In addition, thank you to all the efforts of the ACRB over the years. We are all indebted to the initial leadership of Dr. Shaw and now Dr. Fowler.

We should all feel proud and stand tall as rehab specialist as we look back to where we have come from. Thank you to the support the ACA Board of Governors and members of the House of Delegates that recognized the importance of the Chiropractic Rehabilitation specialist. As a result of all the above efforts, doctors of chiropractic are providing essential services to their patients that are making a vital difference in their lives.

The majority of studies indicate there is a synergistic effect when both chiropractic and active rehab are used in combination. The CCGPP has concluded that use of rehab exercise in conjunction with chiropractic manipulation is likely to speed and improve outcomes as well as minimize episodic recurrence.

There is an ever-accumulating database of evidence demonstrating the combination of chiropractic and rehab offers our patients the essentials to regain function. As a founding member of this council I would like to thank each of you for your ongoing support. Let us all stand tall as rehab specialists.

K.D. Christensen DC, CCSP, DACRB

Private practice of chiropractic, Long Chiropractic Office, Dayton, OH.
Submit requests for reprints to: Dr. Kent C. Long, Long Chiropractic Office, 4978 Northcutt Place, Dayton, Ohio 45414.
Submitted August 25, 2009. Peer reviewed by the American Chiropractic Rehabilitation Board

ABSTRACT

Objective:
This case study discusses management of lumbar disc herniation with degenerative disc disease and facet arthropathy using a program of chiropractic manipulation and an active rehabilitation program, and its effectiveness even after radiofrequency neurolysis has been performed.

Clinical features:
A 25-year-old Caucasian male with three year history of lower back pain and right sciatic pain. Prior medical intervention included physical therapy, treatment with non-steroid anti-inflammatory medications, epidural blocks, lumbar facet injections, and radiofrequency neurolysis, with incomplete resolution of his symptoms. The patient was unable to bend, lift, or sit without pain, and unable to return to regular work or to normal activities of daily living. His lumbar range of motion was restricted in all ranges of motions, severely in flexion and extension. He exhibited a positive SLR and Kemps, producing lower back and right lower extremity pain.

Intervention and outcome:
Treatment plan and intervention consisted of patient education on proper posture and ergonomics, such as proper bending and lifting techniques, for both the home and workplace. An in-office chiropractic and rehabilitative exercise treatment program was commenced, with eventual transition from office based into home based therapy and exercises. The patient initially showed good response to treatment, reporting a decrease in his signs and symptoms and improvement in function with the treatment. Active rehabilitation was continued with the goal of restoring normal range of motion, improving core and spinal stability and strength, and returning the patient to work. Upon reaching these goals he was released to home therapy and supportive chiropractic care with continued positive response.

Conclusion:
Management of lumbar disc herniation with degenerative disc disease and facet arthropathy with chiropractic and active rehabilitation is discussed. A literature review is included. Spinal deconditioning and a weakness of the core and spinal stabilization muscles appeared to be the cause of patient’s symptoms and reduced physical capacities in this particular case. Management including patient education on proper posture, proper lifting techniques, core and spinal stabilization exercises, active strengthening exercise and chiropractic manipulation were effective in this case. Stabilization of the core and spine was able to be achieved with no difficulty, despite the radiofrequency neurolysis procedure that was previously performed.

KEYWORDS

Herniation; Facet Arthropathy; Multifidus; Radiofrequency; Chiropractic Manipulation; Rehabilitation

INTRODUCTION

Low back pain is the most common complaint in orthopedic, neurosurgical, and occupational medicine practices. It is the second most common complaint in primary care. It is the third most common condition requiring surgical procedure. ⁽¹⁾

It has been estimated that 60 to 80% of Americans will suffer low back pain during their lifetime, ⁽²⁾ and most of them will experience recurrent back pain.^(3,4) Approximately 14% of the US population experiences lower back pain at a given time.⁽⁵⁾ According to Waddell, ^(6,7) there is a 3 to 5% lifetime prevalence of sciatica (pain below the knee).

Cases of chronic non-cancer pain are both the most frequent and most difficult that the spine care professional is called upon to treat. The majority of patients with potential neurosurgical disorders can improve or stabilize with conservative treatments such as chiropractic, physical, or osteopathic therapies in 6 weeks to 6 months. ⁽³⁾ However, frequently if these conservative approaches do not sufficiently resolve the disorder, patients will progress to more aggressive or more invasive procedures, such as epidural blocks, nerve blocks (facet blocks), radiofrequency neurolysis (neorotomy/rhizotomy), and multiple forms of surgery. In many cases these more invasive procedures fail to sufficiently resolve the disorder, and the patient returns to conservative treatment. Occasionally these more invasive procedures can produce a situation in which certain conservative procedures become less effective, ineffective, or contraindicated; thus possibly no longer making the patient a good candidate for conservative methods of care.

One of the procedures mentioned above, radiofrequency neurolysis, or lumbar medial branch neurotomy, can be an effective means of reducing pain in patients carefully selected on the basis of controlled diagnostic blocks (facet blocks). ⁽⁸⁾ Nerves leave the spinal cord as mainly primary motor rootlets and sensory rootlets. These join to the nerve root before leaving the spinal canal. After the root canal, the nerve root branches into the ventral root, which contains sensory and motor fibers innervating the extremities, and the dorsal root (i.e. the dorsal ramus), which innervates the posterior structures, for example, the back muscles: the dorsal ramus itself may become irritated (dorsal ramus syndrome). Especially predisposed to entrapment is the medial branch of the dorsal ramus, which innervates the multifidus muscle and also contains pain fibers. ⁽⁹⁾ The lumbar zygapophysial joint (Z-joint) or facet joints are a potential source of low back pain. In general the principle innervation of the Z-joint is the medial branch of the posterior primary ramus of the same level as the target Z-joint as well as the level above.⁽⁷⁾ Ablation of the medial branch of the posterior primary ramus through radiofrequency neurolysis therefore not only reduces pain by affecting the sensory fibers of this nerve, but also denervates the multifidus muscle by affecting the motor fibers of the nerve. In fact, denervation of the multifidus muscle as evaluated by electromyography has become a measurement of successful Z-joint denervation. Sometimes this evaluation has shown the multifidus to be successfully denervated as demonstrated by electromyography, but the Z-joints may be inadequately denervated. ⁽¹⁰⁾

Denervation of the multifidus muscle may also occur in lumbosacral radiculopathy and low back pain syndromes. Asymmetric atrophy of the multifidus muscle has been shown in patients with unilateral lumbosacral radiculopathy. ⁽¹¹⁾ Atrophy of the multifidus muscle has been shown to occur in acute and chronic low back pain. Although chronic changes have been believed to be more widespread, acute changes at one segment are identified within days of injury.⁽¹²⁾ Unilateral wasting isolated to one level suggests that the mechanism of wasting is not generalized disuse atrophy or spinal reflex inhibition in acute/subacute low back pain.⁽¹³⁾ Recent studies support that the pattern of multifidus muscle atrophy in chronic low back pain patients is also localized rather than generalized. These studies have shown that the pattern of atrophy is both vertebral level and side specific.⁽¹⁴⁾ Chronic low back pain has been shown to not only effect the multifidus muscle in decreased size, but there is also evidence provided of corresponding reduced ability to voluntarily contract the atrophied muscle.⁽¹⁵⁾

The multifidus muscle may also be a source of local and referred pain.⁽¹⁶⁾ Investigation of the relationships between lumbar multifidus muscle atrophy and low back pain, leg pain, and intervertebral disc degeneration shows the correlation between multifidus muscle atrophy and leg pain to be significant, which may explain referred leg pain in the absence of MRI abnormalities.⁽¹⁷⁾ The activity of the multifidus has been shown to be dysfunctional in people with recurrent unilateral low back pain, despite resolution of symptoms. Because multifidus muscle activity is critical for normal spinal control, this provides a mechanism for recurrent episodes. ⁽¹⁸⁾ Multifidus muscle recovery is not spontaneous on remission of painful symptoms. Lack of localized, muscle support may be one reason for the high recurrence rate of low back pain following the initial episode. ⁽¹⁹⁾

Multifidus muscle recovery is more rapid and more complete in patients who receive exercise therapy. ⁽¹⁹⁾ Multifidus muscle atrophy can exist in highly active elite athletes with low back pain. Specific stabilization exercise retraining resulted in an improvement in multifidus muscle recovery and a decrease in pain. ⁽²⁰⁾

The contribution of the multifidus muscles to spinal stability is well established. Five clinical beliefs have arisen: (i) the deep fibers of the multifidus muscle stabilize the lumbar spine whereas the superficial fibers of the lumbar multifidus and the erector spinae extend and/or rotate the lumbar spine. (ii) The deep fibers of the multifidus muscle have a greater percentage of type I (slow twitch) muscle fibers than the superficial multifidus and the erector spinae. (iii) The deep fibers of the multifidus muscle are tonically active during movements of the trunk and gait, whereas the superficial multifidus and erector spinae are phasically active. (iv) The deep fibers of the multifidus muscle and the transverses abdominis co-contract during function. (v) Changes in the lumbar paraspinal muscles associated with low back pain affect the deep fibers of the multifidus muscle more than the superficial fibers of the multifidus muscle or the erector spinae. ⁽²¹⁾ Architectural analysis and intra-operative measurements demonstrate the unique design of the multifidus muscle for lumbar spine stability. The architectural design (a high cross-sectional area and a low fiber length-to-muscle length ratio) demonstrates that the multifidus muscle is uniquely designed as a stabilizer to produce large forces. Furthermore, multifidus sarcomeres are positioned on the ascending portion of the length-tension curve, allowing the muscle to become stronger as the spine assumes a forward-leaning posture. ⁽²²⁾

The specific stabilizing exercise approach appears to be effective in conservative treatment programs of low back pain and lumbar disk disease. ⁽²³⁾ Specific stabilization exercise therapy in addition to medical management and resumption of normal activity may be more effective in reducing low back pain recurrences. ⁽²⁴⁾ Muscle endurance is an important variable to measure in the assessment of back muscle function. The multifidus shows the highest fatigue rate during the trunk holding test, which may be due to the higher activity level of the multifidus muscle during the trunk holding contraction. ⁽²⁵⁾ the static holding component between the concentric and eccentric phase was found to be critical in inducing multifidus muscle hypertrophy during stabilization exercise. Treatment consisting of stabilization training combined with an intensive lumbar dynamic-static strengthening program seems to be the most appropriate method of restoring the size of the multifidus muscle. ⁽²⁶⁾

It has been questioned whether a patient could achieve proper stabilization and recovery through physical rehabilitation after receiving radiofrequency neurolysis, considering the important role the multifidus muscle plays in spinal and core stabilization. The purpose of this case study is to address this issue of achieving spinal and core stabilization, via chiropractic manipulation and active physical rehabilitation, on a patient who had previously undergone radiofrequency neurolysis.

CASE REPORT

A 25-year-old Caucasian male presented with a chronic 3 year duration low back injury. He complained of pain that originated in his lower back and radiated down his right gluteal region and into the back of his right posterior thigh and lateral calf. He reported his original injury occurred three years ago while at work. The day prior to his injury he had performed an entire day of heavy bending and lifting at work unloading trucks. The following day he was unloading produce from a cooler, was bent over lifting a 50 pound box of lettuce, and felt what he described as an immediate “explosion of pain”, originating in his low back and radiating down his right leg. He stated initially his pain levels were 8 or 9 on the verbal analog scale, and the pain ran from his low back and radiated all the way down to his right foot. Initially he had numbness that encompassed his entire right lower extremity to the foot. The patient reported he was a recovering drug addict, and was not able to take any medications for his injury other than a mild over the counter NSAID.

Initial treatment consisted of NSAID treatment and physical therapy at the industrial medical center. The physical therapy consisted of unsupervised exercises and some stretching. The patient stated his pain levels were so bad at that point in time, that the physical therapy did not help his condition, and in fact seemed to exacerbate his condition. He had an MRI performed which revealed degenerative disc disease, central disc herniations, and facet arthropathy at L4-5 and L5-S1. He went through a second unsuccessful program of physical therapy and was subsequently referred to a pain management specialist. The patient received two sets of 3 epidural blocks, facet injections, and eventually underwent the procedure of radiofrequency neurolysis. The patient stated the blocks and injections helped significantly reduce his pain levels, but the relief was temporary and his symptoms eventually returned. He had radiofrequency neurolysis performed approximately one month prior to entering the chiropractic office, which initially helped reduce his pain about 40%, but his symptoms gradually returned again. He remained unable to return to work from the time of his injury.

The patient was given outcome measures to complete in the office. He rated his lower back pain as 8/10 on the Visual Analog Scale. The Oswestry Disability Index ^(27,28,29) was 46%, severe disability. The patient reported a history of occasional mild achy low back problems in his past, but no significant low back injuries or trauma prior to his work injury. His past medical history was significant for chemical dependency, chicken pox, mononucleosis, and migraine headaches. He exhibited no red flags ⁽³⁰⁾ to conservative treatment.

The initial examination of this patient included a physical, chiropractic, orthopedic, and neurological examination. The patient was 25 years old, 6 feet 1 inches tall, and weighed 130 pounds. His initial blood pressure was 120/80. Pulse was 80 beats per minute and respirations were 18 per minute. His lumbar range of motion was restricted in flexion 10°/90°; extension 5°/25°; right lateral flexion 10°/25° and left lateral flexion 15°/25°. Manual motor testing was performed on the lower extremities. He exhibited full strength against resistance bilaterally of the hip flexor and extensor muscles; knee extensor and flexor muscles; ankle flexor and extensor muscles; and great toe extensor muscles. Heel walk and toe walk were normal. The patellar and achilles deep tendon reflexes were equal and active bilaterally. Pinwheel sensory test was normal bilaterally for the lower extremities.

Orthopedic examination of the lumbar spine revealed a positive SLR at 55° on the right, producing lower back and right leg pain. Kemps test was positive on the left producing low back pain, and positive on the right producing low back and right leg pain. Hyperextension test was positive producing low back pain, and Spring test was positive for restricted joint motion and pain at the levels L3, L4, and L5.

MRI of the lumbar spine was reviewed. The upper lumbar levels were unremarkable. The L3-4 level showed some slight facet arthrosis. The L4-5 level showed degenerative disc disease and some mild disc space narrowing. Broad based central disc herniation caused some effacement of the ventral aspect of the thecal sac. Facet arthritic changes were present at this level, and combined to produce mild canal stenosis. The foramina appeared patent. The L5-S1 level showed disc degeneration and disc space narrowing as well. There was a central or slightly right central disc herniation present at this level, again causing some mild effacement of the ventral aspect of the thecal sac. The foramen were patent.

The patient was diagnosed with lumbar disc herniation with degenerative disc disease and facet arthropathy. He was treated conservatively in the office with a treatment regimen consisting of passive and active treatment at three times per week for three weeks. He was treated with lumbar spinal manipulation, consisting of flexion distraction manipulation and side posture manipulation, as tolerated by the patient. Additionally, modalities were utilized consisting of interferential current and manual therapy techniques to the lower back region. The patient was instructed in and placed on McKenzie exercises, to be performed at home 10 times per day at 10 repetitions each session.

The patient noted improvement in his lower back and right leg pain over the next three treatments. He had some mild difficulty with low back soreness from the extension component of his exercises, but reported overall improvement. On the fourth visit the patient was instructed in proper abdominal breathing, abdominal bracing, and anterior and posterior pelvic tilting exercises. By the seventh visit the patient reported centralizing of his right leg pain and reduced low back pain to an average pain level 3-4 on the verbal analog scale. The patient was scheduled for a Qualitative Functional Capacity Evaluation for the next visit.

On the eighth visit the patient was cleared with a Physical Activities Readiness Questionnaire, and also read and signed an informed consent to perform the Qualitative Functional Capacity Evaluation. The Qualitative Functional Capacity Evaluation was performed on the patient, consisting of age and gender specific flexibility, strength and endurance testing. The following were his results:

Results demonstrated significant deficiencies in strength and endurance of the core and spinal extensor muscles. Of particular importance was the major deficiency in static back endurance and repetitive arch up, which involves primarily the multifidus muscles, along with the iliocostalis and longissimus. Informed consent to begin a physical rehabilitation program was obtained. An in office supervised program of low tech floor exercises was initiated consisting of quadruped alternate arm/leg extensions, horizontal side bridges, curl ups, and sit backs. All exercises were performed with concurrent abdominal bracing. The patient performed these exercises at 3 sets of 10 repetitions, 3 days per week for 4 weeks. Superman and see-saw exercises on a gym ball were initiated on week 5, to further challenge the spinal extensor muscles. Repetitive back extension and lateral trunk flexion exercises were initiated (3 sets of 10) on a Roman Chair on week 8.

The patient was re-evaluated after 90 days on this regimen and achieved the following results:

Since the follow-up testing, the patient has returned to full time employment and is performing his regular activities of daily living with no restrictions. At the time of reporting this case study, two years post-rehabilitation, no exacerbation or significant recurrence of back or leg pain has occurred. The patient’s pain level has remained at an average 1 or 2 out of 10. His Oswestry Disability Index is 16%, minimal disability. His lumbar range of motion is unrestricted in all planes.

DISCUSSION

It has been questioned whether a patient could achieve proper stabilization and recovery through physical rehabilitation after receiving radiofrequency neurolysis, considering the important role the multifidus muscle plays in stabilization.

In this case study the patient had radiofrequency neurolysis performed prior to his rehabilitation program. Functional performance testing prior to beginning rehabilitation showed major deficiencies in static back endurance and repetitive arch up tests, which involves primarily the multifidus muscles. For this reason, rehabilitation was focused on stabilization and strengthening of the core and spinal stabilization muscles, and was primarily extension based, focusing on the multifidus muscles. Functional performance testing after rehabilitation showed above normal levels in static back endurance and repetitive arch up tests, which would suggest the multifidus muscles were sufficiently strengthened and rehabilitated.

Two-year follow up after completion of his rehabilitation program reveals the patient has not had an exacerbation or significant recurrence of back or leg pain. The Static Back Endurance (Sorenson) test is an excellent predictor of future lower back pain. ⁽³¹⁾ Asymptomatic individuals with very poor scores are three times more likely to suffer from lower back pain in the next year than those scoring considerably higher. ⁽³²⁾ The static back endurance test involves primarily the multifidus muscles. The multifidus muscle activity is critical for normal spinal control, and weakness or dysfunction of the multifidus provides a mechanism for recurrent episodes of low back pain and dysfunction. ⁽¹⁸⁾ Lack of multifidus muscle recovery may be one reason for the high recurrence rate of low back pain following the initial episode.⁽¹⁹⁾ These facts combined with the lack of recurrence of back or leg pain in this case suggests that proper multifidus recovery was obtained.

A factor worth taking into consideration in cases such as these is whether the radiofrequency neurolysis procedure completely denervated the multifidus muscle. Studies have shown that occasionally the multifidus is not successfully denervated, as demonstrated by electromyography; Studies have also shown that occasionally the multifidus is successfully denervated, as demonstrated by electromyography, but the Z-joints may be inadequately denervated. ⁽¹⁰⁾ Thus, just because the procedure has been performed, it does not necessarily assure the multifidus has been denervated.

The theory also exists that stabilization may occur through compensation by strengthening the uninvolved multifidus muscles, thus achieving overall spinal stability without achieving recovery of the specific level of the involved multifidus. However, recent studies support that the pattern of multifidus muscle atrophy in chronic low back pain patients is also localized rather than generalized. These studies have shown that the pattern of atrophy is both vertebral level and side specific. ⁽¹⁴⁾

CONCLUSION

A patient with a clinical diagnosis of lumbar disc herniation with degenerative disc disease and facet arthropathy, post radiofrequency neurolysis procedure, responded positively to a clinical trial of manipulation and active therapeutic rehabilitation which included flexion distraction, specific adjustments to the lumbar spine, and rehabilitative exercises designed for core and spinal stability. Firm conclusions cannot be derived from the outcomes of a single retrospective case study. However, this study does suggest that chiropractic and rehabilitative care can still relieve lower back and leg pain; symptom recurrence rates can be reduced; and core and spinal stability can still be achieved, despite prior radiofrequency neurolysis procedure having been performed. This study also suggests that prior radiofrequency neurolysis procedure should not be considered a contraindication to chiropractic manipulation and rehabilitation. Additional studies need to be completed, using more specific techniques and measures: such as measuring cross sectional areas and performing electromyography of the specific involved multifidus muscles, both pre and post rehabilitation, to specifically determine if actual multifidus recovery is obtained through specific treatment protocols.

REFERENCES:

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9. Sihvonen T, Lindgren KA, Airaksinen O, Leino E, Partanen J, Hanninen O. Dorsal ramus irritation associated with recurrent low back pain and its relief with local anesthetic or training therapy. J Spinal Disord. 1995 Feb;8(1): 8-14.

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13. Hides JA, Stokes MJ, Saide M, Jull GA, Cooper DH. Evidence of lumbar multifidus muscle wasting ipsilateral to symptoms in patients with acute/subacute low back pain. Spine. 1994 Jan 15; 19(2): 165-72.

14. Hides J, Gilmore C, Stanton W, Bohlscheid E. Multifidus size and symmetry among chronic LBP and healthy asymptomatic subjects. Man Ther. 2008 Feb; 13(1): 43-9.

15. Wallwork TL, Stanton WR, Freke M, Hides JA. The effect of chronic low back pain on size and contraction of the lumbar multifidus muscle. Man Ther. 2008 Nov 20.

16. Cornwall J, John Harris A, Mercer SR. The lumbar multifidus muscle and patterns of pain. Man Ther. 2006 Feb; 11(1): 40-5.

17. Kader DF, Wardlaw D, Smith FW. Correlation between the MRI changes in the lumbar multifidus muscles and leg pain. Clin Radiol. 2000 Feb; 55(2): 145-9.

18. MacDonald D, Moseley GL, Hodges PW. Why do some patients keep hurting their back? Evidence of ongoing back muscle dysfunction during remission from recurrent back pain. Pain. 2009 Apr; 142(3): 183-8.

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20. Hides JA, Stanton WR, McMahon S, Sims K, Richardson CA. Effect of stabilization training on multifidus muscle cross-sectional area among young elite cricketers with low back pain. J Orthop Sports Phys Ther. 2008 Mar; 38(3): 101-8.

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E-mail: spiro_c@yahoo.com

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.

A thirty-year-old male personal trainer presented with right shoulder pain. He is well built and exhibits the body of a weight lifter – small waist, big broad shoulders with well-developed chest and arm muscles. He has a history of overuse injuries from weight lifting. He initially presented to my office with inflammatory symptoms and tenderness to palpation of the right biceps tendon, supraspinatus muscle/tendon, and anterior deltoid muscle. The subacromial space felt decreased and was tender to palpation. He had pain with resistive tests for the same muscles. Resisted flexion caused pain at the bicipital groove. He exhibited a painful arc in external rotation and abduction. These muscles and tendons are most likely the site of the source of pathology and his symptoms. His working diagnosis was tendinitis and impingement syndrome.

The serratus anterior and lower trapezius muscles test 3/5 and are unable to withstand resistance applied throughout the range. The upper trapezius muscle tests are 4-/5. There is tightness of the pectoralis minor. This allows uncontrolled scapula forward tilt, which is associated with shoulder ‘impingement’ type symptoms. Most repetitive micro-trauma shoulder complaints are related to uncontrolled movement of either the scapula or humerus. These may present as dysfunction of articular motion associated with abnormal myofascial structures.

Because this client is a personal trainer, it made it more important for his shoulder rehab and retraining to identify the necessary modifications in terms of weight lifting techniques. The first part of his rehab program was to design a workout repertoire that started with foam rolling the overactive latissimus dorsi and pectoralis minor. After foam rolling he was instructed to stretch the tight pectoralis minor and latissimus dorsi. After stretching he was taught to focus on core stability. I made sure he was integrating low threshold recruitment of local and global muscle systems. He is used to high threshold strength training of the global stabilizer and global mobilizer muscle system.

Review of normal shoulder biomechanics and scapulohumeral rhythm:
During flexion & abduction of the humerus, there s a 2:1 ratio of movement in the humerus to the scapula, with 120 degrees occurring at the GHJ & 60 degrees at the Scapulo-thoracic joint. There are 3 phases:

1. In the first 30 degrees the outer end of the clavicle elevates 12 to 15 degrees while the scapula is “setting”
2. During the next 60 degrees the clavicle will elevate 30 to 60 degrees & there will be a 2:1 ratio of scapulohumeral movement
3. During the final 90 degrees of motion there continues a 2:1 ratio & the clavicle rotates posteriorly 30-60 degrees. The movement of the scapula on the thorax allows the glenoid fossa to follow humeral head motion thus maintaining a consistent length-tension relationship among the muscles of the GHJ. There is a force-couple relationship between the serratus anterior and upper and lower trapezius for scapula rotation. During full elevation in abduction the humerus must externally rotate (glide caudally) for the greater tubercle to clear the coracoacromial arch. If this does not occur it may lead to impingement.

The joint capsule must have the appropriate flexibility and the rotator cuff muscles must be functioning properly to bring the head of the humerus down and in (compresses and downward translation). There is another force-couple relationship between the rotator cuff and deltoids. When stability of the scapula is lost, the deltoid becomes less efficient, rotator cuff stabilizing strength is decreased, and the humerus elevates superiorly leading to suprahumeral impingement.

Movement impairment criteria: This patient displayed faulty movement of the
humeral head in the GH joint. The treatment plan was to reduce his symptoms, the corrective exercise rehabilitation plan was to correct his faulty movement.

What is normal alignment of the humeral head? Less than 1/3 of the humeral head should protrude in front of the acromion; neutral rotation should be present; the antecubital crease faces anteriorly; the olecranon faces posteriorly; the proximal and distal ends are in the same vertical line.

Post Rotator Cuff Injury & Impingement (Tendonitis) Rehab. The acute phase and pain reduction was managed with the Deep Muscle Stimulator (DMS), Class IV Laser, and mobilization.

Specific weight lifting exercise modifications for clients with shoulder injuries:
BENCH PRESS
• Narrow hand spacing
– No wider than 1.5 times biacromial width
– Minimizes peak shoulder torque while pressing
– Reduces anterior/posterior rotator cuff and biceps tendon requirements for humeral head stabilization
– Maintains shoulder abduction to less than 45 degrees
– Decreases compressive forces at the distal clavicle

Additional Recommendations for the Bench press
• Maintain shoulder extension at less than 15 degrees
• The bar “touch” point is superior to the xiphoid process, decreasing the net torque on the shoulder
• Overhand grip (pronated position)
- Internal rotation moves biceps tendon from under acromion
- Positions supraspinatus muscle portion of RC beneath the anterior acromion
• Underhand grip (supinated position)
- Places long head of biceps under the acromion during the pressing motion
- Supraspinatus is rotated posteriorly, away from the acromion

• NO INCLINE BENCH PRESS
- Places person in “High 5” shoulder position (90 degrees of shoulder abduction and 90 degrees of shoulder external rotation (instability).
- Places increased stress on anteroinferior & anterior shoulder instability with increased strain on middle & inferior glenohumeral ligament complex

Bench press: posterior shoulder instability
• Increase hand spacing to more than 2 times the biacromial width
• This wide grip
– Structural approximation of the humeral head in the glenoid fossa
– Decrease strain on the posterior shoulder
– Shoulder abduction of greater than 80 degrees

• NO DECLINE BENCH PRESS
- Keep the angle between the arms & forearms at 80 degrees abduction.
- Wide bar grip
- Horizontal abduction of greater than 15 degrees at start of concentric phase of lift
- Horizontal adduction less than 20 degrees at finishing position
- Mandatory “handoffs” for all lifts

SHOULDER PRESS
Behind the neck press is not allowed. The physiological effects of this exercise can be replaced with: Rear deltoid raises, Seated rows, and/or Dumbbell rows.

Front Shoulder Press is performed in the scapular plane.
• Hands placed slightly wider than shoulder width
• Bar rests on anterior deltoid muscles & SC joint
• Final bar position is directly overhead with arms in line with both ears

• These are the precautions for the front shoulder press: Horizontal translation (path) of the bar is anterior to posterior during the lift. Increased strain on inferior GH ligaments. Increased risk of GH subluxations by increased external rotation as the exercise concludes.

• The modifications for the front shoulder press: Use of Power Rack (weight on the bar)
• Seated Isometric presses at a progression of:
– 60 degrees of flexion
– 90 degrees of flexion
– 120 degrees of flexion
– 6 to 10 reps each angle
– 5 second “isometric” hold for each rep
• Shoulder press “lock outs”
– Limited weight
– Reduced stress to shoulder and low back (no arching)
• Limited shoulder ROM
• Teaches technique of UE in line with the ear at completion of the exercise and avoids excessive shoulder flexion/ER

LATS PULL DOWN
The latissimus dorsi pull down is not performed behind the neck.
The modified trunk position is seated with 30 degrees of trunk extension.
Bar grip of 1.25 to 1.5 times biacromial grip.
Exercise begins from overhead to slightly above the xiphoid process.
Emphasis is placed on scapular retractors and latissimus dorsi muscles.
Front pull avoids High 5 position and negates stress on inferior GH ligament complex. The front pull also has a greater mechanical advantage for lat insertion (EMG analysis).

Do not use a incline type bench (bench with a back) when performing the lats pull down. This would assists fixation of scapula and may inhibit normal scapular/humeral rhythm

POWER CLEAN
The Power Clean is a total body exercise. It has high power output (up to 6 HP). The exercise is performed in less than 1 second with initiation of the legs and a transfer of force/power to the upper extremities. The Power Clean is sports specific, and it trains muscles that provide scapula stability.

Power Clean Precautions: Repetitive motion (“catching” the bar) places possible risk of “microtrauma” to distal clavicle and wrist joint. SLAP Lesion at risk during acceleration and deceleration phases of the exercise.

The Power Clean modifications include pulls instead of cleans. The wrist remains in neutral position; No AC joint microtrauma.

SLAP Lesions: Perform from “Hang” position vs. floor; Use bumper plates to eliminate bar deceleration; Reposition prior to each lift.

BACK SQUAT
The Back Squat requires the upper extremity to be in an abducted and externally rotated position (High 5 position). This may be fine with some clients (i.e. pitchers and not with others i.e. linebackers). The common modifications include:
The Buffalo bar decreases both abduction and external rotation. The grip should be wider to decrease ABD & ER.

Another modification is the Front squat. I use the Kettlebells for these. They actually provide a safer “environment” for the shoulder because it remains adducted.

References
Sahrmann SA 2002 Diagnosis & Treatment of Management Movement Impairment Syndromes. 1st Mosby, USA.

Kendall FP, McCreary EK, and Provance PG 1993 Muscle Testing & Function, 4th Edition, Williams & Wilkins.

Price et al. 2000 Active and passive scapulohumeral movement in healthy persons: a comparison. Arch Phys Med Rehabil 81:1 28-31.

Comerford, M. Course lecture notes 2007, 2008, 2009.

All the coaches and trainers I have worked with over the years.

Dr. Jeffrey Tucker, D.C., D.A.C.R.B, is a rehabilitation specialist, author, lecturer, and healer best known for his holistic approach in supporting the body’s inherent healing mechanisms and for integrating the art and science of chiropractic, exercise, nutrition and attitudinal health. He instructs for the National Academy of Sports Medicine and the Chiropractic Rehabilitation Association. He practices in West Los Angeles, CA. For more information, please visit: www.drjeffreytucker.com.

Dates: Nov. 13-15 2009, Tempe, AZ

ISCRS Members Receive a $100 Discount

Presented by
Craig Liebenson, D.C.
L.A. Sports and Spine
Los Angeles, CA

DNS Seminar Registration Info:
Fee: $995
ISCRS Discount: $895
craigliebensondc@gmail.com

Location
Physiotherapy Associates
1025 E. Broadway Rd. #10

Misc

• Additional Fee applies for CEU application (varies by state)
• $50 fee for Credit Cards
• Take an additional $100 off for registering by July 15!

Faculty

Pavel Kolar, PT, Paed. Dr., Ph.D. – Day 1 only
Clare Frank, PT – Local certified DNS instructor
Magdalena Lepsikova, PT – Prague school physiotherapist
Alena Kobesova, MD – translator for Pavel Kolar

COURSE OBJECTIVES

• The basic principles of developmental kinesiology
• Development during the first year of life:
• Stabilization of the spine in the sagittal plane, development of the phasic movements coupled with trunk rotation
• Spontaneous motor patterns during first year of life
• The relationship between development during the first year of life and pathology of the locomotor system in adulthood
• Posture from a developmental point of view
• Evaluate and correct poor respiratory patterns
• New terminology such as functional joint centration and decentration, stabilization, punctum fixum, punctum mobile
• The integrated stabilizing system of the spine
• The most important principles of reflex locomotion: locomotion patterns – stepping and support function and stimulation zones
• The basic techniques for reflex locomotion, i.e. reflex turning and reflex creeping
• Assessment of the deep spinal stabilizing system
• Techniques used in the treatment of the deep stabilizing system of the spine based on the principles of reflex locomotion
• Integration of corrective exercises based upon the DNS functional tests taught and initial RL positions
• How DNS corrective exercises can integrate with other exercise strategies
• Clinical management: how to integrate DNS protocols into regular practice, including patient education
• Establish individual goals (DNS understanding and skills) for participants to be optimally prepared for the next level of training
• (Course “B”)

Testimonials

“I thought this course was comprehensive with respect to early development and the potential impact to pain & dysfunction later on in life. I even recommended it to several Pediatricians I know. The skills and knowledge learned from Pavel Kolar can apply to physical therapists in all aspects of care from pediatrics to orthopedics to neurologically compromised individiuals. Definitely a great course.”

Melissa Kolski, P.T., Rehabilitation Institute of Chicago

“Pavel Kolar’s evaluation and treatment techniques will not only change the way you practice but will change the way you think. Pavel’s courses are invaluable in practice and they will help take your clinical expertise to a whole new level. At the Chicago ’06 course Pavel, Alena Kobesova, MD, and his 2 P.T.s providing an unparalleled supervision making for a “hands-on” experience that was critical in helping you integrate Pavel’s concepts immediately Monday morning.”

Corey Campbell, DC, DACRB, Nebraska Spine Center, LLP

“The last program done in Chicago with Kolar was the best yet. The organization, notes, and topics were exactly what I needed to be able to apply this material in practice. I would highly recommend this course to anyone who is treating the musculoskeletal system.”

Brett Winchester, DC DACRB, Troy , MO

“Reflex locomotion stimulation and the theory behind gives you an understanding of how problems arise and at the same time a tool for correction.”

Teddy Fohlmann, Chiropractor and member of multidisciplinary “back team” in Esbjerg,Denmark

“You get a good model of explanation for the function of the locomotor system, and tools for examination and treatment of the chronic and hypermobile patient. These are the patients lacking central stability, that has tried rehab unsuccessfully in the past”

Mogens Frost, GP and member of multidisciplinary “back team” in Grindsted, Denmark

” Through very specific positions and stimulation points the patient learn to activate the deep stabilising muscles, enabeling voluntary control to develop before more advanced training is started. When this basic step is lacking failure of rehabilitation is seen. Simply an ingenious technique.”

Grethe Jensen, Physiotherapist and member of multidisciplinary “back team” in Grindsted. Denmark

“I have always sought results, and you certainly get them using this technique”

Ida Nørgaard, Chiropractor & MSc., London

2009-2010 Chiropractic Rehab Diplomate Series

Pennsburg – Pennsylvania

300 Hour Certification Series in preparation for -
Level I Registry Status
Level II Registry Status
Level III Registry Status
Diplomate American Chiropractic Rehabilitation Board

SAVE MONEY – SAVE TIME: REHABILITATION DIPLOMATE NOW IN 1 YEAR

The 300 Hour Rehabilitation is now 12 Sessions of Workshop (144 hours) and 12 Sessions of Online (156 hours) education. The 12 sessions of workshop and online education can be completed in 12 months. Instead of 3 years to complete, it is now 12 months. One workshop (12 hours) plus online (13 hours) are completed each month for a total of 25 hours. The cost savings are huge. Instead of $399/month for 3 years the cost is now $399/month for 1 year. Class size is limited to only 15 participants.

Download the registration form here

COURSE BEGINS OCTOBER 17, 2009

Workshop Location
2791 Geryville Pike
Pennsburg, PA 18073
(215) 679-8866

Outline

October 17, 2009
Human Movement System concepts; Core concepts & remedial core training program; foam roll training.

November 14, 2009
Forward Head Posture; Functional Movement Screen & corrective exercises; Muscle length testing; Kettlebell weight training.

December 12, 2009
Low Back conditions & rehab exercises; Flexibility training; Isolation exercises; Balance pads, balance boards, BOSU, slides.

January 16, 2010
Neck conditions, headaches & rehab protocols; TMJ treatment.

February 20, 2010
Thoracic spine conditions & rehab protocols; Thoracic Outlet Syndrome; Band/tubing training (mini-bands, bands with handles); Low-load isolation exercises.

March 20, 2010
Shoulder conditions & rehab protocols; bodyweight exercises; stability ball exercises.

April 17, 2010
Hip conditions & rehab protocols; Free-weight training.

May 15, 2010
Knee conditions & rehab protocols; Group exercise training concepts.

June 12, 2010
Feet/ankles conditions & rehab protocols; medicine ball training; Plyometrics.

July 17, 2010
Carpal Tunnel Syndrome; Cardio training concepts; Speed/agility; Post-surgical therapy.

August 14, 2010
Forms; Nutrition; Performance Enhancement.

September 11, 2010:
Chronic pain treatment; Review; Wrap up.

Download the registration form here