comfortable insert. Additional padding under the forefoot is a recent addition that appears to be very helpful.

Conclusion

Flatfoot in adults may be congenital (the medial arch never developed), or acquired (the connective tissues no longer can support the medial arch). A rigid flatfoot is due to an osseous deformity, such as a tarsal coalition. As long as a flat foot is flexible, orthotic support for the medial arch can improve foot and ankle biomechanics, decreasing hyperpronation and enhancing performance in daily activities and during sports.

References

1. Magee DJ. Orthopedic Physical Assessment. Philadelphia: WB Saunders; 1987, 329.

2. Kemp HC. Current Pediatric Diagnosis and Treatment. Norwalk: Appleton and Lange; 1984, 614.

3. Notari MA. A study of the incidence of pedal pathology in children. J Am Podiatr Med Assn 1988; 78:518-521.

4. Wetton EA. The Harris and Beath footprint: interpretation and clinical value. Foot & Ankle 1992; 13:462-468.

5. Huang CK, et al. Biomechanical evaluation of longitudinal arch stability. Foot & Ankle 1993; 14:353-357.

6. Basmajian JV, Stecko G. The role of muscles in arch support of the foot. J Bone Joint Surg 1963; 45A:1184-1190.

7. Kitaoka HB, et al. Stability of the arch of the foot. Foot & Ankle 1997; 18:644-648.

8. Hoppenfeld S. Physical Examination of the Spine and Extremities. New York: Appleton-Century-Crofts; 1976, 232.

9. Forrester D, Kerr R, Kricun ME. Imaging of the Foot and Ankle. Gaithersburg: Aspen Pubs; 1988.

10. Gould N. Evaluation of hyperpronation and pes planus in adults. Clin Orthop Rel Res 1983; 181:37-45.

11. Yale JF. The conservative treatment of adult flexible flatfoot. Clin Pod Med and Surg 1989; 6:555-660.

12. Otman S, et al. Energy cost of walking with flat feet. Prosthets and Orthots Intl 1988; 12:73-76.

13. Subotnick SI. Sports Medicine of the Lower Extremity. New York: Churchill Livingstone; 1989, 159.

14. Kuhn DR, et al. Radiographic evaluation of weight-bearing orthotics and their effect on flexible pes planus. J Manip Physiol Ther 1999; 22:221-226.

Table 1. Flexible Flatfoot Associated Pathology (11)

  • Medial longitudinal arch strain with pain in the spring ligament
  • Abductor hallucis strain, pain, and spasm
  • Plantar fascial inflammation
  • “Jamming” at the first metatarsophalangeal joint with resultant traumatic arthritic changes
  • Plantar fascial insertional strain and inflammation, with or without calcaneal exostosis (heel spur)
  • Periarticular fibrocystis of the second metatarsophalangeal joint (Morton’s syndrome)
  • “Pinching” of the calcaneofibular ligament
  • Secondary fifth toe contraction deformities
  • Shearing hyperkeratotic lesions beneath the metatarsal heads
  • Second or third intermetatarsal space neuritis or neuroma
  • Sinus tarsi syndrome
  • Achilles tendinitis
  • Anterior or posterior Achilles bursitis
  • Peroneus longus spasm
  • Tibialis posterior overuse (posterior shin splints)
  • Tibialis anterior overuse (anterior shin splints)
  • Patellar tendinitis
  • Medial collateral knee ligamentous strain
  • Patellofemoral syndrome
  • Synovial plica syndrome
  • Popliteus muscle syndrome
  • Iliotibial band syndrome at knee or hip level
  • Hip adductor tendinitis
  • Greater trochanteric bursitis
  • Hamstring muscle strain and spasms (usually at night)
  • Lumbosacral muscle spasms
  • Sciatic neuritis
  • L4, L5, S1 disc narrowing symptoms
  • Cervical muscle spasm
  • Temporomandibular joint syndrome

How to Improve Exercise Compliance

by K.D. Christensen DC, CCSP, DACRB

Here’s a frustrating fact: a large percentage of patients don’t do the home-based rehabilitative exercises that are recommended to them. [1] Even though you spend precious time deciding which exercises will be helpful and explaining them to the patient, your experience has probably been the same as most Chiropractors: too many patients just can’t seem to do their exercises. And yet, you know that if they would just do the exercises, they would get better faster. Patient cooperation and satisfaction with at-home exercise programs are important for successful outcomes. [2]

In my opinion, each patient has several barriers or “hurdles” to get over in order to reach the goal of exercising. The more hurdles we can lower or even eliminate, the more likely it is that the exercises will get done. Here are some ways to lower the hurdles and help your patients get to the “finish line.”

Start Small

Lower the first big hurdle by initially recommending only one (or at most two) exercises initially. This minimizes the start-up effort and decreases the amount of time required. Once a patient has been doing one or two exercises regularly for a couple of weeks, additional or more complex exercises can be more easily implemented.

Schedule for Consistency

Consistency helps to ensure success in many areas. When a new habit needs to be learned, frequent and regular repetition helps. [3] Trying to schedule exercises into a busy schedule is difficult, especially when your patient has to decide which days to exercise and which days to rest. Since rehabilitative exercises do not tear down muscles, daily exercising is safe, and the scheduling hurdle can be eliminated. Initially, instruct your patients to “do the exercises every day.”

Explain and Motivate

Make sure your patient knows why the exercise needs to be done, and what benefits to expect. Motivation improves compliance with exercise. [4] Motivation is much better when a purpose is understood and a mutual goal has been established. Explain that doing the exercise will help your patient better perform the activities he or she enjoys.

Keep It Simple

Keep instructions to patients clear and simple. This is particularly important when discussing the numbers of repetitions and “sets” (groups of repetitions). Many doctors recommend six repetitions of the exercise, followed by a brief (up to one minute) rest, done three times. This “three sets of six” concept is quick to perform and easy to understand. Recent research has shown that only one set of 10 to 12 repetitions can be just as effective. This is particularly true when patients are just starting to exercise, and especially when they are exercising daily. Use either approach, but keep the instructions clear.

No Set Schedule

Any time of day is the right time to exercise — what’s most important is getting the exercises done. Even though some professionals feel that athletic activities are somewhat safer in the afternoon (when muscles and joints are warmer), encourage your patients to exercise whenever it works for their schedule (and once a day is plenty).

Recruit Allies

A spouse or family member should accompany the patient when exercises are taught, so they can help ensure correct and regular performance of the exercise. A second person who wants your patient to get better can be a tremendous ally, [1] one who will provide encouragement and reminders.

Stress Functional Position

Exercising in a comfortable weight-bearing position is generally easier for patients. In addition to being more focused and practical, upright exercising trains and strengthens the spine to perform better in everyday activities. Patients like the idea of doing an exercise that clearly prepares them for better function during normal activities of daily life.

Guide the Performance

Demonstrate, then watch and correct your patients’ performance of the exercise. When patients need an exercise, they usually can’t do the exercise correctly. Diagrams, pictures, even videos can’t ensure that patients will be able to figure out the suggested exercise. When you spend the time to show them the exercise, and then you guide them through it, they realize that you believe this is an important part of their treatment. Patients are then much more likely to do the exercise. [1]

Make It Easy to Do

Well-designed, easy-to-use home rehab equipment helps to ensure compliance. [5] Home equipment should be easy to figure out and set up, and should help guide your patients through the necessary exercises.

Monitor Regularly

As an integral part of their rehab while under your care, all patients must record their exercising in some form of exercise log. This allows them to “give themselves a pat on the back” each time they do the exercise. And remind them to bring the exercise log with them to every adjustment, so you can see how the exercises are going. Make sure to give them praise and recognition for the exercises they perform.

Review the Exercise

At least once a week, have the patient perform their exercise in front of you. This allows you to confirm that it’s being done properly, and you can correct any faults that creep in. A regular review also reinforces in the patient’s mind the importance of the exercising and encourages them to continue.

Customize the Exercise

There is nothing more motivating than the feeling that the most important exercises are being done. Make sure that the exercise(s) you are recommending will produce a rapid response, so the patient starts to feel the benefits of the exercising immediately. Don’t give all patients the same six exercises; instead, try to start the patient on the most important exercise for his or her condition. [1]

Conclusion

If you implement these rehab tips, your patients will be more likely to do their exercises faithfully. Once they have established the habit of doing one or two exercises, you can use the rehab review to add other exercises. With this method, a patient can gradually develop a good general fitness and spinal health exercise program while under your care.

Word will soon get around your community that you care enough about your patients to help them establish a regular spinal health and exercise program. This will build your practice, and also improve the reputation of Chiropractic for years to come.

References

1. Kamiya A, Ohsawa I et al. A clinical survey on the compliance of exercise therapy for diabetic outpatients. Diabetes Res Clin Pract 1995; 27(2):141-145.

2. Chen CY, Neufeld PS et al. Factors influencing compliance with home exercise programs among patients with upper-extremity impairment. Am J Occup Ther 1999; 53(2):171-180.

3. Rejeski WJ, Brawley LR et al. Compliance to exercise therapy in older participants with knee osteoarthritis: implications for treating disability. Med Sci Sports Exerc 1997; 29(8):977-985.

4. Friedrich M, Gittler G et al. Combined exercise and motivation program: effect on the compliance and level of disability of patients with chronic low back pain: a randomized controlled trial. Arch Phys Med Rehabil 1998; 79(5):475-487.

5. Stenstrom CH, Arge B, Sundbom A. Home exercise and compliance in inflammatory rheumatic diseases: a prospective clinical trial. J Rheumatol 1997; 24(3):4700-476.

Cross Education Exercise and Injury Recovery

by K.D. Christensen DC, CCSP, DACRB

Research supports the premise that exercising soon after an injury can actually speed up the healing process. In a 1995 study by Gregory et al. (1) using laboratory rats, the rats all received a contusion injury to a hamstring muscle, and were then sorted into five different groups. One group (the control) was not exercised. Two groups were returned to their cages to rest for 72 hours, and then started exercising (one group began swimming daily; the other began running every day). The final two groups began their swimming or running exercises within an hour of being injured.

Results by Group

The four rat groups which exercised all showed earlier resolution of their injuries than did the control (no exercise) group. The immediate (same day) exercisers showed more rapid healing response than those who rested for three days. Surprisingly, the data indicated that the injuries in the running group were resolving much more quickly than those of the swimmers. In fact, the study concluded that “Running with immediate onset is the regimen of choice. Any of the given exercises is preferable to no exercise, immediate onset of exercise is preferable to delayed onset, and running is preferable to swimming.” (1)

Clinical Impact

The Gregory et al. study results may impact on the methods of rehabilitative exercise therapy we perform in our clinics. However, keep two important facts in mind: First, many of our acute injury patients are trying to repair a sprain/strain type of injury, not a contusion. Strains and sprains involve tissue tears, while contusions produce a crushing of tissues. When tissues are torn, some period of decreased or restricted activity is needed, in order to allow for early repair of the tear by fibroblasts. The injuries sustained by the rats in the above study may be quite different from most injuries many chiropractors deal with, especially those found in the spine.

Secondly, the time the lab rats spent swimming or running was 15 minutes every day in all exercise groups. It’s possible that longer periods of exercise may have worsened the damage and delayed healing, rather than speeding the process. More research is needed to clarify these concerns.

Cross Education Exercise

An excellent way to stimulate an injured area, while avoiding excessive irritation, is to employ what is known as “cross education.” This neurological curiosity has been known for years, but it is apparently rarely employed by health care professionals treating acute injuries. Cross education is a procedure which has been found to be particularly useful in the treatment of shoulder and ankle injuries, and also provides benefits in most other types of injuries.

When a muscle performs resistance exercise, a neurological stimulus crosses the spinal cord and is received in the corresponding muscle group on the other side of the body. The technical description of this phenomenon is “neural integration of interlimb coordination.” (2) This concept can be used to help patients recover rapidly from an acute injury.

Cross Education and Your Patients

To use cross education in your practice, you must first identify the exercises your patient needs to perform for an injured area. Prior to starting, have the patient perform the desired exercises on the uninjured side. In a case involving a major acute injury (or during post-surgery), the exercise of the opposite uninjured muscle group should continue for between several days to numerous weeks, depending on the extent and severity of the damage. The cross educational exercises should specifically be done any time an injury is immobilized (casted or pinned), or when the area directly injured is too painful to consider direct exercise.

As healing progresses, your patient should begin exercising the injured region. Even at this stage, however, the patient could begin and end each session by exercising the uninjured side. Cross education will permit early, aggressive exercising without directly irritating or further damaging the injured area. This, in turn, should lead to a more rapid recovery.

An Example of Cross Education

A common example of cross educational exercise would involve an acute right shoulder injury which prevents abduction. Immediately start the patient doing abduction exercises with the uninjured left arm. When the patient is ready to start limited exercising of the injured right shoulder, the patient should first perform a similar pattern of left shoulder abduction against resistance.

Cross Educational Research

A 1997 study investigated the various parameters of cross education on human volunteers. (3) Both quadriceps muscles of the subjects were tested for strength, and then progressive resistance exercising was performed with the left leg only. Twelve weeks after the inception of the study, significant strength gains were measured in the unexercised legs. Researchers found the most significant improvement and the greatest gains in strength in the group that used lengthening (eccentric) exercises.

Conclusion

Arrange for your acute injury patients to begin an exercise program immediately after an injury; however, have them avoid direct exercise of the injured area initially. Recommend cross educational exercises to supply the stimulus necessary to take advantage of the early exercise phenomenon, while avoiding the potential for re-injury of the damaged area. Show the patient which exercises to do, but start the exercises on the opposite side of the body for the first several days.

Consider that patients focus on the lengthening (eccentric) part of the exercise movement, in order to make rapid progress. As they progress, and the injury begins to heal, the symptomatic region can be safely exercised and remember the uninjured side is exercised at the beginning and end of each session.

References

1. Gregory TM, Heckman RA, Francis RS. The effect of exercise on the presence of leukocytes, erythrocytes, and collagen fibers in skeletal muscle after contusion. J Manip Physiol Ther 1995; 18:72-78.

2. Howard JD, Enoka RM. Maximum bilateral contractions are modified by neurally mediated interlimb effects. J Appl Physiol 1991; 70:306-316.

3. Hortobagyi T, Lambert NJ, Hill JP. Greater cross education following training with muscle lengthening than shortening. Med Sci Sports Exerc 1997; 29:107-112.

Adjunctive Therapies to the Adjustment Children and Scoliosis

by K.D. Christensen DC, CCSP, DACRB

Scoliosis is defined as “any lateral deviation of the spine from the mid-sagittal plane.” (1) While there are many causes for scoliosis, children and adolescents with a scoliosis who present to chiropractors usually fall into one of three categories. Successful treatment is very dependent upon differentiating the underlying cause of the spinal curvature. In most children, the scoliotic spine is not symptomatic. The spinal curvature is first noticed either by a parent who becomes concerned about a child’s posture, or during a screening examination, usually at school. The importance of a good evaluation and early treatment is to prevent progression and worsening of the curvature. Children with all three major causes of scoliosis should have a careful evaluation of the lower extremities as part of their spinal examination to determine associated or contributing components to the spinal deviation.

Structural vs. Nonstructural Scoliosis

A structural scoliosis is defined as a spinal curvature that does not correct during recumbent, lateral flexion radiographs. The two most common causes of a structural scoliosis are congenital and idiopathic. A nonstructural scoliosis can be reduced when lying down, and will correct with recumbent lateral flexion. This type of spinal curvature is sometimes called a “functional curve,” and is often secondary to a leg length discrepancy.

Congenital Scoliosis. Of the three major etiologies of scoliosis, this is the least common. Congenital scoliosis develops secondary to a bony anomaly of the sacrum, vertebrae, or ribs. These are often defects of formation or segmentation, resulting in wedged, blocked, or hemi-vertebrae. In some cases, the abnormality will require corrective surgery. In many children, a heel lift or shoe build-up can provide sufficient structural support, and help to maintain a balanced spine.

When a congenital spinal anomaly is discovered, it’s important to remember that there are usually multiple affected areas. For instance, it is more common to have multiple bony abnormalities than just a single level. Non-osseous and extraspinal deformities are also often present. These may include the cartilaginous and connective tissues, and even genitourinary or cardiovascular abnormalities. Clubfoot, a congenitally dislocated hip, or an anatomically short leg often will contribute to the spinal imbalance.

Idiopathic Scoliosis. Idiopathic scoliosis can be progressive, worsening significantly during periods of rapid growth. In the more severe cases bracing, or possibly surgery, may be necessary to prevent substantial deformity. (2) After skeletal maturity, most curvatures progress only slowly, if at all. Recent scientific research has focused on hormonal and neurological causes for idiopathic scoliosis, with some promising early results, but no definitive conclusions.

Hormonal Influences

The pineal gland appears to have some influence on the development of a balanced spine, at least in chickens and rats. Surgical removal of the pineal gland in young chickens (3) and more recently in bipedal rats (4) produced spinal curvatures that are very similar to human idiopathic scoliosis, including vertebral rotation and rib humps. In the recent study on rats, the investigators found that providing a source of melatonin prevented the development of scoliosis in pinealectomized rats. They theorize that “melatonin may facilitate the fine neuromuscular coordination needed to maintain the 24 stacked vertebrae in balance.” While some studies have found that human patients with progressive scoliosis do have lower levels of melatonin, other investigations have not been able to establish a direct correlation. Injections of 5-hydroxytryptophan (a precursor to serotonin) into pinealectomized chickens prevented the development of scoliosis in most of them. (5) These researchers report that “…normal spine growth requires a precise and delicate balance of equilibrium and postural tone. The results of our current study and those we have reported previously imply that both melatonin and serotonin, and appropriately balanced use of both, are required for normal spine growth…” Does imply that nutritional support may be an answer?

Coordination and Gait

Numerous studies over the years have shown that humans with scoliosis have various defects in muscle coordination and standing balance. The source of these difficulties with fine motor control is unknown, and many theories have been developed and then discarded. The gait of children with scoliosis has been found to be somewhat abnormal, but there is controversy about whether this causes a curvature to develop or is simply a result of walking with a curved spine.

A recent study using sophisticated measuring devices and advanced computer analysis found a significant difference in gait between normal subjects and those with scoliosis. (6) This was most noticeable in the medial-lateral component of gait, indicating problems with pronation and supination control. They observed that the “…differences between the scoliosis and the control group, together with previously reported abnormalities of torsion in the tibia and femur and the hypothesis of pelvic rotation, suggests these are primary mechanisms of the cause of idiopathic scoliosis.”

These researchers believe that gait asymmetry could very well be the underlying cause of the balance and coordination problems that result in a curved spine. In fact, they conclude that “Patients with scoliosis exhibit balance problems during the stance phase of gait and have significant asymmetry in the frequency characteristics. These findings could be a primary effect that contributes to the medial-lateral deformity of the spine and its initiation and progression.”

Nonstructural Scoliosis

When a child’s lateral spinal curvature reduces significantly during recumbency, and side-bending is relatively symmetrical, a biomechanical imbalance must be considered. The causes include postural habits, muscle imbalances, pelvic and spinal misalignments and subluxations, and leg length discrepancies. These are all very responsive to conservative care, as long as the underlying source of the imbalance has been identified.

Pelvic and Spinal Imbalances

Muscular imbalances and recurrent subluxations may develop secondary to a child’s postural habits. Asymmetrical development of musculature used frequently in a sport can also be the source of a nonstructural scoliosis. These curves are usually mild, and will correct rapidly with education, corrective exercises, and chiropractic treatment.

Leg Length Difference

A discrepancy in the lengths of the legs during growth will cause a tilted sacral base, with a lumbar curvature. Once again, the scoliosis is usually mild, but the underlying cause should be identified and corrected in order to allow balanced spinal growth. If there is an anatomical difference in the length of the legs, a heel lift (or sole lift, in some cases) should be supplied. A functional short leg is due to an asymmetry in alignment, most commonly excessive pronation and/or lack of development of an arch of one foot. It is very important to recognize the functional short leg, since providing a heel lift instead of an orthotic is likely to perpetuate any associated sacroiliac subluxations. (7) There is little reliable information on the radiographs to differentiate these conditions. A pelvic tilt, a lower sacral base, and a femur head discrepancy seen on an x-ray of a child with a lumbar scoliosis indicate a lower extremity source, but not whether it is an anatomical or a functional short leg. A good clinical postural exam with lower extremity screening (including shoe wear patterns) is a way to make this determination.

Orthotic Support

All three major causes of scoliosis in children have been related to lower extremity asymmetries. Placing a child with a lateral curvature in custom-made orthotics provides an appropriate chance for developing a balanced spine, supports the chiropractic adjustments, and contributes to structural balance. If a heel lift is considered, an preferred method is to provide orthotics with an adjustable lift. This allows for increases or decreases that may be needed due to bone growth and lengthening. Of course, the orthotics themselves will need to be replaced as the child’s feet grow.

Conclusion

A child with a scoliosis must receive a careful spinal examination to determine the cause of the lateral curvature. In all cases, an assessment of the alignments and lengths of the lower extremities must be included. Accurate, standing x-ray films are also necessary, first to measure the amount of lateral deviation, rotation, and angulation of vertebrae, second to determine the spinal maturity (and risk of progression), and finally to rule out any leg length inequality. In many cases, custom-fitted orthotics (sometimes with added heel lifts) are needed for long-term results.

When conservative treatment of idiopathic scoliosis is indicated, nutritional support for the pineal gland should be considered. Perhaps most importantly, the neurological system needs to be checked thoroughly, and any interferences and sources of incoordination eliminated. Exercises to develop fine control of balance and posture, as well as gait training may be helpful. Custom-fitted orthotics should be provided early in treatment of all patients with scoliosis, to improve bilateral balance and gait symmetry.

References

1. Yochum TR, Rowe LJ. Essentials of Skeletal Radiology, 2nd ed. Baltimore: Williams & Wilkins; 1996. 307.

2. Rowe DE, et al. A meta-analysis of the efficacy of non-operative treatments for idiopathic scoliosis. J Bone Joint Surg 1997; 79A:664-674.

3. Dubousset J, Queneau P, Thillard MJ. Experimental scoliosis induced by pineal and diencephalic lesions in young chickens: its relation with clinical findings. Orthop Trans 1983; 7:7.

4. Machida M, et al. Pathogenesis of idiopathic scoliosis: experimental study in rats. Spine 1999; 24:1985-1989.

5. Machida M, et al. Role of serotonin for scoliotic deformity in pinealectomized chicken. Spine 1997; 22:1297-1301.

6. Giakas G, et al. Comparison of gait patterns between healthy and scoliotic patients using time and frequency domain analysis of ground reaction forces. Spine 1996; 21:2235-2242.

7. Rothbart BA, Estabrook L. Excessive pronation: a major biomechanical determinant in the development of chondromalacia and pelvic lists. J Manip Physiol Therap 1988; 11:373-379.

Children and Rehabilitation

by K.D. Christensen DC, CCSP, DACRB

As with adults, children often need to do some exercises as part of their Chiropractic treatment. A common question asked by physicians is whether children can safely perform exercise with resistance? How much weight is appropriate for a growing body? Which exercises are most effective? Doctors of Chiropractic may hesitate to recommend exercises for their younger patients because of these and similar questions. Since this is such an important topic, here is a reasoned and experienced response, along with useful consensus information.

Prepubescence is the phase of childhood prior to the onset of secondary sex characteristics. Rapid, but variable growth occurs during this period, with open physes and changing muscle and ligament lengths. Adolescence begins with the onset of secondary sex characteristics and continues until physical and skeletal maturity. Selecting the best exercise approach for each child’s situation is important, since needs may vary during growth. [1] However, all children should be encouraged to engage in frequent and regular fitness activities.

Benefits of Exercise

The benefits of youth physical activity include fitness, weight control, and the development of habits having the potential to span a lifetime. One study systematically determined the amount of moderate to vigorous physical activity students obtain during elementary and middle-school physical education classes (time spent performing moderate to vigorous physical activity/total class time). The researchers concluded that the amount of physical activity observed (elementary schools, 8.6%; middle schools, 16.1%) was significantly less than the estimated national average of 27% and far below the national recommendation of a minimum of 50%. [2] A review of current youth fitness data indicates that children in the United States are fatter, slower, and weaker than children in other developed nations. Also, children in the United States appear to be developing a sedentary lifestyle at earlier ages. A low level of exercise is a contributing factor for childhood obesity and hypertension, and predisposes the individual to premature death from coronary heart disease. [3] Fortunately, through intervention in children and adolescents in the form of education and motivation, exercise levels may be increased to the recommended minimum of 30 minutes on most days. [4]

Resistance Exercise Safety

High-intensity resistance training appears to be effective in increasing strength in preadolescents. Children make similar relative, but smaller absolute strength gains when compared with adolescents and young adults. Resistance training appears to have little if any hypertrophic effect, rather being associated with increased levels of neuromuscular activation. Researchers have found that the risk of injury from prudently prescribed and closely supervised resistance training appears to be low during preadolescence. [5] In 1993, Mazur reviewed the types and causes of injuries to preadolescents and adolescents resulting from weight lifting/training. [6] The researchers concluded that “prepubescent and older athletes who are well-trained and supervised appear to have low injury rates in strength training programs.”

A risk that must be considered in the immature skeleton is the susceptibility of the growth cartilage of the epiphyseal plates (physes). Weight training in a submaximal controlled, supervised situation is beneficial to bone deposition. Strength training can be a valuable and safe mode of exercise provided 1) instructors are properly educated; 2) participants are properly instructed; and 3) the absolute necessity of avoiding maximal lifts is reinforced. [7] The most important factors in avoiding injury in children who are doing resistance exercises are: proper performance of the exercise; avoiding overload by focusing on repetitions, not weight; enforcing rest periods during exercise; and resistance training only twice a week. Exercise tubing is an excellent tool for strength training of children, since the risks of injury are minimized, and a spotter or expensive equipment is not needed (Fig. 1).

Training Coordination and Balance

For many children, it is more important to learn the fine neurological control necessary for accurate spinal and full body performance than to simply build strength. Better coordination and balance will often result in improved physical function, both in daily and in sports activities. This may entail performing exercises while standing on one leg, with the eyes closed, while standing on a mini-tramp, or using a rocker board. The advantage of these balance exercises is seen when children engage in sports activities and perform at advanced levels for their age group.

Exercises are effective when done in an upright, weight-bearing position, since the entire body is in a closed chain position during the training. The stabilizing muscles, the co-contractors, and the antagonist muscles all learn to coordinate with the major movers during movements that are performed during closed chain exercising. This makes these types of exercises very valuable in the long run, particularly for children who are interested in becoming competitive athletes.

Corrective Spinal Exercises

Children’s spinal problems are often associated with poor postural support. A spinal asymmetry such as scoliosis and kyphosis is invariably accompanied by neuromuscular imbalance. This may be compounded by poor postural habits and tendencies to “slump.” One important factor in Chiropractic treatment is the correction of any loss of the normal upright alignment of the pelvis and spine. In addition to general strengthening and coordination exercises, patients (including children) should be shown corrective exercises that are specific for the postural imbalances they have developed. For instance, when the pelvis is carried flexed forward, a patient of any age will need to retrain with resisted pelvic extension exercises. Likewise, when there is a forward head, posterior translation exercises for the cervical region are very important (Fig. 2).

Whenever a child shows evidence of abnormal gait or begins to develop lower extremity complaints, a careful evaluation for the need for shoe inserts is warranted. Custom-fitted orthotics can improve performance and spinal alignment by ensuring proper lower extremity alignment and reduce overuse injuries by providing additional shock absorption.

Conclusion

A well-designed exercise program for children who need to strengthen, develop better coordination, and improve postural support will allow the doctor of Chiropractic to provide cost-efficient pediatric spinal care. Exercises performed with the spine upright (standing or sitting) can specifically train and condition all the involved structures to work together smoothly. In some children, orthotic support is necessary to help ensure correct alignment from the lower extremities. The end result is a more effective rehab component and young patients who will make a rapid response to their Chiropractic care. With a few common-sense cautions and careful supervision, children are capable of performing rehabilitative exercises very safely.

References

1. American College of Sports Medicine. Guidelines for Exercise Testing and Prescription, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2000.

2. Simons-Morton BG, Taylor WC. Observed levels of elementary and middle school children’s physical activity during physical education classes. Prevent Med 1994; 23:437-441.

3. Cunnane SC. Childhood origins of lifestyle-related risk factors for coronary heart disease in adulthood. Nutr Health 1993; 9:107-115.

4. US Dept. of Health and Human Services. Physical Activity and Health: a Report of the Surgeon General. Atlanta:1996.

5. Blimke CJ. Resistance training during preadolescence: issues and controversies. Sports Med 1993; 15:389-407.

6. Mazur LJ, Etman RJ, Risser WL. Weight-training injuries: common injuries and preventative methods. Sports Med 1993; 16:57-63.

7. Schafer J. Prepubescent and adolescent weight training: is it safe? Is it beneficial? Natl Strength Conditioning Assoc J 1991; 13:39-45.

About the Author

Kim D. Christensen, DC, CCSP, DACRB, is co-director of the SportsMedicine & Rehab Clinics of Washington. He is a popular speaker at numerous conventions and participates as a team physician and consultant to high school and university athletic programs, as well as being a Chiropractic faculty member. He is currently a postgraduate faculty member of numerous Chiropractic colleges and is the current president of the American Chiropractic Association (ACA) Rehab Council. He recently received the “Founding Father” award at the annual ACA meeting from the American Chiropractic Rehabilitation Board. He has participated in college sports, and has served as a trainer, coach, and team doctor. Dr. Christensen is the author of numerous publications and texts encompassing musculoskeletal rehabilitation and nutrition. He has recently been appointed as a Board Member of the Commission on Accreditation of Rehabilitation Facilities (CARF). Dr. Christensen has also recently been appointed to the HCFA Therapy Review Program (the only Chiropractor in the United States on this government panel). He can be reached at Chiropractic Rehabilitation Associates, 18604 NW 64th Avenue, Ridgefield, WA 98642.

[captions for illustrations]

Fig. 1. Resistance exercise with a rubber tubing system (light resistance for children)

Fig. 2. Posterior translation exercise for the cervical region

Athletes and Cervical Injuries

by K.D. Christensen DC, CCSP, DACRB

Serious cervical spine injuries among athletes (e.g., fractures, dislocations) generally occur as a result of axial loading. 1, 2, 3 Whether resulting from a hockey player pushed into the boards head first, a football player striking an opponent with the crown of his helmet, youth soccer “header” injuires, or a poorly executed dive into a shallow body of water where the subject strikes his or her head on the bottom, the fragile cervical spine is compressed between the rapidly decelerated head and the continued momentum of the body.

Reasonable and appropriate rule changes recognizing this mechanism can have a marked effect on the number of serious cervical injuries in a sport. For example, permanent cervical quadriplegia has decreased significantly in high school and college level football, thanks in part to changes in the rules involving tackling. Presumably, educational efforts designed to inform the public of the dangers of diving and ice hockey would have a similar effect.

The predominance of the axial loading mechanism is not as clearly defined in trampoline and mini-trampoline injuries. However, both of these devices can be dangerous when used in the best of circumstances, and their use has no place in recreational, educational, or competitive gymnastics.

Body Collisions in Sports

Bruce 4 reports that 80% of severe sports-related central nervous system trauma occurs as a result of collision sports, chiefly American football and rugby union football, followed by wrestling and gymnastics. Although serious head injury is uncommon, episodes of concussion are frequent. Repeated concussion should be grounds for suggesting that the athlete give up collision sport. American and rugby union football are the sports mainly responsible for cervical spine injury with resultant quadriplegia.

Epidemiology

Those athletes with abnormal findings on screening examination were twice as likely to have a head or neck injury at some point in their college careers as those players with a normal screening examination, according to Albright. 5 The greater the degree of abnormality on screening examination, the more severe the neck injury in college was likely to be.

Warning Signs

Athletes who have been found to have a congenitally narrow cervical vertebral canal followed by head trauma may result in the transient quadriplegia. A myelogram should be considered for patients with a history of transient quadriplegia, numbness, or a burning sensation down the back or the lower extremities, even if other radiographic studies are interpreted as negative. Some experts state that athletes who have stenosis of the cervical spine should be advised to discontinue participation in contact sports. 6

Sagittal canal/vertebral body ratios were measured on cervical spine lateral radiographs of 124 professional football players and 100 rookie football players. 7 A total of 894 levels were measured in 224 players. Forty of the 124 professional football players (32%), and 34% of the 100 rookies had a ratio of less than 0.80 at one or more levels from C3 to C6. The 0.80 ratio has been considered indicative of cervical spinal stenosis.

This is the first time that the incidence of spinal stenosis, as determined by Torg’s ratio, has been demonstrated in a population of professional and rookie football players. Because one-third of this population has cervical spinal stenosis as determined by the Torg ratio, other factors should be considered in the evaluation of a player with a transient quadriplegic episode when making continued play decisions.

Neurapraxia

The sensory changes of neurapraxia include burning pain, numbness, tingling, and loss of sensation, while the motor changes range from weakness to complete paralysis. The episodes are transient and complete recovery usually occurs in ten to fifteen minutes, although in some patients gradual resolution occurs over a period of thirty-six to forty-eight hours. Except for burning paresthesia, pain in the neck is usually not present at the time of injury and there is complete return of motor function and full, pain-free motion of the cervical spine. Routine roentgenograms of the cervical spine are negative for fractures or dislocations. However, the roentgenographic findings may include developmental spinal stenosis, congenital fusion, cervical instability, or intervertebral disc disease. Using the ratio method to determine spinal stenosis, a measurement of less than 0.80 indicates significant spinal stenosis as compared with a ratio of approximately 1.00 or more in control groups. There is generally a statistically significant spinal stenosis in many of such patients.

The phenomenon of neurapraxia of the cervical spinal cord occurs in individuals with developmental stenosis of the cervical spine, congenital fusion, cervical instability, or protrusion of an intervertebral disc in association with a decrease in the anteroposterior diameter of the spinal canal. In athletes with diminution of the anteroposterior diameter of the spinal canal the spinal cord can, on forced hyperextension or hyperflexion, be compressed, causing transitory motor and sensory manifestations. 8

Neck Injuries

Cervical disk injuries in football are injuries associated with neurological deficits, radicular symptoms, or radiological evidence of disk degeneration, but not with a fracture or a dislocation of the cervical spine. The majority of the radicular signs and symptoms are from the fourth and fifth cervical root. The roentgenographic changes are most common at the fourth and fifth intervertebral disk spaces. Most of the cases respond well to adjustments and simple cervical collar and cervical traction. The athletes who present with radicular signs and symptoms may require up to five months to return to full sports activities, and 60% of these may have residual symptoms after completion of treatment. 9

Football players with diagnosis of “stinger” that were examined in one report were proven to have C6 radiculopathy rather than lateral stretch of the brachial plexus. 10 The most frequent mode of injury was neck flexion during tackling. These athletes should not return to competition until abnormal neurologic signs disappear.

The traumatic C3-C4 level injuries sustained by young athletes and documented by the National Football Head and Neck Injury Registry reveals that the response to energy inputs at the C3-C4 level differ from that of those involving the upper (C1-C2) and lower (C5-C6) cervical segments. 11 Specifically, these lesions appear unique with regard to infrequency of bony fracture, difficulty in effecting and maintaining reduction, and their more favorable response to early aggressive treatment. It still believed that these lesions resulting from athletic activity are due to axial loading.

References

1. Thomas BE, McCullen GM, Yuan HA. Cervical spine injuries in football players. J Am Acad Orthop Surg 1999; 7(5):338-347.

2. Torg JS, Vegso JJ, Sennett B, Das M. The National Football Head and Neck Injury Registry: 14-year report on cervical quadriplegia, 1971 through 1984. JAMA 1985; 254(24):3439-3443.

3. Torg JS. Epidemiology, pathomechanics, and prevention of athletic injuries to the cervical spine. Med Sci Sports Exerc 1985; 17(3):295-303.

4. Bruce DA, Schut L, Sutton LN. Brain and cervical spine injuries occurring during organized sports activities in children and adolescents. Prim Care 1984; 11(1): 175-194.

5. Albright JP, McAuley E, et al. Head and neck injuries in college football: an eight-year analysis. Am J Sports Med 1985; 13(3):147-152.

6. Ladd AL, Scranton PE. Congenital cervical stenosis presenting as transient quadriplegia in athletes: report of two cases. J Bone Joint Surg 1986; 68(9):1371-1374.

7. Odor JM, Watkins RG, et al. Incidence of cervical spinal stenosis in professional and rookie football players. Am J Sports Med 1990; 18(5):507-509.

8. Torg JS, Pavlov H, et al. Neurapraxia of the cervical spinal cord with transient quadriplegia. J Bone Joint Surg [Am] 1986; 68(9):1354-1370.

9. Kumano K, Umeyama T. Cervical disk injuries in athletes. Arch Orthop Trauma Surg 1986; 105(4):223-226.

10. Poindexter DP, Johnson EW. Football shoulder and neck injury: a study of the “stinger”. Arch Phys Med Rehabil 1984; 65(10):601-602.

11. Torg JS, Sennett B, Vegso JJ. Spinal injury at the level of the third and fourth cervical vertebrae resulting from the axial loading mechanism: an analysis and classification. Clin Sports Med 1987; 6(1):159-183.

Assessing the Injured Low Back

by K.D. Christensen DC, CCSP, DACRB

Back pain is the most frequent primary symptom reported by patients seeking chiropractic care, and the second most frequent primary symptom among medical patients. 1 While 90-95% of acute spinal patients will resolve their conditions within three months of injury, chronic or recurrent back disability may persist for years. 2 Despite the fact that millions of people suffer from chronic back pain, there have been few safe and effective means of quantifying injury and aggressively rehabilitating these patients.

Considering the work-related costs of back injury (over 50% of dollars paid out by compensation claims, yet only 5% of injuries), the dollar savings to industry could be very substantial. It is possible for industry to have employees return to work productively when their backs are ready. Simple prescreening or a rehabilitation program costs very little compared to a $100,000 disability claim, or even a $10,000 claim.

A positive and objective approach by the chiropractic physician, employer and employee, coupled with careful rehabilitation or return-to-work conditioning programs, means health care dollars and compensation costs can be administered more cost-effectively. Additionally, we will all be promoting better quality and more accurate health care.

In the objective assessment of back dysfunction, the chronic patient appears to provide the best subject population. As is well-known, chronic back pain is a primary socio-economic problem. It rates as the number one cause of disability below the age of 45, and as the third major cause over the age of 45. 2 The accompanying high costs are related not only to medical and surgical care, but also to litigation, worker’s compensation, long-term disability insurance and social security payments, as well as lost work time.

Previous Assessment Limitations

The absence of objective functional capacity measurements is a possible cause for much of the present confusion in spine care. In the extremities, clinicians rely on visual observation of joint motion and stability, extremity circumference, right-left comparisons, as well as ergometry and muscle strength measurements to help guide treatment programs after injury. In the spine, small well-camouflaged joints and deep muscles with complex multplanar movements and interconnections make visual feedback impossible, thus leading to a near-total reliance on subjective pain complaints and radiographic imaging to guide the treatment regime.

The potential value of objective measurement of spine function leading to the same understanding of the spine as is currently utilized in the extremities has been recognized for some time: “Self-report of pain and medical history, structural measures (e.g., radiographic imaging), and functional capacity measurements are the three critical components necessary for diagnosis and clinical decision making in the extremities. However, only the first two of these components are currently utilized in spine treatment and decision making. The addition of this latter component to spine assessment is essential.” 2

Modern Systems and Standards

Technology has now advanced to the point that functional capacity measurements can be performed to quantify spinal function. Computerized mechanical muscle testing devices as well as low-tech procedures allow the clinician to quantitatively and objectively measure performance deficits or improvements. Graphic and numerical reports of range of motion and torque are computer generated, as well as abnormal movement. Torque patterns can be identified, providing an objective basis for a rehabilitation program.

The patient is positioned within a testing device or functional position with appropriate stabilization for isolated joint evaluations or appropriately to actively simulate “real life” functional movement. Many systems test for torso and extremity strength, functional range of motion, endurance, painful arcs, bending capability, twisting capability, lifting capability, etc. Reproducibility, validity, and reliability of the testing is made possible with the use of microcomputers, analog to digital converters and appropriate software. The computerized data is collected and the stored information can be retrieved for trial comparisons at future testings. Such testing provides “pure objective” functional data documenting functional impairment during movement. Repeat testing documents “curative” management and “permanent” residuals when the patient becomes stationary.

Triano 3 provides in the Chiropractic Rehabilitation Association’s (CRA) Chiropractic Rehabilitation Standards Manual the following indications and contraindications to functional capacity evaluation as well as muscle strength and endurance testing:

A. Indications

(1) Muscular spine disorders

(2) Mechanical spine disorders

(3) Unchanged musculoskeletal (spine and non-spinal) condition for two to

three weeks

(4) Monitor outcome of rehabilitation

B. Contraindications

(1) Acute pain status

(2) Progressive neurologic deficit

(3) Cauda Equina signs

(4) Metabolic bone disease, including severe osteoporosis/malacia

(5) Gross instability

(6) Rheumatoid arthritis

(7) Ankylosing spondylitis

(8) Early post-operative cases

(9) Malignancy

Besides storing and analyzing data, patient performances can be categorized in terms of age, sex, height, weight, occupation, work task, pathology, and other descriptors. It becomes possible to compare performance data with thousands of others throughout the nation.

Multi-Party Involvement

There are many possible players in the occupational back arena: the employee, his/her union, the employer, the physician, third-party payers, lawyers and the courts. All the players have the same goal: to take care of and provide for the truly injured worker.

Third-party payers are paying out millions of dollars for compensable injuries. Industry is spending more for increased insurance premiums. Both groups desire to see the employee return to a productive condition and, at the same time, feel comfortable that the worker’s compensation paid out is, in fact, a credible reflection of a real disability. They do not want the injured employee to return to work earlier or later than his/her back injury will allow.

The health care professional’s goal is to provide the best quality and most accurate health care by confirming the employee’s low back injury, providing for treatment or rehabilitation, and determining the degree of disability. A patient’s premature return to work can result in further and future impairments and disabilities, and could also present additional liability and increased costs to industry. The employee’s delayed return to work means unnecessary lost work time and more workman’s compensation benefits. Yet, you may have had no choice. In many cases decisions have been, and still are, based on subjective evaluations only.

The CRA standards manual 3 states the following findings within the patient’s history indicate chronicity where mechanical and functional muscle testing intervention would be appropriate:

(1) Musculoskeletal complaint unchanged for two to three weeks

(2) Evidence of anxiety or depression

(3) Regular continued use of non-prescription analgesics

(4) Continued disability

Cost-Effective Care

Functional capacity evaluation and mechanical muscle testing provides for quantitative comparisons or measurements of patient status and progress. Thus, a quantitative, repeatable, and objective testing procedure of human spinal and extremity performance has been a long time coming. With millions of hours of clinical testing and pathological and post-surgical patients safely tested, studies indicate that the data obtained from functional capacity evaluations, mechanical muscle testing of the spine and extremities can provide the chiropractor with the information necessary to formulate the most cost-effective direct care and rehabilitation regime. 4

The ACA Rehab Council has initiated efforts to shortly make available a CD program for the reporting of functional capacity evaluations. The program compares the patients results with normative data and thus documents deficiencies in function. Additionally, the program documents the patients progress during repeat evaluations.

The chiropractor truly interested in quantifying impairment and prescribing an effective rehabilitation program should seriously consider adding functional capacity evaluations to assess function and to routinely utilize the data obtained in enhancing the decision-making process to formulate the most cost-effective rehabilitation program.

References

1. Hurwitz EL, Morgenstern H. The effects of comorbidity and other factors on medical versus chiropractic care for back problems. Spine 1997; 22(19):2254-2263.

2. Mayer, Gatchel, Kishino et al. Objective assessment of spine function following industrial injury. Spine 1985; 10(6):482-493.

3. Chiropractic Rehabilitation Association. 1991 Chiropractic Rehabilitation Facility Standards Manual. CRA, 1990.

4. Jarvis KB, Phillips RB, Morris EK. Cost per case comparison of back injury claims of chiropractic versus medical management for conditions with identical diagnostic codes. J Occup Med 1991; 33(8):847-852.

Adjunctive Therapies to the Adjustment Successful Ankle Sprain Management

by K.D. Christensen DC, CCSP, DACRB

Sprain injuries to the ankle joint complex cause temporarily disability (and sometimes long-term devastation) to competitive and recreational athletes. Return to all activities at pre-injury levels is the goal of treatment. The ankle must be able to perform complex movements while supporting high weights and forces during normal walking. It provides support for the leg and the entire body, it absorbs and adapts to loads, shocks, and uneven surfaces, and it also assists in propulsion during gait. Regaining full function, such as running, cutting, and jumping during sports requires a surprisingly significant amount of strength, coordination, and stability.

Acute Ankle Sprains

Ankle sprains are the most common injury among athletes, and inversion injuries of the anterior talofibular (ATF) ligament are the most prevalent type of ankle sprain. (1) Most sprain injuries to the ankle can be successfully treated with a conservative regimen, although some conditions have a worse prognosis and may need a specialist or surgical consultation. The ability to bear weight after an ankle injury is an important consideration in deciding whether x-rays are needed. If a patient is unable to bear weight, or if there is significant tenderness at the posterior aspect of the lateral or medial malleolus, then x-rays are needed to rule out a fracture, which should be immobilized in a cast or repaired surgically. (2) In addition to the standard AP and lateral radiographic views, a “mortise” view is very helpful. If there is no evidence of fracture, or one less than 3 mm. of displacement, then conservative care is generally appropriate. (3)

Cryotherapy

Initial care definitely should include the frequent application of cold packs over the injured area, right from the beginning. Comparison studies have found that early implementation of cryotherapy results in an earlier return to sports activities. (4) The local cooling controls inflammation, limits the extent of bleeding and effusion, and inhibits pain. Hourly applications are ideal with the involved leg should be elevated above the heart level throughout each maximum of 10 minutes of cold treatment.

Controlled Movement

Ankle strapping will help reduce movement in response to mild (non-weightbearing) stress. Initially, crutches can be used in a three-point, partial weight-bearing gait to allow protected mobility. (5) A rigid, yet comfortable stirrup support that allows dorsal and plantar flexion, while limiting inversion/eversion (such as an Aircast brace) encourages early mobilization, and improves early functional results. (6) This controlled movement appears to stimulate a better collagen repair, while limiting adhesion formation.

Return to Function

In addition to managing the pain and inflammation during the acute phase, we have to prepare our patients to return to all pre-injury activities. Exercises and orthotic supports are very helpful in this regard, and can prevent recurrences.

Strength

During the initial acute stage, exercises for the damaged ankle are not appropriate. However, general full body conditioning should be continued, using methods that do not place undue stress on the healing ankle such as arm-hip swimming without ankle motion. A stationary cycle with pedal straps provides some joint mobilization, and at the same time helps to avoid deconditioning. The injured ankle motion is entirely passive. (7) Once the joint can be actively moved through a limited range without significant pain, resistance exercising of the peroneal muscles using elastic tubing can generally be started. (8) Initially these exercises start with standing knee flexion/extension with limited painfree ankle plantarflexion and dorsiflexion motion. Finally, peroneal strengthening should be performed from a seated position with the heel resting on the floor, which reduces the forces on the ankle joint while still maintaining the functional alignment.

As strength builds, the patient should progress to standing gait training during the exercises, in order to re-train the ankle support muscles in a closed-chain position. Further sport-specific exercises should be introduced to ensure that an athlete has all the strength and mobility to participate in sport activities. Examples include rope jumping which progresses to side-to-side jumps, carioca steps, figure eight runs, and even backwards running. Plyometric procedures should be introduced only when all other capabilities have returned to pre-injury capacity.

Coordination

Early research demonstrated that altered proprioceptive input predisposes to recurring injuries in patients with a history of sprained ankles. (9) Freeman et al. called this phenomenon “articular de-afferentiation” to recognize the importance of inappropriate afferent signals from injured ankle and foot proprioceptors. They pointed out that “since articular nerve fibers lie in ligaments and capsules, and since these fibers have a lower tensile strength than collagen fibers, it seems inevitable that a traction injury to a ligament or capsule will lead to the rupture of nerve fibers as well as collagen fibers. (10) Any patient who wants to regain the ability to handle uneven surfaces and be able to respond to quick balance changes will have to retrain the neurological coordination of the foot and ankle. This is best done spending time on unstable surfaces, such as a mini trampoline or a balance board. (11)

Initial exercises should be done sitting, focusing on range of motion in all directions. The patient progresses to standing on a balance board with both legs, and then rotating in both directions. Next, time is spent performing single leg “stork stands,” learning to maintain balance on the board, first with eyes open, and then with eyes closed. (12) Subotnick recommends that an athlete should be able to demonstrate a “stork stand” for a least one minute on the injured leg before being allowed to return to full competition. (13) Eventually, the difficulty can progress to rotations in both directions and single leg squats for the more advanced athletes. (14)

Stability

Customized biomechanical support for the foot and ankle is an important long-term treatment that can be supplied after an ankle sprain. A custom made orthotic will help to maintain the foot and ankle in its proper alignment during stressful sports activities. Support for the arches provides the stability that is often lacking once the ATF and other ligaments have been damaged. Since either prolonged pronation or excessive supination can interfere with the biomechanics of the foot and ankle, a well-designed orthotic can be the most effective means for preventing chronic, recurring ankle pain.

Conclusion

Sprain injury to the ankle results in a temporary limitation in normal mobility that can have long-lasting effects on gait and stability. Proper treatment during the acute phase immediately after injury results in a rapid return to daily activities. To regain full function, however, most competitive, and many recreational athletes will need to consider the three factors of strength, coordination, and stability. Specific exercises and custom-fitted orthotics should be considered and recommended for most patients who present with a history of ankle sprain injury.

References

1. Marder RA. Current methods for the evaluation of ankle ligament injuries. J Bone Joint Surg Am 1994; 76:1103-1111.

2. Sousa TA. Differential Diagnosis for the Chiropractor. Gaithersburg: Aspen Pubs; 1997. p. 347.

3. Steill IG, McKnight RD, et al. Implementation of the Ottawa ankle rules. JAMA 1994; 271:827-32.

4. Hocutt JE, Jaffe R, Rylander CR, Beebe JK. Cryotherapy in ankle sprains. Am J Sports Med 1982; 10:316-319.

5. Hertling D, Kesssler RM. Management of Common Musculoskeletal Disorders 2nd ed. Philadelphia: JB Lippincott; 1990. p. 397.

6. Konradsen L, Holmer P, Sondergaard L. Early mobilizing treatment for grade III ankle ligament injuries. Foot & Ankle 1991; 12:69-73.

7. Roy S, Irvin R. Sports Medicine: Prevention, Evaluation, Management, and Rehabilitation. Englewood Cliffs: Prentice-Hall; 1983. p. 394.

8. Kibler WB, Herring SA, Press JM. Functional Rehabilitation of Sports and Musculoskeletal Injuries. Gaithersburg: Aspen Pubs; 1998. p. 276.

9. Bosien WR, Staples OS, Russell SW. Residual disability following acute ankle sprains. J Bone Joint Surg Am 1955; 37:1237.

10. Freeman MAR, Dean MRE, Hanham IWF. The etiology and prevention of functional instability of the foot. J Bone Joint Surg Br 1965; 47:678-685.

11. Bassewitz HL, Shapiro MS. Persistent pain after ankle sprain: targeting the causes. Phys Sportsmed 1997; 25:12.

12. Losito JM, O’Neill J. Rehabilitation of foot and ankle injuries. Sports Med Rehab 1997; 14:533-57.

13. Subotnick SI. Sports Medicine of the Lower Extremity. New York: Churchill Livingstone; 1989. p. 284.

14. Miller AS, Narson TM. Protocols for proprioceptive active retraining boards. Chir Sports Med 1995; 9:51-5.

Rebalancing Hip Muscles

by K.D. Christensen DC, CCSP, DACRB

While the value of establishing proper strength and balance in the trunk muscles (the “core stabilizers”) when treating or preventing spinal problems is obvious, the hip muscles are often overlooked. The hip joint is intrinsically stable due to its construction as a ball in a deep socket, and is further enhanced by a very thick joint capsule reinforced by strong spiral ligaments. (1) Then there are the several powerful groups of muscles that surround this joint. The hip muscles form a vital link in the lower extremity kinetic chain — transferring ground-reaction forces from the legs to the trunk during gait. These important muscle groups supply coordinated propulsion, and at the same time must provide balanced stability for the pelvis and spine. Through repetitive use patterns and after injuries, it is not unusual for some of these muscles to develop shortening and/or weakness. A comprehensive program must include exercises to address these imbalances.

Surprisingly, an appropriate and successful exercise program to rebalance the hip muscles does not require expensive, joint-specific equipment. In fact, the low-tech approach can be very effective for the treatment of most hip and pelvic conditions. With a few simple stretches (properly performed) and some home resistance exercises, the hip muscles can be easily strengthened and rebalanced. (See Examples)

The Hip Rotators and the Pelvis

The role of the hip rotator muscles (Table 1) is frequently overlooked when addressing prevention and rehabilitation of lumbar spine injuries. Deconditioned and/or shortened hip rotators will contribute to abnormal lumbopelvic posture and cause compensatory motion in the lumbar spine during daily activities. (2) This becomes particularly important during strenuous and competitive athletic efforts. The detrimental effects of inadequately conditioned and prepared hip rotators predisposes the athlete to lumbar spine injuries (3), many of which are eventually seen by the sports-oriented doctor of chiropractic.

Flexibility and strength deficits in the hip rotators can add substantial stress to the pelvis and sacroiliac joint, as well as the lumbar and even thoracic spinal regions. (4) For instance, there may be an anteverted (forward flexed) pelvis in conjunction with limited external hip rotation. In such cases, a combination of stretching and strengthening will be necessary for a complete response to chiropractic care. The chiropractic correction of the flexed pelvis will help to provide greater external hip rotation. On the other hand, if the flexed pelvis is secondary to shortened hip rotator muscles, then corrective exercises to increase the range of motion of the hip internal rotators will be needed. This can be accomplished by stretching the shortened internal rotators and strengthening the antagonist external rotator muscles.

Stretching and Increasing Motion

Tightness of the external rotator muscles will limit internal rotation of the hip, while shortening of the internal rotators decreases external hip rotation. For some hip problems, improving the flexibility of short and tight muscles is necessary. Frequent, gentle, and sustained stretching of either the internal or external rotators should be demonstrated to the patient, who can usually start the stretching immediately, even in the early stages of chiropractic treatment.

Piriformis syndrome and iliotibial band syndrome are two hip conditions that will benefit from specific stretching exercises. In both of these, tight muscles contribute to an overuse condition that irritates sensitive tissues. Piriformis syndrome develops when a tight piriformis muscle inflames the sciatic nerve, causing posterior hip aching along with paresthesiae down the back of the leg, in the sciatic distribution. Since the piriformis is an external rotator of the hip, treatment must include inward rotation stretches for the piriformis muscle. Complete chiropractic care will also encompass corrections of subluxations and biomechanical faults of the pelvis, as well as predisposing factors such as an anatomically short leg and/or foot pronation. (5) Iliotibial band syndrome causes pain at the lateral aspect of the knee, where a tight iliotibial band rubs over the lateral aspect of the distal femur, causing a painful irritation, especially in runners. Correction of abnormal biomechanics such as leg length discrepancies must be part of the treatment, and foot orthotics may be needed. (6)

Resistance Strengthening

Weaker or injured muscles can be quickly strengthened with the use of isotonic resistance exercises. The resistance can come from a machine, from weights, from elastic tubing, or just using the weight of the body. Since the hip functions as part of a closed kinetic chain during most daily and sports activities, weight-bearing exercises, which require the co-contraction of accessory and stabilizing muscles, can be most effective. Open chain exercising (done with the foot and lower leg freely moving) is most helpful in the early stages of hip strengthening, to reduce the stress on the surrounding muscles after an injury. With athletes, exercise selection should also consider the sport-specific movement patterns. Kickers (such as soccer players and martial artists) can concentrate on open chain strengthening, while runner and golfers will benefit more from closed chain exercises.

Open chain exercises. Open chain exercising can be started very early with a symptomatic hip, since it doesn’t require the musculoskeletal structures to bear the weight of the body. The easiest method is to rotate the entire leg against the resistance of elastic tubing. Initial exercising should be done with a limited amount of movement — within a pain-free range of motion. These exercises are particularly useful for patients who have an injured rotator muscle, or even a “snapping hip.” Surprisingly, strengthening of the muscle and tendon involved in a snapping hip (such as the tensor fascia lata, iliopsoas, or biceps femoris muscles) is more useful than stretching for resolving the snapping. (7) Rehab for patients with any evidence of degenerative arthritis of the hip should also start with open chain exercising, since the joint is more safely exercised when the damaged cartilage is not bearing weight directly. As the patient progresses, additional resistance can safely be supplied with heavier tubing.

Closed chain exercises. Weight-bearing strengthening exercises, with the foot on the floor, should be included when an athlete is preparing to return to sports activities. Examples of closed chain exercises for the hip rotators include partial squats, lunges (especially to the side), and single-leg body rotations. Initially, body weight will be sufficient. Resistance can be gradually and progressively increased with the use of hand weights or elastic tubing. The particular benefit from closed chain exercises is their ability to re-train the co-contractions of accessory hip support muscles.

Functional Hip Alignment

A major underlying reason for developing an imbalance in the hip rotator muscles is an imbalance in weight-bearing alignment of the lower extremities. Alignment problems need to be addressed in order to prevent recurring hip muscle imbalances and eventual joint arthritis. Leg length discrepancies and foot pronation problems are frequently found in association with symptomatic muscle imbalances such as iliotibial band syndrome, and piriformis syndrome. A study by Ora Friberg, MD has found that osteoarthritis is much more common in the hip joint of a longer leg. (8) Recurrent muscle strains (especially hamstring and groin pulls) can be an indicator of asymmetry in structural alignment. The use of custom-fitted orthotics and/or heel lifts is often necessary in order to establish long-term balance in the hip muscles.

Outcomes Assessment

In order to assess the effectiveness of a hip treatment plan, both objective and subjective data on patient results on outcomes must be collected and documented. The data typically focus upon the physical changes noted at the time of consultation and in subsequent visits. Ongoing outcome assessment data utilizing the Hip Rating Questionnaire with comparative graphs over treatment time (available at www.outcomesassessment.org) documents the longterm results and effectiveness of the rehab procedures.

Conclusion

Early in their treatment, patients with hip complaints and sports injuries should be started on appropriate and progressive rehabilitative programs that include muscle stretching and strengthening. (9) These rehab techniques are easy and accessible, since they do not require expensive equipment or great time commitments. It isn’t difficult to select the best exercise approach for each patient’s hip problem. A home exercise program which is closely monitored allows the doctor of chiropractic to provide rehabilitative care which is cost efficient and effective.

Muscle alignment problems are frequently found in association with chronic and/or recurring hip imbalances. Therefore, patients must be screened for excessive leg length discrepancies and/or pronation. If these complicating factors are not recognized, the result will be frustrated patients who don’t respond to the balancing exercises, or who develop symptoms that vary in location due to the effects of the underlying biomechanical stress. Proper alignment of the lower extremities will lead to muscles that are strengthened and lengthened, and hip joints that work smoothly. Patients will be then be able to enjoy improved sports performance, as well as better mobility during daily activities.

Table 1.

ROTATOR MUSCLES OF THE HIP JOINT (4)
External Rotators Internal Rotators
Psoas Major Gluteus Minimus
Iliacus Gluteus Medius (anterior)
Sartorius Tensor Fascia Lata
Gluteus Maximus Adductor Longus
Piriformis Adductor Brevis
Quadriceps Femoris Semimembranosus
Gemellus superior and inferior Semitendinosus
Obturator externus and internus
Gluteus Medius (posterior)

References

1. Hertling D, Kessler RM. Management of Common Musculoskeletal Disorders (2nd ed.). Philadelphia: JB Lippincott, 1990:280.

2. Hruska R. Pelvic stability: influences of lower extremity kinematics. Biomechanics 1998; 5:23-29.

3. Regan DP. Implications of hip rotators in lumbar spine injuries. Strength Cond J 2000; 22(6):7-13.

4. Ninos J. A chain reaction: the hip rotators. Strength Cond J 2001; 23(2):26-27.

5. Souza TA. Differential Diagnosis for the Chiropractor: Protocols and Algorithms. Gaithersburg, MD: Aspen Publishers, 1998:134.

6. Subotnick SI. Sports Medicine of the Lower Extremity. New York: Churchill Livingstone, 1989:312.

7. Souza TA. Differential Diagnosis for the Chiropractor: Protocols and Algorithms. Gaithersburg, MD: Aspen Publishers, 1998:265.

8. Friberg O. Clinical symptoms and biomechanics of lumbar spine and hip joint in leg length inequality. Spine 1983; 8:643-645.

9. Heiser JR. Rehabilitation of lower extremity athletic injuries. Contemp Podiat Phys 1992; Aug:20-27.

About The Author

Kim D. Christensen, DC, CCSP, DACRB, is codirector of the SportsMedicine & Rehab Clinics of Washington, and current president of the American Chiropractic Association Rehab Council. He can be reached at Chiropractic Rehabilitation Association, 18604 NW 64th Avenue, Ridgefield, WA 98642 or via email: kimdchristensen@hotmail.com.

Rehab of the Achilles Tendon

by K.D. Christensen DC, CCSP, DACRB

The Achilles tendon transmits the forces of the large gastrocnemius/soleus muscle group from the lower leg into the foot. It inserts into the heel at the most posterior aspect of the calcaneus. Conditions such as tendinitis and tears of this tendon will require appropriate rehabilitation in order to prevent continuing problems and disability. Rehab of the Achilles tendon is easily performed in a chiropractic office, since it doesn’t require expensive special equipment or extraordinary time commitments.

Biomechanical Function

Most injuries of the Achilles tendon begin with the report of a recent acute injury; but have actually developed gradually, over a period of weeks or months. These are “overuse” or “misuse” conditions, and are caused by excessive and/or repetitive motion, often with poor biomechanics. The end result is a microtrauma injury – the body is unable to keep up with the repair and re-strengthening needs, so the tissue begins to fail and becomes symptomatic. If it is not very painful (or when the pain is eliminated by pain-killing drugs), continued stress can eventually lead to complete failure, with a resulting acute tear of the tendon.

The Achilles tendon insertion on the calcaneus is medial to the axis of the subtalar joint, making the calf muscles the most powerful supinators of the subtalar joint. (1) Therefore, when excessive pronation occurs, eventually the tendon undergoes overuse degeneration and inflammation. Researchers at the University of British Columbia described how “pronation generates an obligatory internal tibial rotation which tends to draw the Achilles tendon medially. Through slow motion, high-speed cinematography we have seen that pronation produces a whipping action or bowstring effect in the Achilles tendon. This whipping action, when exaggerated, may contribute to microtears in the tendon, particularly in its medial aspect, and initiate an inflammatory response.” (2) These investigators believe that the control of functional overpronation with corrective orthotic devices is a necessary treatment for most patients with Achilles tendinitis.

Impaired circulation may be a contributing factor to Achilles tendon overuse injuries, especially with tendon tears. The same researchers speculate that “in individuals who overpronate, the conflicting internal and external rotatory forces imparted to the tibia by simultaneous pronation and knee extension may blanch or wring out vessels in the tendon and peritendon causing vascular impairment and subsequent degenerative changes in the Achilles tendon.” (Fig. 1) This “region of relative avascularity” extends from 2 to 6 cm above the insertion into the calcaneus, and is a common site of rupture of the Achilles tendon. This makes it especially important to ensure good blood flow during the healing of this condition.

Achilles Tendinitis/Tendinosis

It’s not surprising that abnormal biomechanics of the foot and ankle can cause problems with the largest tendon in the leg. Symptoms are usually described as diffuse pain in or around the back of the ankle (from the calf to the heel). The pain is aggravated by activity, especially uphill running or climbing stairs, and relieved somewhat by wearing higher-heeled shoes or boots. Palpation will find a tender thickening of the peritendon, and there may be crepitus during plantar and dorsiflexion. Often, a recent increase in activity levels (such as more stair-climbing) or a change in footwear is reported by the patient.

Macroscopically, overused Achilles tendon tissues examined at surgery are dull, slightly brown, and soft, in comparison to normal tendon tissue, which is white, glistening, and firm. (3) There is a loss of collagen continuity and an increase in ground substance and cellularity, which is due to fibroblasts and myofibroblasts, and not inflammatory cells. (4) This is the reason that anti-inflammatory strategies (such as NSAIDS drugs and corticosteroid injections) are not indicated for these conditions, and actually may interfere with tendon repair. (5) We now know that the condition we usually have described as “tendinitis” is actually better understood as “tendinosis,” and is not due to inflammation, but an underlying degeneration of collagen tissues in response to mechanical overuse. (6) This “new paradigm” will help to guide our management of all tendon problems, and provide more effective rehabilitation for Achilles tendons.

Rehabilitation of the Achilles Tendon

When an injury is acute, an initial period of relative rest is needed. Occasionally, the weakened tissues will tear through, resulting in a ruptured Achilles tendon. This may require surgical repair and a period of rest before rehabilitation can begin. During this period, though, exercise of the opposite ankle should be encouraged. Vigorous exercise of the uninvolved contralateral ankle muscles produces a neurological stimulus in the injured muscles (called the “cross-over effect”), and helps to prevent atrophy. (7) Initial treatment should also include heel lifts to reduce the strain on the Achilles tendon, and cross-fiber friction to improve circulation. Complete return to function will then require attention to range of motion, functional strength, and orthotic support.

Range of motion. In addition to appropriate foot and ankle adjustments, stretching of the tight and shortened gastrocnemius/soleus muscle complex is a necessary part of Achilles tendon rehabilitation. Gentle stretching should be started early, putting a linear stress on the tendons and stimulating connective tissue repair. The standard is the “runner’s stretch,” performed against a wall (Fig. 2). Patients with tightness and pronation will often allow the foot to flare outwards while stretching, which forces the medial arch to drop. This tendency must be carefully corrected, with the foot positioned straight ahead and the medial arch kept elevated. (8) Even better is to perform the stretches with corrective orthotics in place.

Functional strength. Isotonic strengthening exercises that focus on the eccentric (negative) component have been shown to improve the healing of tendons and accelerate return to sports participation (Fig. 3). (9) These exercises should be progressed to closed-chain, heavily-loaded eccentric exercises, in order to stimulate collagen fiber re-orientation and strengthening. (10) The patient is instructed to stand on the edge of a stair, do a toe raise up, then rapidly drop the involved heel as far as possible, returning by pushing back up with the uninvolved leg.

Orthotic support. A shoe insert made of viscoelastic material will help decrease the amount of stress on the feet, legs, and back during running. (11) Orthotics have been found to be very useful in the long-term improvement of running biomechanics. (12) While there is still controversy regarding exactly how and why orthotics are so useful, there is solid empirical evidence of their benefits to runners, for both treatment and prevention of overuse injuries. (13) As described above, most Achilles tendon problems develop from poor foot and ankle biomechanics, and control of pronation is needed to prevent recurrent injuries. (14) Custom-made, flexible orthotics are now available that can support the hindfoot, midfoot, and forefoot, thereby providing biomechanical control throughout the entire gait cycle.

Outcome Management. The common outcome assessment tool in regards to Achilles

tendon management available to chiropractors is the Ankle Grading Questionnaire

(Mazur et al, 1979). This is a 100 point index awarded based upon the following

criteria:

Pain – 50 points

Function – 6 points

Walking – 6 points

Support – 6 points

Hills (up) – 3 points

Hills (down)- 3 points

Stairs (up) – 3 points

Stairs (down) 3 points

Toe Rising – 5 points

Running – 5 points

ROM – 10 points

This questionnaire and others requires permission from the copyright owners to utilize which has been obtained and available thru FCER (800-622-6309, see www.OutcomesAssessment.org).

Conclusion

Achilles tendon injuries can be successfully rehabilitated conservatively. Steroid injections and casting are seldom used these days. Once the local inflammation has been controlled, improved blood flow to the region of relative avascularity is necessary. Correct stretching and strengthening exercises can be demonstrated and monitored in the office. One of the most important factors for the long term is to reduce any tendency to pronate excessively. In addition to custom-fitted orthotics, all runners should be encouraged to wear well-designed shoes that provide good heel stability with a small amount of additional heel lift. This helps to prevent Achilles tendon problems, and is especially important in athletes running for more than a few miles at a time.

References

1. Subotnick SI. Sports Medicine of the Lower Extremity. New York: Churchill Livingstone; 1989. 475.

2. Clement DB et al. Achilles tendinitis and peritendinitis: etiology and treatment. Am J Sports Med 1984; 12:179-184.

3. Astrom M, Rausing A. Chronic achilles tendinopathy: survey of surgical and histopathologic findings. Clin Orthop 1995; 316:151-164.

4. Khan KM et al. Histopathology of common tendinopathies: update and implications for clinical management. Sports Med 1999; 27:393-408.

5. Almekinders LC, Temple JD. Etiology, diagnosis, and treatment of tendonitis: an analysis of the literature. Med Sci Sports Exerc 1998; 30:1183-1190.

6. Khan KM et al. Overuse tendinosis, not tendinitis. Part 1: a new paradigm for a difficult clinical problem. Phys Sportsmed 2000; 28:38-48.

7. Hertling D, Kessler RM. Management of Common Musculoskeletal Disorders. 2nd ed. Philadelphia: JB Lippincott; 1990. 334.

8. Ninos J. Chain reaction: a tight gastroc-soleus group. Strength Cond J 2001; 23:60-61.

9. Niesen-Vertommen Sl et al. The effect of eccentric versus concentric exercise in the management of Achilles tendinitis. Clin J Sport Med 1992; 2:109-113.

10. Alfredson H et al. Heavy-load eccentric calf muscle training for the treatment of chronic Achilles tendinosis. Am J Sports Med 1998; 26:360-366.

11. Schwellnus MP, Jordaan G, Noakes TD. Prevention of common overuse injuries by the use of shock absorbing insoles. Am J Sports Med 1990; 18:636-641.

12. Gross ML, Napoli RC. Treatment of lower extremity injuries with orthotic shoe inserts. Sports Med 1993; 15:66-70.

13. Gross NL, Davlin LB, Evanski PM. Effectiveness of orthotic shoe inserts in the long-distance runner. Am J Sports Med 1991; 19:409-412.

14. Busseuil C et al. Rearfoot-forefoot orientation and traumatic risk for runners. Foot & Ankle Intl 1998; 19:32-37.

Fig. 1. Achilles tendon circulation

Fig. 2. “Runners stretch” against wall

Fig. 3. Isotonic stretching (plantar flexion)

Rehab and the Sacroiliac Joint

by K.D. Christensen DC, CCSP, DACRB

A dysfunctional sacroiliac (SI) joint is often ignored or dismissed as an insignificant feature of musculoskeletal health. (1,2) However, SI subluxation is a legitimate syndrome, separate from the type of low back pain associated with disc conditions, lumbago, or sciatica. (1-6) In fact, SI joint dysfunction has been implicated as a common cause of back pain in more than 30% of children. (3) Additionally, a study involving the correction of SI joint dysfunction in patients presenting to a chiropractic center over one day found an incidence of 57% for SI joint dysfunction. (7)

Clinically, the SI joint can give rise to buttock and leg pain, which is often difficult to differentiate from other causes of low back pain. (8) Furthermore, dysfunction of the SI joint may be a contributing factor in failed back surgery syndrome. (9)

What the SI Joints Do

The role of the SI joints is to functionally participate in converting the pelvis into a “resilient, dynamic, accommodating base that dissipates weight, absorbs shock, and provides a singular proficiency unique to bipedal locomotion.” (10) In four-legged animals, body weight is distributed horizontally over the spine. Taken from an engineering point of view, this weight-distribution method is superior to the upright human musculoskeletal system, which has a single cantilevered support at the hips. The human spinal column is configured so that the total weight of the upper body rests on the two small SI joints at the juncture of the sacrum and ilia. The stress placed on this area in the upright position makes the lower back susceptible to injury.

SI Dysfunction

Primary SI dysfunction arises from trauma such as blows, falls on the buttock, or from attempts to save oneself from falling. Knocking the SI joints out of place can affect the structural integrity of the entire spine. The SI joints themselves are held in place by small ligaments, which can be stretched out of position if there is a traumatic dislocation. The whole pelvic girdle can be tilted to one side in the aftermath of a traumatic injury. Tissues in the area become inflamed and muscles spasm, pulling on the hip bones and rotating them out of place.

A secondary dysfunction comes on slowly, producing a chronic misalignment. Muscle atrophy on one side and overdevelopment on the other may be associated with a scoliosis with pelvic tilt or an actual shortening of one leg. (5) Over time the entire spine can be affected, and one shoulder blade or one side of the ribcage may appear more pronounced than the other. Eventually, uneven pressure on the spine may grind away at the protective discs between the vertebrae.

Treatment Approaches

The goal of treating SI subluxation is to restore a normal relationship between the sacrum and ilium and to maintain it with suitable support. (2) Many authors concur in principle but differ in exact methods of restoration and supportive care. (1,5,9,11) After the SI joint is examined and evaluated, the direction of displacement is determined. Joint correction is made by inducing a “rotary movement of the ilium in the direction exactly contrary to the one in which the displacement has occurred.” (5)

Achieving suitable support to maintain joint integrity requires consideration of predisposing factors. Here is where special attention should be paid to the kinetic chain. Beginning at the foundation of the chain, the feet may exhibit excessive pronation or supination that can contribute to SI syndrome. Effects may manifest as muscular imbalance and skeletal distortion that transmit directly to the pelvic ring. Functional leg length inequality can also result from foot disorders or structural anomalies. Custom-made orthotics and lifts should be pursued in treating the corresponding symptoms. (1,11,12)

The effects of heel-strike shock on the pelvic structure should also be noted. Shock forces of 5-7 g’s (5-7 times body weight) are transmitted and dissipated through the body and reduced to 0.5 g at the jaw. (13) Hip and back pain are natural consequences when such force is present, particularly in cases where SI dysfunction exists. A shock-absorbing material built into a custom-made orthotic can have a significant effect in reducing initial heel impact.

Corrective exercise done at home can be recommended as an adjunct to clinical treatment. (1,5,14) Activity should focus on developing strength in the abdominals and supporting pelvic muscles. This can also enhance the shock-absorbing properties of the tissues.

Patients exhibiting marked SI instability may require use of a corset, belt, or strapping. (1,2,11) Additional lumbar support can also be provided by a postural back rest when seated, or by a pillow designed to provide adjustable support for either the lumbar or cervical areas. Proper cervical support during sleep is an often overlooked area of consideration in SI cases. Because the body is essentially a kinetic chain, elongation of supporting soft tissues in the cervical spine may ultimately lead to spinal misalignments that can aggravate the SI syndrome. Cervical support pillows help to promote patient comfort, and also help adjustments to hold.

SI Rehab: Do’s and Don’t’s

Here is some additional advice for your patients with SI dysfunction/pain:

Do walk briskly 2-3 miles a day to strengthen stretched-out sacroiliac ligaments and reduce them to their proper size and position.

Don’t rely on bed rest — ligaments will further slacken from disuse.

Don’t bring your knees to your chest, perform sit-ups, or bend over from the waist with your knees straight. All of these motions will displace the SI joints.

Don’t use heat treatments after a back injury. Heat expands the ligaments, contributing to further instability.

Do ice the area. Ice reduces inflammation and relaxes muscles.

References

1. DonTigney RL. A review. Physical Therapy 1985; 65(1):35-44.

2. Cox HH. Sacro-iliac subluxation as a cause of backache. Surg, Gynec & Obstet 1927; 45:637-648.

3. Mierau DR et al. Sacroiliac joint dysfunction and low back pain in school aged children. JMPT 1984; 7(2):81-84.

4. Jessen AR. The sacroiliac subluxation. ACA J of Chiro 1973; 7(s):65-72.

5. Cyriax E. Minor displacements of the sacro-iliac joints. Br J Phys Med 1934; 9:191-193.

6. Freiberg AH, Vinke TH. Sciatica and the sacro-iliac joint. J Bone & Foot Surg 1934; 16:126-136.

7. Gemmell HA, Heng BJ. Low force method of spinal correction and fixation of the sacroiliac joint. The Amer Chiro 1987; Nov:28-32.

8. Gemmell HA. The sacroiliac joint. Success Express 1988; 12(1):56-59.

9. McGregor M, Cassidy DC. Post-surgical sacroiliac joint syndrome. JMPT 1983; 6(1):1-12.

10. Janse J. Clinical biomechanics of the sacroiliac mechanism. ACA J of Chiro 1987; 12(s):1-8.

11. Grieve GP. The sacroiliac joint. Physiotherapy 1976; 62(12):384-400.

12. Schafer RC. Clinical Biomechanics. Baltimore: Williams & Wilkins, 1983.

13. Voloshin AS, Burger CP. Interaction of Orthotic Devices and Heel Generated Force Waves. Ninth Intl. Congress on Applied Mechanics. Canada, 1983.

14. Thompson A. How to Cure Your Aching Back. New York: Doubleday, 1971.

Hip Extension and Abduction Dysfunction

By Donald J. Fedoryk, DC, CCSP, DACRB

abstract: Hip extension and abduction movements involve coordinated muscular contractions occurring in a specific sequence. When a change occurs in the sequence of muscular contractions, a new movement pattern will develop called “an altered movement pattern”. Understanding muscle function during hip extension and hip abduction allows muscle imbalance and altered movement patterns to be recognized. Treatment to correct the muscular imbalance causing an altered movement pattern is the rehab treatment plan.

key words: Hip extension; hip abduction; altered movement patterns; muscle imbalance; rehabilitation.

INTRODUCTION

Muscles facilitate joint movement in the body and help maintain posture. Muscle strength can change due to different reasons, which include sitting or standing, repetitive motion, injury, lack of exercise and deconditioning causing a muscle imbalance in the body. According to Vladimir Janda(1), muscle imbalances develop between muscles that have a tendency to develop tightness and other muscles which are prone to inhibition. Janda classified muscles into two groups “postural and phasic”. Postural muscles have a tendency to become overactive, hypertonic, weak and shortened in length. An example of a postural muscle is the psoas muscle, a hip flexor. On the other hand, phasic muscles have a tendency to become weak and inhibited. An example of a phasic muscle is the gluteus maximus muscle, a hip extensor. The tendency for a specific muscle to become overactive and another muscle to become inhibited occurs over time creating a muscle imbalance and an altered movement pattern.

The physician must be able to recognize the muscular imbalance and the altered movement pattern in order to prescribe appropriate relaxation and strengthening exercises to restore the normal movement pattern in the body.

An ” altered movement pattern” is a movement pattern in which a change occurs in the coordination of the muscle firing sequences for a specific group of muscles, facilitating a specific joint movement. The primary muscle responsible for the specific joint movement may become weak and inhibited, causing a synergistic muscle/muscles to become the primary muscle/muscles responsible for that joint movement. As a result, a different sequence of muscular contractions occur called “an altered movement pattern”. The altered movement pattern is a sign of muscle imbalance in the body because of muscular dysfunction. Altered movement patterns do not occur randomly. They can develop because of repetitive motion, injury, pain, illness, muscle deconditioning or sedentary lifestyle.

Changes in posture are often noted with an altered movement pattern in the body. The changes in posture may be observed while the person is sitting, standing or walking. An example of change in posture is one in which the person stands slightly flexed at the waist, unable to stand erect because of hypertonicity of the psoas muscle and weakness of the erector spinae muscle. The hypertonicity of the psoas muscle has a tendency to flex the lumbar spine, causing the lumbar spine to diminish in lordosis especially when a weakness of the erector spinae is present.

The muscles involved in hip extension and abduction can be divided into two groups, postural and phasic (Table 1). Postural muscles have a tendency to become overactive, hypertonic, shortened and weakened because of the physical demands placed upon them. They are composed of red muscle fibers, because they contain significant myoglobin and are innervated by small Alpha a2 motor neurons. Hennemans Size Principle states that the smaller the fiber the easier it activates, the larger the fiber the faster it conducts. This is why postural muscles have abundant red fibers. The neurons are smaller and easier to activate, constantly sending impulses with correction messages to the postural muscles to maintain body position. The red fibers are “slow twitch” fibers and are important in endurance activities or as a base in the activation of a strength effort. This is the reason why red fibers are often referred to as “tonic”, referring to tone or posture. Phasic muscles have a tendency to become weak and inhibited as a result of the action of postural muscles. The phasic muscles are composed of more white fibers and are innervated by Alpha a1 motor neurons. The white fibers receive their name partially from their innervation. It takes more to activate the Alpha a1 neurons but once they are activated, the white fibers are capable of a rapid “fast twitch” reaction. Thus white fibers are referred to as “dynamic”or phasic and are best suited for quick burst activities.

Table 1.

POSTURAL MUSCLES PHASIC MUSCLES

Biceps Femoris Gluteus maximus

Hip Adductors Gluteus medius

Piriformis

Rectus Femoris

Psoas

Erector Spinae

Quadratus Lumborum

TFL

RECOGNIZING ALTERED MOVEMENT PATTERNS AND MUSCULAR IMBALANCES

There is a specific pattern to the sequence of muscle activation involved during joint movement. Two specific patterns to be discussed are Hip Extension and Hip Abduction(1). Hip extension and hip abduction movement patterns involve specific muscles. The muscles involved in the movements are gluteus maximus, gluteus medius, psoas, quadratus lumborum, erector spinae, piriformis, TFL, biceps femoris, adductors and rectus femoris. These muscles are categorized either as the primary mover/agonist, antagonist or synergist according to their function (Table 2). The primary mover/agonist is the muscle responsible for initiating and performing the main function for that specific joint movement. The synergist assists the agonist during the movement. The antagonist acts in opposition to the agonist and moves the joint into the opposite direction of the action of the agonist.

Table 2.

MUSCLE ACTION SYNERGIST ANTAGONIST

Gluteus maximus hip extension Erector spinae, Biceps femoris Psoas, Rectus Femoris

Gluteus medius hip abduction Quadratus lumborum, Psoas, Adductors

Piriformis, TFL, Rectus femoris

HIP EXTENSION

Hip extension involves the action of three muscles contracting in a coordinated sequence. The three muscles are the gluteus maximus(primary mover/agonist), biceps femoris(synergist) and erector spinae(synergist). Any deviation from the specific muscle activation is considered an altered movement pattern. This will cause hip extension dysfunction, muscle imbalance, pain and contribute to changes in posture. The normal sequence of muscular contractions for hip extension involves the contraction of the gluteus maximus and the ipsilateral biceps femoris, followed immediately by the contraction of the contralateral(opposite side) erector spinae and then the ipsilateral erector spinae.

The gluteus maximus is the primary muscle responsible for the motion of hip extension. The ipsilateral biceps femoris assists during gait by flexing the knee. Immediately after the contraction of these two muscles, the contralateral side erector spinae muscle contracts, followed by the contraction of the ipsilateral erector spinae muscle to help stabilize the lumbar spine and pelvis allowing movement of the hip during gait. Any change in this sequence of muscular contractions is considered an “altered movement pattern”. A change often seen in altered hip extension movement is the contraction of the ipsilateral erector spinae muscle before the gluteus maximus muscle contracts, to initiate the movement of hip extension. This can be observed with the patient prone and performing hip extension. When this occurs, the erector spinae becomes the primary muscle initiating hip extension. Weakness of the gluteus maximus prevents itself from functioning as the primary muscle initiating hip extension.

What can cause an altered hip extension movement? Weakness or inhibition of the gluteus maximus can be the result of an injury to the muscle, deconditioning as a result of an illness or injury limiting the activity of walking, overuse due to excessive repetitive motion or overactivity of an antagonistic muscle. The gluteus maximus muscle will display signs of a weakened contraction, flattened shape and triggers points be found in the muscle. The psoas muscle, a hip flexor and an antagonist muscle of gluteus maximus, is often another cause of altered hip extension. Tightness or hypertonicity of the psoas muscle resulting from prolonged sitting in a flexed position can mechanically restrict the motion of hip extension. A tight psoas muscle will restrict hip extension range of motion, which normally is 20 degrees, and will result in a decreased stride. Tightness of the psoas can also cause postural changes in the lumbar spine by decreasing the lumbar lordosis. The rectus femoris muscle also functions as an antagonistic muscle to gluteus maximus since it also assists in hip flexion. Together, the action of the psoas and the rectus femoris, can mechanically inhibit hip extension range of motion. Weakness in the gluteus maximus muscle will cause recruitment of a synergistic muscle, the erector spinae to initiate hip extension. The erector spinae will change its’ function and become the primary muscle responsible for hip extension causing an altered movement pattern. The erector spinae will contract on the ipsilateral side of hip extension before contraction of the gluteus maximus to initiate hip extension and stabilize the pelvis. As a result, the erector spinae muscle acts as the primary muscle, initiating hip extension replacing the gluteus maximus. This will cause an increase in the stress on the lumbar spine. The erector spinae will also become hypertonic, causing an increase in the stress(load) on the lumbar facet. Pain in the lumbar spine increasing while walking will also be a symptom along with decreased passive and active ranges of motion of hip extension. Tightness of the psoas and/or rectus femoris muscles may also be present. Altered hip extension can occur unilaterally or bilaterally.

Along with mechanical inhibition of the gluteus maximus, a neurological inhibition will occur because of the change in sequence in muscle activation. The new neurological sequence or pathway initiating hip extension will be stored in the cerebellum, which will also inhibit activation of the gluteus maximus.

HIP ABDUCTION

Hip abduction is another movement where an altered movement pattern can develop in the hip. The gluteus medius muscle is the primary muscle responsible for hip abduction. The synergist muscles are the psoas, piriformis, TLF, quadratus lumborum and rectus femoris. The hip adductor muscles are the antagonists to the glutues medius.

Hip abduction involves the contraction of the gluteus medius, causing a smooth lateral abduction of the lower extremity away from the body. “An altered hip abduction movement” is any change in this movement. Changes in the movement will occur when the gluteus medius muscle can not initiate and perform hip abduction by itself. Conditions that can weaken or inhibit the gluteus medius muscle include an injury to the muscle, deconditioning due to an illness or injury limiting the activity of walking, overuse due to excessive repetitive motion and overactivity of an antagonist. The causes are the same types of causes associated with causing hip extension dysfunction.

One sign of altered hip abduction is “hip hiking”. Hip hiking is the raising of the pelvis on the side of the body during gait movement caused by the premature contraction of the quadratus lumborum muscle on the side of hip abduction before contraction of the ipsilateral gluteus medius muscle. The contraction of the quadratus lumborum muscle initiates the sequence of hip abduction. This will occur when gluteus medius is not strong enough or is inhibited in intiating the movement of hip abduction. Hip hiking can be observed while the patient is walking. It can also be diagnosed with the patient laying on his side while performing a hip abduction movement. Another sign of an altered hip abduction movement occurs with the hip drifting into flexion during hip abduction. This occurs because of overactivity of any or all of the following muscles: psoas, rectus femoris, TFL. These muscles will cause the hip to move into flexion during abduction because of their hypertonicity, especially when there is weakness of the gluteus medius in performing hip abduction. External rotation of the lower extremity is another sign of altered hip abduction, which occurs during hip abduction because of an overactive piriformis muscle. The last two dysfunctions of hip flexion and external rotation of the lower extremity can best be observed while testing the patient laying on his side and abducting the hip toward the ceiling.

In gluteus medius weakness, the gait may be diminished along with a slight drop in the pelvis on the swing-leg side(2). Inhibition of the gluteus medius can occur with tightness or hypertonicity of the adductor muscles, which are the antagonists to the gluteus medius muscle limiting the normal range of motion of 45 degrees. Weakness of the gluteus medius will also be noted with difficulty standing on one foot. There will also be preference of the person to shift his body weight to the stronger limb when standing on both feet. The inability to abduct the hip when lying on one side or the inability to isometrically hold the hip in abduction for 30 seconds will also be indications of gluteus medius weakness. Another sign of hip muscular imbalances due to hypertonicity of the quadratus lumborum and adductors will be leg length deficiency on the ipsilateral side. TFL hypertonicity can cause lateral knee pain, creating a lateral shift of the patella associated with a groove noted in the lateral thigh. Sacroiliac joint dysfunction because of gluteus medius weakness will occur. Trigger points in the gluteus medius will also be present. Altered hip abduction usually occurs unilaterally but can occur bilaterally. As mentioned in hip extension, the primary muscle responsible for hip abduction can become inhibited both mechanically and neurologically over time, as part of the altered movement pattern syndrome.

TREATMENT

Treatment protocols for hip extension and abduction dysfunction are the same.

Check for the presence of any altered movement patterns first. If an altered movement pattern is detected, identify the tight, hypertonic, overactive muscle/muscles and the weak, inhibited muscle.

Stretching to relax the overactive muscle/muscles is the next procedure.

Two postisometric stretching procedures are effective in relaxing an overactive muscle and increasing the passive range of motion. They are “Hold-Relax” and “Contract-Relax”(1,3). The main difference between the two is the type of the contraction, depending upon whether pain is present. If pain is present, the Hold-Relax technique is utilized because it relaxes the overactive muscle increasing the range of motion and diminishing pain. The Contract Relax technique is used when pain is not present. It is used to facilitate relaxation and to increase range of motion of the hypertonic muscle. Another procedure, “Contract-Relax-Antagonist-Contract” or “CRAC” may also be utilized.

The Hold-Relax technique involves placing the tight muscle into a stretch position, the doctor instructs the patient to inhale, holding his breath utilized if pain is present, because it relaxes the overactive muscle, increases the range of motion and diminishes the pain. The Hold-Relax technique involves placing the tight muscle into a stretch position. The doctor then instructs the patient to inhale and hold her breath while isometrically contracting the muscle slowly, building up resistance in the tight muscle before pain is elicited, holding the position for 5-8 seconds before relaxing the muscle and exhaling. The procedure is repeated three times.

The Contract-Relax technique is used when pain is no longer present, to facilitate relaxation and increase the range of motion of the muscle. It involves placing the tight muscle into a stretch position, the doctor then instructs the patient to inhale and hold his breath while strongly contracting the involved muscle for 5-8 seconds, then exhaling and relaxing the muscle with an increase in length. The procedure is also repeated three times.

The Contract-Relax-Antagonist-Relax technique is the same as the Contract-Relax technique except that after relaxing the muscle, the antagonist muscle is immediately contracted and relaxed, further facilitating an increase in the range of motion of the tight overactive muscle.

There are two purposes for relaxing a tight, overactive, hypertonic muscle. The first purpose is to increase the range of motion and flexibility of the tight muscle. This eventually will cause an increase in the strength and endurance of that muscle. The second purpose is to cause relaxation of the muscle inhibiting the agonistic muscle, so that the agonist can be exercised without inhibition of its’ overactive antagonist. Relaxing the antagonist and strengthening the agonist muscle facilitates the specific muscle movement desired for the proper sequence of muscle activation, reestablishing the correct muscular movement pattern for hip extension and abduction. The movement pattern becomes an established neurological pattern and is stored in the cerebellum of the CNS.

After performing relaxation procedures to the antagonist, the agonist should be actively exercised to increase strength. Initially, isometric exercises can be used, however they offer limited strength gain after the first month. Isokinetic and isotonic exercises should be used to maximize strength gains.

After strengthening the agonist muscle, strengthening of the antagonist muscle should also be performed since the hypertonic shortened antagonistic muscle is a weak muscle.

The desired result after following this type of a rehab program will be a coordinated muscular movement pattern. Any inhibition, whether neurological or mechanical, should no longer be present, muscle imbalances are absent and normal muscle functions should exist.

CONCLUSION

Hip extension and abduction muscular imbalances are fairly common problems affecting the hip, sacroiliac and lumbar spine encountered in a chiropractic practice. Understanding the actions of the muscles associated with these movements allows the practitioner to recognize any altered movement patterns, overactive antagonistic muscles, and weak inhibited agonistic muscles. Understanding that muscular changes are contributing to the patient’s symptoms, a corrective rehab program for these muscular imbalances can be prescribed. The rehabilitation protocols described for hip extension and abduction are one option available to the practitioner, in addition to manipulation to use in treating a patient with these problems.

References

1. Liebenson, C. Rehabilitation of the spine: a practitioner’s manual. Baltimore: Williams & Wilkins 1996

2. DeFrance, G. Pelvic locomotor dysfunction: a clinical approach, Aspen Publishers, Inc. 1996

3. Christensen, KD. Rehabilitation guidelines for chiropractic: first edition. Chiropractic Rehabilitation Association. 1992

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American Chiropractic Association Rehab Council