LOW Technology Rehabilitation

Introduction
In today's changing healthcare environment, individual practitioners must be able to adapt to the demands of their healthcare profession. It is imperative for the chiropractic profession to be prepared to defend itself with rational and scientific evidence of its procedures and effectiveness. With increased utilization and greater scrutiny, accountability is paramount because of managed care systems.' This accountability has driven healthcare administrators to identify new efficiencies of better care at lower costs for their insured.'

Fortunately, the Oakland study analyzing cost of care for common low back disorders concluded that a chiropractor, as the first contact person, costs substantially less per episodes compared with medical doctors.' It is clear that we deserve careful consideration in strategies adopted by employers and third-party payers to control healthcare spending.4

For cases such as the spinal-related disorder case discussed below, the literature suggests that the passive-active continuum is the most clinically and cost-effective treatment approach.' This identification has placed greater emphasis on active care over continuous passive care for our profession. The change to the a passive-active care continuum coincides more efficiently with the three stages of the healing process (acute, repair, and remodeling stages). The challenge for us as practitioners is to institute this passive-active care continuum system with both cost and clinical effectiveness.

A patient sought alternative care for chronic leg pain. He had herniated his L4-LS disc 7 months previous to entering this office. This 61-year-old chemist had been treated for 7 months for left leg pain, the result of a fall on the ice. His major complaints included sciatic pain, pain in both the left side of his lower back and left gluteal region, and weakness in his left leg. A secondary complaint was difficulty sleeping through the night because of the leg pain.

This patient was a type A personality working in a management position. He supervised a number of employees and sat for more than half of the day. He had high blood pressure and atrial fibrillation, which were controlled by four medications.

His previous treatments were by his primary care physician and various specialists. The diagnoses ranged from degenerative disc disease, arthritis, muscle spasms, and pinched nerve, depending on the doctor. His treatments ranged from receiving five epidural nerve blocks, to taking pain killers, muscle relaxants, valium, and over-the counter non-steroid anti-inflammatory drugs (NSAIDS). He had taken a month off from work but his condition had not improved.

Radiographs revealed a demineralized bone structure with a minimal scoliosis of the lumbar spine and minimal degenerative changes and loss of disc space at L4-L5. Degenerative changes were seen in the region of the iliac wings, pubic rami, and the greater trochanter of both hips.

Magnetic resonance imaging (MRI) studies revealed degenerative disc disease, with loss of disc height and signal at T12-L1, concurrent with a small disc protrusion. At L4-LS was seen mild desiccation with loss of disc height and signal with disc bulging. Evident at L5-S 1 was slight desiccation and loss of disc height and signal. Disc bulging was seen with some mild facet hypertrophy.

Objective findings were muscle tightness in the left gluteal complex and left lumbar erector musculature, and rigidity of the thoracic spine. The straight leg raise (SLR) was positive; however, no significant loss of motor function or reflexes was evident. The patient did have excessive left foot pronation.

Subjective findings were pain originating from the low back and radiating down to the ankle following the L5 dermatome path, as well as generalized weakness of the left leg.

Chiropractic treatment consisted of adjustments to the full spine, hydrocollator packs, ultrasound, and electrical muscle stimulation therapy. Within the first month, the patient suffered two exacerbations, one after he tripped and fell and the second after a 6hour car ride that exacerbated his leg pain. This latter event happened a month after starting treatment and after he had already made significant progress. In the next 3 weeks, the patient progressed well. He was able to discontinue all medication for his leg pain and was sleeping through the night.

The patient was placed on a walking program within the first 2 weeks of treatment as symptoms started to centralize and diminish. Daily walks were instituted on a 10- to 15minute time frame. They were increased to 20 minutes and then increased to a hard day/easy day routine of 40 minutes/20 minutes, respectively, as his strength and endurance progressed.

Exercise recommendations were the modified Williams exercises (Fig. 1), both the single and double leg to the waist, the supine bridge exercise (Fig. 2), and the opposite arm/opposite leg exercise, starting with just one extremity for the first 2 weeks and then adding the second extremity.

The patient's stretching program included the modified hamstring stretch (Fig. 3) to avoid nerve root irritation and the modified piriformis stretch (Fig. 4) to avoid unnecessary stress and torque of the low back.

Additionally, he received home therapy because of the chronicity of the injury. The patient was advised to use heat in the morning when rising, and ice both after work because of the compression forces of sitting and after walking as a preventive measure. He was sleeping without a head pillow, but placed a pillow under his knees at night for comfort. He was advised to assume the "hook line" supine position on the floor or mattress, starting after work for 15 minutes at a time and increasing on a gradual basis to 30 minutes or beyond as time permitted. He was advised to avoid any unnecessary sitting.

Single Leg Flexion

Double Leg Flexion

Supine Bridge

Opposite Arm/Opposite Leg

Figure 2. Extensor exercises.

Figure 3. Modified hamstring stretch

Dealing with certain personalities demands an encompassing approach to rehabilitation. It has been postulated that during severe chronic or recurrent emotional stress, a concurrent adrenocortical reaction affects the osmotic imbibitory balance of the disc, thus altering its mechanical stability.' The disc in its weakened state is subjected to additional mechanical stresses from the activities of daily living. Disc failure, therefore, can result from a combination of factors, and it is a complex issue to manage in returning the patient's health.

Sitting, a necessary evil complicated by incorrect posture, produces eleven times more pressure on the third lumbar disc than a supine position.' This working position is a necessity, but it is detrimental in treating disc injuries. Fortunately, in

Bed rest has been established as a "red flag" for deconditioning syndrome! Early activity after an injury and a return to activities of daily living accelerate recovery, usually days to weeks earlier than complete bed rest. Complete bed rest eliminates the effects of gravity, but these antigravity muscles stay contracted from the injury and pain caused by nociceptive stimuli. They do not relax in a supine antigravity posture.' For disc injuries, it is recommended to eliminate sitting or bending to the end points as much as possible, and to substitute with 30 minutes of walking and 20 minutes of ice on the injured area in a recumbent position on an hourly schedule.' Remember, walking is probably the best exercise for maintaining a healthy low back.'

Normal stress on an abnormal low back can cause failure on exposure to normal everyday activities.' For example, disc injuries and joint dysfunction are more likely to occur with spondylosis. The symptomatic disc protrusion usually requires the triad of anatomic defect, inflammation, and joint dysfunction. Joint dysfunction causes reflex activation of intersegmental muscles, the secondary movers, and reflex inhibition of the prime movers, a situation that perpetuates muscle and joint dysfunction.

The SLR test is the only reliable lumbar test for diagnosing disc protrusions.' The acceptable range of the SLR with nerve root involvement ranges from 0° to 50°.9 The patient demonstrated dermatome distribution reflecting the L5 nerve root with L4-L5 disc involvement.' His case demonstrated mainly sensory involvement, which constitutes 85% of disc lesions, whereas only 10% occur with nerve irritation being both sensory and motor and only 5% motor alone."

It has been shown that hypomobility generally is the problem in a pathologic condition of the spine. The stiff spine is more like a rusted chain than an excessively movable one." Therefore, mobilization of the spine should be performed first to effect greater pain reduction, muscle recruitment, and strength gains.

Orthotic use was necessary for the following reasons. The effects of unilateral pronation or asymmetric bilateral pronation produces a pelvic tilt." Excessive pronation is a primary cause of functional leg length insufficiency, and this weakness can further contribute to lumbosacral stress and instability." This structural weakness is the major source of most chronic low back pain." Taking into account that shock waves pass through the skeleton at more than 200 miles an hour and jolt the base of the brain up to a millimeter in normal walking, these compression forces are traumatic to an abnormal spine. '6 When the patient has degenerative changes in the spine, this force can cause persistent, painful and stiff joints. All of these factors lead to repetitive microtrauma. This continuous type of insidious repetitive injury will cause permanent damage. The structural change will cause longterm overuse of the muscular system, with shortening and myofascial spasms." All were observed in this case.

A certain degree of vibration occurs in all automobiles. Any continuous vibration at 5 Hz or more does not allow the disc to be fed; the lack of imbibition results in a decrease of fluid and nutrients into the disc; consequently, the patient experienced exacerbation to his spine after the long car ride."

Modified Williams flexion exercises (Fig. 1) were recommended for this patient because regular flexion exercises can intensify the posterior migration of the nucleus of the disc.' The knee to hand movements were slowly alternated and controlled for the single leg. The double leg movements were also recommended.

Extension exercises (Fig. 2) were needed to increase the strength of the erector spinae and the rest of the extensor group. Recent studies have demonstrated that back extensors should be 30% stronger than the flexor muscle groups." The extension exercises demonstrated were as follows. In the supine bridge exercise, a lift-up sufficient to allow the fist underneath the gluteals, hold-up for 5 seconds, then lower and rest for 10 seconds. Do not arch or "max out"; stay low back neutral. The opposite arm/opposite leg exercise starts with the leg first, with whichever one the patient is most comfortable. Take the leg straight out to posterior and then elevate to the height of the pelvis. Do not torque the pelvis or low back. Hold each extremity for 5 seconds, return to neutral, stay low back neutral and then repeat with opposite extremities. One set of 10 repetitions was recommended and increases were made as the patient progressed in strength and endurance. It is important to instruct patients to exhale during contraction and inhale during the relaxation phase of exercise repetitions.

The modified hamstring stretch (Fig. 3) was recommended to prevent irritation of the nerve root and to stretch the hamstring. The tightness seen in this patient can place additional stress on the lumbosacral region, including excessive posterior annulus disc stress and posterior ligamentous and erector spinal muscle strain.' The modified figure four piriformis stretch (Fig. 4) was recommended to stretch the piriformis muscle and associated gluteal musculature and to protect the low back. For these modified stretches, a gym ball or a more stable chair is recommended for support. The hamstring stretch may seem easy, but be careful not to cause irritation. All exercises and stretches were recommended for use in the pain-free range of motion! Usually up to three sets of an exercise were recommended, but because of time constraints, only one set in the morning and two sets in the evening were time-efficient for this patient. Stretches were recommended twice a day using the hold and relax proprioceptive neuromuscular facilitation (PNF) method.

Modified stretching was recommended to alleviate the hypertonicity of the type I postural muscles, namely the piriformis, hamstrings, iliopsoas, erector spinae, upper portion of the trapezius, sternocleidomastoid, and scalenes.8

The centralization phenomenon of healing, a little known observation tool, was helpful in evaluating and treating the patient with low back and radiating leg pain." This progression of leg pain drawing slowly up into the low back also provides the patient with a gauge to measure progress.

References

1. Miller JE. Pathways to success seminar offers new strategies for success in today's health-care environment. Journal of the American Chiropractic Association 1996:33(8):33-40.

2. Miller JE. Integration, quality initiatives addressed at national managed health care congress. Journal of the American Chiropractic Association 1996:33(7):13-16.

3. Murphy DR. The passive/active care continuum: a model for the treatment of spine-related disorders. Journal of the Neuromusculoskeletal System 1996:4(1):1-7.

4. Stano M. The economic role of chiropractic: further analysis of relative insurance costs for low back care. Journal of the Neuromusculoskeletal System 1995:3(3):139-144.

5. Cailliet R. Neck and arm pain, 3rd ed. Philadelphia: FA Davis;1991.

7. Cox JM. Low back pain: mechanism, diagnosis and treatment,
4th ed. Baltimore: Williams & Wilkins; 1985.

8. Liebenson C. Rehabilitation of the spine: a practitioner's manual. Baltimore: Williams & Wilkins; 1996.

9. Banks S. Rehabilitation of the lumbar spine. Harrisburg, PA: Chiropractic Rehabilitation Association; 1995.

10. Foot Levelers, Inc. The lumbar spine. Practical Research
Studies 1991;2(2):93.

11. Humphreys CR. Electomyography interpretation. Harrisburg, PA: Chiropractic Rehabilitation Association; 1996.

\12. Saluga RS. Rehabilitation of spinal disorders. Harrisburg, PA: Chiropractic Rehabilitation Association; 1995.

13. Austin WM. Home care rehab protocols. Harrisburg, PA: Chiropractic Rehabilitation Association; 1996.

14. Foot Levelers, Inc. Posture starts from the ground up. Practical Research Studies 1996; 6(5):2.

15. Foot Levelers, Inc. Treatment of chronic low back conditions.Practical Research Studies 1994;5(2):1.

16. Hyland JK Chiropractic rehab protocols for the acute and chronic patient. Harrisburg, PA: Chiropractic Rehabilitation Association; 1995.

18. Donalson R, Silva G, Murphy K. Centralization phenomenon: its usefulness in evaluating and treating referred pain. Spine 1990:15(3): 211-213.