Spiro N. Comis, DC
Recovery from illness or injury demands a specific plan of care to insure adequate results and the best outcomes available for the patient. Injuries take time to heal but may not always heal correctly or as well as possible leaving the patient to often suffer persistent recurring problems and at times unnecessary physical limitations that could easily have been avoided by choosing a more thoughtful course of care. It should always be the physician’s hope that the recovery will be full and speedy and that maximum gains are made in the final recovery. Far too often the decision to ignore an active rehabilitation plan is made due to cost factors. At times the benefit of a carefully laid out rehab plan can be unfortunately underestimated, sacrificing benefits to lower cost. To help insure premium care it becomes the duty of the trusted physician to see that quality care is applied. Health care providers must come to understand that saving money with shortcuts might often do more harm than we would intend.
“Everyone wants to cut costs. But what if saving my life is expensive” As the title demonstrates, the article in Slate points out a very real fear of cost containment thinking and the debate on effective care vs. overspending when not necessary.(1) As cost containment becomes even a bigger issue in our healthcare system the demand to quantify our results in Chiropractic will determine the fate of what we do in our care plans. As research points out that the combination of spinal manipulation and exercise is a cost effective physical treatment for back pain in primary care, we in chiropractic must be prepared to offer rehabilitation as part of our patient care plans.(2)
We now understand that the best recovery from injury must include a rehabilitation plan that includes manipulation and some form of exercise. There is always the question of overutilization to consider so it is important to understand the benefits vs. the costs in these matters. It is noted in the study that exercise alone is not as effective as manipulation alone but in combination there is additional benefit for the patient.(3)
Attempts at bed rest compared to being active demonstrate that there is more harm to inactivity and so it is evident that staying active during the recovery is in the best interest of the patient.(4) The principles of chiropractic rehab also recognize that active rehabilitative care promotes the best recovery.
The concern over safety with manipulation in the presence of disc protrusions has been argued, generally in an attempt to limit care from the chiropractor. Research is demonstrating that active spinal manipulation vs. simulated manipulation demonstrates more effect. Even with sciatica present, the evidence is mounting that puts manipulation in a better position regarding patient treatment and in the interest of both results and patient safety. Better results utilizing manipulation quells the argument that manipulation does harm.(5)
In the evaluation of the patient’s condition, further evidence collection is possible utilizing additional in-office diagnostic methods, such as electrodiagnostic testing. The benefits of pre and post evaluation are an excellent aid in setting treatment goals and clearly document both patient care needs and benefits following care. (6) “Electro diagnostic testing can provide the primary care provider the data needed to make an informed decision regarding advanced imaging studies and to institute appropriate therapy or to intelligently refer a patient for follow-up.”(7) Dynamic surface EMG studies help demonstrate functional asymmetries, muscle control, spasm and quality of the muscle tone. It also demonstrates agonist / antagonist relationships and flexion relaxation phenomenon which helps define pathophysiologic dissymmetry, guarding and muscle inhibition. These values also aid in the evaluation of permanent impairment. There is more work that needs to be done to add validation to the routine use of SEMG but it’s value is unquestionable as it stands.(8)
As part of the chiropractic rehab programs it is a main concern to bring the most fruitful choices of treatment to the patient care plan. The selection of which rehab procedures and exercise we utilize are based on our treatment goals and stem from our examination and evaluation of the patient. Postural, pathological and structural concerns will help develop a plan of care. An effective evaluation and an understanding of the biophysics will help build a foundation for our rehabilitation treatment methods. The level of injury and disability will define many of our treatment parameters. Our goals will always be to reach active care as quickly as possible and to avoid lingering in a passive care mode.
Spinal manipulation will always be our primary tool as it accentuates normal spinal function and the return to normal physiology that is needed and essential for a full and proper recovery. Understanding the principles of chiropractic rehabilitation helps us to enhance the initial benefit of spinal manipulation alone. This care compliments the adjustment and adds greater benefit to the patient’s recovery.
Avoiding the patient’s fear of pain and helping the patient return to activity is a primary goal of the chiropractic rehabilitation specialist. Aggressive exercise will act to bring positive feedback to the patient and help the confidence level for future activity and a quicker and longer lasting return to health.(9) Stabilization exercise will help if the need is indicated by instability.(10) Chronic lower back pain without instability will not respond to stability exercise and a more comprehensive program of exercise will be indicated. There are a great number of patients that do respond to spinal stability training. Segmental instability may be due to weakness, degenerative disease, loss of passive tension and injury.(11) Exercises like bridges and planks are spinal stability enhancers. Pelvic tilt training and holding a mid, “safety zone”, posture are helpful training and lead to less pain while the patients learn a safer way to move about and they can become more active quicker.
SEMG testing is helpful in detecting muscle activity during training. Testing demonstrates there is increased muscle activity when exercise is done on an unstable surface. This adds a dynamic component to the activity of the muscles and increases the benefit.(12) Because sports skills are often performed off balance, greater core stability provides a foundation for greater force production in the extremities. Balance can be improved by training and, therefore, help benefit the athlete.(13) I have learned that the use of a balance board in the chiropractic office is invaluable.
Aerobic fitness also adds to the benefits of better spinal health. The addition of aerobic exercise to the treatment plan will help to improve the patient’s health. Maximal oxygen consumption was lower in women with lower back pain. Exercise will help to improve strength and endurance and increase general activity levels.(14) With the addition of aerobics the patient will be more active and recovery will be enhanced. The addition of aerobic exercise to the chiropractic rehabilitative plan should be included.(15) Before beginning strenuous activity a Par-Q form will be helpful in ruling out contraindications.
The addition of a Swiss ball to the chiropractic rehabilitation regiment to aid in the patient’s recovery from injuries or back problems or pain offers many opportunities for the chiropractor to employ specific exercise protocols and programs that deal directly with stability and functional development, including balance, strengthening and proprioceptive training and enhancement.(16) This tool is a great asset in accomplishing many basic rehabilitation principles. In my own experience there is added benefit of patient compliance as it is fun and easy to learn and patients can do these exercises at home. I have been very surprised at how well the Swiss ball has been utilized by my patients of all ages and backgrounds.
In addition to spinal manipulation the utilization of mobilization and McKenzie Techniques bring even more to the table for treatment options that can be utilized by the chiropractor. Clinical evidence supporting McKenzie therapy is very positive.(17) McKenzie protocols offers one more tool that will help relieve the suffering experienced by many that seek care from a chiropractor.
The more information that the chiropractic practitioner has with respect to treatment options and techniques that supplement spinal manipulation and brings patients more positive outcomes sooner and better and directly leads to a full recovery only help our profession in general. That is why it is important to learn chiropractic rehabilitation skills. The information being taught in today’s chiropractic rehabilitation courses are just that; great information that will influence quicker and longer lasting results and that are also cost effective.
1. Beam, Christopher. “Your Money or Your Health.” Slate June 26, 2009: Print.
2. Beam, “Back pain exercise and manipulation randomized trial.” BMJ 329(2004): 1287. Print.
3. Beam, “Back pain exercise and manipulation randomized trial.” BMJ 329(2004): 1377. Print.
4. Hagen, Hilde, Jamtvedt, Winnem, KB, G, G, MF. “The Cochrane review of advice to stay active as a single treatment for low back pain and sciatica.” Spine 15; 27(16)(2002): 1736-41. Print.
5. Santilli, Beghi, Fiucci, V, E, S. “Chiropractic manipulation in the treatment of acute back pain and sciatica with disc protrusion: a randomized double-blind clinical trial of active and simulated spinal manipulations.” Spine 6(2006): 131-7. Print.
6. Morningstar, MW. “Improvement of lower extremity electrodiagnostic findings following a trial of spinal manipulation and motion-based therapy.” Chiropr Osteopat 14:20(2006): Print.
7. Iannelli, Humphreys, Triano, G, CR, JJ. “Electrodiagnostic testing in back and extremity pain..” Manipulative Physil Ther. 6(1993): 401-10. Print.
8. Ritvanen, Zaproudian, Nissen, Leinonen, Hanninen, T, N, M, V, O. “Dynamic surface electromyographic responses in chronic low back pain treated by traditional bone setting and conventional physical therapy..” Manipulative Physiol Ther. 30(1)(2007): 31-7. Print.
9. Cohen, Rainville, I, J. “Aggressive exercise as treatment for chronic low back pain.” Sports Med. 32(1)(2002): 75-82. Print.
10. Koumantakis, Watson, Oldham, GA, PJ, JA. “Trunk muscle stabilization training plus general exercise versus general exercise only: randomized controlled trial of patients with recurrent low back pain.” Phys. Ther. 85(3)(2005): 209-25. Print.
11. Mannion, Helbling, Pulkovski, Sprott, AF, D, N, H. “Spinal segmental stabilisation exercises for chronic low back pain: programme adherence and it’s influence on clinical outcome.” Eur Spine J. July (2009): Epub ahead of print. Print.
12. Kolber, Beekhuizen, MJ, K. “Lumbar Stabilization: An evidence-based approach for the Athlete with low back pain.” Strength and Conditioning Journal: 29(2007): 26-37. Print.
13. Norwood, Anderson, Gaetz, JT, GS, MB. “Electromyographic Activity of the Trunk Stabilizers Durhing Stable and Unsstable Bench Press.” Journal Strength Conditioning Res. 22(2)(2007): 343-347. Print.
14. Willardson, J. “Core Stability Training.” Journal Strength Conditioning Res. 21(2007): 979-85. Print.
15. Hoch, Young, Press, AZ, J, J. “Aerobic fitness in women with chronic discogenic nonradicular low back pain.” American Journal Physical Med. Rehabil 85(2006): 607-13. Print.
16. Lehman, Hoda, Oliver, GJ, W, S. “Trunk muscle activity during bridging exercises on and off a Swiss ball.” Chiropractic Osteopat. July (2005): 14. Print.
17. Busanich, Verscheure, BM, SD. “Does McKenzie therapy improve outcomes for back pain?” Journal Athletic Trainer 41(1)(2006): 117-9. Print.