For President – Jerrold Simon, DC, DACRB
For Vice President – Alf Garbutt, DC, DACRB
For Secretary/Treasurer – Jeffrey Tucker, DC, DACRB

If you would like to nominate another candidate for one of the above Rehab Council offices, please submit their name by e-mail to ACA Rehab Council Secretary/Treasurer, Dr. Alf Garbutt (E-mail: doc@4your-wellness.com) by no later than Monday, May 21st, 2012, 12:00 Noon ET. Thank you.

EHR Questionnaire

1. What system/brand do you have for your EHR?
2. Did you investigate more than the unit you currently have? Briefly what was better about the unit you bought vs. others?
3. Where you able to put your office data needs in the program easily or did you need an outside vendor to do this for you?
4. Was the information in the computer when you originally bought the EHR adequate for your office without adding anything?
5. Can you do initial history, reports and SOAP notes with a portable pad of some type that connects to the main unit?
6. Can you quickly do SOAP at the time of the patient encounter if you see 40+ patients per day?
7. How long does it take to do the SOAP notes?
8. What was the cost of your EHR’s?
9. How much did the fed govt pay you for your first year of use?

Dr. Ben and Dr. Gwen of The Core Experience, LLC

The Core Experience, LLC
16 S. Main Street
Manheim, PA 17545
717-665-1888

INTRODUCTION

Breathing is the process that moves air in and out of the lungs for the purpose of delivering oxygen to tissues in exchange for carbon dioxide. The centers for the motor engram of breathing are located in parts of the brain stem, the medulla oblongata and the pons and are under the control of the autonomic nervous system. More specifically, these centers are referred to as the pneumotaxic center, the apneaustic center, and the dorsal and ventral respiratory groups. Breathing, although essential for living, can be detrimental to the spine if the motor engram for breathing is dysfunctional. Alterations in the motor engram for breathing may occur as a result of pain, poor posture, poor nutrition, stress, or anxiety. In the presence of breathing pattern dysfunction in patients with spine pain, rehabilitation of the spine, upper or lower quadrants alone may be unsuccessful or short lived unless the breathing pattern is also normalized.

A MISSING LINK IN SPINAL REHABILITATION

Clinicians involved in spine rehabilitation are well aware of the presence of overactive and/or shortened muscles, weak or inhibited muscles, altered motor control, and decreased muscular endurance in spine pain patients. Clinicians who are thinking outside the box realize that the site of pain may not be the cause of pain and will perform a functional examination of the entire upper and lower quadrants, in addition to the spine, to uncover a weak link to be targeted in the rehabilitation program. An overlooked component of the functional examination may be the assessment of breathing patterns.

A normal breathing pattern is essential for the maintenance of spine stability. Inherently, the rehabilitation of dysfunctional breathing patterns is paramount in spine rehabilitation. Assessment of breathing patterns is quick and easy and can be achieved in a relatively short period of time, starting from the initial subjective examination of the patient. The information gained from assessing breathing patterns is invaluable and could play a major role in the rehabilitation of spine pain patients.

THE RELATIONSHIP BETWEEN BREATHING AND SPINAL STABILIZATION

The diaphragm, scalenes, transverse abdominis, pelvic floor and deep intrinsic spinal muscles are among the primary muscles of breathing. The sternocleidomastoid and upper trapezius are accessory muscles that get recruited when respiration demands are increased. The latissimus dorsi, pectoralis major and pectoralis minor are not typically thought of as accessory muscles of breathing, but may be recruited in the faulty movement pattern of paradoxical breathing (the abdomen moves in on inspiration and out on expiration).

A complex interplay exists between the diaphragm, transverse abdominis and pelvic floor during normal quiet breathing. During normal quiet inhalation the diaphragm contracts and descends towards the abdomen. This causes a decrease in intra-pleural pressure and increase in intra-abdominal pressure. The increased intra-abdominal pressure causes an outward expansion of the abdomen. The transverse abdominis and pelvic floor work synergistically with diaphragm to increase intra-abdominal pressure. As the diaphragm continues to contract and descend, its attachment to the lower ribs causes the lower ribs to begin to expand horizontally. The horizontal expansion of the ribs proceeds rostrally, providing a gentle mobilization to the spine and ribs at every level. A dysfunctional breathing pattern existed when there is decreased, asymmetrical or absent lateral rib excursion. This is indicative of an inhibited diaphragm. As a result, normal rib and spine motion is lost and spine stabilization is compromised. Recurrent or chronic thoracolumbar pain may be the end result of an inhibited diagram in this example of dysfunction.

The scalenes play a crucial role in stabilizing the rib cage during inhalation. The scalenes were once thought to be an accessory muscle of breathing. It is now understood that they are active at a low level with every breath. As intra-pleural pressure decreases, the scalenes along with the parasternal muscles contract to prevent inward movement of the upper ribs during inhalation. This creates a horizontal expansion of the upper ribs and sternum. The dysfunctional breathing pattern of chest breathing (vertical elevation of the upper ribs, sternum, or clavicles) is indicative of over activity of the upper trapezius, scalenes, and/or levator scapulae. If chronic, deep supraclavicular grooves may be observed. This dysfunctional breathing pattern may be a cause of repetitive stress and overload to pain sensitive structure of the cervical spine. Also, vertical elevation the rib cage may cause thoracolumbar pain due to repetitive hyperextension of the thoracolumbar junction that occurs as the rib cage is vertically elevated with each breath. Normal quiet exhalation is the exact opposite and involves passive elastic recoil of the ribs, lungs and abdomen. A dysfunctional breathing pattern during exhalation exists if breath holding occurs and air is not fully exhaled or paradoxical breathing occurs.

EVALUATION OF BREATHING PATTERN DYSFUNCTION

As previously stated, evaluation of breathing pattern dysfunction begins during the subjective examination of the patient. It is essential to avoid informing the patient that his or her breathing pattern is being assessed. This may alter the patient’s stereotypical motor engram for breathing and give the clinician a false positive. Simple observations such as frequent yawning, rapid or labored breathing, nasal flaring, mouth breathing, tension in the face lips or jaw, shoulder elevation on inspiration, and altered respiratory rate are indications that a dysfunctional breathing pattern may be present. In addition, the presence of deep supraclavicular grooves, gothic shoulders, upper or lower cross syndrome, thoracolumbar hypertonicity are all compensations that may occur in the presence of a dysfunctional breathing pattern. Formal assessment of the breathing pattern should be performed in the standing, seated and supine position.

The following is a list of key findings indicative of a dysfunctional breathing pattern:

1. Breathing is initiated in the chest during inhalation
2. Chest breathing predominates over abdominal breathing during inhalation. This finding is best assessed in the supine position, as the postural role of the abdominal muscles is eliminated. Chest breathing can be assessed visually or manually by the clinician placing one hand on the chest of the patient and one hand on the abdomen of the patient during normal quiet breathing. Alternatively, the clinician can ask the patient to place his or her hands on the chest and abdomen as previously described while the clinician observes the breathing pattern
3. Decreased, absence or asymmetrical lateral excursion of the lower ribs. This finding is best assessed in the seated position. The clinician stands behind the patient and places his or her hands on the lateral borders of the lower ribs of the patient during normal quite breathing.
4. Vertical elevation of the upper rib cage, sternum, and/or clavicles during inhalation
5. Paradoxical breathing

One or more of these findings may be present. In addition to assessment in the standing, seated and supine positions, it is also important to observe the patient’s breathing pattern during manual muscle testing or during a functional movement (such as the overhead squat). A patient may display a normal pattern of breathing when assessed standing, seated and supine, however, when a patient is presented with a challenge the aberrant breathing pattern may be revealed.

REHABILITATION OF BREATHING PATTERN DYSFUNCTION

Besides poor posture, stress, anxiety, or poor nutrition, breathing pattern dysfunction can result from sinister pathology. If breathing pattern dysfunction is found, the clinician must first rule out underlying pathology contributing to the etiology of the dysfunction. If an underlying pathology is suspected, a referral to the appropriate specialist must be made before beginning breathing pattern rehabilitation.

Once underlying pathology is ruled out, breathing pattern rehabilitation may begin. The following is a suggested protocol for breathing pattern rehabilitation:

1. Educate the patient on the relationship between an altered breathing pattern and repetitive stress and strain to the spine.
2. Suggest spine sparing strategies such as the Brugger relief position and McGill’s overhead reach to improve posture and facilitate normal breathing mechanics.
3. Allow the patient to experience his or her breathing dysfunction. This can be done by having the patient observe his or her breathing in a mirror and by having the patient manually palpate the dysfunctional pattern of chest breathing, aberrant lateral rib excursion, and/or vertical deviation of the upper ribs, sternum or clavicles.
4. Provide a visual demonstration of normal breathing mechanics. This can be demonstrated fairly easily and effectively with a balloon. Emphasize to the patient that as air enters the balloon, expansion of the balloon begins from the bottom and proceeds upward as the balloon expands from both front to back and side to side. Also, if possible, demonstrate the anatomy of the spine and ribs on a skeleton to re-enforce the anatomy involved in the process of breathing that was described during the balloon demonstration. This allows the patient to visualize what the lungs and rib cage should be doing during normal breathing and provides the patient with an improved and accurate cortical representation of normal breathing mechanics. Visualization is an invaluable tool in rehabilitation.
5. Retrain the dysfunctional breathing pattern. One or more of the key findings associated with a dysfunctional breathing pattern may have been identified in the assessment. Each of findings may initially require separate rehabilitation and then must be integrated together into a normal breathing pattern. Techniques can be used to help to facilitate the diaphragm and lateral rib excursion.
   • If chest breathing initiates or predominates during inhalation: place the patient in the supine position with feet flat on the table, with 45 degrees of hip flexion and 90 degrees of knee flexion. Instruct the patient to place both hands on the abdomen. As the patient inhales, instruct the patient to exert a slight pressure on the abdomen with both hands. As the patient exhales, instruct the patient to relax the pressure on the abdomen.
   • If there is a decrease, asymmetrical or absence of lateral rib excursion during inspiration: place the patient in the supine position with feet flat on the table, with 45 degrees of hip flexion and 90 degrees of knee flexion. Instruct the patient to place both hands on the lateral border of the lower ribs. As the patient inhales, instruct the patient to exert a slight pressure on the lateral border of the lower ribs with both hands. As the patient exhales, instruct the patient to relax the pressure on the lateral border of the lower ribs. This can also be accomplished by tying elastic tubing around the lateral border of the lower ribs.
   • If vertical elevation of the upper ribs, sternum, and/or clavicles is present during inhalation: place the patient in the supine position with feet flat on the table, with 45 degrees of hip flexion and 90 degrees of knee flexion. The patient is then instructed to place both hands behind the head interlocking the fingers with 90 degrees of shoulder abduction and external rotation. If in addition to vertical elevation of the upper ribs, sternum, and clavicle, chest breathing and/or altered lateral rib excursion is also present, the clinician may then manually facilitate the diaphragm and/or lateral rib excursion using the same instructions described above.
6. Once a normal pattern of breathing is established, the next step is to focus on the breathing rhythm. Initially, instruct the patient to gradually increase the length of exhalation relative to inhalation. The patient can be instructed to exhale with pursed lips (visualize blowing out of straw) to decrease exhalation time. An ideal goal is to achieve 3 seconds of inhalation followed by 6 seconds exhalation (1:2 ratio) during breathing pattern rehabilitation.
7. Practice the normal breathing pattern and rhythm in a seated, then standing position. Eventually, integrate the new breathing pattern while performing spinal stabilization exercises.
8. Prescribe home breathing exercises for the patient. Have the patient perform 2-3 breaths every hour the patient is awake and 10-20 breaths upon awakening in the morning and before bed. Instruct the patient to perform the breaths with the newly learned pattern of breathing along with the 1:2 ration of inhalation to exhalation as previously described. Instruct the patient to stop the exercises if they feel weakness, dizziness or light headedness.

CONCLUSION

The importance of rehabilitating breathing pattern dysfunction to aid in the rehabilitation and restoration of spine stability cannot be overstated. The same muscles that are weakened, inhibited or facilitated in spine pain patients can become dysfunctional if a patient’s breathing pattern is dysfunctional. Spine pain can lead to changes in the breathing pattern of the patient, conversely altered breathing patterns can cause a repetitive stress and overload to pain sensitive structure in the spine. In the presence of breathing pattern dysfunction in spine pain patients, rehabilitation of the spine, upper or lower quadrants alone may be unsuccessful or short lived unless the breathing pattern is also rehabilitated and normalized.

REFERENCES

1. Liebenson C. Rehabilitation of the Spine: A Practitioner’s Manual, (2ed). Lippincott, Williams and Wilkins, Baltimore, 2007.
2. Page P., Frank, C., Lardner, R. Assessment and Treatment of Muscle Imbalance: The Janda Approach. Human Kinetics, 2010
3. Standaert, C., Weinstein, S., Rumpeltes, J. Evidence informed management of chronic low back pain with lumbar stabilization exercise. Spine J 2008;8: 114-120
4. Muscle dysfunction in cervical spine pain: Implications for assessment and management, JOSPT 2009;29:324-333
5. De Troyer A, Estennne M. Coordination between rib cage muscles and diaphragm during quiet breathing in humans. J Appl Physiol 1984; 57:899.
6. De Troyer A, Estennne M. Functional Anatomy of the Respiratory Muscles. In: Belmen M, ed. Respiratory Muscles: Function in Health and Disease. Philadelphia: WB Saunders, 1985:175-195.
7. Hruska J. Influences of dysfunctional respiratory mechanics on orofacial pain. J. Orofacial Pain Related Dis 1997; 41:21-27.

Abstract

Often many health care providers perform orthopedic and neurological testing without functional assessment. In depth assessment of acute and chronic conditions is paramount to forming an accurate diagnosis. Complete assessment is equally important in designing an effective treatment plan. Accurate assessment and an effective treatment plan enhance the chances of a favorable outcome.

Continue Reading…

Palmer College of Chiropractic
1000 Brady Street
Davenport, IA 52803

Corresponding author:
David D. Juehring, DC, DACRB
Juehring_d@palmer.edu
Palmer College of Chiropractic
1000 Brady Street Davenport, IA 52803
563-884-5455
(fax) 563-884-5865

Abstract:

Introduction: A role delineation process was used to develop content, validate knowledge, and skills statements needed for competencies used by the American Chiropractic Rehabilitation Board for diplomat certification examinations.

Methods: Three phases were used in the process of completion of the role delineation. The first phase contains the initial development, evaluation of domains, tasks, knowledge, and skill statements by a 7-member role delineation expert panel. In the next phase, a representative sample of professionals (in the field of chiropractic rehabilitation) utilize Cronbach’s alpha. Finally, the third phase contains the development of test specifications based on the domains, tasks, knowledge, and skills statements.

Results: This role delineation was shown to be a valid study with all its’ reliability coefficients scores which are strong within the domains; all domains exceed the critical value of 0.7 for importance, criticality and frequency.

Conclusion: Compared to the DACRBs sample, the work of the expert panel is shown to be valid. This valid role delineation study allows a new, defensible, and content outline with testing percentages to be used by the ACRB. This is used for implementation to Rehabilitation Diplomat programs and Rehabilitation Residencies.

Keywords: role delineation, validation, domain

Introduction:

Before a content-valid examination is developed, knowledge and skills must be determined by professionals in a respective field. The process for identifying these competencies is through a role delineation, which serves as a blueprint for examination development. A role delineation is helpful in determining the content, and type of examination along with the development of a percentage breakdown in order to assess competency. Certain logically sound and legally defensible procedures for developing examinations must be followed (Standards for Educational and Psychological Testing 1999). The critical reason for conducting a role delineation study is to ensure that an examination is content-valid. Content validity is the most commonly applied and accepted validation strategy utilized in establishing certification programs (Rykiel 1996). In psychometric terms, validation is the way a test developer documents the competence inferred from a test score, which is actually measured by the examination. A content-valid examination appropriately evaluates knowledge, or skills required to function as a competent practitioner in the field. A content-valid examination contains a representative sample of items that measure the knowledge, or skills contained in the profession/group being tested. Currently, the American Chiropractic Rehabilitation Board (ACRB) is the major credentialing organization in the Chiropractic profession; they are responsible for overseeing programs and quality assurance by testing competence for the Diplomat American Chiropractic Rehabilitation Board (DACRB) credentials. The Board ensures competence, professionalism in the field of chiropractic rehabilitation, and provides assurance that the certified practitioners have met the specific criteria designed; a set standard on examinations is used to affirm their adequacy. Thus, the role delineation study is an integral part of ensuring that an examination is content-valid. In essence, the aspects of the profession covered on the examination, reflect the tasks performed in practice settings. For both broad content areas and tasks, the study identifies their importance, criticality, and frequency. These ratings play an important role in determining the content of the examination. This role delineation was performed to verify that knowledge, and skill statement (along with percentage breaks of these competencies) was content-valid for the ACRB.

Methods:

This role delineation study consisted of the following 3 phases, which are the focus of this report:

1. Initial Development and Evaluation. The 7-member role delineation panel was assembled by a project chair. Then the panel was given the assignment to identify the domains, tasks, knowledge, and skills essential for a chiropractor to perform the most effective clinical rehabilitation. A Delphi approach was used to gather data from the panel (Rowe 1999). This material was then evaluated by the group based on importance, criticality and frequency.
2. Validation Study. A representative sample of professionals in the field of chiropractic rehabilitation (attendees of the General Assembly meeting at the 2008 National Chiropractic Rehabilitation Convention) reviewed the above domains, tasks, knowledge, and skills statements; they validated the work of the panel again based on importance, criticality and frequency. Reliability was measured utilizing Cronbach’s alpha.
3. Development of Test Specifications. Based on the ratings gathered from the above mentioned representative sample, the test specifications for the certification examination were developed.

Results:

Phase One – Initial Development and Evaluation:

The initial steps in the role delineation were the identification of first, the major content areas or domains, secondly, the listing of tasks performed under each domain, and finally, the identification of the knowledge and skills associated with each task. This phase was accomplished by the work by an expert panel. An ACRB elected project chair assembled the panel based on the recommendations of chiropractic rehabilitation diplomat administrators from Southern California University of Health Sciences (SCU), the Chiropractic Rehabilitation Association (CRA), National University of Health Sciences (NUH), American Chiropractic Educational Systems (ACES) and the recommendations of the ACRB along with various major authors within chiropractic rehabilitation. The panel members represented a variety of practice settings, geographic regions and gender as well as being assembled of ACRB members, SCU and CRA instructors along with a layman familiar with rehabilitation in a chiropractic setting. The following steps were undertaken to complete Phase I:

1. The above panel was posed with the question, “What knowledge and skills does it take for a chiropractor to perform the most effective clinical rehabilitation?” ¹ The panel through numerous blinded e-mail correspondences determined that the topic area of chiropractic rehabilitation could be divided into 2 major content areas or performance domains. These performance domains were as followed:
   1. Assessment
   2. Patient Care/Management
2. Next, the panel broke down each of the domains into task statements. Thirteen tasks were developed for the Assessment domain, and 21 tasks were developed for the Patient Care/Management domain. The panel subsequently took each task statement; they broke the statements into knowledge, and skills requirements needed to perform each task. Varying numbers of knowledge and skill requirements were developed for each task statement within the respective domain.
3. Last, the panel rated each domain and task statement within the domain, on importance, criticality, and frequency. They defined Importance as the degree to which knowledge in the domain and each task is essential in the overall job performance as a chiropractor performing rehabilitation. Criticality was defined as the degree to which the inability to perform the domain and each task in each domain would be seen as causing harm to a patient, the rehabilitation DC, the public, etc. “Harm” may be physical, emotional, financial, etc. Frequency was defined as the percent of total case time within the specific domain, and task within the domain, spent performing rehabilitative duties associated with an average rehabilitative case. With all three ratings, domains were first rated relative to the other domains, and then on completion of this requirement each task was rated relative to other tasks exclusive to the specific domain².
   This phase of the role delineation was accomplished via numerous guided e-mails by the project chair. Based on this phase of the role delineation panel, the project chair developed an 18-page survey ³.

Phase Two – Validation Study:

The 18-page questionnaire was distributed to and completed by a representative sample of professionals in the field of chiropractic rehabilitation for evaluation. The questionnaire gave feedback on the role delineation expert panel’s domain, and task statements. Next, the sample group rated each aspect of the domains and tasks based on importance, criticality, and frequency. The survey was distributed to the attendees of the General Assembly meeting at the 2008 National Chiropractic Rehabilitation Convention in Las Vegas NV. The survey was distributed to 52 attendees with the requirement for a return of the survey within at least thirty days. Of the 52 questionnaires distributed, 34 (65.4%) usable responses were returned within the cut-off period. Biographical information was also solicited on the survey in order to ensure a representative response and completion by appropriately qualified individuals. The majority of respondents (29 or 85.3%) are male, with 5 (14.7%) female. The average age was 46.5 with a range of 34 to 64. The most common state represented in the survey was Pennsylvania with 13 (38.2%) respondents followed by Ohio with 4 (11.8%), Minnesota 3 (8.8%), California 3 (8.8%), Washington 2 (5.9%) and 1 (2.9%) for New Jersey, Maryland, Texas, Nevada, North Carolina, Missouri, South Dakota, Oregon and Arkansas. Note: due to rounding error the state total is 99.6%. Continuing education program sponsors for DACRB certification programs represented in the study was SCU, CRA, ACES, Palmer Chiropractic College and Canadian Memorial Chiropractic College⁴.

The reliability of the respondents’ results of the survey was assessed relative to the panel’s results in order to determine how well the tasks consistently measured the domain of question. Reliability refers to the degree to which tests or surveys are free from measurement error. Reliability was measured by internal consistency via Cronbach’s alpha (Reynaldo 1999) using the respondent’s ratings of importance, criticality, and frequency for each domain in order to draw defensible conclusions. Cronbach’s alpha can be written as a function of the number of test items, and the average inter-correlation among the items. Below, for conceptual purposes, we show the formula for the standardized Cronbach’s alpha:

Here it states that N is equal to the number of items, c-bar is the average inter-item covariance among the items, and v-bar equals the average variance. Calculations were performed on an Excel spreadsheet for all domains and tasks within the domains. Only the calculation of the Assessment Domain Frequency was shown⁵ and all other calculation results are listed in the below Reliability Table. Reliability coefficients can be low, when the pattern of respondents to a particular task in a domain is different from the pattern of respondents to the other tasks in the domain. This calculates the extent to which each task rating within each domain consistently measures what other tasks within that domain measure. Reliability coefficients range from 0 to 1 and should be above 0.7 to be judged as adequate (Reynaldo 1999). Reliability values below 0.7 indicate an unacceptable amount of measurement error (Reynaldo 1999). As shown below, the reliability statistics are strong since all domains exceed the critical value of 0.7.

Phase Three – Development of Test Specifications:

The final phase of the role delineation study was the development of test specifications. These identify the proportion of questions from each domain and task and appear on the DACRB examinations. Test specifications are developed by combining the overall evaluations of importance, criticality, frequency, and the converting of the results into percentages. These percentages are listed below; they are used to determine the number of questions related to each domain and task that should appear on examinations.

The results of the Test Percentage Specific Document⁶ were forward to the ACRB to ultimately be distributed to the diplomat certification programs as content guidelines for their education programs.

Conclusion:

The expert panels’ content and outline are valid compared to the sample DACRBs, including the testing breakdowns. The results of this role delineation study were determined to be valid. The new content outline and testing percentages were forwarded to the ACRB for implementation to Rehabilitation Diplomat programs and Rehabilitation Residencies. Each reliability rating for importance, criticality, and frequency were all based on Cronbach’s alpha. Therefore the domains, tasks, knowledge, and skills developed by the role delineation panel constitute an accurate definition of the work of the credentialed DACRB.

References:

1. Reynaldo J, Santos A 1999 Cronbach’s Alpha: a tool for assessing the reliability of scales. Journal of Extension 37(2)
2. Rowe G, Wright G 1999 The Delphi technique as a forecasting tool: issues and analysis. International Journal of Forecasting 15(4):353-375
3. Rykiel EJ 1996 Testing ecological models: meaning of validation. Ecological Modeling, 90:229-244
4. Standards for Educational and Psychological Testing published by the American Educational Research Association, 1999
5. 
6. 

Julie is in her junior-year in high school and is a club team soccer player. She came to see me on a Monday afternoon complaining of left-sided frequent mild to moderate patellofemoral pain as well as some distal IT band pain and tightness. Her last match was on Saturday. She fell on the outside of her left knee, when she collided with another player. Her evaluation did not show any ligament laxity in her main knee ligaments (MCL, LCL, ACL, and PCL), nor did she exhibit signs of meniscus involvement. Past history included experiencing Osgood Schlatter’s condition in her left knee early in her freshman year of high school while playing soccer. She had a physical therapist provide treatment for the Osgood Schlatter during and after her freshmen soccer season.

The patient complained of plus 2-3 tenderness and soreness upon palpation of her infra-patellar tendon, and along the bony deposit (bump) on her tibial tuberosity (this was more uncomfortable to palpation than the infrapatellar tendon). She felt tenderness with palpation around the medial aspect of her patellofemoral joint.

After performing knee range of motion and standard orthopedic tests, I performed functional movement tests. Julie was unable to perform a one-legged bridge using her gluteus maximus, without overactivity of her hamstrings and loss of pelvis position.

Next, I asked Julie to perform the Thomas Test. The psoas was tight and this will inhibit the gluteus maximus. To test the strength of the psoas muscle, I had Julie sit at the edge of the examining table with both feet lightly touching the floor and control the natural lumbar arch (neutral posture) as she lifted and held her bent leg in flexion past 90 degrees (I said “just lift your knee up past 90 degrees”). She was unable to hold the leg even slightly off the floor without slumping in her low back. This indicates weakness of the psoas. One way to strengthen a weak psoas is by bringing your knee above 90 degrees. Sit with your knees bent on a low box or bench (6 to 10 inches high). Maintaining good posture and keeping your abs tight, use your hips to raise one bent knee slightly higher than your hips. If you lean forward or backward, you’re not performing the exercise correctly. I had Julie hold it for10 seconds, and return to the starting position. She was instructed to complete 3 sets of 5 repetitions per leg.

Next I watched Julie perform the hands held Overhead Squat movement assessment. Her overhead squat assessment displayed excessive torso forward lean, toes rotating outward, and slight knee valgus. Her single leg squat assessment showed knee valgus and foot flattening. During her passive ROM assessment there was significant lack of dorsiflexion in both ankles. She exhibited tibial internal rotation during passive dorsiflexion.

I suggest that as practitioners we always assess tibial alignment in three positions: 1) weight bearing static posture, noting rotation; 2) non-weight bearing passive tibial rotation when the ankle is dorsiflexed; and 3) weight bearing tibial rotation during active motion during the squat. During the overhead squat motion analysis and passive analysis, I look at the tibia and measure by the direction in which the tibial tuberosity faces relative to the patella and relative to the second toe with the foot in neutral alignment. This patient’s tibia rotated medially on passive motion. I manually tested the muscle strength of the medial versus lateral hamstrings. The semitendinosus and semimembranosus tested tight but weak. This suggests performing manual stretching and fascial release work to the semitendinosus and semimembranosus. I found the best results when I worked the tissue toward the knee. The short head of the biceps femoris was also tight and needed to be worked away from the knee. I think it is important to consider the direction of movement that you do when performing fascial therapy.

Running, cutting, and jumping were all activities that increased Julie’s knee symptoms. When I analysed Julie’s running posture on a follow-up visit she was very flexed at the hip, almost leaning over at about a 20-25 degree angle. This correlates with the weak glut max and tight/weak psoas.

Sarcevic (2008) did a study in regards to the relationship between limitations in ankle dorsiflexion and the occurence of Morbus Osgood Schlatter in children that were participating in athletic activities. He studied 45 children, all of whom were clinically diagnosed with Morbus Osgood Schlatter (MOS). Forty subjects were boys coming ages ranging from 11-14 years of age, and 5 subjects were girls, ages ranging from 10-12 years of age.

Sarcevic defines MOS as a “traction apophysitis of the tibial tubercle caused by repetitive strain, as well as a chronic avulsion of the secondary ossification center.” Many practitioners attribute the main cause of MOS to a strong, chronic pull of the quadriceps during athletic activities. The presence of inflexbility of the hamstrings and quadriceps is a common finding. Strategies for corrective exercise intervention included focusing on the thigh musculature (quads and hamstrings) and improving ankle dorsiflexion.

The results of the Sarcevic study showed that 37 of the 40 boys studied exhibited a dorsiflexion angle (DFA) of 10 ° or less, and 3 had a DFA of 10° or more. All of the 5 girls that participated in the study exhibited a DFA of 10° or less (Sarcevic, 2008). The quadriceps muscle group eccentrically decelerates the lower leg during the stance/ support phase of the running gait. Limitations in ankle dorsiflexion have been associated with pronation of the foot, internal rotation of the tibia, as well as an increase in knee flexion (Sarcevic, 2008). The lack of dorsiflexion in Julie’s ankle probably contributed to  the torso lean during the overhead squat and her running gait. The combination of these motion disturbances and the presence of limitations in ankle dorsiflexion may create an increase in shear stress on the quadriceps tendon/ patellar tendon during the act of running. Limitations in dorsiflexion can be attributed to overactivity in the gastroc /soleus complex, and movement compensations are observed during the overhead squat as well as the single leg squat assessments. The correlation that Sarcevic is making between limited dorsiflexion and the presence of MOS can lead the practitioner to identify and address overactivity in the gastroc/soleus complex (inhibit and lengthen) as a possible way to proceed in designing a corrective exercise strategy. Self Myofascial Release (foam rolling) and lengthening techniques of static stretching and PNF can be useful tools in this situation (Clark and Lucett, 2011). This reinforces the concept that conditions such as Morbus Osgood Schlatter should not only focus on a localized area , but address dysfunction affecting the entire kinetic chain.

TREATMENT

Initial treatment focused on relieving the pain around the patella, using warm laser. I did soft tissue/fascial therapy to the quads, hamstrings, gastrocsoleus, and psoas. I performed mobilization to the ankle joint to increase dorsiflexion. I had Julie perform foam rolling to the overactive calfs, and stretch the quads and hamstrings. I got her to perform one-legged bridges to increase glute max strength. I felt that she was overusing her quads as a consequence of poor hip flexion. Julie’s symptoms eased up quickly once we restored ankle dorsiflexion and she could recruit her stabilizing muscles. I encouraged her to continue her exercises for eight weeks so she could fully incorporate the muscular recruitment patterns into her soccer play.

Clark, M., and Lucett, S. NASM Essentials of Corrective Exercise. (2011) Lippincott Wiliiams and Wilkins. Baltimore, MD.

Sarcevic, Z. Limited Ankle Dorsiflexion: a predisposing factor to Morbus Osgood Schlatter? (2008) Knee Surgery, Sports Traumatology, Arthroscopy. 6: 726-728

Authored, September 8, 2009

Peer reviewed by the American Chiropractic Rehabilitation Board

Introduction

There have been a growing number of chiropractic physicians that have been treating patients after surgical procedures.  After reviewing the literature, there have been no studies involving Chiropractic Management of multilevel post surgical fusion.  In fact, a review of the literature was very sparse, only a handful of case studies pertaining to chiropractic management of post surgical cases.  Cases reported include wrist rehabilitation ⁽¹⁾, post surgical neck ⁽²⁾, post surgical disk herniation ⁽³⁾, Achilles tendon rupture ⁽⁴⁾, failed back surgery ⁽⁵⁾, sacroiliac syndrome ⁽⁶⁾, and calceanal exostectomy ⁽⁷⁾.

There have been many reported complications of spinal fusion surgery ⁽⁸⁾.  They include in hospital mortality, deep infection, superficial infection, deep vein thrombosis, pulmonary embolus, neural injury, donor site complications, graft extrusion, instrumentation failure and other myocardial infarction, urinary tract infections, respiratory complications, gastrointestinal, transfusion reactions, peripheral vascular complications, accidental cut or puncture during the procedure ⁽⁹⁾. Reactions to anesthesia and comorbid conditions also need to be considered ⁽⁸⁾.

There have not been any indications established for spinal fusion surgery. However, fusion has been performed in patients with spinal stenosis, degenerative disk disease, disk herniation, unstable spine (8), and significant nerve root compression ⁽¹⁰⁾. According to Bederman et. al., there exists no clear consensus on the ideal management for these patients despite overall improvement with surgical management.

The incidence of surgeries has increased ⁽¹⁰⁾, but there also has been an increase in the number of failed back surgeries ⁽¹⁰⁾.  Information regarding chiropractic management of these failed back surgeries is sparse; however, there have been several suggested reasons why surgeries fail. These include iatrogenic changes, the original diagnosis was wrong; there was little or no rehabilitative effort after the procedure ⁽⁵⁾. In addition, Chiropractic management can occur when no other surgery is warranted.  This will include physical therapy to reduce pain, remove myofascial trigger points and restore mobility and finally increase strength and aerobic capacity. It will also include work hardening and educational programs directed toward pain management and disability ⁽⁵⁾.

The role of Chiropractic manipulation is not certain as described in the literature ^{(5, 11)}. The fusion regardless of instrumentation must be solid as shown on flexion/extension radiographs.  Healing depends on the patient but usually takes three to five months ⁽¹¹⁾.

Case Report

Physical Examination

A thirty year-old African American presented with lower back pain and right sided sciatica following an L3-S1 laminotomy, foraminotomy, and decompression with instrumentation.  Before the surgery, she completed a course of Chiropractic manipulative therapy and rehabilitation, as well as interventional pain management.

Vital Signs performed included Ht, 66in, Wt 213lbs, Oral temperature 98.7°F, Blood Pressure 104/70, Pulse 75 BPM, and Respiration at 15 RPM.

The revised oswestry low back pain disability index was given and disability index was 58%. Par-Q was also given and the patient was given clearance for rehab despite initial hesitation.

Upon Physical examination, Patient presented alert and orientated to person, place, and time.  The patient stated that she was depressed, agitated and angry due to the complications after surgery. Range of motion was difficult to measure due to the degree of the patient’s pain.  Observed was a six inch surgical scar midline. Upon palpation tenderness and tightness was palpated along the lumbosacral erector spinae with joint dysfunction above and below the surgical fusion.  Straight leg testing revealed pain and tight hamstrings bilaterally at 20°.  Quadriceps tightness and lower back pain was observed bilaterally on Nicholas’ test.  Gainslens’s, Yeoman’s, and Patrick’s Test were all positive for low back pain and leg pain. Gait was antalgic and guarded.

Neurologic Examination

Cranial nerves, cerebellar function, coordination were all intact. Muscle strength testing of the right psoas, rectus femoris, quadriceps, hamstrings, gastronemius, soleus and peroneus muscles tested at grade 3 when compared to the left which tested at grade 5. Deep tendon reflexes 1+ bilaterally for patella and Achilles reflexes. Sensory testing of pain and light touch revealed increased sensation to the entire right leg when compared to the left leg, which was within normal limits.

Functional Examination

At time of initial examination, a functional examination was not able to be performed due to the patient’s acute symptoms, however, will be performed when the acute symptoms resolve.

Treatment Plan

Initial treatment consisted of posture and proper lifting instruction as well as hip hinge advice. Abdominal breathing exercises and initial core strengthening consisting abdominal bracing were done in a sitting position due to the patient’s discomfort in the prone position.  Also, proprioceptive balance training was used.  It consisted of one-legged standing in a door way with shoes off.  Additionally, the patient was given a lumbar roll and educated on maintaining a neutral spine. The patient felt relief of symptoms on the first day.  During the first week, the abdominal bracing and abdominal breathing were progressed to sitting on a physioball.  The patient was instructed to perform these exercises several times per day at home.

After the first week, the patient felt a decrease in leg pain; however, the low back pain was still present.  Her gait and activities of daily living improved. At that point, higher level core strengthening exercises including side bridges with bent legs and bridges on back. The patient was instructed to perform the exercises using the abdominal brace combined with abdominal breathing.  McKenzie examination was performed and upon repeated extension it was observed to centralize leg pain.  Prone pressups were prescribed ten repetitions every hour.  Proprioceptive treatment progressed to balance pad with eyes open.  At this point the patient still had trouble sleeping. The patient was instructed to add the new exercises to her home exercise program.

After two weeks of therapeutic exercises, Cox Flexion-distraction technique was added to address the joint dysfunction. Sleeping became easier.  Sciatic pain decreased and low back pain improved.  Activities of daily living improved.

At this point a functional examination was performed.  Testing included breathing observation, t-4 mobility test, squat, lunge, one leg standing, hip abduction, hip extension and sit to stand.  Results from the functional examination included chest breathing, improper squat and lunge mechanics, inhibited gluteus maximus and medius bilaterally and improper sit to stand mechanics. Treatment for the findings began immediately with basic gluteus medius and maximus retraining and progressing to squats and lunges.

At five weeks after the initiation of treatment, functional activities were added.  These included squats with physioball and lunges.  Balance pad proprioceptive exercises included increasing the resistance and rocker board exercises.  With McKenzie extension exercises, she was able to control her leg pain.  Low back pain was decreasing and Activities of daily living were consistently improving.

At seven weeks after initial treatment, functional training continued.  Side bridges were progressed to straight legs.  Lower back extensions on the Strive™ machine were added with the overload in a bell-shaped curve.  Cardiovascular training was added using a recumbent bicycle for ten minutes.  McKenzie extensions were now being used for prophylaxis with occasional progression of forces if needed.  Again, the patient added the new exercises to her home program.

Ten weeks included balance training on a Bosu™ ball walking lunges and core stabilization exercises. Manipulation of motion segments adjacent to the fusion was initiated.  The patient felt an immediate increase in range of motion after the manipulation was performed. Future manipulation was only considered if joint dysfunction was present.

At this point, a quantitative functional capacity examination was performed to determine functional deficits.  The patient results were below average for strength of the legs, low back extensors and side bridges.  Quadriceps femoris were still tight bilaterally.  A therapeutic exercise program consisting of side bridges, squats and lower back extension as well as quadriceps stretching was emphasized and progressed for one month upon re- evaluation.  McKenzie extension exercises were prescribed prophylactically.

Three months following initial presentation, the patient’s back pain reduced and sciatica was eliminated.  Sensation returned and the patient resumed all activities of daily living. She began exercising in a gym and was instructed to perform home exercises in addition to her strength program.  McKenzie exercises were to be done daily to prevent sciatic pain from returning.  The patient was discharged with instructions to return if her current status regressed.

Discussion

Therapeutic intervention involved a combination of rehabilitation protocols complicated by a multilevel surgical fusion. A combination of diaphragmatic breathing, abdominal bracing, proprioceptive balance exercises, and McKenzie protocol progressing to functional training were used. There was no one treatment that alone seemed to elicit symptom resolution.  The patient responded very well to treatment and was able to maintain her resolution of symptoms.

Manipulative therapy consisted of Cox Flexion-distraction and diversified manipulation but was used only PRN.  The role of high velocity–low amplitude manipulation in post surgical rehabilitation is not understood.  If a Chiropractic physician chooses to perform that modality, care should be taken and the fusion needs to be stabilized.  Mobilization or non-force technique should be used at first to determine if manipulation would be appropriate.

The outcome of this case is encouraging and the avoidance of repeated surgical intervention is also encouraging. Upon reviewing the case, the quantitative functional capacity exam should be performed sooner in the course of treatment. If radicular symptoms returned an MRI and a flexion/extension radiograph would have been ordered to determine stability of the lumbar spine and any adjacent disk degeneration.

Conclusion

This case provides supporting evidence determining the role of Chiropractic physicians in a multidisciplinary setting, particularly in the post surgical spinal fusion arena.  More research needs to be conducted to determine the role of the chiropractic physician in the care of post surgical fusion patient.

References

1)McDermott A. A Chiropractic Case Study in Post-Surgical Wrist Rehabilitation. J Can Chiropr Assoc. 2003:40(10):32-4.

2)Polkinghorn BS, Colloca CJ. Chiropractic Treatment of Postsurgical Neck Syndrome with Mechanical Force, Manually Assisted Short-Lever Spinal Adjustments. J Manipulative Physiol Ther. 2001:24(9):589-95.

3)Estadt GM. Chiropractic/Rehabilitative Management of Post-Surgical Disc Herniation: A Retrospective Case Report. J Chiropr Med. 2004:3(3):108-15.

4)Ramelli FD. Diagnosis, Management and Post-surgical Rehabilitation of an Achilles Tendon Rupture: A Case Report. J Can Chiropr Assoc 2003:47(4):261-8.

5)Walker BF. Failed Back Surgery Syndrome.Cosmig Rev.1992: 1(1):3-6.

6)Diakow PR, Cassidy JD, DeKorompay VL. Post-surgical Sacroiliac Syndrome. J Can Chiropr Assoc. 1983:27(1):19-21.

7)Kobsar B,Alcantra J.Poat-surgical Care of a Professional Ballet Dancer Following Calceanal Exostectomy and Debribement with Re-Attachment of the Left Achilles Tendon. J Can Chiropr Assoc.2009:53(1):17-22.

8)Turner JA et. al. Patient Outcomes After Spinal Fusions. J Am Med Assoc. 1992:268(7):907-11.

9)Deyo RD et. al. Morbidity and Mortality in Association with Operations on the Lumbar Spine. J Bone and Joint Surg. 1992:74-A(4):536-543.

10)Bederman et.al. The Who, What and When od Surgery for the Degeneative Lumbar Spine: A Population-Based Study of Surgeon Factors, Surgical Procedures, Recent Trends and Reopration Rates. Can J Surg.2009:52(4):283-90.

11)Triano JJ, McGregor M, Skogsburg DR. Use of Chiropractic Manipulation in Lumbar Rehabilitation. J Rehab Research and Development. 1997:34(4):394-404.

Author’s contact information:

Scott Schreiber, DC, DACRB, MS, Cert. MDT, CKTP, CNS
Delaware Back Pain & Sports Rehabilitation Centers

2600 Glasgow Ave, Suite 210
Newark, DE 19702