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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.

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