A recent study lead by researchers from Boston Children’s Hospital, the Department of Pediatrics at Harvard Medical School and several other institutions, concludes that the clinical trials for drugs approved as “treatment” for ADHD were not designed to assess adverse events or long-term safety and efficacy.
Dynamic Warm-Up In The Workplace May Increase Workplace Productivity, Safety: A Call to Research Based On Results Of Implementation In The Athletic CommunityMarch 2nd, 2015
Nathan J. Porcher DCa, *; and Thomas J. Solecki DC, DACBSP, DACRBb
aPrivate Practice, Arlington Heights, IL
bAssistant Professor, National University of Health Sciecnes, Lombard, IL
*Corresponding Author. Nathan Porcher DC, 115 N. Arlington Heights Road, Suite 104, Arlington Heights, IL 60004. Email address: firstname.lastname@example.org (N. J. Porcher)
Running Head: Dynamic Warm-Up In The Workplace
Introduction: Virtually every company is looking for ways to make their employees safer, more effective, and protected from injury. The United States Bureau of Labor Statistics reports that hundreds of thousands of non-fatal injuries involving sprains, strains, tears, and back injuries affect the American workforce annually. While a push for pre-work stretching and designing of an ergonomic workstation have helped, an even greater decrease in work-related injuries could result from replacing static stretch routines with a dynamic warm-up, involving various, tailored exercises and proprioceptive tasks for employees to perform prior to the start of their work day.
Methods: We searched the terms, “dynamic warm-up,” on Pubmed. Our search was limited to human subjects, articles published within the last 10 years (August 2004- 2013), and published in English.
Results: The search yielded a total of 116 articles. We examined each article for relevancy, study design, and significance of findings, and selected to review pertinent articles that compared the efficacy of a dynamic warm-up (DWU) to models of static stretching (SS). Our findings demonstrate evidence that may support the use of dynamic warm-ups as a replacement to static stretching warm-ups.
Conclusion: Much evidence shows both the detriment of static stretching before athletic performance (strength, power, muscle efficiency) as well as the enhancement of performance by the use of a dynamic warm-up. This suggests that the occupational community, especially blue-collar-type jobs, could follow the athletic community in researching these interventions, in order to enhance work performance, to decrease work-related strain injuries, missed days of work, and workers’ compensation payouts by employers.
Key Words: Dynamic Stretching, Static Stretching, Workplace Injuries, Worker’s Compensation, Work-Related Injuries, Repetitive Strain Injury
Former student athletes who return to visit their alma mater’s sports team at practice or competition may be surprised to see coaches instructing athletes to prepare for competition in a way that is different than when they were on the team several years prior. It is really no surprise, however, that many coaches have greatly decreased the amount of static stretching (SS) and replaced much of it with a type of warm-up that much of the evidence in current literature may be pointing to as superior—dynamic warm-ups (DWU). Dynamic warm-ups and dynamic stretching, in contrast to static stretching, include active movements where muscles are taken through the full range of motion, and often include movement drills (i.e. light plyometrics, tri-planar exercises). A good coach wants to see his or her hard-working athletes performing to their highest potential, and of course, does not want to see them be sidelined for injuries that could have been prevented by using the most effective warm-up techniques. In the same way, every employer wants their employees, whom they have spent hours training, and who are the means of making their business function, be functioning at the highest level possible, and not absent from work due to injuries experienced on the job, and so a similar approach, using dynamic warm-up strategies for workers could potentially prove as beneficial.
“Repetitive strain injuries,” or RSIs, cause the average employee to miss 8 days of work each year, and the incidence of RSIs have soared by 30% in the last decade, according to a recent study, costing businesses over $600 million in workers’ compensation payout . Recently, the US Bureau of Labor Statistics published on their website that these types of sprain, strains and low back injuries have become a detriment to over 500,000 working individuals annually.
RSIs have been on the forefront of occupational injury discussions for the past 30 years and have a number of causative factors . Without providing too much detail, they are the result of a continuing cycle of cumulative trauma to the soft tissues over days, months, and years. The severity of insult to the tissues is a product of the number of repetitions by a muscle or tissue, the force of tension on that tissue, and is also dependent on the amplitude of each repetition (how much the muscle or tissue must lengthen and shorten, and whether or not significant rest is employed between repetitions) [17,22]. From a machinist, to an assembly line worker, to an electrician, and even to a keyboardist, all of these factors play a role. Because most individuals are de-conditioned and are not warming up properly, their muscle contractions require a higher percentage of muscle fiber recruitment in order to produce the needed amount of force to complete the task, thereby increasing the tension in the muscle and on the musculo-tendinous interface . Additionally, because many individuals are weak or are not properly warmed up, there is more overall load on the tissues and less of a chance for relaxation of these work-required muscles during the workday. The lack of both relaxation and relief of tension in a muscle prevents the proper amount of arterial and venous blood flow. Decreased blood flow leads to increased levels carbon dioxide and metabolic wastes lingering in these affected tissues. This results in chemotaxic stimulation of fibroblast cells, which lay down disorganized collagen fiber, essentially producing weak and non-compliant scar tissue, in and around muscles and the musculo-tendonous junctions. Because of the infiltration of scar tissue, the muscles and tendons thereby become weaker, less resilient, more sensitized to pain, and more likely to become re-injured, thus perpetuating the cycle . Because of this glaring issue, many employers have implemented programs such as pre-work static stretching, personal demands analysis (PDA), work task risk assessments, and ergonomic equipment into their workforce over the last couple of decades. These programs have helped somewhat to decrease these work-related sprain/strains, but the burden of dollars paid out annually by American companies with these interventions is clearly still astounding—this raises the question—are there still missing pieces in solving the puzzle of occupational RSI?
Perhaps, the idea of following the athletic community, and their research, implementing tailored dynamic warm-up routines for the occupational community, (and combining it with ergonomic advances already in place), could prove to be a key to cutting down on repetitive strain injuries, and therefore a company’s workers’ compensation payouts. In the previous 10 years, there have been a number of scholarly research articles published that demonstrate the benefits of a tailored, dynamic warm-up for the athletic population, in contrast to older static stretching routines, which are still in place in most occupational settings. The purpose of our study is to review the current literature for specific examples of how the realm of athletics has seen significant increases in performance measures and decreases in soft tissue injuries when utilizing dynamic warm-up routines, rather than static stretching alone. Our findings are intended to create a movement where research in the realm of the efficacy of DWU in the workplace is a better intervention than SS routines in increasing work performance and decreasing RSIs. The working public, whose responsibilities at work often require musculoskeletal efforts that in some ways correlate to the more complex efforts in sport-specific activities. While an athlete may be performing large scale global movements, the individual who lifts and loads boxes into a truck, a carpenter who moves heavy materials and applies forces through tools, or the assembly line worker who feeds sheet metal through a press for 8 hours each day have similar challenges to the muscles and other soft tissues. These findings could provide the groundwork for further research of how effective dynamic warm-up routines could positively affect a company’s workers’ compensation payouts, days of productivity lost, and therefore their annual overhead.
Our methods for this research included a search of scholarly articles on the topic in Pubmed. We used the terms, “dynamic warm-up,” in the subject line. In order to provide the best and most current evidence for our research, we limited our findings to articles published within the last 10 years (April 2004-April 2013). We also limited our search to studies involving human subjects, and chose to pursue only studies that were written in English. After we applied these filters, there was a yield of 116 articles. After this, we looked through all of the articles and selected those that were most pertinent to our study, comparing the efficacy of a dynamic warm-up to static stretching routines for athletes/employees to perform before beginning work. Before going any further, we examined each of the studies we selected for any bias that could have lead to significant alterations in their results. For this possible exclusion from our review, we ensured that the conclusions drawn from these studies matched the individual results from their research and had statistical significance, and that the studies were carried out in a professional manner with proper data collection. We also inspected data regarding project funding, if shown, to see if there may have been any conflict of interest that could potentially influence their conclusions or results. We are aware that, even in spite of our selection criteria, that there may have been articles published having similar data or results that were missed and were therefore not included in the study, but we felt that these studies reviewed below, as examples, were fair studies that adequately compared the efficacy of a dynamic warm-up routine to that of a static stretching warm-up. This narrative review of the literature regarding the efficacy of dynamic warm-up over static stretching, the benefits of dynamic warm-up, and the potential detriments of static stretching is designed to show that DWU-type routines may be superior to static stretching routines in the athletic population, and to suppose that the findings would translate well to the working population. Our research is intended to create a spark for research into whether or not replacing static stretching in the workplace with DWU routines is an effective way to create optimum performance, well-being, and most importantly, to lower repetitive strain injuries.
NARRATIVE SUMMARY OF SELECTED ARTICLES
The first study we selected was the most comprehensive overview of the contrast between dynamic and static stretching routines on performance. Behm and Chaouachi demonstrated, in a systematic review study, how static stretching has a negative effect in most cases . They examined 42 different studies, containing over 1600 participants who performed static stretching prior to performing activities that measured isokinetic force and torque, isokinetic power, and one-rep maximum performance activities, such as squats and bench presses. Of all the measures taken from the sum total of the 42 trials, there were over 50 measures that showed significant impairment brought on by static stretching before the activity, almost 20 that showed no change, and only 11 that showed improvement due to static stretching. They also examined 20 studies that had individuals performing vertical jump tests, countermovement jumps (moving in multiple planes), and squat jumps. Of these measures, 17 showed significant impairment on performance due to static stretching prior to testing, 7 showed no difference in performance, and 6 showed improvement. Most of these studies demonstrated moderate time spent stretching each muscle group of interest, from 90 seconds to 2 minutes each. Additionally, they cited previous work by Behm, et. al. , and Nagano et. al. , which demonstrated how static stretching could actually cause impairments in reaction time and balance. They also cited Power et. al. , which demonstrated impairment in muscle activation and maximal volumetric contractions for 2 hours post static stretching. To be fair and objective, as stated above, not all studies analyzed by Behm and Chaouachi were unanimous in detecting negative effects of static stretching prior to activity . Worrell, et. al. showed increase in hamstring torque following 15-20s stretches to the hamstrings . There were also several studies, as stated above, that showed that there was no statistically significant detriment to performance brought on by static stretching [26,30]. A few studies were mentioned where middle-aged participants were used. One study  showed no detriment to static stretching, but another was consistent with the majority of studies, showing negative effects on performance . Behm and Chaouachi’s review examined the acute effects of a dynamic warm-up. While there were a much wider variety of types of dynamic stretching (i.e. taking the muscle carefully through full range of motion, plyometric exercises), they demonstrated in many papers that there were benefits on subsequent performance . Some articles they reviewed showed dynamic warm-ups to have no effect, but no studies provided examples of any negative effects. At times, these studies used movements that simulated parts of the total upcoming performance motion. Their research also showed that longer periods of dynamic stretching (the day of, as well as implementation over days or weeks) were more likely to produce significant positive effects on performance. The authors stated that further research was needed in the realm of dynamic warm-ups.
The second study we examined was a very recent e-publication from the Journal of Strength and Conditioning Research by Haddad et. al. Their study selected 16 junior soccer players between the ages of 17 and 19. They chose to use the five jump test (5JT), repeated sprint ability test (RSA), and 30 meter sprints (with 10 and 20 meter splits)—tests which have been designed to measure lower body efficiency and explosiveness. Each of the 16 individuals was taught how to stretch statically and dynamically, and were familiarized with what to do for the “control” group setting. Each player performed testing at the 2nd and 4th week of pre-season training sessions, 24 hours after each of the different stretch protocols. Protocols were tested on separate days, not together. The athletes did not use either stretching protocol after a basic warm-up the morning of the testing. The results of the study demonstrated that statistically significant inhibition of lower body efficiency and explosiveness was a result of static stretching, even 24 hours prior to the test, as seen in the 5JT and 30m sprint. The repeated sprint ability was not affected significantly by static stretching 24 hours prior to testing .
The next study we chose to examine more closely regarding the benefits of a dynamic warm-up (DWU) in contrast to a static stretching warm-up (SWU) was from the Journal of Strength and Conditioning Research in 2012. Aguilar et. al. had 45 healthy male and female individuals from recreational soccer teams participate in the study. The study looked at the measures of large muscle group flexibility, concentric and eccentric strength of these muscle groups, and vertical jump performance. All participants were pre-tested and then randomized into DWU, SWU, and control (CON) groups. All groups began with a 5-minute aerobic warm-up on a stationary bike. The DWU group performed a plethora of active movements such as dynamic stretching, plyometrics, running, and dynamic stretching containing a proprioceptive (balance) requirement. SWU performed 10 minutes of static stretching on the muscle groups of interest, and the control group sat resting for the 10-minute duration. Following those three separate 15-minute warm-up interventions, participants were re-tested. The DWU group showed significant increase in hamstring flexibility, as well as in peak quadriceps torque in both concentric and eccentric types of contraction from pre-test to post-test. The SWU group had findings indicating that the optimum hamstring to quadriceps strength ratio may have even been upset by prolonged static stretch duration .
Another very helpful study in this realm of dynamic warm-ups was written by Daneshjoo et. al. and published in the PLOS One Journal in December 2012. This study examined very different measures from those above regarding the efficacy of a dynamic warm-up on proprioception and both static and dynamic balance. Thirty- six participants from professional soccer teams were randomized into three groups. Two of these groups used one of two pre-written dynamic warm-up routines (FIFA 11+ and HarmoKnee), and the third group acted as a control and were not instructed to warm up in any specific way, but were told to warm up according to their normal routine. Unlike other studies, these dynamic interventions were performed for 24 sessions ( over a period of 2 months) between pre-testing and post-testing. Some of the dynamic warm-ups performed daily by these individuals included planks, side planks, single leg balance with a medicine ball, vertical jumps, bounding, walking lunges, hamstring curls against resistance, and glute bridging. The testing measures included having patients standing on a Biodex Isokinetic Dynometer (essentially measuring change in center of pressure) with their knee flexed at 30, 45, and 60 degrees over 3 different trials. Dynamic postural control was assessed via the Star Excursion Balance Test, having subjects reach in 8 different directions. Individuals were to touch their non-dominant foot to the star-patterned floor tape in each direction as far as possible from the center. Leg length was standardized for each individual and factored into their tests. Further distances reached indicated greater dynamic balance, and tests were discarded and repeated when test subjects either lost their balance or moved their stance foot from the center of the star. Lastly, a standard Single Leg Stance (SLS) test was administered with the individuals’ hands on their hips. Data were collected for both eyes-open and eyes-closed trials, and all subjects were timed from the moment they lifted their leg to the point at which they put their leg down, broke stance, or removed their hands from their hips. Each individual was allowed to have three trials in the SLS test. Results of the dynamic warm-up programs both significantly decreased proprioceptive error at 45 and 60 degrees of knee flexion. For the 11+ and HarmoKnee groups, dynamic balance increased by 12.4% and 17.6%, respectively. Additionally, static balance also increased with eyes open 10.9% and 6.1%, respectively; and testing with eyes closed increased by 12.4% and 17.6%, respectively, over the course of 2 months .
In late 2009, there was another article in the Journal of Strength and Conditioning Research, by Curry et. al., showing the effects of dynamic stretching, static stretching, and light aerobic activity on muscular performance. Twenty-four active, but untrained women in their mid-twenties were recruited for the study. The first aspect of the study looked at potential intervention-driven changes in quadriceps length as measured by passive knee flexion in Modified Thomas position using goniometry. Counter-movement jump (CMJ) performance was also measured pre- and post-testing, as was the time to peak force of the quadriceps muscle (at 90 degrees of knee flexion), which was tested using KinCom isokinetic dynometer. All participants were familiarized with each type of warm-up intervention, but they were not told the names of each intervention. All administers of the testing measures were blinded to the type of warm-up that each subject had performed prior to testing. Each outcome measure was pre-tested on each individual after 5 minutes on a stationary bike. After this, 15 minute cycles of each intervention were administered in separate sessions to the same subjects. Post-warm up testing was performed at 5 minutes, and 30 minutes to show the lasting effects of each warm-up intervention. All three techniques showed improvement in muscle length, which decreased in all three from 5 minutes to 30 minutes. CMJ performance increased significantly with light aerobic activity and dynamic stretching at 5 minutes, and static stretching was shown to cause significant detriment. After another 25 minutes of sitting at rest, all three intervention groups were lower than at their pre-test results. Time to peak force (TPF) had decreased significantly after dynamic stretching, and continued to stay at a significantly faster time than pre-testing even 30 minutes after the dynamic stretching and movements had been executed. Both static stretching and light aerobic warm-up interventions showed little change in Time to Peak Force (TPF) at 5 minutes, and TPF was actually longer than the baseline times at 30 minutes post-intervention .
Herman et. al. also demonstrated the effects of a repeated, tailored dynamic warm-up routine, as compared to the effects of static stretching and on a number of different measures in 24 Division I collegiate wrestlers. Their dynamic warm-up intervention consisted of both movement drills and calisthenics, and the static stretch group instead performed 8 stretches during the allotted time. These groups performed their respective warm-up routines 5 times per week for 4 weeks. The performance measures used were a standing broad jump, medicine ball toss, peak torque of quadriceps muscle, sit-ups, push-ups, 300m, and 600m runs. In each test, the dynamic warm-up positively influenced the results, whereas the static-stretching warm-up did not cause any improvement. Furthermore, the push-up tests and 600m run outcomes decreased significantly, on average, among the static stretching group .
There were a few other studies that showed that a dynamic warm-up following static stretching could potentially “redeem” the upcoming performance that would have otherwise been inhibited due to the properties of muscle affected by a static stretch . One of the more straightforward studies was done by Morrin and Redding, for the Journal of Dance Medicine and Science, in early 2013, although there have been other studies implicated in having similar findings [28,29]. They selected 10 experienced dancers that would visit 4 different locations, to perform 4 different types of warm-ups (static only, dynamic only, combined, and control—no warm-up). They were then tested for ROM of the muscle groups stretched, vertical jump, and balance (measuring ellipse area of center of gravity shifts on balance platform.) Dynamic stretching gave the least amount improvement in ROM, but the combination of both types of stretching techniques produced nearly equal results to the positive ROM change observed in the static stretch trial. Average vertical jump heights and balance were statistically better for the dynamic warm-up group than the static stretch group, and also generally better than the combination group.
It has become fairly common knowledge to the American public that specific warm-ups increase blood flow and raises temperature in the body parts that will be used more strenuously in the subsequent workload [27,6]. To a exercise physiologist, sports physician, or athletic trainer, it is known that proper warm-ups also speed up nerve impulses, decrease muscle viscosity, increase muscle post- activation potentiation (greater response and speed of contraction for added power and strength), increase proprioception, and ultimately lead to safer, peak performance. Unfortunately, this knowledge is almost always placed under the category of athletic performance and seldom thought of in the realm of occupational performance. Athletes in various sports tend to perform global, whole body movements, using complex muscle coordination to accomplish the task that their sport requires. However, just as an athlete must execute specific skills or movements, requiring force development in order to compete and practice their disciplines, individuals who perform some jobs, especially, but not limited to those with heavier-duty work, require similar amounts of force production, torque, and dynamic activity. From the rugby player, to the competitive weight lifter, to the concrete cutting contractor, and to the steel worker, the same muscle tissues must produce specific forces for a sustained period of time. Because of this often-overlooked association, America’s workforce is likely missing out on what the current literature deems to be the best type of pre-work routines to prevent injuries and maximize performance.
It is common knowledge that static stretching programs and ergonomic interventions in the workplace have been implemented in recent past, but it seems that very few, if any companies, are following how the current literature is weighing out static stretching versus a dynamic warm-up, and experimenting with additions of DWU protocols to their employees’ daily warm-ups. By looking at the best of the recent studies regarding the benefits of dynamic warm-up strategies for athletes, we can surmise that a similar effect would be generated when applied to the occupational workforce.
In a majority of the articles discussed above, it is demonstrated that a stand-alone static stretching protocol may not only be inferior to dynamic warm-up routines, but may be an actual hindrance to performance of an athlete, and therefore a factory worker, carpenter, or any other profession requiring force and dynamic activity. Behm and Chaoachi’s paper brought in a number of sources showing the detrimental effects of static stretching on performance, as well as the potential benefits of dynamic stretching . What’s more, compelling evidence from Haddad, et. al., demonstrated that this deleterious effect may last as long as 24 hours . Competitive athletes and the working public all have the same muscles and tissues, but something to consider as we relate the two groups is that much of the American workforce is de-conditioned to some degree. Because of being in a de-trained state, it is possible that static stretching programs would have even greater negative effects on them as they entered their workday. Egan et. al. and Unick et. al. in 2006, and 2005, respectively, demonstrated that untrained subjects saw a more deleterious effect on performance following static stretching routines [11,31]. This was likely due to the fact that trained individuals had a more pliable musculo- tendinous junction that could tolerate the visco-elastic changes in the muscles following their bouts of static stretching. Aguilar et. al. showed that a dynamic warm-up routine contributes to proper muscle strength and flexibility ratios of the hamstring and quadriceps muscles, which in turn enhanced performance and likely protected the surrounding joints influenced by those muscles from wear and tear . The interplay of the hamstrings and quadriceps working properly around a joint can be related to most other agonist-antagonist muscle relationships in the body. Daneshjoo et. al. showed significant positive effects on proprioception, static and dynamic balance when individuals followed a specified, tailored dynamic warm-up routine for 8 weeks. These authors also commented in their discussion that in order to improve the dynamic warm-up measures, further core exercise implementation should be added for greater stabilization effect. Herman and colleagues’ work also demonstrated that a DWU routine implemented over a longer period of time can have positive effects on muscle strength, power, endurance, agility, and flexibility . Curry et. al. mentioned that even in untrained individuals, that dynamic stretching had not only an immediate effect on time to peak torque of a muscle (a measure that essentially demonstrates the effective strength of that muscle), but also had a lasting effect that would likely be perpetuated by continued occupational or athletic activity . Morrin et. al. also demonstrated improved proprioception due to a dynamic stretching or combined dynamic and static stretching . Many past studies have demonstrated how individuals suffering from low back pain were much more likely to have proprioceptive deficits both sitting and standing than those individuals who did not [24,25,32,33]. Since a great number of individuals in America’s workforce experience low back pain on a daily basis, any measure of increasing proprioception, by different dynamic strategies would be likely be welcomed.
We realize that there are a number of limitations to our research. We did not perform a systematic review of the literature; thus, the articles we selected to review and summarize were intended to stir up a desire for others to research the subject, not make any assumptions about the efficacy of dynamic warm-up routines in the work place. Despite our intentions, we realize that there is potential for author bias. Unfortunately, there is not yet any published research that we are aware of that compares and contrasts DWU and SS routines in the workplace, and so our research is aimed at the athletic realm, where these two types of warm-ups have been thoroughly studied. Yet, again, our research intends to steer an interest for research in that direction, not provide a definitive answer as to which is better. We also acknowledge that our search methods may have missed some pertinent studies.
FUTURE SUGGESTIONS FOR RESEARCH:
We suggest that, based on what has been found in the literature by many studies, like ours, that future research should look at the potential benefits of DWU over SS routines, or a combination of both in the workplace using outcome measures of work performance, discomfort/pain experienced while on the job, documented soft-tissue injuries, and the like, which could prove useful for employees, as well as their employers.
With these studies mentioned above, as well as a great number of other studies, it is clear that there may be a real benefit to either adding a DWU routine to stretching, or even replacing the SS altogether with a DWU in the athletic population. Based on the physiological effects happening with these two types of warm-up routines, this conclusion could perhaps be true for the working population, as well, although further research is needed, as we have stated above to investigate the effects in that setting. Still, it is worth noting that while static stretching may cause acute and somewhat lasting detrimental changes in overall muscle performance, should not be avoided altogether, because of the several studies that demonstrate that static stretching at the end of the day in order to gain back muscle length, or in situations where the acute effects of it will not alter performance [2,18]. It still does have benefits of increasing range of motion, muscle length (especially at the musculo-tendinous interface) . It also will, over time, make the tissue more compliant and less stiff for the intended movements . This is especially true in middle-aged populations, where there is a likelihood of workers having lived in a de-conditioned state for a longer duration of time and having a greater degree of muscle-tendon unit stiffness. Perhaps, if these results were translated to the workplace, employers could use DWU routines before work, but still suggest that their workers use static stretching after a work day, or on days off. Still, it may be judicious, according to the preponderance of the evidence, to avoid static stretching protocols prior to performance, such as beginning an 8-hour day of hauling equipment around, or performing tasks associated with road construction . Workplace injuries, including sprains, strains, and low back injuries, keep an average employee out of work for 8 days each year, and cost employers hundreds of millions of dollars each year in workers compensation and other costs associated with losing man-hours, and even spill over into the private/group healthcare burden . We feel that is it time for those in research, and company ownership/management to begin to look at the weight of the evidence in the literature regarding better warm-up methods, and begin to study and learn how to implement these measures into the daily practice of their employees before they embark on a full day’s work. The benefits may lead to a happier staff, safer workplace, and may end up saving millions of dollars in unneeded workers’ compensation payouts.
FUNDING SOURCES AND POTENTIAL CONFLICTS OF INTEREST:
No funding sources or conflicts of interest were reported for this study.
The authors thank the Interlibrary Loan Department from the National University of Health Sciences’ Learning Resource Center for their assistance with obtaining full-text journal articles for the review.
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29. Taylor KL, Sheppard JM, Lee H, Plummer N. Negative effect of static stretching restored when combined with a sport specific warm-up component. J Sci Med Sport. 2009 Nov;12(6):657-61.
30. Torres EM, Kraemer WJ, Vingren JL, Volek JS, Hatfield DL, Spiering BA, Ho JY, Fragala MS, Thomas GA, Anderson JM, Hakkinen K, Maresh CM. Effects of stretching on upper body muscular performance. J Strength Cond Res. 2008; 22:1279–1285.
31. Unick J, Kieffer S, Cheesman W, Feeney A. The acute effects of static and ballistic stretching on vertical jump performance in trained women. J Strength Cond Res. 2005 Feb;19(1):206-12.
32. Willigenburg NW, Kingma I, and Van Dieen JH. Center of Pressure Trajectories, Trunk Kinematics and Trunk Muscle Activation During Unstable Sitting in Low Back Pain Patients. Gait Posture. 2013 Mar 5: epub ahead of print.
33. Willigenburg NW, Kingma I, van Dieen JH. Postural Control of Upright Trunk Posture in Low Back Pain Patients. Clin Biomech. 2012 Nov; 27(9):866-71.
34. Worrell T, Smith T, Winegardner J. Effect of hamstring stretching on hamstring muscle performance. J Orthop Sport Phys. 1994; 20:154–159.
35. Young W and Behm DG. Should Static Stretching be Used During a Warm- up for Strength and Power Activities? Strength Cond J. 2002; 24: 33-37.
Familial Predisposition in Cervicogenic Disequilibrium, as it Relates to Functional Disturbances and Somatotype – A Case StudyMarch 2nd, 2015
Eugene Serafim, DC, DACRB, CSCS
Dizziness is a nonspecific term that means various things to various people. It falls under a greater category of vertigo, but for our purposes we will concentrate on the subcategory of disequilibrium. This paper will review the origins, testing procedures and common disturbances of the physiologic and neurologic systems that affect balance and contribute to disequilibrium. This study will further concentrate on the familial link between structure and function of the cervical spine and the pathogenesis of cervical disequilibrium in a mother and daughter case study.
Dizziness has a variety of meanings, but it is most often used as a means of describing unsteadiness. Notwithstanding layman’s terms, more specific identifiers are required, including lightheadedness, presyncope, disequilibrium and vertigo. The diagnostic triage must include a thorough history, specialized testing, and an orthopedic and neurological workup to discern the specific symptom, correct diagnosis and optimal treatment. Allopathic medicine has traditionally addressed these symptoms pharmaceutically, however a chiropractic rehabilitation approach can be successful in addressing the underlying structural root cause.1 In the case study cited, a mother/daughter case, both patients benefited from an approach using chiropractic and rehabilitative techniques. While this is not an exhaustive study, these cases provide an insight into the inherited structural or physiological etiology of disequilibrium.
In discussing balance and the loss of it (disequilibrium), we must start with reviewing the components that would affect it. Balance is accomplished through various systems that are integrated in the cerebellum. Proprioception, the vestibular system, visual sensory input and tactile sources combine to facilitate balance and coordination. Proprioception in the cervical spine provides sensory afferent input, which contributes to coordination of the eyes, head and body.
Proprioception in the cervical spine is controlled by a variety of reflexes that include the cervico- collic reflex, the tonic neck reflex and the cervico-occular reflex. Bolton (1998) states that the first reflex stabilizes the head and integrates with the vestibulo-collic reflex (where the neck muscles are acted upon by input from the semi-circular canals). The tonic neck reflex is an asymmetrical reflex present in newborns that controls the tonic activity of the limbs.2 In discussing the tonic reflex, research by Hikosaka and Maeda has documented the association of neck afferents originating at the dorsal roots and cervical facets at level C2/C3 and the vestibular nuclei.3 These reflexes communicate with the vestibulo-ocular reflex. When sensory input is interrupted, it causes a disparity in perceived information received from the vestibular system and cervical proprioceptive or visual systems disequilibrium results.4 Research conducted by Dejong and Dejong further supports this data.5
There are a number of differentials that should be excluded before a diagnosis of cervicogenic disequilibrium can be assigned. Some diagnoses include benign paroxysmal positional vertigo (BPPV), Ménière’s disease and vertebrobasilar insufficiency. Discerning between terminologies that patients use to describe dizziness is another important aspect in evaluating a patient with unsteadiness. They include presyncope, disequilibrium, vertigo, dystaxia, ataxia and lightheadedness. To further complicate matters, in its slang form, dizziness has been used to describe those that lack mentation.
vertigo, cervical disequilibrium, lightheadedness, presyncope, dystaxia, ataxia, proprioception, cervico-collic, tonic neck reflex, cervical-ocular reflex
Dizziness, in general, is widely complained of and can have a component in virtually any medical condition. For our purposes, we will only consider one symptom of dizziness – cervical disequilibrium. The diagnosis of cervicogenic disequilibrium is largely one of exclusion, thus one should strive to rule out diseases of the inner ear (vestibule-cochlear apparatus), vertebral arteries and the spinal canal. Special attention must be paid to patients with a post-traumatic onset. In those cases, vertebral artery compression and dissection, spinal stenosis, cerebral spinal fluid leak and whiplash should be ruled out or referred to the appropriate provider before initiating a rehabilitation protocol.
Evaluation of any disease begins with a thorough history and treating cervicogenic disequilibrium must include a detailed history. Factors of interest would include the onset, duration, trauma, description, intensity, mechanism, previous treatment, cause, previous history, aggravating factors (positional relation), relieving factors, environmental related triggers, previous episodes, effects on ADL’s and functional deficits.
Outcome assessments provide a qualitative baseline to allow for accurate case management. They also measure pain, disability and psychosocial status. Questionnaires that measure pain would include the visual analog scale, McGill and pain drawing. For disability, questionnaires include the neck disability index, the Dizziness Handicap Inventory (DHI), the Henry Ford Headache Disability Inventory (HDI), Activities-specific Balance Confidence (ABC) Scale, somatic perception and the Physical Activity Readiness Questionnaire (PAR-Q). Psychosocial assessment would include Beck and SCL-90-R.
Orthopedic, functional and neurological testing must be combined to comprehensively evaluate a patient with cervicogenic disequilibrium. The orthopedic testing that would be appropriate includes Jackson’s, Bakody’s, cervical distraction, Berrie-Lou, Dekline’s, Maigne’s, Dix-Hallpike maneuver, Barany caloric test, Hoffman’s sign, Romberg’s, vertebral artery test, rapid alternating movement (diadochokinesis), Lhermitte’s and saccadic and smooth pursuits eye movements. Functional testing would include the Berg balance scale, the Clinical Test for Sensory Interaction in Balance6, posture and gait analysis, platform stabilometry,7 cervical flexion test,8 Jull’s cervical cranial test (to quantify),9 T4-T8 mobility test, wall angel,10 respiration,11 Hautant’s test12 and rotating stool test.13 Neurologic testing would include cranial nerves (especially auditory), pathologic reflexes, deep tendon reflexes and sensory dermatomes, as well as gait and station. Diseases of the brainstem (central lesion) affecting the vestibulocochlear nerve will also affect adjacent cranial nerves (VII and IX).
Physical examination should focus on the vitals, with special attention being paid to both the vitals and auscultatory exam to rule out arrhythmias, stenosis, prolapse or congestive issues. Blood pressure should be assessed bilaterally as well, going from sitting to standing and laying down to standing. Specialized testing for dizziness should rule out TIA, vertebrobasilar insufficiency, Ménière’s disease, benign paroxysmal positional vertigo and myelopathy. Such specialized testing could include, but should not be limited to, rotary chair testing, transcranial doppler sonography, MRI angiogram,14 ENG (caloric), audiometry, CSF leakage, hypoglycemia, cardiovascular disorders, cervical and cranial MRI’s, electrolyte panel (disturbance of the acid base balance could lead to dizziness),15 coagulation profile and lipid profile (to evaluate for vertebrobasilar disorders),16 and serology (to rule out infectious diseases, including syphilis and Lyme disease).17
CASE STUDY #1
A 76-year-old woman reported with a chief complaint of sub-occipital neck pain, headache and stiffness, complicated by dizziness that has a positional relationship. She noticed these symptoms most while flexing her head forward to putt during golf. It presents intermittently and its duration lasts anywhere from three days to three weeks. She reports suffering from stiffness and dizziness for the better part of her adult life. Her sedentary computer occupation worsens her neck pain and stiffness. Movement of the head, especially ballistic, seems to increase her unsteadiness. She experiences feelings of movement from side to side and denies spinning (disequilibrium). She denies any tinnitus or obvious hearing deficit. These problems limit her daily living activities when the unsteadiness is at its worst (difficulty standing). She is also disabled from playing golf during these episodes. She had not sought treatment for this problem in the past.
Disability indexes were assigned and included: neck disability index – 46%, moderate; Dizziness Handicap Inventory; the Henry Ford Headache Disability Inventory – 10 on the emotional subscale and 25 on the functional subscale; Activities-specific Balance Confidence Scale (Powell) – rated at 75% episodically; PAR-Q – cleared; and red flags – yes to over 50 and 70 years old. Psychosocial assessment included Beck – 10 (not depressed or mildly) and Modified Somatic Perception Questionnaire – 13 (high level of somatic complaint). The patient could not relate or report any family or social history that would apply to her complaint. The clinical impression was ataxia, disequilibrium and cervical spasm. Her working diagnosis was cervical disequilibrium related to functional disturbance.
Her evaluation was as follows: Vitals; 5’9”, 128 pounds, BP 130/86 on the right, BP 128/80 on the left, pulse – 50 beats per minute, temperature 99.0°F and respiration – 15 breaths per minute. No change in blood pressure was found in sit to stand or lying down to stand. Auscultation of the carotids and inferior vena cava was normal. Observation showed a well formed, aware and alert 76-year-old female. Percussion revealed tender paravertebral musculature at the occiput, cervicothoracic junction and the lumbosacral junction. Palpation revealed myofascial trigger points at the occiput, levator scapulae, sternocleidomastoids (SCM), lumbar erector spinae and gastroc/soleus complex. All findings were bilateral. Cervical spine x-ray examination confirmed a decreased cervical spine lordotic curve and generalized spondylosis from C3-T1. Cervical range of motion was found to be minimally limited in right lateral flexion, extension and right rotation. Lumbar range of motion was minimally limited in flexion and bilateral lateral bending.
Postural analysis yielded rounded shoulders, anterior lean, anterior head carriage, head tilt to the left, decreased cervical lordotic curve, Dowager’s hump, decreased lumbar lordotic curve and posterior pelvic tilt. Chiropractic examination revealed shortened/facilitated SCM’s, levator scapulae, scapular retractors, hamstrings and gastroc/soleus complex. Lengthened/inhibited muscles included cervical and lumbar erectors, longus coli, knee flexors and pectoralis. Subluxation complexes were found at occiput (inferior) C2 (right rotation restriction), T1 (right lateral flexion restriction), L4 (left rotation restriction) and a right posterior inferior ilium.
Examination began with a neurological exam, including cranial nerves (within normal), sensory dermatomes (within normal), pathological reflexes (absent) and deep tendon reflexes (+2/5 upper and lower bilaterally). Orthopedic examination consisted of cervical compression (negative with pain), Jackson’s (negative with pain), cervical distraction (negative), Berrie-Lou (negative), Dekline’s (negative), Maigne’s (negative), Dix-Hallpike maneuver (positive), Hoffman’s sign (absent), Romberg’s (positive), the vertebral artery test (negative), rapid alternating movement (diadochokinesis – negative), Lhermitte’s (negative), saccadic and smooth pursuits eye movements (negative) and the swivel chair test (negative). Functional testing revealed chin pointing with the supine neck flexion test, disequilibrium with the sit to stand test worsening towards the 5th repetition, a medium fall risk (35/36) on the Berg standing,18 clinical testing of sensory interaction for balance19 failing the 5th condition (eyes closed on unstable surface) within five seconds and gait analysis ataxia was noted with a wide stance being used. Functional analysis of respiration revealed paroxysmal breathing patterns.
One legged standing failed at six seconds on the right and four seconds on the left. Other functional activity testing revealed scapular winging and altered scapular abduction. No specialized testing was performed at the time, as no underlying pathology was suspected.
The patient’s primary diagnosis was Layer Syndrome, her secondary diagnosis was cervical disequilibrium and her tertiary diagnosis was cervicalgia. Complicating factors included subluxation complex (full spine), cervical spondylosis, myofascial pain syndrome, altered gait, muscle weakness, muscle imbalance and diminished proprioception.
Treatment consisted of passive care for the initial two weeks of care and included electrotherapies, soft tissue work and manipulation three times a week. After the acute care thresholds were passed, transitional care was provided for an additional six weeks. It included facilitated stretching techniques, myofascial trigger point therapy and non-weight bearing short foot protocol on balance pads and pelvic stabilization protocols. Active care was initiated next and included weight bearing proprioceptive protocols, postural retraining (passive and active), as well as home exercises. The active care lasted 12 weeks at a frequency of three times a week.
Outcomes were measured at two week intervals and dictated the transition of her care. Her disability indexes improved consistently and after four weeks were as follows: neck disability index20 – 32%; the Henry Ford Headache Disability Inventory21 – 10 on the emotional subscale and 15 on the functional subscale; and Activities-specific Balance Confidence Scale22 – rated at 50%. The ABC assessment was most profoundly influenced by the active phase of rehabilitation (25% at 6th week of active care). Other benchmarks for advancing stages of care included performance of orthopedic and functional testing.
|Initial||2 weeks||4 weeks||6 weeks||8 weeks||12 weeks|
|DHI (physical/ emotional/functional)||22/12/18||￼18/12/14||16/10/14||￼12/8/10||￼8/8/10||8/6/10|
|One leg balance||10 sec R
6 sec L
|8 sec R
14 sec L
|￼15 sec R
22 sec L
|25 sec R
33 sec L
|40 sec R
38 sec L
|40 sec R
46 sec L
At the completion of her 12 week rehabilitation protocol, the patient was able to perform Romberg’s test with an acceptable level of sway and her one legged balance had improved from six seconds to 72 seconds on the right. Performance of functional activity improved in the neck flexion test, breathing patterns improved and forward lean improved with the squat. Postural analysis showed a marked decrease in the upper crossed syndrome. She complied with her home exercise protocol, as well as the sparing strategies for her work. At that point, she was discharged.
CASE STUDY #2
A female 42-year-old related family member (to the first patient) presents with a similar complaint of suboccipital neck pain, dizziness and headaches of a 14 year duration. Her complaint has no vector of injury or known causative factor. She suffers from her pain and unsteadiness intermittently and it persists for weeks at a time. She admits to an average of one attack per month and relates her problem to work and emotional stress. Her work is a sedentary office position as an entrepreneur. She describes her dizziness as an unsteady feeling, as a sensation of movement from side to side. This is exacerbated with rapid head movements and from laying to sitting. It is an intense sensation which severely affects and limits her daily life. She denied any hearing difficulties or ringing in the ears. Outcome assessment in the form of neck disability index (54%, moderate), pain disability questionnaire (60/180), the Henry Ford Headache Disability Inventory (14 on the emotional subscale and 20 on the functional subscale), Activities-specific Balance Confidence Scale23 (rated at 36%) and PAR-Q (answered no to all questions) were performed during an episode. Family history was relevant, due to the obvious similarities to her mother’s complaint. All other familial and social factors were denied. She had not seen any other provider for this problem. The clinical impression was postural overuse, psychosomatic pain, dysmetria and disequilibrium.
Her evaluation was as follows: Vitals; 5’11”, 147 pounds, BP 146/72 on the right, BP 140/78 on the left, pulse – 72 beats per minute, temperature 97.0°F and respiration – 15 breaths per minute. No change in blood pressure found in sit to stand or lying down to stand. Auscultation of the carotids and inferior vena cava was normal. Observation revealed a well formed, but distressed 42-year-old female. Percussion to the spine reveals tender musculature at the occiput, cervicothoracic junction and the lumbosacral junction. Palpation showed active myofascial trigger points at the occiput, levator scapulae, SCM’s, rhomboids, lumbar erector spinae, psoas and plantar muscles. All finding were bilateral, with the exception of the left lateral head tilt. Cervical spine x-ray examination confirmed a “military spine” and mild spondylosis at C5-C7. Cervical range of motion was found to be minimally limited in right lateral flexion, extension and right rotation. Lumbar range of motion was minimally limited in extension and mildly in flexion. Postural examination revealed forward head carriage with a left head tilt and rounded shoulders. Chiropractic examination showed shortened SCM’s, levator scapulae, upper trapezius, pectorals, anterior deltoids, psoas and hamstrings. Segmental dysfunction was noted as follows: occiput (inferior) C2 (right rotation restriction), C6 and C7 (right lateral flexion restriction), L5 (left rotation restriction) and an anterior sacrum.
During a neurological examination, she showed no pathologic reflexes, all deep tendon reflexes were +2/5 bilaterally, cranial nerve examination was within normal limits and sensory dermatomes were intact. Orthopedically, she tested positive to Dix-Hallpike maneuver and Romberg’s. Previously mentioned testing was performed and found to be negative. Functional testing revealed chin pointing on curl up, disequilibrium with the sit to stand test worsening towards the 2nd repetition, a medium fall risk (35/56) on the Berg standing24, clinical testing of sensory interaction for balance25 failing the 5th and 6th condition (eyes closed on unstable surface and under the dome) within five seconds and gait analysis showed toeing out.
Functional analysis of respiration revealed paroxysmal breathing patterns. Scapular winging and altered scapular abduction were noted in the push up and shoulder abduction, respectively.
The patient’s primary diagnosis was upper crossed syndrome, her secondary diagnosis was cervical disequilibrium and her tertiary diagnosis was cervicalgia. Her complication factors included psychosomatic stress, myofascial pain syndrome, subluxation complex, muscle imbalance, muscle weakness, diminished proprioception and altered gait.
Acute care included management of myofascial pain through electrotherapy, trigger point compression, spray and stretch techniques, PIR stretching, diversified CMT, as well as contrast treatment. Transitional care focused on patient reactivation and included gait training, PNF stretching, pelvic stabilization, scapular stabilization, postural retraining and sparing strategies at home and work. Active care included isometric to isotonic strengthening and closed chain kinematics (from supine to prone to quadruped, then seated to standing). We also provided ergonomic analysis, coping strategies (to address the bio-psycho-social aspect and to limit chronicity) and a home stretching and strengthening routine.
Treatment was initiated at a three times a week frequency and passive care lasted three weeks. Transitional care was rendered at two times per week for two weeks and active rehabilitation was rendered at two times per week for six weeks. Outcome measures were given every two weeks and were compared to clinical benchmarks to progress the patient through the phases of care. Her pain and disability showed improvement subjectively and, on the neck disability index at the 4th week assessment (35%), they improved. Her disequilibrium and headaches did not respond until the 4th week of active rehabilitation. At the end of her treatment protocol, her outcome assessments were as follows: neck disability index – 20%, moderate; pain disability questionnaire – 30/180; the Henry Ford Headache Disability Inventory – 4 on the emotional subscale and 10 on the functional subscale; and the Activities-specific Balance Confidence scale26 – rated at 65% (administered during an episode). Repeated functional testing confirmed her improvement with a low fall risk (45/56) on the Berg standing,27 clinical testing of sensory interaction for balance28 failing the 5th and 6th condition (eyes closed on unstable surface and under the dome) after 35 seconds and improved posture and gait (improved head and shoulder carriage and no toeing out on gait). She was released to prn care and was instructed to return if her symptoms reappear.
|Initial||2 weeks||4 weeks||6 weeks||8 weeks||12 weeks|
|DHI (physical/ emotional/functional)||22/12/18||18/12/14||16/10/14||12/8/10||8/8/10||8/6/10|
|One leg balance||6 sec R
4 sec L
|8 sec R
7 sec L
|33 sec R
22 sec L
|59 sec R
55 sec L
|40 sec R
56 sec L
|72 sec R
66 sec L
TREATMENT PROTOCOLS AND BENCHMARKS
The short-term goals of both of the patients included stretching shortened facilitated muscles and activating inhibited muscles (PIR), decreasing myofascial trigger points, improving subluxation complex, instructing to maintain positions of comfort and decreasing pain. The intermediate goals centered around early reactivation and included postural re-education, stretching shortened facilitated muscles, activating inhibited muscles (PNF, flex building), improving proprioception (non-weight bearing), improving core stabilization via breathing techniques, monitoring and tracking progress via outcome assessment and ruling out vestibular dysfunction. Considering the patient’s complicating factors, we initiated sparing strategies according to the patient’s ADL’s.
Long-term goals would include home/self care activities and active rehabilitation. Stage 1 active rehabilitation – core and postural stabilization – enhances equilibrium by improving faulty mechanics/postural imbalances, propriosensory retraining, a system of exercises that utilize balance boards, balance beams, rocker boards, wobble boards and balance shoes,29 increased proprioceptive input (weight bearing) and improved coordination/integration of the vestibular, ocular and tactile sources of balance (via closed chain kinematics and unstable sources).
Stage 2 active rehabilitation – endurance training – improves aerobic potential (brisk walk, HIIT30). Stage 3 active rehabilitation – strength training – includes isometric protocols to improve functional reserve of strength in the postural muscles. Hettinger-Muller protocols are instituted to create static strength at 2/3 maximum contraction, then they are graduated to multiple angles. Isotonic strength is the next progression31 and D.A.P.R.E. protocol is used. The adaptation in the D.A.P.R.E. protocol makes it ideal for the rehabilitation setting.32 Stage 4 active rehabilitation – home protocol – includes self care, which is administered in the form of a home exercise routine and includes stabilization exercise, postural training and applicable muscle lengthening procedures.
The similarities in these cases are by no means a quantitative measure of the effects of functional disturbances on the balance and stabilization systems of the body. They do, however, provide a basis for further testing and a qualitative example of structure as it relates to function. These two cases, while not genetic, still share many of the postural and altered movement patterns. The shared link in these cases is the upper cervical dysfunction. Hulse has shown the relationship between upper cervical joint dysfunction and disequilibrium and recommends an integrated approach.33 The aforementioned etiologies can prompt disturbances in the cerebellar integration of sensory afferents of cervical proprioception, as nociception can contribute to dysafferentation from the zygapophyseal joints.34
Chiropractic care and the rehabilitation mindset in treating cervicogenic disequilibrium is custom tailored to identify and address the root causes of this issue and equally suited to alleviate the contributing factors. The advantage over other types of providers would be in the ability to treat, diagnose and monitor simultaneously, the last of which is pivotal. This is because the complaint can constantly change when the treatment is implemented. The practitioner must be ready for an immediate and unexpected reaction. Therefore, it is imperative that the practitioner rule out more sinister etiologies before instituting a conservative care program. In addition, one must be equipped with the diagnostic triage required in a working diagnosis. The distinction between central and peripheral lesions causing vertigo/dizziness must be accurately deduced and is a major differential in case management that would determine conservative care versus further investigation and outside referral.
Dizziness, and more specifically cervicogenic disequilibrium, is a complex and multi-faceted issue with a very high prevalence. It is concluded that 23-30% of adults have experienced at least one episode of dizziness and 3.5% of adults experience a chronic, recurrent episode greater than a one year duration by age 65.35 Familial similarities (body type, psychosomatic stress and postural stress) can sometimes predispose a patient to functional disturbances. Disequilibrium can commonly be related to cervical dysfunction36 and manipulation is a safe37 and effective38,39 way of restoring proper cervical function. The correct diagnosis, along with a diversified approach that concentrates on addressing joint dysfunction, soft tissue changes and functional disturbances, can correct such issues. The rehabilitation mindset, along with outcome assessment tools, is essential in monitoring progress, establishing benchmarks and justifying changes in the clinical protocols. Self care and stress management are other valuable tools in maintaining positive results.
1 Hulse M, Holzl M. The efficiency of spinal manipulation in otorhinolaryngology. A retrospective long-term study.
2 Bolton, P, (1998). The somatosensory system of the neck and its effects on the central nervous system. J. Manip. & Physiol. Therapy., 21 (8): 553-563.
3 Hikosaka O & Maeda M, (1973). Cervical effects on abducens motoneurons and their interaction with vestibulo-ocular reflex. Exp. Brain Res.,18: 512-539
4 D. Boyling, G. Grieve & G. Jull, (2004). Grieve’s modern manual therapy: the vertebral column. Elsevier, 463pp.
5 De Jong P, De Jong M, Cohen B, Jongkees L. Ataxia and nystagmus induced by injection of local anesthetics in the neck. Ann Neurol, 1, 240-246, 1977
6 Shumway-Cook A, Horak FB. Assessing the influence of sensory interaction on balance: Suggestions from the field. Phys Ther. 1986;1584-1550.
7 A.Bastos Evaluation of patients with dizziness and normal electronystagmography using Stabilometry. Rev Bras Otorrinolaringol. V.71, n.3, 305-10, may/jun. 2005
8 C. Liebenson (Ed), Rehabilitation of the Spine. A Practitioner’s Manual. Lippincott Williams & Wilkins Philadelphia, Pennsylvania: 2007, 870 pp.
9 C. Liebenson (Ed), Rehabilitation of the Spine. A Practitioner’s Manual. Lippincott Williams & Wilkins Philadelphia, Pennsylvania: 2007, 872 pp.
10 C. Liebenson (Ed), Rehabilitation of the Spine. A Practitioner’s Manual. Lippincott Williams & Wilkins Philadelphia, Pennsylvania: 2007, 864 pp.
11 C. Liebenson (Ed), Rehabilitation of the Spine. A Practitioner’s Manual. Lippincott Williams & Wilkins Philadelphia, Pennsylvania: 2007, 862pp.
12 Lewit K. Manipulative Therapy in the Rehabilitation of the Motor System. Boston: Butterworths, 1985.
13 Fitz-Ritson D. Assessment of cervicogenic vertigo. J Manipulative Physiol Ther 1991; 14(3):193-198.
14 Rigmor M, et al. Magnetic Resonance Imaging Assessment of the Alar Ligaments in Whiplash Injuries A Case-Control Study. SPINE Volume 33, Number 18, pp 2012–2016, 2008
15 Labtestsonline. American Association for Clinical Chemistry. October 13, 2011
16 Merkmanuals online. E.A. Giraldo, MD. The Merk Manual for Professionals. April, 2007
17 Merkmanuals online. D.L. Tucci, MD. The Merk Manual for Professionals. January 2009
18 Berg KO, Wood-Dauphinée S, Williams JI & Maki B (1992). Measuring balance in the elderly: validation of an instrument. Canadian Journal of Public Health, 83 (Suppl 2): S7-S11.
19 Shumway-Cook A, Horak FB. Assessing the influence of sensory interaction on balance:Suggestions from the feild. Phys Ther. 1986;1584-1550.
20 Vernon H, Mior S. The Neck Disability Index: A study of reliability and validity. J Manipulative Physiol Ther 1991;14:409-415, Copyright Vernon H and Hagino C, 1990.
21 Jacobson GP, Ramadan NM, et al. The Henry Ford Hospital headache disability inventory (HDI). Neurology 1994;44:837-842.
22 Powell, LE & Myers AM. The Activities-specific Balance Confidence (ABC) Scale. J Gerontol Med Sci 1995; 50(1): M28-34
23 Powell, LE & Myers AM. The Activities-specific Balance Confidence (ABC) Scale. J Gerontol Med Sci 1995; 50(1): M28-34
24 Berg KO, Wood-Dauphinée S, Williams JI & Maki B (1992). Measuring balance in the elderly: validation of an instrument. Canadian Journal of Public Health, 83 (Suppl 2): S7-S11.
25 Shumway-Cook A, Horak FB. Assessing the influence of sensory interaction on balance:Suggestions from the feild. Phys Ther. 1986;1584-1550.
26 Powell, LE & Myers AM. The Activities-specific Balance Confidence (ABC) Scale. J Gerontol Med Sci 1995; 50(1): M28-34
27 Berg KO, Maki BE, Wiliams JI, Holliday PJ, Wood-Dauphinee SL. Clinical and laboratory measures of postural balance in an elderly population. Arch Phys Med Rehab.1992;73:lO73-lO8O.
28 Shumway-Cook A, Horak FB. Assessing the influence of sensory interaction on balance: suggestion from the field. Phys Ther. 1986;66: 1548-1550
29 Murphy, Donald, and Craig Liebenson. “Chiropractic Rehabilitation in the Treatment of Dizziness.” Dynamic Chiropractic. 1983. Web. 17 Nov. 2011. http://www.dynamicchiropractic.com/mpacms/dc/article.php?id=40608
30 Tabata I, Nishimura K, Kouzaki M, et al. (1996). “Effects of moderate-intensity endurance and high- intensity intermittent training on anaerobic capacity and VO2max”. Med Sci Sports Exerc 28 (10): 1327–30
31 Hettinger, T., and E.A. Muller 1953. Muscle strength and training. 15:111-26
32 T.Beacham & R. Earle. Essentials of Strength and Conditioning. Champaign: Human Kinetics. 2008. 536pp
33 Hulse M. Disequilibrium, caused by a functional disturbance of the upper cervical spine. Clinical aspects and differential diagnosis. ManMed 1983; 1:18-23.
34 Biemond A, De Jong JMBV. On cervical nystagmus and related disorders. Brain 1969; 92:437-458.
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37 Haldeman S, Kohlbeck FJ, McGregor M (1999) Risk factors and precipitating neck movements causing vertebrobasilar artery dissection after cervical trauma and spinal manipulation. Spine 24(8):785-94.
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Dr. Greg Rose, co-founder of the Titleist Performance Institute (TPI), is the keynote speaker for our 2015 Rehab Symposium scheduled for March 20th – 22nd, 2015 at the Disney Swan Hotel in Orlando, FL. Greg is a chiropractic physician and an engineer.
The Titleist Performance Institute (http://www.mytpi.com/about) is the world’s leading educational organization and research facility dedicated to the study of how the human body functions in relation to the golf swing.
His topic title will be “The Body-Swing Connection – making the link between the body and the swing.”
To register for our Spring 2015 Rehab Symposium, click http://www.ccptr.org/next-annual-symposium/
Solecki, Thomas J. DC, DACBSP DACRB, ICSSD
Grzeszkowiak, Konrad DC, PAK, CES, PES, FMT, PMT
Kramer, Abby BS, PAK, CPT, FMT, PMT
Froberg, Collene BS, FMT
Kinesiology taping is a commonly used method to treat various conditions and aid in rehabilitation. Many research studies to date analyze the effects of kinesiology taping around the ankle joint. Kinesiology taping is proposed to: normalize muscular tone1; increase range of motion2; increase endurance3; and improve functional movement4.
Kinesiology taping is a relatively new technique, which differs from using standard white athletic tape. It contains elasticity and can be stretched up to 180% of its original length before applying to the skin.5 The tape then provides a constant pull or shear force to the skin. Kinesiology tape can be worn for several days and remain intact as it is air permeable and water resistant. Standard athletic tape can be restrictive while kinesiology taping can be therapeutically effective and useful following injury and rehabilitation.6 Dr. Kenzo Kase, founder of the kinesiology taping method, proposed the following mechanisms for the effects of kinesiology tape: 1. Altered muscle function by the tapes effects on weakened muscles, 2. Improved circulation of blood and lymph by eliminating tissue fluid or bleeding beneath the skin, 3. Decreased pain through neurological suppression, and 4. Repositioning of subluxed joints by relieving abnormal muscle tension, and helping to affect the function of fascia and muscle. A fifth mechanism has been suggested by Murray, which is that kinesiology tape increases proprioception through increased stimulation to cutaneous mechanoreceptors.7 8
The purpose of this study is to address the immediate and 48 hour effect of kinesiology taping on muscle strength, range of motion, functional movement, and endurance. It appears that only one study has addressed the effect of kinesiology tape on muscle tone, thus increasing functionality, which yielded no statically significant result.9 This could be potentially due limited stretch of the tape used (120%). Rocktape© kinesiology tape contains 180% stretch, which has been hypothesized to have a stronger effect on muscle tone and function. We have hypothesized that taping specific muscles, during a specific vector of movement may increase muscle response. To date, no research study to our knowledge has tested the validity of this hypothesis.
Participants: Twenty-one male and female gymnasts between the ages of 12 and 18 volunteered to participate in this study. Informed consent was obtained from all subjects and all subjects were eligible to participate. Criteria for participation included no current ankle injury that is being treated professionally or conservatively. Participants verbally acknowledged no current pain in bilateral lower extremities. No mentions of previous injury to lower extremities were assessed. No one was harmed during this experiment.
Test Procedures: The subjects were tested using manual muscle testing (MMT) of six muscles surrounding the ankle joint: tibialis anterior, tibialis posterior, fibularis longus and brevis, fibularis tertius, and gastrocnemius. All muscles were scaled on a 0-5 scale. The standard references for muscle testing evaluation are based on the original work of Kendall and Kendall, Muscles: Testing and Function.10 Ankle range of motion (active dorsiflexion) was measured weight bearing and non-weight bearing using a digital inclinometer. A functional squat was performed and knee valgosity was recorded and measured in degrees with software from Spark Motion. Ankle agility and neuromuscular control was assessed using the Shark Test.11 Subjects were then kinesiology taped to increase tone for any neurologically inhibited muscles found. All assessments were repeated and reevaluated immediately following specified taping protocols. All assessments were also reevaluated in a 48-hour follow-up assessment.
Manual Muscle Test: Manual muscle testing began with the technique created by Lovett in 1912. Muscle testing is a system for grading muscle strength and was used for disability evaluation in polio and other diseases by the Kendall’s in 1936 and was first published in 1949. Techniques for manual muscle testing were expanded upon outside of conditions like polio and are now used to diagnose and treat muscle inhibition. Dr. Goodheart, founder of applied kinesiology, introduced his method of manual muscle testing to the Chiropractic profession in 1964, which have been further developed by the International College of Applied Kinesiology (I.C.A.K.).12 In this study, manual muscles testing of 5 muscles surrounding the ankle were used to assess neurological facilitation or inhibition. The five muscles around the ankle were all tested bilaterally before taping, immediately after taping, and 48 hours following the initial assessments. Certified Professional Applied Kinesiologists through the ICAK performed all manual muscle testing.
To test the tibialis anterior the athlete was seated with the leg to be tested extended and neutral. The tester dorsiflexes and inverts the ankle, having the athlete resist fully against the testers hand. The testers stabilization hand was resting on the distal leg laterally, superior to the ankle while the testing hand cupped the medial foot.
|1. Tibialis Anterior Manual Muscle Test|
To test the tibialis posterior the athlete was seated with the leg to be tested extended and neutral. The tester plantar flexed and inverted the ankle, having the athlete resist fully against the testers hand. The testers stabilization hand was resting on the distal leg laterally, superior to the ankle while the testing hand cupped the medial foot.
|2. Tibialis Posterior Manual Muscle Test|
To test the fibularis longus and brevis muscles, the athlete was seated with the leg to be tested extended and neutral. The tester plantar flexed and everted the ankle, having the athlete resist fully against the testers hand. The testers stabilization hand was resting on the distal leg medially, superior to the ankle while the testing hand cupped the medial foot.
|3. Fibularis Longus/Brevis Manual Muscle|
To test the fibularis tertius the athlete was seated with the leg to be tested extended and neutral. The tester dorsiflexed and everted the ankle, having the athlete resist fully against the testers hand. The testers stabilization hand was resting on the distal leg medially, superior to the ankle while the testing hand cupped the medial foot.
|4. Fibularis Tertius Manual Muscle Test|
To test the gastrocnemius the athlete was seated with the leg to be tested extended and neutral. The tester bent the knee so the foot was off of the testing surface and plantar flexed the foot. The tester placed the stabilization hand on the athlete’s knee laterally and the testing hand cupping the calcaneal surface of the foot. The athlete resisted the testers pull which is posterior to anterior in a caudal direction.
|5. Gastrocnemius Manual Muscle Test|
Ankle range of motion was measured both weight bearing and non-weight bearing. To measure range of motion non-weight bearing the subjects started in a seated position and barefoot with the ankle to be tested extended and in neutral position. The inclinometer was placed on the dorsal surface of the foot and then zeroed. Upon starting the test the subject dorsiflexes the foot to maximal active dorsiflexion and the angle is measured. This measurement is repeated on the opposite leg. All measurements were taken before taping, immediately after tape application, and at a 48-hour follow up visit.
|6. Starting Position of ROM Testing Seated||7. Ending Position of ROM Testing Seated|
To measure weight bearing ankle range of motion the subjects stood on a flat surface barefoot with the feet shoulder width apart and hands resting on the hips. The inclinometer was placed vertically along the anterior surface of the tibia and then zeroed. Upon starting the test the subject dorsiflexed the ankle by performing a squat until maximal active dorsiflexion was achieved. The final angle at end range of motion was measured. This assessment was repeated on the opposite leg. All measurements were taken before taping, immediately after tape application, and at a 48-hour follow up visit.
|8. Starting Position of ROM Testing Standing||9. Ending Position of ROM Standing|
Functional Squat Assessment:
Athletes were instructed to stand barefoot with feet comfortably shoulder width apart with hands on hips. Athletes performed a squat passed 90 degree of knee flexion. Athletes were video recorded using an IPad© 3 with motion analysis software by Spark Motion©. Athletes were recorded prior to kinesiology taping, immediately post kinesiology taping, and 48 hours after kinesiology taping. Analysis of squat was done using Spark Motion© software. Bilateral knee valgosity was measured in degrees at 90 degrees of knee flexion during all three squats in all three videos.
|10. Beginning of Over Head Squat||11. Ending Position of Over Head Squat|
Shark Skill Test:
The Shark Skill Test was performed as described by Michael Clark, DPT in NASM’s Essentials of Sports Performance Training. The test is designed to assess lower-extremity agility and neuromuscular control. Increased agility and neuromuscular control leads to improved function and increased endurance. The athlete was positioned in the center box of a grid, with hands on hips and standing on one leg barefoot. The athlete was instructed to hop to each box starting from their top left, always returning to the center box, only hopping into each box once. The athlete performed one practice run through the boxes with each foot. The athlete was then timed while performing the test one time for each leg. .01 seconds were added for each of the following deductions when they occurred each time: non-hopping leg touches ground; hands come off hips; foot goes into wrong square; foot does not return to center square. Athlete repeated same procedure after being kinesiology taped. 48 hours after being taped, athletes performed the same Shark Skill Test procedure with no initial practice trial.
|12. Beginning of Shark Skill Test||13. First Box Jump of Shark Skill Test|
Kinesiology Taping Procedure:
Kinesiology tape was applied towards specific muscles in a specific vector of movement. The specific vector of movement corresponded to the facilitation of
that specific muscle as demonstrated by a manual muscle test described by Kendall. Kinesiology taping was administered by practitioners certified in
Fascial Movement Taping (FMT)© and Performance Movement Taping (PMT)©. This method of movement taping consists of the athlete maximally stretching the
specified muscle that is to be taped. Tape is then applied from insertion of the muscle to the origin of the muscle as the athlete maximally contracts the
specified muscle. Kinesiology taping was applied to only the muscle(s) that demonstrated ⅘ MMT. If no muscles demonstrated a ⅘ MMT, posterior tibialis was
For the gastrocnemius muscle kinesiology tape application, the athlete’s position was prone. The base of the kinesiology tape was applied to the dorsal
surface of the base of the calcaneus with no tension as the ankle in full dorsiflexion. The tape was then rolled out with 25% stretch over the path of the
Achilles tendon and up the middle of the gastrocnemius muscle belly, ending inferior to the popliteal fossa. While the tape was rolled out, the athlete
moved the ankle into maximal plantar flexion, activating the gastrocnemius muscle, along with the rest of the triceps surae complex.
|14. Beginning of Gastrocnemius Taping||15. Taping of Gastrocnemius with Movement||16. Finished Taping of Gastrocnemius|
For the fibularis longus and brevis muscle kinesiology tape application, the athlete’s position was seated. The base of the kinesiology tape was applied to the plantar surface of the base of the 1st metatarsal with no tension, as the ankle was plantar flexed and inverted. Tape was then rolled out with 25% stretch over the path of the fibularis longus tendon, passing behind the lateral malleolus and ending on the fibular head. While the tape was rolled out, the athlete moved the ankle into the plantar flexed and everted position activating the fibularis longus and brevis muscles.
|17. Beginning of Fibularis Longus/Brevis||18. Taping Fibularis Longus/Brevis with Movement|
|19. Continued Taping of Fibularis Longus/Brevis||20. Finished Taping of Fibularis Longus/Brevis|
For the fibularis tertius muscle kinesiology tape application, the athlete’s position was seated. The base of the kinesiology tape was applied to the dorsal surface of the foot on the fifth metatarsal with no tension, as the ankle was dorsiflexed and inverted. The tape was then rolled out with 25% stretch over the path of the fibularis tertius tendon, passing anterior to the lateral malleolus and ending on the fibular head. While the tape was rolled out, the athlete moved the ankle into the dorsiflexed and everted position activating the fibularis tertius muscle.
|21. Beginning Taping of Fibularis Tertius||22. Taping of Fibularis Tertius with Movement|
|23. Finished Taping of Fibularis Tertius|
For the tibialis anterior muscle kinesiology tape application, the athlete’s position was seated. The base of the kinesiology tape was applied to the base of the 1st metatarsal head with no tension, as the ankle was in the plantar flexed and everted position. The tape was then rolled out with 25% stretch over the path of the tibialis anterior muscle crossing over to the lateral leg and ending near the fibular head. While the tape was rolled out, the athlete moved the ankle into the dorsiflexed and inverted position activating the tibialis anterior muscle.
|24. Beginning of Tibialis Anterior Taping||25. Taping of Tibialis Anterior with Movement|
|26. Finished Tibialis Anterior Taping|
For the tibialis posterior muscle kinesiology tape application, the athlete’s position was seated. The base of the kinesiology tape was applied to the base of the 5th metatarsal for added stabilization with no tension, as the ankle was in the plantar flexed and everted position. The tape was then rolled out with 25% stretch over the path of the tibialis posterior muscle along the medial border of the tibia just distal to the knee. While the tape was rolled out, the athlete moved the ankle into the plantar flexed and inverted position activating the tibialis posterior muscle.
|27. Beginning of Tibialis Posterior Taping||28. Taping of Tibialis Posterior with Movement|
|29. Taping Tibialis Posterior with Movement||30. Finished Taping of Tibialis Posterior|
Immediate Results Post Taping
16 out of 21 subjects were found to have muscle(s) demonstrating a 4/5 MMT. All 4/5 inhibited muscles that were taped demonstrated facilitation to a 5/5 MMT post taping. 4 out 21 subjects originally demonstrated a 5/5 MMT in all ankle muscles bilaterally. Post taping of posterior tibialis muscles bilaterally demonstrated to maintain a 5/5 MMT. Left and right non weight bearing ROM both resulted in a 0.58 P value post taping for a 5 degree decrease in ROM. Left weight bearing ROM resulted in a 0.66 P value and right weight bearing ROM resulted in a 0.68 P value for a 5 degree decrease in ROM. Left Shark skill test resulted in a 0.35 P value and right Shark skill test resulted in a 0.44 P value. Left squat knee angle assessment resulted in a 0.57 P value and the right squat angle assessment resulted in a 0.59 P value.
|31. Resulted P-Values From Performed Functional Tests After Tape Application|
48-Hour Follow Up Post Taping
All 16 out of 21 subjects that originally demonstrated muscle(s) graded a 4/5 and that facilitated to 5/5 immediately post taping, demonstrated to maintain a 5/5 MMT 48 hours post taping. Left non-weight bearing ROM resulted in 0.62 P value and right non-weight bearing ROM resulted in a 0.65 P value. Left weight bearing ROM resulted in a 0.58 P value and right weight bearing ROM resulted in a 0.54 P value. Left Shark skill test resulted in a 0.31 P value and right Shark skill resulted in a 0.35 P value. Left squat angle assessment resulted in a 0.62 P value and the right squat angle assessment resulted in a 0.60 P value.
|32. Resulted P-Values of Performed Functional Tests upon 48-hour Follow Up|
In order to minimize any potential bias, we used a sample population that was near the same age range, activity level, and that performed similar movements through out the day and during their training. We also assessed our sample population at same time of day to limit daily activity variables. At no time during the study did any of the participants experience any discomfort or pain, either from the assessment, or from the taping application. Participants may have demonstrated a 4/5 MMT due to previous injury (not assessed), overuse injuries with no subjective measures (not assessed), and/or potential muscle imbalances due to compensation or improper biomechanics (not assessed).
The results of this study confirm that kinesiology taping did not decrease the subjects’ performance on any assessments. This agrees with the current literature on the topic of kinesiology taping.13 14 15
In the range of motion, shark skills test, and overhead functional squat assessment there was not a significant difference in the subjects’ performance before taping, after taping, and in the 48 hour follow up study. However, the athlete’s performance for these assessments were not diminished either.
The results for the MMT portion of the study were very significant. 16 of the 21 subjects demonstrated muscle(s) of 4/5 strength. All 16 of the subjects with muscle(s) of 4/5 strength, post taping demonstrated 5/5 strength of those muscle(s). During the 48-hour follow up assessment, all muscles that were taped demonstrated a maintained 5/5 strength with the MMT. The kinesiology tape, taped in the specific application as explained above to a muscle displaying a 4/5 MMT, demonstrated an increase in muscle tone and did not appear to have a negative effect subjectively or objectively in the surrounding musculature. This could prove to be a very effective technique to use for athlete rehabilitation and retraining of faulty firing patterns, as there were no negative effects from this taping technique.
4 out of the 21 subjects originally had all ankle muscles bilaterally test for 5/5 strength and tape was applied to the tibialis posterior muscle bilaterally to look for any change in the muscle facilitation. All of these subjects maintained 5/5 strength of the tibialis posterior muscle. This again demonstrates that the kinesiology tape did not provide a negative affect to muscles demonstrating 5/5 strength.
This effect can be explained by the elastic properties of kinesiology tape enhancing the function of muscle fibers and tendons. Myofascial units16 and muscle spindle fibers have the ability to act synergistically and antagonistically. Myofascial units are specialized mechanoreceptors at the musculotendinous junction. Ib afferent fibers are entangled within the myofascial unit and innervate it. The afferent fiber receptor depolarizes as weight and tension compresses the myofascial unit. This depolarization stimulates the Ib interneuron, which inhibits the corresponding alpha motor neuron that is normally stimulated by the neuromuscular spindle.17 Using kinesiology tape to decompress the weight on a myofascial unit by “lifting” the skin and affecting the fascia, may decrease depolarization of the Ib afferent fibers, decreasing stimulation of the Ib interneuron, allowing increased firing of the alpha motor neuron and facilitation of muscle fibers. Through these mechanisms by applying kinesiology tape (with tension) to a muscle, one can affect a muscle on a neurologic level. 18 One previous study found that kinesiology tape did not evoke this response, but was explained that their findings could be potentially due limited stretch of the tape used (120%). 19 Rocktape© kinesiology tape contains 180% stretch, which has been hypothesized to have a stronger effect on muscle tone and function. In this study, using kinesiology tape with a stronger adhesive and stretch has shown evidence in facilitation of muscles when they were specifically taped in the manor described above.
Two testers participated in this study, both certified in muscle testing through the International College of Applied Kinesiology. Both testers used the muscle testing technique from original work by Kendall and Kendall. When using a correct and specific technique, there are significantly less problems with inter-tester reliability.20
In further studies, it would be of interest to address hyper tonicity of muscles. Since the muscles are being facilitated, it would be important to note if the muscles are in a hypertonic or normotonic state while the tape is applied to the skin. Another issue to address would be how long the result of a 5/5 muscle lasts for. This study assessed muscle strength before taping, immediately after taping, and 48 hours later with the tape still applied to the skin. In further studies, one could examine subjects after the tape has been removed for muscle strength.
The results for non-weight bearing and weight bearing range of motion were not significant before and after taping. For some athletes the tape increased their range of motion. However, results for range of motion testing could be subjective for several reasons. In a further study for more accurate results, range of motion should be taken bilaterally 3 times and the scores averaged. This was not performed during this study in the interest of time, as the subjects were studied during their training hours. Results for ROM in the 48-hour follow up study were similar. The sample population used for the study may also have contributed to why statistical significance in range of motion was not observed. The sport of gymnastics requires extreme flexibility and potentially hypermobility. Because of this requirement, subjects may have already attained their maximal range of motion in the ankle mortise joint and were physically not able to gain further range of motion. The subject’s age may have been a factor as well. At such a young age, range of motion may be increased due to the natural occurrence of hypermobility in non-calcified joints. Again, the kinesiology tape did not significantly change ROM, however it did not negatively affect it either.
Results for the shark skills test were not statistically significant. No scores were necessarily diminished, and many of the subjects’ scores did improve, just not enough to show statistical significance. There is currently no normative baseline for the shark skills test. Therefore, in future studies there may be a better test, which could be used to assess muscular endurance. This test was solely used to measure the difference in endurance pre and post taping application. If scores improved, it could be implied that the tape helped with efficiency of muscle firing patterns, thus improving endurance. This improvement could also be due to the fact that for many of the subjects, it was their first time performing this assessment, so naturally each additional time the assessment is performed their score improved. In the 48 hour follow up many of the subjects scores also improved, however whether this improvement was due to the kinesiology tape or not remains unclear. It can be hypothesized that if the participants were re-taped every 48-72 hours, and were instructed to train with rehabilitation exercises for the ankle, that increased performance (decrease in time for the Sharks Skill Test) may be seen. A further study may be developed to explore this hypothesis.
Results from the overhead functional squat assessment were not statistically significant. It was noted to be rather difficult to get an accurate reading for measuring the angle of knee valgosity for the subject. In a further study it would be helpful to mark the points of interest on the subject before using the video analysis software. If the ASIS, patella, and talocrural joint were marked, one could expect a more accurate measure of knee valgosity. Also, in the interest of time these measurements were taken once before taping, after taping, and in the 48 hour follow up. For a more accurate reading it would be of interest to measure each knee angle 3 times and use the average of the 3 angles for assessment.
In future studies there are a few things to consider. When working with an athletic population, the subjects were very active over the 48 hours in whih the study took place. It is unclear at this time how that affected the outcome of the study, but one may note that the function of the kinesiology tape could have been affected as all of the subjects were training during the time of the study. As mentioned before, it would be of interest to look at the results from taping once the tape has been removed to see if the increase in muscle strength was sustained for a longer period of time without tape. This study addressed taping of individual muscles, however, one could examine other taping methods such as taping a functional movement instead of isolated muscles and that effect on specific assessments. Lastly, although for many assessments the results were not statistically significant, one could address feelings of confidence and stability. Other studies have demonstrated that even if the kinesiology tape does not change functional assessments, the subjects have increased sense of confidence, reassurance, and stability when tape is applied.21
Limits of this study include a small sample size (n=21) and a very specific population of young competitive gymnasts. While this was ideal to see how the kinesiology tape produced results in a specific population, it would be of interest to examine a larger sample size and population. Time was also a limitation, and an average of 3 assessments per type of assessment were not done. Having participants not be assessed during their training period may allow more time for multiple assessments.
Kinesiology tape showed no statistical functional changes positive or negative for effects on ankle range of motion, endurance, or an overhead squat. It would be worthwhile to study long-term effects (2 weeks or more) of kinesiology taping of muscles and introduction of rehabilitation exercises, to increase performance and endurance. In addition, it would be of interest to study different brands of kinesiology tape, with different amounts of stretch, in order to assess just how important the amount of built-in stretch in the tape is to a positive outcome. Kinesiology tape did provide very significant results for muscle strength via the manual muscle test. This displays that the kinesiology tape does impact muscle strength and would be a valuable tool to use when assessing subject’s muscle imbalances and facilitating rehabilitation. This study offers valuable information in how the use of kinesiology taping can help facilitate neurologically inhibited muscles, thus helping to aide in correction of imbalance and dysfunction.
All kinesiology tape was provided by Rocktape©
1610 Dell Ave
Campbell, CA 95008
Video Analysis software was provided by SparkMotion©
Digital Goniometer used was manufactured by Baseline©
Funding sources and conflicts of interest:
All kinesiology tape was provided by Rocktape©. Video Analysis software was provided by SparkMotion©.
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2 Chang HY, Chou KY, Lin JJ, and Wang CH. “Immediate effect of forearm Kinesio taping on maximal grip strength and force sense in healthy collegiate athletes.” Phys Ther Sport 2010 Nov;11(4):122-7. doi: 10.1016/j.ptsp.2010.06.007. Epub 2010 Aug 1.
3 D. Morris, et al. “The Clinical Effects of Kinesio Tex Taping: A systematic review.” May 2013, Vol. 29, No. 4 , Pages 259-270.
4 An, Hyun Mo; Miller, Catherine Grove; McElveen, Michael; and Lynch, James M. (2012) “The Effect of Kinesio Tape® on Lower Extremity Functional Movement Screen™ Scores,”International Journal of Exercise Science: Vol. 5: Iss. 3, Article 2.
5 Halseth T, McChesney JW, DeBeliso M, et al. “The effects of kinesio taping on proprioception at the ankle.” Journal of Sports Science and Medicine (2004) 3, 1-7
6 Kase K, Hashimoto T, Tomoki O. “Development of kinesio taping perfect manual.” Kinesio Taping Association 1996; 6-10: 117-8
7 Yoshida A, Kahanov L. “The Effect of Kinesio Taping on Lower Trunk Range of Motions.” Res Sports Med 2007 Apr-Jun;15(2):103-12.
8 Murray H, Husk L. Effects of KinesioTM taping on proprioception in the ankle. J Orthop Sports Phys Ther 31: A-37, 2001.
9 Tieh-Cheng Fu, Alice M.K. Wong, Yu-Cheng Pei, Katie P. Wu, Shih-Wei Chou, Yin-Chou Lin. “Effect of Kinesio taping on muscle strength in athletes – A pilot study.” Sports Medicine Australia doi:10.1016/j.jsams.2007.02.011
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12 Schmitt Walter H, Cuthbert Scott C. “Common errors and clinical guidelines for manual muscle testing: the arm test and other inaccurate procedures.” Chiropr Osteopat. 2008; 16: 16
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14 Greene TA, Hillman SK. Comparison of support provided by a semirigid orthosis and adhesive ankle taping before, during, and after exercise. Am J Sports Med . 1990; 18:498–506.
15 Amanda S, Buchanan MS, Carrie L, et al. Functional Performance Testing in Participants With Functional Ankle Instability and in a Healthy Control Group. J Athl Train . 2008; 3(4):342-6.
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19 Tieh-Cheng Fu, Alice M.K. Wong, Yu-Cheng Pei, Katie P. Wu, Shih-Wei Chou, Yin-Chou Lin. “Effect of Kinesio taping on muscle strength in athletes – A pilot study.” Sports Medicine Australia doi:10.1016/j.jsams.2007.02.011
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Some of you have asked to see photos taken at our 15th Annual Rehab Symposium which was held at the Paris Casino Hotel in Las Vegas this past Spring. The Rehab Council now has an official photographer, Dr. Amanda Fisher. To view photos taken at this our last Symposium please click on the below Shutterfly link:
The 16th Annual ACA Rehab Council Educational Symposium is scheduled to take place at the Disney Swan Hotel in Orlando, Fl on Friday, March 20th, 2014 – Sunday, March 22nd, 2015. If you enjoyed our last Symposium this past Spring at the Paris Casino Hotel in Las Vegas, come prepared … for the best is yet to come in Orlando.
For starters, there will be a welcome reception for all ACA Rehab Council members and ACRB Diplomates on Friday evening, March 20th at the Disney Swan Hotel (further details to follow). Then, the 12 CEU hour educational weekend kicks off on Saturday, March 21st, and features our keynote speaker, Greg Rose, DC/Engineer, Co-Founder of the Titleist Performance Institute, who will be discussing how to evaluate and rehab golf injuries. Greg travels the globe teaching amateurs and professionals how to be a better golfers as well as teaching clinicians how to better take care of patients with golf injuries. Jon Mulholland, DC, CCSP, CSCS will follow up with a spcial two hour presentation on athletic performance enhancement with a unique focus on foot and ankle biomechanics. Jon has played an integral role in the training and rehab of multiple Olympic medal winner and professional athletes and is currently the Sports Medicine Consultant for the New Zealand Olympic Cycling Team while acting in the capacity as their Team Doctor during the 2012 London Olympic Games.
On Sunday, March 22nd, the educational excellence continues featuring Sue Falsone, PT, MS, SCS, ATC, past Trainer for the Los Angeles Dodgers, who broke barriers by becoming the first female Head Athletic Trainer in Major American Professional Sports. She will lecture on common sports injuries incurred by professional athletes, how to treat and rehab them and, even more importantly, how to train the athlete in such as way as to prevent the injury from occurring in the first place. After Sue’s presentation, there will be three 2 hour breakout sessions. Brian Bachelder, PhD, from Aline Systems, will discuss movement efficiency, functional biomechanics and rehab as well as lower body biomechanics in the athlete, especially with respect to the foot and ankle. Paul Levy, from Human Scale, will give a 2 hour presentation on how to set up an ergonomic work station at home with a primary focus on improving the health and comfort of work life. Finally, both Luis Vera, DC, DIBCN, DIBE and Walt Engle, DC will lecture one hour each on “Electrodiagnosis and Rehab” and “Manipulation and Rehab” respectively to complete our 12 hour ACA Rehab Educational Symposium.
Although our 16th Annual ACA Rehab Symposium is still 8 months away, the Rehab Council website is already set up for you to register. To register, click here. You’re only a couple of clicks away from being a part of what might be our biggest, most educational and best Symposium the ACA Rehab Council has ever presented.
See you at the Disney Swan Hotel in 2015,
Jerrold J. Simon, DC, DACRB
Dr. Luis C. Vera, Assistant Professor at Palmer College of Chiropractic Florida and President of the American College of Clinical Electrodiagnosis (ACCE) of ACA Rehab Council, has been involved in the martial arts for over 30 years. He is the recipient of 8 State Championships, 5 Regional Championships and is a former U.S. National Champion among other martial arts awards & titles.
Dr. Vera currently holds the rank of San Dan (Third Degree Black Belt) in Goju Ryu Karate and as a result of his accomplishments and contributions will be inducted into the International Martial Arts Hall of Fame this year with other well respected martial artists such as William “Superfoot” Wallace and Vic Moore.
“We are very excited to introduce the newest element of our Biofreeze sampling program,” stated Ethan Pochman, Vice President, US Clinical, Performance Health. “With this new online sampling application, we accept consumer requests for free Biofreeze samples and provide those requests to healthcare practitioner resellers in the consumer’s area. The local practitioner will mail the free Biofreeze sample to the consumer. This creates an opportunity for the consumer to be introduced to both Biofreeze and a place to purchase it.”
Consumers looking to trial Biofreeze can request a free sample at samples.biofreeze.com.
Craig Liebenson is coming to Philadelphia July 18-20th and December 5-7th for a 3 day course. 18 CE’s will be available through New York Chiropractic College for each seminar in PA, NY, NJ, DE, and MD.
He will be teaching two 3 day Workshops on “Prague School to Athletic Development”
(Mag 7 & Prague School assessments, rehabilitation exercises, pain matrix, upper quarter & lower quarter, functional training, and performance training.)
The rehabilitation world is changing and to keep up on all the changes seems impossible. Craig travels all over the world and interacts with many of the industry leaders in rehabilitation, sports, and fitness trainers. This is a great opportunity to check your skill-set and spend a 3 day weekend with like-minded clinicians. Typically, he does the west coast symposiums so for anyone who hasn’t seen him in 3-4 years he has updated his lecture courses. Check out what others have said about this course at Craig Liebenson, DC | Prague School to Athletic Development Series.
Craig wants to offer all ACRB members a special discount, ONLY to ACRB members. When you register, select the NON-CLINICIAN rate for the 36 hour series ONLY – which is the trainer/student price ($1350 versus $1800)! This only applies to early bird registration so don’t procrastinate, do it before May 7th . Please reserve your seat ASAP, there is limited enrollment.
In order for the discount to apply, you will need to become ISCRS/R2P member – www.rehab2performance.com. R2P is basically a multidisciplinary version of ACRB with trainers, PTs & DCs who are bridging the gap. Below are some of the benefits. The free Back Letter & JMBT Journal easily pays for the initial fee.
· Phil Snell’s Myrehabexercise.com
· Free JMBT & The Back Letter Subscription
· Free access to my Self-Care Exercise Library
Chad Buohl and Jason Brown are ACRB diplomates and ISCRS/R2P members, if you have any questions please contact either one of them regarding these courses. email@example.com, firstname.lastname@example.org or rehabchiropractor.com.
Chad what you can offer which will be real sweet is any ACRB member can register at the NON-CLINICIAN rate for the 36 hour series ONLY – which is the trainer/student price! Remember they have until April 23rd.
More and more the Chiropractic profession is being targeted to assist with referring patients for pychiatric type drugging. It is vital that you have the correct data in this area. The following video and article links should be of value to your patients’ and family’s safety.
Dr. Alf Garbutt, Editor
The 15th Annual ACA Rehab Council Educational Symposium is scheduled to take place at the Paris Hotel & Casino in Las Vegas, NV on Friday, Feb. 28th, 2014 – Sunday, March 2nd, 2014.
If you are interested in a captivating weekend filled with excellent instruction on Rehab techniques, exposure to the latest in Rehab supplies and equipment, an exotic and fun filled locale, camaraderie with doctors who share your same interest in spinal and extremity rehabilitative procedures as well as receive 12 hours of license renewal credits in most states, look no further.
Featured speakers include Stuart McGill, PhD, professor of spine biomechanics at the University of Waterloo, ON, Canada, presenting his program on Training Maximum Performance which teaches the mechanism and techniques used with the fastest and strongest athletes. In addition, Lee Burton, PhD and Gray Cook, PT will be expounding on their 4 X 4 Matrix which explains the exercise strategy used by the Functional Movement Systems and Selective Functional Movement Assessment programs.
The time to register is now. Book your room at the Paris Casino Hotel by calling (877) 796-2096 and be sure to ask for the “ACA Rehab Council” rate at $159.00/night.
To register for the symposium, just click here to buy your ticket.
See you there,
Jerrold J. Simon, D.C.
Dr. James Brantingham just published a new e-book entitled Hip Osteoarthritis; Manipulative and Multimodal Therapy with Rehabilitation
Below is a statement about the eBook from the author to the ACA Rehab Council:
“I hope you saw my the recent article (in JACA) which discussed important and ground breaking research that I, and others have done – particularly on using HVLA grade 5 manipulation (& to a lesser degree mobilization) and exercise for Hip Osteoarthritis. Over 5 RCTs and many other studies have now demonstrated, that manipulative and multimodal therapy is effective in treatment of Hip Osteoarthritis.
Certainly this research could help you and other doctors who specialize in or take an Rehabilitation approach in treatment of many older patients, or younger patients (that have developed early Hip OA after trauma). This book also covers manual therapy research on Knee OA (particularly if it is co-morbid knee OA), and may help patients increase exercise or sports activity (for health or pleasure) but are seriously restricted because of lower extremity OA. Arthroscopic surgery is no longer recommended for common OA (with exceptions of course) so, this niche is not being offered and I believe we can help many of these suffering patients. I very much wish that chiropractic (my college when I was trained LACC now SCUHS) had taken rehabilitation more seriously (exercise and stretch among many other modalities are part and parcel of almost all of our lives).”
James W. Brantingham DC, PhD
The e-book can be purchased for $25.00 at Dr. Brantingham’s website: jamesbrantingham.com
OptoGait: 50% of new price – used less than 10 times. New sells for $6,895.00
The recent ACA Rehab Council membership vote on the proposed two new sub specialty Colleges and their respective Bylaws passed by a wide margin. Specifically, the American College of MUA (ACMUA) and the American College of Clinical Electrodiagnosis (ACCE) have met voter approval as specialty Colleges under the auspices of the ACA Rehab Council by its membership. The final vote and approval process now needs to be brought before the ACA HOD (House of Delegates). Thanks to the authors of the ACMUA Bylaws, namely Drs. John Cerf, Walt Engle, Alf Garbutt and Craig Morris. Thanks also to the authors of the ACCE Bylaws, namely Drs. Gary Smith, Jeff Ross, Mike Schneider and George Petruska.
At last weekend’s ACA House of Delegate’s (HOD) Meeting held in Greeley, CO the HOD approved the proposed Rehab Council’s Resolution on e-voting (see below) which means that all future elections and membership votes can proceed electronically:
PHYSIOLOGICAL THERAPEUTICS AND REHABILITATION
OF THE AMERICAN CHIROPRACTIC ASSOCIATION
CONSTITUTION AND BYLAWS
Resolution – Electronic Transmission
ARTICLE VII VOTING
B. At the discretion of the officers of the Council, when they feel it is in the best interest of the Council, the election of the officers will be by ballot at the annual meeting or by mail ballot. If the election is by mail ballot, the ballot will be mailed to each member forty-five (45) days prior to the annual meeting, and all the ballots MUST be returned thirty (30) days prior to the meeting. All ballots returned after that date will not be counted. Only members in good standing are permitted to vote.
With respect to the Constitution and Bylaws of the American Chiropractic Association Council on Physiological Therapeutics and Rehabilitation, the use of the terms mail, written document and letter can be used interchangeably and have the same legal authority as the terms verified e-mail and electronic transmission.
A Level 2 Functional Movement Systems Seminar is being held in Las Vegas at the Paris Hotel & Casino on Feb. 28th, 2014 from 8:00am – 5:00pm in conjunction with the 2014 ACA Rehab Symposium. Although not sponsored by the ACA Rehab Council, this Level 2 FMS Seminar will be held at the same location (Paris Hotel & Casino in Las Vegas) as our 2014 Rehab Symposium. The FMS Seminar date is 2/28/14, whereas the ACA Rehab Symposium dates are 3/1/14 – 3/2/14. To register for the FMS Seminar, log on to FunctionalMovement.com. More details of the FMS Seminar can be found below:
Level 2 Functional Movement Systems Seminar Description
This course is designed to enhance exercise professionals’ perspectives on improving fundamental movement patterns. The Functional Movement Screen will be reviewed and corrective exercise will be discussed based on movement dysfunction. The functional exercise progressions will be demonstrated and focus will be placed on how to utilize the FMS to properly prescribe and implement corrective strategy. More hands-on and practical information will be presented, using case studies and lab settings to show how the FMS can be used to provide a foundation for improvement in overall exercise programming. Objectives of this seminar:
- Provide more insight into the implementation of the FMS into your training philosophy.
- Enhance your ability to use the FMS to progress from corrective exercise to functional and traditional exercise.
- Introduce other assessment techniques which complement the FMS.
- Describe traditional and non-traditional strength and conditioning exercises and how they fit into the Functional Movement System.
To Register, log on at FunctionalMovement.com
WHAT: Five one-day course series of practical hands-on training in corrective exercise/rehab taught by Dr. Jeffrey Tucker.
WHO: This class is open to DC’s, PT’s, AT’s & students (personal trainers need to speak to Dr. Tucker before enrolling).
Credits earned by both doctors and students at these courses may be used toward the ACA Rehab Diplomate credential (DACRB).
WHERE: Premiere Spine & Sport 4982 Cherry Ave. San Jose, CA 95118
WHEN: Saturdays from 8:00a.m to 7:00pm
Seminar: 8:00 a.m. – 7:00 p.m.
Includes two 15-min. breaks; (late morning & late afternoon)
Lunch: 1:45 p.m. to 2:30 p.m. Lunch provided by host
OBJECTIVES: Create specific rehabilitation and/or exercise programs
COST: Registration: 7:30 – 8:00 a.m. Doctor cost per course: $325 Registration Students cost per course $230 Registration Early Bird Registration – Register 30 days in advance & save $30 per course! Or Pay $1,295 for all 5 Courses (Save $330.00!)
Registration is limited to the first 40 registrations.
We cannot accept walk-ins without advance notice
CONTACT: Questions? Contact Course Chair: Dr. Jeffrey Tucker Email: DrJTucker@aol.com or Phone: (310) 339-0442 Phone: 1-310-444-9393
June 8, 2013, Hip: This course in an application of diagnosis, assessment, and rehabilitation principles to common orthopedic conditions such as hamstring and groin sprains/strains, hip labral tears, pubic symphysis conditions. You will gain knowledge in functional anatomy and management of hip pain. It also covers open closed chain/functional movements, lower extremity functional-whole body exercises, as well as advanced issues in the objective measurement of soft tissue injury and specific stability ball exercises.
July 13, 2013, Knee & OA: This course presents rehabilitation for the management of osteoarthritis and the knee. Assessment of the knee and specific corrective exercises will be taught. Rehabilitation for common sports and industrial injuries will be presented. The functional anatomy and management of lower extremity pain will be taught. Open closed chain/functional movement, lower extremity functional-whole body exercises.
August 3, 2013, Ankle-Feet, plyometrics & balance training: This is an in-depth course in the evaluation of gait and functional anatomy of the foot and ankle. Functional management and exercises of common sports and industrial injuries of the lower extremity pain are taught. Beginner to intermediate issues in the principles and protocols in balance & stabilization training, ball, band /tubing, & bodyweight training as it relates to the lower extremities.
September 7, 2013, Shoulder: This course provides an in-depth analysis to the upper quarter and shoulder functional anatomy and movement assessments. This is a workshop for shoulder rehabilitation (application of rehabilitation principles to common orthopedic conditions) using low load exercises, bands, free weights and kettlebells. Course goal is proficiency in the management of shoulder and upper extremity pain. Specific band exercise training will be taught.
Resolution of Recurrent Acute Episodes of a Chronic Lumbar Disc Herniation Utilizing Chiropractic Rehabilitation Procedures and a Multi-Modal Wellness Model of CareMarch 28th, 2013
Peer Reviewed by the American Chiropractic Rehabilitation Board
Michael W. Mathesie, DC, CCSP, DABFP, DACRB*
*Chiropractor; Private Practice
10617 West Atlantic Boulevard
Coral Springs, Florida 33071
Structured Abstract: A Retrospective Treatment/ Management Case Report
Objective: To document and describe a multi-modal treatment method approach, that can be utilized in resolving a case of long term recurrent exacerbations of a lumbar disc herniation, resulting in low back pain and sciatica in a 39 year old construction worker.
Methods: The review of the literature suggests numerous methods for the treatment of lumbar disc herniation; this is including: spinal manipulation, physical therapy methods, rehabilitation, NSAIDS, steroid epidural injections, and surgery. The methods used in this case include non pharmaceutical and non surgical methods available to the chiropractor. Nutritional advice included elimination of corn syrup and sugar drinks, an increase in water intake, a reduction of breads and grains, the addition of supplements (including niacin and omega 3 essential fatty acids) and a daily general supplement pack with enzymes. A heel lift was fit for the patient for an anatomical short right leg. During the passive phase of care, modalities including High Volt Electrical Muscle Stimulation @ 80-150Hz, Interferential Electrical Muscle Stimulation @ 1-10Hz, Ice, breathing exercises, and 910nm LASER, were utilized in the acute stages of treatment along with Chiropractic Spinal Manipulation for the first 8 visits. During the transitional phase of care Post Isometric Relaxation Muscle Energy Techniques progressing to Post Facilitation Stretch, Manual Therapy Soft Tissue Techniques, Foam Roll Maneuvers, Posture Stretches, Side Bridges Progression, Cat-Camel, Dead Bug and Quadruped Bracing Progressions, were introduced with continued 910nm Laser Therapy and PRN Chiropractic Spinal Manipulation over the next 9 visits. During the active phase of care, after a full functional assessment, the patient began a 20 minute cardiovascular training program and continued progressions of the previous transitional program exercises. Additional rehabilitation was initiated consisting of: Deep Neck Flexion, Push-ups, Scapulo-Thoracic Facilitation, McGill Curl Up Lumbar Stabilization Exercises, Cook Hip Lift Lumbar Stabilization, Side Bridge McGill Lumbar Stabilization Exercises, Prone Bridge McGill Lumbar Stabilization, Supine Bridges with Progressions to Gym Ball, Standing Lunges, Superman with Gym Ball, Bird Dog, Wall Squat with Gym Ball, and Balance Training on Rocker Board for an additional 10 visits, which were performed for a total of eight weeks. A one month follow-up visit occurred for a total of 28 visits. In this case, the visits were completed within a three month period.
Discussion: Considering that the cause of low back pain is so complex, it would not be efficient to limit the treatment option to one mode. In this case, the patient was brought through the passive, transitional, and active phases of chiropractic rehabilitation. The patient also followed simple nutritional recommendations for weight loss, general health, and to lower blood pressure, inflammation, triglycerides, and cholesterol levels. He was given a heel lift for an anatomical short leg, to balance the lumbar spine and improve a lumbar convexity. He improved his cardiovascular fitness in the office and at home, and was taught to strengthen his spinal stabilizing core while being treated with a 250 Watt peak power; this included a 2 Watt average power, and a 910nm wavelength LASER that would have the ability to reach the target tissue of the lumbar facet and discs.
Conclusion: The patient responded well with treatment in a two month time frame, and then with a one month follow- up. There was no longer any residual chronic low back pain or sciatic radiculopathy, which has not been able to be accomplished in nearly 20 years for this patient. A normal strength and flexibility level was reached, using referenced Physical Performance Ability Test Methods and Measurements. There was a near normal BMI accomplished from previous obesity, normal cholesterol ￼￼￼￼ from previous hypercholesterolemia, normal glucose from borderline hyperglycemia, 33 pounds of weight loss, a decreased resting heart rate, and a decreased blood pressure. Common outcome assessment tools were utilized, and scores were dramatically improved including: Roland–Morris Low Back Pain and Disability Questionnaire (RMQ), Revised Oswestry Back Pain and Disability Questionnaire, and Health Status Questionnaire/SF-36/Rand 36.
Keywords: Lumbar Disc Herniation, Chiropractic Rehabilitation, 910nm Superpulsed Laser, Weight Loss, Heel Lift, Outcome Assessments, Chiropractic Spinal Manipulation
This case is an example of a common type of patient presenting to a chiropractic office, which includes: a nutrient deficient, obese, de-conditioned, early middle aged male physical laborer, with signs of pre-diabetes, hypercholesterolemia and elevated blood pressure. Along with a chief complaint of nearly 20 years of recurrent exacerbations of a lumbar disc herniation, resulting in chronic low back pain and acute episodes of sciatica. The objective, in this case, is to document and describe a wellness model of care using a multi-modal treatment method; an approach for a portal of entry chiropractor that could be utilized in resolving the presenting musculoskeletal conditions of the patient as well as the underlying additional health conditions that are co- morbidities affecting the healing process and the future health of the patient.
Case Report Presentation:
History of Present Illness (HPI) and Chief Complaint/ Symptoms: The patient entered the office explaining that at 8:30 AM he had bent over and lifted a small generator at a construction site, turned, and felt a pop in his lower back. He immediately felt pain in his lower back region, and it progressively got worse throughout the day. The pain eventually began to radiate to his right buttock and posterior thigh, his girlfriend had to drive him to the office. The symptoms remained to be constant; 100% of the time, they were severe in intensity, rated as an 8 to a 9 on a Quadruple Visual Analog Scale, with 8 being the best and 9 being the worst. His current and average pain levels were at a 9. The symptoms were further described as low back pain, from the bilateral ribs to the top of the crests, and then pain in the right butt cheek, under the butt cheek, and down the back of thigh stopping right before the back of the knee. The patient also described his back as being swollen. He said the pain he felt was sharp, dull, deep, burning and achy. The pain diagram filled in by the patient matched the description. He stated that lying on his back decreased the pain by a little, and putting weight on the right leg, including any movement, increased the pain. Prior to this episode, he has suffered from chronic low back pain, on and off, for 20 years, since high school sports. He also expressed, that he always feels stiffness and tightness in his body, even in the mid back region and neck, but those regions were not as painful in comparison to the pain he felt in his lower back. The patient revealed that 2 years ago he went to a pain doctor who ordered him a lumbar MRI; the patient brought in the results of the MRI for my review.
Activities of Daily Living Form revealed that there were no activities that could be performed except sedentary items and those not related to movement.
Outcome Assessment Forms, Red Flag and Risk Factor Assessments: These questionnaires were filled out to assess risks and set up baselines for future comparisons, and to determine levels of improvements; the results can be evaluated below in Table 1.
Past Medical History: The patient revealed a history of an appendix and tonsil surgery as a child: a broken right middle finger in high school, lacerated thumb requiring 20 stitches a few years ago, an automobile accident five years ago with no treatment, many traumas to the spine and extremities from high school sports, and he admitted to 8 episodes of this similar problem over the last 10 to 20 years. There was no other history of major illnesses, hospitalizations, or traumas revealed. His last physical examination was approximately two years ago, when he went to the pain doctor for pain medication and had injections. There was no blood work-up performed, according to the patient at that time, and he thinks it has been over 5 years since he’s had blood taken. Current Medication: He took 2 unknown pain pills from a co-worker this morning. For many years, he has been regularly taking two Motrin (400mg) every day, for his low back pain. Allergies: Pollen; Codeine; no other known allergies were listed.
Family History: The patient revealed that there was no heart disease, blood pressure conditions, cancer, or strokes in his immediate family. However, he revealed that his father has just been diagnosed with diabetes, and his father and mother both have high cholesterol. Since the patient had not had a blood work-up in over five years, further evaluation will occur regarding serum cholesterol and glucose levels.
Social/Occupational History: This patient is divorced, has an occasional two cigarettes a week, and consumes two alcoholic drinks a day with an occupation as a self employed carpenter/construction worker. His duties include construction, carpentry, form work, and framing which is often very strenuous. The highest level of education reached, is the completion of high school. The patient reveals that he does believe he has stress in his life, with some financial worries and trying to find work all the time, but not too high. He rarely takes a multi vitamin and often has fast food, processed food, and soda/sugar drinks at work all day. Prior to this injury, he had exercised less than moderately. He occasionally participates in other sports and activities, and he states that he usually does not get 6 to 9 hours of sleep each night.
Review of Systems: There were no symptoms of weakness, fatigue, fever, night sweats, weight loss, or any indication of vision, hearing, nasal, or throat disorders, coughing, difficulty breathing, chest discomfort, difficulty or loss of bladder or bowel control, rashes, numbness, major mental or hormonal disorders, or other blood, immune, or lymphatic abnormalities. However, he mentioned the feeling of pins and needles in his right leg. There was stuffiness mentioned for the nasal system, contributed to the allergies and construction dust, but there were no other additional symptoms noted to indicate additional organ dysfunction, except muscle/joint pain/back pain/stiffness was listed. However, this is part of the chief complaint, because he also has a chronic intermittent lower back condition.
Clinical Impression/Working Diagnosis: Based on the history, the patient most likely has a sprain/strain in the lumbar spine, with sciatic neuritis and possible disc herniation aggravation. A comprehensive examination will be performed to confirm this working diagnosis.
Physical Findings: This was a 39 year old, 5′ 11″, 225 pound, slightly disheveled appearance, endomorph body type, afebrile, Caucasian male with blood pressure of 138/89, and a pulse rate of 90 bpm with normal rate, rhythm and amplitude, and respiration rate of 19 breaths per minute. He would be considered obese based on the Body Mass Index calculation of (225 #/71 inches2) X 703 = 31.4 BMI. This would be considered within the “30 BMI and above” which would be the obese category; 18.5 to 24.9 would be normal category. Observation/Inspection of the skin, revealed no rashes or major scars of the head, neck, trunk, back, or extremities, except the hands, fingers, and forearms had multiple scars from working in construction. The fingernails were normal, there were no tattoos, no contusions, cuts, or discolorations noted on the spine or pelvis regions.
Percussion of the bony structures around the spine and pelvis, using a reflex hammer, revealed all normal findings except that the lower lumbar spinous processes were very tender when being struck with severe levels of increased pain. This was a suspicious finding, although hitting the painful areas would typically increase the pain, this level was more than would be expected.
Palpation/Inspection of the head, neck, trunk, back, and extremities (including skin, lymph nodes and thyroid gland) revealed all to be within normal limits except the bilateral lumbar paraspinals, and right quadratus lumborum were in spasm—rated at a 2— which is a spasm existing without provocation. Tenderness of this area would be graded as +4; thus, the patient complained of severe tenderness and withdraws immediately in response to the test pressure, and was unable to bear sustained pressure. The right Gluteals and piriformis muscles were in spasm, rated as a 1, which is triggered with movement or external pressure. These areas would be graded a +3 for tenderness, which is considerable tenderness, and withdraws momentarily in response to test pressure. The hamstring muscles were very tender to palpation, rated as a +2, which is moderately tender. The cervical paraspinal muscles revealed mild trigger points that were tender, graded as +1, which would be mildly tender or annoying.
Peripheral Vascular Evaluation consisted of auscultation of the carotid, subclavian, abdominal aorta, and femoral arteries for which there were no bruits heard. There was no swelling distally in the ankles or feet.
Specialized Testing consideration was appropriate at this point, because there was significant provocation upon percussion of the spinous processes of the lumbar spine, suggesting a possible fracture of the spinous processes, which could occur with some lifting injuries. This was considered in order to prevent further damage to the patient, from performing more strenuous testing. AP, lateral, left and right posterior oblique x-ray views of the lumbar spine, was taken on this patient before the exam was continued, in order to rule out the red flag of fracture of the spinous processes. The films did not reveal any fractures or other pathology; thus, the examination proceeded. The x-ray findings will be listed in a subsequent paragraph.
Range of motion of the cervical spine using dual inclinometer method reveals Flexion 45/50, extension 50/60, right lateral flexion 40/45, left lateral flexion 40/45, right rotation 65/85, and left rotation 70/85. There was no pain reported in the cervical spine, just stiffness. The lumbosacral spine ranges of motion were measured at flexion 30/65 (reached 24 inches from the toes) and pain in lumbar and right gluteal/posterior thigh, extension 10/30 with pain at lumbosacral region/right SI joint, and upper gluteal, right lateral flexion 10/25 right gluteal/hamstring pain, and left lateral flexion 20/25 with no increase in pain. Thoracic ranges of motion were flexion 40/60, right rotation 15/30, and left rotation 20/30. These movements increased low back pain. Range of motion of the hip joints, using goniometer revealed flexion to be 120/135 on the left and 50/135 on the right with both movements, resulted with increasing pain in the lower back and down the right posterior thigh. The Extension was 20/30 on the left and 10/30 on the right; both caused low back pain. Abduction and Adduction were too painful for him to complete. Internal rotation was 30/35 on the left and 25/35 on the right, with an increase in pain in the right gluteal. External rotation of the hip revealed 30/45 on the left and 20/45 on the right with increased pain in the right buttock with movement. Knee flexion was 115/135+ on the left and 105/135+ on the right. There was only a mild increase in low back pain upon knee flexion, no knee pain. The knee could be fully extended and there was obvious abnormal movement patterns noted in the spine.
Posture evaluation revealed: anterior head translation, a left head tilt, a high left shoulder, bilateral internally rotated shoulders, an increase in thoracic kyphosis, a high left ilium, mild left torso translation, a pendulous abdomen, and flattened Gluteals. Gait revealed a mild limp with the patient putting more weight on the left leg, no pronation of the feet, a mild right external rotation of the foot, and a slow cadence of gait were all noted.
Chiropractic evaluation, utilizing motion palpation of spinal joint play, was performed. Ligamentous fixations were noted at C1/C2, C5/C6 and C7/T1, T5/T6 and T12/L1, L4/L5, and Bilateral SI joints were fixated to a moderate degree. These fixations indicated kinesiopathology components of the subluxation complex. There was no crepitation or hypermobilities noted. No contusions were visually evident in these regions. There was obvious hypertrophy of the lower thoracic musculature and tenderness of the lumbar paraspinals as noted above, as well as additional right sided hypertrophy apparent from a lumbar spinal right convexity. There was also inflamed muscle tissue noted with mild edema, palpated along the paraspinals and right iliac crest.
Neurological Examination: The patient was oriented to time, place, and person. The mood was normal. A normal review of the cranial nerves was noted. Peripheral vascular system revealed normal skin temperature, and normal pulses of the upper and lower extremities. The Muscle tone in the upper and lower extremities was normal with no atrophy, fasciculations, spasticity, or flaccidity noted. Dermatome sensation to light, touch, and sharp stimulus was normal bilaterally along both upper and lower extremities (except S1 on the right would be considered hyperesthesia) because it was perceived as an increase in sensation compared to the left S1 dermatome, as well as the right L5 dermatome above, and S2 dermatome below. Muscle strength was 5/5 for all major upper and lower extremity muscle groups. Deep tendon reflexes of the upper and lower extremities were 2+, normal. Tandem Gait was difficult and not completed due to pain. Babinski’s Sign was absent with the toes going into plantar flexion. Rhomberg Sign was absent. Coordination testing of finger to nose was normal. Cerebral function was assessed with the patient being able to count backwards from 35 in intervals of 7. He was able to rapidly move his hand to his thigh, chest, and other hand. The girth of his left calf was 15 inches and the right calf was 15 inches.
Orthopedic Examination: In addition to the above findings, a musculoskeletal examination including inspection and palpation of the bilateral joints, bones, muscles, and tendons with stability/provocative testing revealed the following: Vertebral Basilar Artery Functional Maneuver was negative for vertebral artery insufficiency. Thoracic outlet syndrome testing was negative. Cervical foraminal compression, Maximum Compression, and Soto-Hall/forced flexion were all negative for any increase in cervical pain or radiation of pain. Shoulder depressor testing was negative but did cause a mild pulling sensation of the trapezius muscles, not pain. Jull’s Test with the patient asked to hold their head off the table for 10 seconds, resulted in chin jutting indicating weak deep neck flexors. An increase in intrathecal pressure caused an increase in lower lumbar spine pain. Straight Leg Raise Test caused an increase in low back pain bilaterally and also radiation to the right posterior thigh above the knee at 50° of right passive hip flexion. The hamstrings were shortened bilaterally with 70 degrees on the left and 50 degrees on the right. Bowstring Sign was negative bilaterally. Patrick’s Test was performed causing pain on the right side indication a possible right hip lesion and indicating very tight groin muscles bilaterally. Milgram’s Test was performed causing pain in the lower lumbar spine almost immediately and revealed very weak abdominals and/or hip flexors. Thomas’ Test revealed shortened Iliopsoas muscles bilaterally. Pelvic compression testing revealed pain in the right SI joint and surrounding regions. Nachlas’ Test caused pain in the right lumbosacral region and Sacroiliac Joint. Hibb’s Test revealed pain in the right SI joint and deep gluteal region when pushing away the right leg, also causing the left pelvis to rise, indicating piriformis shortening. There was no pain on the left Hibb’s Test. There was tight quadriceps muscles noted bilaterally with the patient unable to reach the heels to the buttocks with a passive stretch. Yeoman’s Test was positive on the right for SI joint pain. Kemp’s/Quadrant Test caused local low back pain and radiation of pain on the right when rotating the patient posteriorly on the right. Passive Scapula Approximation Test was negative for interscapula pain. There were no deformities, step offs, masses or instabilities noted.
X-rays: The views that were taken included the upright AP lumbopelvic, AP spot, lateral, and left and right posterior oblique x- ray views of the lumbar spine. As discussed previously, the physical exam was discontinued until fractures were ruled out and then the examination proceeded. The films did not reveal any fractures, on any of the projections, within any portion of the spinous processes or vertebral bodies. The AP lumbopelvis view revealed a lumbar convexity with an 11 degrees Cobb’s angle to the right, with a pelvic deficiency of 9 mm on the right side, measured at the heads of the femur, indicating an anatomical short leg on the right side. The L4/L5 and L5/S1 facets showed mild arthrosis. There was mild global left spinous rotation noted of the lumbar spine. The lateral projection revealed mild L5 disc space narrowing. The intervertebral foramens were patent. A mild loss in the lumbar lordosis is evident. Mild anterior spondylosis is evident on the vertebral bodies of L2/L3 and L5/S1. The oblique projections show no separation of the pars.
MRI: The patient brought in with him a copy of a lumbar spine MRI report, and compact disc from a local MRI Center dated 12/18/09, 15 months ago, which was ordered during his last episode of pain similar to this. The report written by a medical radiologist, who was considered reputable in the community, revealed a right paracentral herniation L5-S1 with loss of lumbar lordosis and a very mild dextroscoliosis. These findings were compared to the images and were accurate, thus the report was initialed.
No physical performance testing was attempted on this visit, to establish a baseline or weak link, because of the acute inflammatory phase or stage of the patient’s condition.
Diagnostic Impression/Assessment: This is an acute new injury over a pre-existing chronic weakness.
1. 847.2-Lumbar Spine Sprain/Strain
2. 724.3-Sciatic Radiculitis/S1
4. 728.85-Muscle Spasm; Piriformis
5. 739.3-Lumbar Joint; 739.4 SI Joint; Dysfunction/
Non-Allopathic Lesion/Subluxation Complex
1. 722.10-Lumbar Disc Herniation/L5
2. 739.2-Thoracic Joint Dysf./Non-Allopathic Lesion/ Subluxation Complex 3. 728.87 Muscle Weakness
4. 719.7-Difficulty Walking
5. 781.92-Abnormal Posture
Complicating Factors: The patient had co-morbidities noted; he was de-conditioned, had a pendulous abdomen, had a 9mm right short leg contributing to a mild right convex lumbar curvature, he was obese by at least 40 pounds, worked a laborious job, had an alcohol intake of two drinks per day, and occasionally smoked.
Prognosis: Fair. He has had this condition for many years, with on and off flare-ups every one to two years. He has never truly addressed the underlying weaknesses contributing to the problem. He works in a job that requires the use of his back. He has a confirmed L5 disc herniation that appears moderate in size. This condition could become more stable with proper methods applied. If he chose to follow my directions and treatment plan, this prognosis could be elevated.
Discussion, Decision Making, Treatment Goals and Initial Treatment Plan: The initial treatment plan was recommended to consist of short term, one to three weeks of ice with compression on the lumbar spine. This includes electrical stimulation of the lumbar spine and right piriformis/gluteal region to decrease pain and tissue swelling, starting with high volt galvanic at 80 to 150 Hz (encephalon release) and then after several visits, interferential at 1-10 Hz (endorphin release). He was instructed to wear an all elastic lumbar support brace for the next five days; it was to be worn only when moving and traveling places, and not when in bed or sitting at home. The brace is not rigid, but semi-flexible. He was required to return the back brace support to the office to assure he did not wear it past five days. The use of this brace was for short term only, to protect the injured area from re- injury while it was healing, to rest the injured tissue and to compress the injured tissue. At the same time, there was an attempt to prevent further weakness and disuse atrophy of the small spinal muscles of the spine. Also recommended, was LASER therapy to the lower lumbar region, L5 and SI joint, and right piriformis muscles for the reduction of pain, inflammation, and for the biostimulatory effects on the joint and soft tissue. To reach the facet and disc, which is at least 3.5cm to 5cm deep, a 910nm LASER must be used. Chiropractic Manipulative Treatment/Adjustments/Manipulation was recommended to the thoracolumbar region, lumbosacral and sacroiliac subluxation complex kinesiopathophysiological components as indicated during this initial stage of care. He was also given a soft tissue supplement pak, containing 660 mg of turmeric root extract, 705 mg of an enzyme blend of protease, amylase, papain, lipase, bromelain and others, quercetin, GABA, vitamin C, B-6, calcium, and magnesium for the inflammation and tissue repair. This would be taken as directed on the box and brochure given, and would immediately be stopped if any nausea occurred. If this occurs try to take it with food. The patient would then be re-evaluated within approximately 3 weeks unless indicated earlier or later. Treatment frequency would be three times a week, but he could be seen daily for the first few days in result of the severity of pain. He was treated on the day of this initial examination.
The clinician would be evaluating for improvement of symptoms and function. Short term treatment goals, by two to four weeks, will be a 50% decrease in the symptoms intensity, elimination of the majority of tissue swelling, the ability to sit, drive, and stand for more than one hour without an increase in pain, and the ability to walk without a limp, and to be able to perform basic functional testing maneuvers to assess his baseline. An additional goal for this patient was to lose 15 pounds in 30 days. He wanted to finally get rid of the chronic back pain that kept returning. The patient was concerned about his elevated blood pressure and wanted his cholesterol checked, and he agreed to listen to my recommendations. The patient would also utilize ice on the lumbar spine and right gluteal region with compression at home; applying a bag of crushed ice on a moist towel over the complaint area for 15 minutes, and then re-apply when the skin is normal to touch. The patient was given a requisition form to go to Quest Labs and have blood drawn for a comprehensive metabolic panel, thyroid panel, CBC, and Lipid Panel to evaluate the fatigue, thyroid, cholesterol levels, and glucose levels; it was done with the consideration of the borderline elevated blood pressure, obesity, and scores on the health status questionnaire.
This was an acute injury/condition with multiple components to the diagnoses. It required a low to moderate complexity of medical decision making, including the reviewing of diagnostic images and reports, low risk of morbidity, as well as the length of time spent face to face with the patient of over 75 minutes, with at least 25 minutes involving counseling. However this was regarding the options for him, including the referral for pharmaceutical intervention or epidural injection consultation, or the following up with a rehabilitation program with this office over the next 3 to 15 weeks. The risks of treatment and the risks of not getting treatment, were discussed with the patient and listed on the separate signed informed consent form, and the patient stated that he understood all elements and wanted to start the treatment plan that day.
The patient was able to stand on the platform of a hi-lo table, and the table was then lowered to the prone position. Four adhesive electrode pads were attached to the four lead wires, and placed over the left and right L5 paraspinal/quadratus regions and the right upper and middle buttock. The high volt galvanic (HVG) (G0283) was set at 80-150 Hz for encephalon release and pain relief to slightly more than patient perception for 20 minutes. Ice (97010) was also applied to the same region with compression for no longer than 15 minutes to prevent an increased reaction of blood flow. After the ice and HVG therapy was complete, a 910nm 250W peak, 2W average power, superpulsed LASER device (S8948) was applied to the patient while in a side lying position at the right side of the interspinous space between L5/S1, the right top of the sacrum, the right SI joint, and the right piriformis muscle with 1344 Joules in a total area of 90 cm2 for a dose or energy density of 15 J/cm2 at the surface over 15 minutes. The use of ice prior to using LASER is often beneficial because less blood in the capillaries will allow better transmission of photons through the tissue. The patient was given an adjustment/spinal manipulation in the side posture position to the Left SI joint, and T11 fixations/subluxation complex. The right SI joint was too acute to manipulate on the initial visit. He tolerated the adjustment (98940) very well. The patient was fitted with an all elastic lumbosacral support brace to protect from re-injury, rest, and compress the lower back to assist in the reduction of swelling and pain. This is a loan to the patient to assure that he returns it and does not wear it for more than 5 days. He agreed to return it within the recommended time period. The patient was instructed not to wear it when sleeping or when sitting for long periods; he was only required to wear it when standing and walking. He understood that it was the goal to not have him become dependent on the brace, and would be utilized short term during the first phase/inflammatory phase. He was instructed to use ice at home with a moist towel on the skin, use a zip lock bag of crushed ice cubes on top of the wet towel for 15 minutes at a time, and then apply the ice again when the skin returns normal to touch (up to four times a day). The patient was given a three page handout on McKenzie self treatment/stretching and sciatica by Liebenson that he should read and attempt to put his body into the positions on the sheets. His breathing patterns were reviewed, also demonstrated and instructed him that while doing the exercises (even when standing or lying down) he must practice inhaling with his abdomen and ribs coming outward, and breathing out/exhaling with his abdomen and ribs coming inward; his shoulders and chest should not rise with breathing. It was explained to him that this could be a great exercise for him to start, and that it is not strenuous for his back and will help him have a head start when additional exercises begin in the weeks to come. The patient was instructed to return the next day. This treatment was performed for 4 visits over the next 7 days.
On the third visit the lab results came back. The results are available in Table 2. In addition to the soft tissue support vitamin/mineral/enzyme pak he was already taking. He was recommended to go to the health food store and purchase additional 100 mg capsules of niacin (B3) in the form of nicotinic acid. The patient was informed about the flush sensation which feels similar to a sunburn, but disappears in approximately 30 minutes. He should start with 100 mg three times a day for a week if tolerated. Then slowly titrate up to 500 mg three times a day. A slight flush, is the maximum he should feel. If it is more than that, he should back off. After three months, he should decrease the amount gradually and just include it in a multiple vitamin or other supplement packs or B-complex. This is to lower the triglycerides and increase his HDL levels and lower his LDL. He was also recommended to take 3000 mg of molecularly distilled Omega 3 essential fatty acids per day (in 1000 mg separate doses) to help lower triglycerides and possibly blood pressure, LDL cholesterol and increase HDL. He should increase his walnut and almond intake every day with at least a handful of each. Since he requested assistance with weight loss and fatigue; dietary recommendations included the complete elimination of all sugar drinks including electrolyte “ade” type, Cola, Iced Teas, and every other drink with sugar and corn syrup. No diet, energy, or vitamin water drinks, or artificial sweeteners were allowed either. He was instructed to drink as much water as he wants to for thirst. He may have plain green or black teas (cold or hot) with no sweeteners. He was able to use squeezed lemon in liquids. He may have two eggs for breakfast. He may also have a mixture of steel cut oats, shredded coconut, sliced almonds, walnuts, pecans, cinnamon, chia seeds, pumpkin seeds, and a banana with almond milk. He may have up to four servings of real beef/chicken/fish a day, but no processed cold cuts or jerky. He can have as much fresh or frozen vegetables (salads or steamed vegetables) as he wants to eat in a day, but can only use extra virgin olive oil, vinegar, lemon, Himalayan Salt, pepper, curry, hot sauce, or other seasonings on them. No other liquid dressings or oils were permitted. He may have one sweet potato or white potato a day if he wants and one serving of bread a day (two slices) if he must. For example, he can have a sandwich for lunch but not a full hero/hoagie roll. He may have four handfuls of fruit a day, (i.e. one whole fruit like an apple, orange, banana is each a handful, a big handful of blueberries is a handful) no more. He was permitted to cheat on his diet only one day a week (a Saturday night). Although this was a big change for him, he understood the parameters and promised to stick with it. He understood his lab results and understood that if the levels did not change in three months, he would need to see a medical doctor for pharmaceutical intervention. On the 5th visit over a 9 day span, the type of EMS was changed to interferential therapy. Interferential therapy (G0283) was applied with four adhesive electrode pads with the leads placed properly in a criss-cross pattern over the lower lumbar muscles/quadratus region and the upper gluteal/piriformis with most of the L5 region pain in the center of the pads vectors attempting to reach deeper in the tissue. The interferential machine was set to 1-10 Hz for endorphin release and continued pain relief, but also to increase circulation and reduce spasm, and set to patient comfort/tolerance for 20 minutes. Ice (97010) was also continued; to be applied to the same region with a compression wrap, but for only 15 minutes because of the tissue thickness and to prevent an increased reaction of blood flow. After the ice and interferential therapy application, a 910nm, 250W peak powered, 2W average powered LASER device (S8948) was applied to the lower lumbar/L5/and Right SI structures, delivering 1344 Joules in a total area of 90 cm2 for a dose or energy density of 15 J/cm2 at the surface over 15 minutes. He was given a side posture adjustment (98940) to the right and left SI joint fixations/subluxations, and supine adjustment to the lower thoracic segments. Light, passive range of motion was applied to the lower extremity to all muscles and all planes of his tolerance levels, and they were done to not aggravate the sciatica on the right, and just to relieve tension on the left side. He was instructed to try to walk a little more during the day and avoid sitting or lying down at all. He can continue to use ice at home as directed. This treatment was performed from the 5th to the 8th visit in slightly over two weeks. On his 6th visit, wall angel exercises were instructed, and performed to assist with the weak scapula stabilizers, tight pectoralis, and thoracic kyphosis. On the 7th visit, since his short right leg measurement was 9mm on the standing x-rays previously taken, he was given a 5mm heel lift to put into his right shoe. He walked around and did not have any problems with the lift. The patient is instructed to always remember to wear it in all his shoes. The pelvis appeared more balanced with the heel lift in the right shoe. On the 8th visit he was re-assessed/examined and functional and physical performance evaluations were performed, provocative tests were less severe regarding positive signs; some of the functional measurements and findings were noted in Table1, Table 2, and Table 3. The patient then began transitional care on the 9th visit to the 17th visit, for which the next goal was to continue with correct breathing patterns, stretching strategies, and stabilizing strategies. He continued to receive spinal adjustment/manipulations on a needed basis as well as the LASER therapy more regularly each visit. He continued on the diet and nutrition regimen, home exercises previously given, and additional ones. The transitional sessions consisted of breathing exercises for 6 to 8 minutes in the office, while stretching supine on a gym ball with the patient’s arms extended above his head, and then out to the sides stretching the pectoralis muscles and extending the thoracic hyperkyphosis. He was explained that with all exercises, the object is to never do a bad repetition to prevent creating a bad motor pattern. Stop at a bad rep and do more sets of fewer repetitions. Next the patient stood looking in the mirror (for awareness) holding perfect posture and abdominal hollowing with a “small foot” for 10 seconds at a time and this was repeated for three sets. He was then instructed to lay supine on a foam roll in the vertical position with arms to the side for 2 minutes and then up above the head for 2 minutes. He was then instructed to lay supine on a foam roll in the horizontal position and roll back and forth on the thoracic spine working the myofascial adhesions of the lower thoracic, and the hyperkyphosis of the upper back for 2 minutes. He was instructed that cavitation may occur and that would be fine. Next the Cat-Camel was performed for 6 to 8 minutes accentuating the correct breathing and reinforcing the tightening of the core, and assisting the form by holding the low back and abdomen for the patient and having him hold the positions. Quadruped Bracing:-on all fours-with chin tucked and neutral spine with a stiffened trunk/core using the “end cough contracted position” technique, and challenging the patient with perturbations when able, was performed. Next a Side Bridge on knees was held for 10 seconds each side for three sets. Then the Dead Bug Beginner: with arm above head, supine with same leg bent with foot on floor, other knee comes up and touches opposite hand coming from above, then switch, all while abdominal bracing and not holding the breath. 10 times three sets. Then Post Isometric Relaxation (PIR) was performed on the quads-hams-adductors- gastrocs-soleus-iliopsoas piriformis and gluteals, with the patient comfortable, with muscle passively lengthened to the slight resistance barrier, patient contracts the muscle with minimal effort against resistance for 10 seconds while breathing in, and then let out and relax. This was repeated 3 to 5 times until no new barrier was met for each group. In addition, Deep muscular manual therapy techniques of ischemic pressure, and stroking massage using the elbow, was applied to the right piriformis and gluteus muscles, and QL for up to 7 seconds. It was then released and repeated at different locations of the tightened trigger points of these muscles. The patient was explained that this deep pressure may be very painful and to not allow the level to pass their tolerance threshold. LASER therapy was applied on the right piriformis muscle, QL on the right and left trigger point areas at L4 and L5 region, and medial superior right SI joint region using a 910nm Superpulsed system, with a 250W peak and 2W average power to stimulates growth factors effecting gene expression, which is necessary for remodeling and formation of healthy tissue. This device also has the ability to penetrate deeper into the tissue because of its power density, wavelength, and delivery properties. 1344 Joules were delivered in a total area of 90 cm2 for a dose or energy density of 15 J/cm2 at the surface over 15 minutes. (S8948). He is recommended to attempt to do all of these routines and stretches gently at home. He was given a roll for the mid back to take home so he could work on the mid back at home. The patient was confident in doing the perfect form and repetition and was given my cell phone number for any questions. He should use ice as directed previously for any pain or flare-ups. At the 12th visit-no spinal adjustment was needed, and the patient was ready for additional intensity but still in the transitional phase of care. PNF techniques of Post-Facilitation Stretch (PFS) were initiated on the quads-hams/biceps femoris-gastrocs-soleus-iliopsoas-glutes and TFL/ITB. Care was used to assure patient comfort, and although he was instructed to contract with near maximum effort, pain should not increase past his average pain levels of 4. He promised not to go too hard with this stretch technique to avoid straining himself. The patient was then instructed to push against my body on each muscle treated, and breathe in slowly (respiratory synkinesis) while resisting on my count of 10 seconds, and have his eyes look (visual synkinesis) into the direction of his contraction. He then was told to completely relax and let go, as the muscle was stretched to the new barrier for 15-20 seconds, and he had his eyes look into the direction of the stretch. He relaxed for another 20-30 seconds and repeated each muscle 4 times. He continued then with breathing exercises for 6 to 8 minutes in the office, while stretching supine on a gym ball with the patient’s arms extended above his head, and then out to the sides stretching the pectoralis muscles and extending the thoracic hyperkyphosis. Again, the importance of proper breathing methods through the abdomen extending outward on inhaling, and that the ribs should come out laterally on inhaling and the shoulders should be relaxed with breathing and not be rising, were all reviewed. He was explained that with all exercises, the object is to never do a bad repetition, in order to prevent creating a bad motor pattern. Stop at a bad rep and do more sets of fewer repetitions. Next the patient stands looking in the mirror (for awareness) holding perfect posture and Abdominal Hollowing with small foot for 15 seconds at a time and this technique was repeated for three sets. This began with expected and unexpected perturbations while standing in this position. Then this was performed with the eyes of the patient closed, trying to assist him with proprioception, and balance while standing on two feet with awareness and perturbations trying to maintain the posture. He was then instructed to lay supine on a foam roll in the vertical position with arms to the side for 2 minutes, and then up above the head for 2 minutes. Next, He was instructed to lay supine on a foam roll in the horizontal position, and roll back and forth on the thoracic spine working the myofascial adhesions of the lower thoracic, and the hyperkyphosis of the upper back for 2 minutes. The patient also began rolling with perfect form, and breathing and bracing on the TFL to release some trigger points and tightness of this soft tissue for 2 minutes. Next the Cat-Camel was performed for 6 to 8 minutes accentuating the correct breathing, and reinforcing the tightening of the core as described previously. Quadruped Bracing was performed as described previously with expected and unexpected perturbations for 4 minutes. Next, a Side Bridge on the feet (instead of the knees) was held for 15 seconds each side for three sets. Dead Bug Second Progression was performed with the arm above head, supine with both knees at 90 degrees, other knee comes up and touches opposite hand coming from above, then switch, all while abdominal bracing and not holding breath, 10 times bilaterally; three sets. Deep muscular manual therapy techniques of ischemic pressure and stroking massage (using the elbow) was continued to be applied as previously described. LASER therapy was continued and performed as described above. A re-evaluation of previous positive maneuvers, as well as a reassessment of functional performance, was performed on the 17th visit of 03/09/11. Some of the results are included in Table1, Table 2, and Table 3. In addition, a Par-Q Form was filled out by the claimant to assess cardiovascular risks for which, allowed us to proceed with the YMCA 3 minute Bench Step Test. He was able to complete the assessment for which, the total visit took 2 hours to complete. On the 18th visit, 03/11/11-we began Active Care. The patient was instructed to continue to perform all the previous exercises at home during the off days. He is also asked to continue the cardio routine at home on his off day that was started today in the office, with the same level of intensity and time. He is also to attempt—with perfect form—the new exercises he was taught. The patient started at a 5 minute slow pace on the bicycle, and then increased the pace for 20 minutes maintaining his target heart rate of 142 bpm and then a 5 minute cool down. He was rated as below average on the YMCA 3 minute Bench Step Test on the assessment. Therefore, he was started at 60% for aerobic training for 20 minutes, and will be progressed up slowly to 80% for 20 minutes over the next several weeks as his fitness levels allow. The Karvonen Method Formula: (220 – age) – (RHR) X (% intensity) + (RHR) = HR target. This patient: 220 -39age = 181HRmax 181HRmax – 83HR rest =98 98 X 60% = 58.8 58.8 + 83HRrest = 141.8 HR target
By this time, the patient had mastered the Cat-Camel, Dead Bug, Mirror Image Posture, Side Bridging, Quadruped Bracing, Breathing Techniques, and has improved in his flexibility; he was able to explain that with all exercises, the object is to never do a bad repetition in order to not create a bad motor pattern. Stop at a bad rep and do more sets of fewer repetitions. He was instructed to continue this routine and use it as part of his warm up before entering the office, and also to perform this routine and all stretches daily. The active rehabilitation routine utilized is listed in Table 4. This rehabilitation routine was progressed slowly over each visit from the 18th visit to the 27th visit, with increased repetitions, sets, and/or resistance. It includes other increases in challenges such as, eyes being closed as indicated in the routine. He stretched and performed one hour of the exercises, and 20 minutes of cardio on his off days from this office, and used ice after all sessions for 15 minutes as previously directed. He was seen 3 visits a week of Monday, Wednesday and Friday until the 27th visit.
On the Final Evaluation, which was the 27th visit, the patient was discharged from active care and told to return in one month. He was stronger and thinner; had better posture and had nearly no back pain. At this point, it was deemed that he would do very well continuing to strengthen his back on his own. The patient should continue to perform all the exercises he was taught in this office, 3 times a week, as a home maintenance program. This would also include his cardio exercise as well. He was also prescribed a general multiple vitamin pack. This is in addition to the fish oil and niacin that he was still taking. He was no longer taking the soft tissue support pack for the last four weeks. He was instructed to reduce one fish oil capsule per day that he has been taking, because this new pack has one in it. He will reduce the niacin in four weeks, titrating down. He will visit his MD within the next four weeks, and have a complete physical and blood workup performed. He returned to work, and was recommended to return here in four weeks for a check-up to see how going back to work affected his back. He may also return to the office PRN (as needed) for any flare-ups, regressions, or reoccurrence of his lumbar condition. On the one month follow- up, the 28th visit, the patient was released and discharge. The patient has done a great job keeping up with the exercises. He looks great and he should return as needed for any tune-ups or flare-ups of any pain. If his condition deteriorates and functions decrease, if his symptoms reoccur, or after his home treatment fails to give relief, he may return for any nutrition purchases. The patient understood the importance of continuing the home plan of exercises with perfect form and proper breathing.
Results/Outcome of Care:
|Key: *right now, average, best, worst listed, PF=Physical Function, BP=Bodily Pain, EF=Energy Fatigue|
|Quadruple Visual Analog Scale*||9,9,8,9||6,6,5,7||2,3,2,5||0,1,0,2|
|Health Status Questionnaire-(Rand)/SF 36||PF-60||PF-90|
|Roland-Morris Disability Questionnaire||18/24||11/24||6/24||1/24|
|Revised Oswestry Back Disability Quest.||39/50||22/50||13/50||5/50|
|Motrin Medication Intake||14x’s/week||2x’s/week||1x/week||0x’s/week|
|Height||71 inches||71.75 inches|
|Resting Heart Rate||90bpm||83bpm||75bpm|
at 60% and then 80%
|*Lumbar Spine Mobility Listed as Flexion, Extension, Lateral Bending Right, Lateral Bending Left (AMA normal values)|
|**Normal Values referenced from Rehabilitation of the Spine, A Practitioner’s Manual, 2nd Ed., Craig Liebenson, Lippincott Williams & Wilkins|
|YMCA 3 Minute Bench Step Test||116bpm; below average||101bpm above average|
|Lumbar Spine Mobility/ROM*||30, 10, 10,10||40, 15, 15, 20||45, 20, 20, 25||55, 25, 25, 25||60+, 25, 25, 25|
|Over Head Squat Test||Score: 0; Fail; Pain||Score: 1; Difficult||Score 3|
|One Legged Standing Test||Score: 0; Fail; 4 secs /open; 0 sec/closed||Score: 1; Difficult; 15 secs /open; 6 secs /closed||Score: 2; some compensation; 30 secs /open; 20 secs /closed|
|Lunge Test:||Score: 1; Difficult||Score: 1-2; Borderline||Score: 3; No Compensation|
|Janda Hip Extension Test||Score: 0; improper sequence; twisting/weak||Score: 1; Weak Glute||Score: 3; Correct Sequence/Normal Glute Max Strength|
|Janda Hip Abduction and Coordination Test||Score: 1; Severe Hip Hike; ext. Rotation||Score: 2; Overactive QL/Piriformis||Score: 3; Normal|
|Side Bridge Endurance Test||Score: 0; Pain; 10 secs||Score:2-35 secs/no LBP/Compensation||Score: 2; held 75 secs; slight compensation **/84.5 ave.|
|Sit and Reach Test||Score: 2; 7 inch mark||Score: 2; 9 inch mark||Score: 3; 12 inch mark/10-16 mark|
|Trunk Flexor||2/50||10/50||35/50reps ; Ave. 27 +/- 14|
|Repetitive Arch Ups||6/50||15/50||30/50reps; Ave. 28 +/- 14|
|Squat Endurance/Repetitive||9/50||18/50||40/50reps; Ave. 37 +/- 12.5|
|Sorenson’s/Static Trunk||30/240||65/240||99/240sec; Ave. 97 +/- 56|
|Deep Neck Flexion||Retraction of chin in the prone, seated or standing position to assist with forward head posture; with nodding the head without and then with resistance with a small gym ball and or head harness or band||Sets of 10 to 20 reps to patient abilities|
|Push Ups||On fists, chin tucked, neutral spine, protraction of shoulders, activate all stabilizers, feet dorsiflexed||5 reps; add reps, add rocking, rotation, and tripod|
|Scapulo-Thoracic Facilitation||In the side lying position, activate scapula stabilizers, patient brings back scapula and shoulder to where the doctor directs||Start with 10 reps each side and then increase|
|McGill Curl Up Lumbar Stabilization||No head jutting, only perform after activation of abdominal bracing, breathing and bracing concurrently, hold and breath multiple times starting with the one leg bent, elbows on the floor, hand behind lumbar spine, upper spine moves only, no lumbar spine movement; progress to elbows off floor and/or both legs bent; then fingers curled next to ears, then adding trunk rotation.||Start with 10 reps and increase to multiple sets of higher reps|
|Cook Hip Lift Lumbar Stabilization||Supine; The focus should be on engaging the hip extensors. Pull one knee towards the chest as much as possible to engage the opposite hip extensors (as opposed to overusing the lumbar extensors)||Hold 10 secs each side; increase secs held /sets|
|Side Bridge McGill Lumbar||Side lying on feet (top in front) and propped up with forearm, square pelvis so no sag, abdominal brace||3 sets of 10 secs with Roll Over and increase|
|Prone Bridge McGill Lumbar||Prone; propped up with both forearms, square pelvis so no sag, abdominal brace, chin tuck; progress from two feet to one foot, and lift other leg up and hold||3 sets of 10 secs and then increased over time|
|Supine Bridge||Maintaining co-contraction including glut max, raising buttocks off the floor, then sacrum, lower lumbar, and upper lumbar spine. Then lower the spine down to the floor with the coccyx last to touch||Hold 10 secs, longer; 2 legs to 1 leg, then ball|
|Superman||On floor, both feet supporting on wall/floor, brace, keep spine neutral, extending the hips, not spine and lift arms up; both hands out, also sideways; hold 3 seconds/10 reps/3 sets||Progress in hold time, reps, sets, and then to gym ball|
|Gym Ball Lumbar Extension||Lay prone on ball, feet on floor, torso hanging off; lumbar extensions, 3 sets of 10 reps, hold each rep for 3 secs.||Progress in reps and sets and hold time|
|Bird Dog||Quadruped; chin tuck, breath, brace and hold, check for abnormal external rotation of hip and lumbar hyperextension, should be neutral then one arm/other leg; hold 3 secs; progress to under touches/ball||3 sets of 10; increase sets, reps, hold time; touches|
|Standing Lunges||Patient steps forward onto Stability Trainer-(green-firm then blue and then black) with perfect erect posture; knee &hip at 90 degrees, then returns to stand; alternate legs; progress to weights on shoulders||3 sets of 15; progress in sets/ reps/colors/lb’s|
|Wall Squat with Gym Ball||Abdominal Brace; Stand with back, shoulders, and head even and straight, leaning against the ball and look straight ahead. Keep shoulders relaxed and feet 1 foot away from the ball and a shoulder’s width apart. Keep head straight, roll down the wall with the ball, lowering the buttocks toward the floor until the thighs are almost parallel to the floor. Hold this position for 10 seconds. Make sure to tighten the thigh muscles while slowly sliding back up to the starting position.||3 sets of 10; progress with time in lowered position, sets, reps, and dumbbells on shoulders|
|Balance Training on Rocker Board||Small foot and subtalar neutral maintained, abdominal hollowing, patient should maintain controlled rocking on the board with ankle joint without bending at the waist; start with 3 minutes and increase.||Progressing to multiple angles eyes closed and round board|
The fact that obesity contributes to higher levels of inflammation and to causing additional abnormal forces on the motor and biomechanical systems, cannot be ignored. A leg length deficiency contributes to uneven forces on the spine structure; often a convexity of the lumbar spine on the same side; and in many cases should be progressively leveled to prevent or slow down the process of boney deformation, osteophytes and syndesmophytes. Joint and tissue mobility and flexibility is the foundation of any rehabilitation protocol and must be attained in order to progress into restoring stability to a weakened and unstable lumbar spine. Chiropractic Manipulative Treatment/Chiropractic Adjustments/Spinal Manipulation is the most researched mode of treatment for low back pain. This of course is the staple of the practice of chiropractic in restoring joint mobility and reduction of the kinesiopathophysiological component of the subluxation complex. Proper functional testing and measurements are key components to the documentation process. This testing and measuring will validate that conservative chiropractic rehabilitation protocols is cost effective with outcomes that not only produce resolution of the abnormal spinal condition, and progress a patient to normal status compared with referenced normal data, but also for the resolution of systemic health conditions that if ignored may require the inveterate use of medications. These outcomes will then possibly confirm that chiropractors are more than qualified to be primary care physicians, not only on health plans but on workers’ compensation plans, including wellness models of healthcare. Nutritional supplementation and cardiovascular fitness is also imperative when attempting to improve a patient’s general health. Proper circulation to the soft tissue with oxygen and micro and macronutrients is required for any successful rehabilitation and conditioning protocol. Finally, with the advances in technology, there are LASER devices which are FDA cleared in the United States that are available with a 910nm wavelength that have the ability to penetrate into the deeper target tissues of the spine with adequate power density to initiate the biostimulatory effects and accelerate the healing process. The practicing chiropractor, depending on his or her practice style, philosophy of practice, state regulatory practice acts, and education have the ability to utilize more than one modality to assist the patient to become well, not just in the spine, but the whole body, and without the need of pharmaceuticals.
This clinical case study did not have a post MRI performed after the treatment was finished. This would have been beneficial to access if the chiropractic manipulation/adjustment, rehabilitation protocols, and laser therapy assisted in the reduction of protrusion size. Thus, resulting in the beneficial results that were seen or if it was just from the improved stability, mobility,
strength and global alignment. Since this patient was self paying for his treatment, ordering another MRI in a pain-free subject may have been difficult. There are also limitations in general when treating this type of chronic condition, because of the amount of treatment time required each visit to accomplish the goal. The typical physician or therapist does not always get reimbursed by third party payers adequately for the hour or more that these visits actually lasted to make it financially feasible to perform on all patients. Furthermore, instead of being impressed with the provider, the third party payer may interpret the amount of effort by the provider as overutilization, making the documentation of the case much more important. Dedicating an hour of time one on one with the patient can be very difficult in a typical practice, which is why so many therapists and physicians often utilize more passive modalities which do not require constant attendance, but do not usually give a long lasting result.
In general terms, case reports should not be generalized beyond the context of a particular case for a larger population of patients. Also, the natural progression of a condition or dysfunction may also explain the results experienced in patient care. This case study submitted, that happened to have stellar results for only one patient with long term reoccurring low back pain and sciatic radiculitis from a documented disc herniation, will hopefully stimulate more large scale studies and utilize multi-mode procedures instead of a single mode procedure. Most of these types of case studies attempt to establish the “best” single treatment; however, the “best” treatment may actually be performing everything that will restore the patient to whole body full function and wellness, not just treating the pain or the assumed source of pain.
This case study was completed in part for the purpose of a requirement for board certification by the American Chiropractic Rehabilitation Board. The learning process and the assistance from the instructors such a George Petruska, DC was invaluable to me. The professionalism of the testing process and the staff and members of the ACRB was an example for all to follow. I am grateful for the opportunity to be a part of it.
Funding sources and potential conflicts of interest:
No funding sources or conflicts of interest were reported for this study.
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If you are an active ACA Rehab Council member in good standing, on Monday, Jan. 21st, 2013, you will be receiving an e-mail from Josh Damon, Corporate Affairs Assistant of the ACA, with respect to the proposed ACA Rehab Council Bylaws Amendment, Article XVIII (the proposed Amendment and the Rationale for this Amendment can be found below. The Rationale is in italics). The Bylaws Amendment has the full support of your Rehab Council Executive Committee and has been reviewed by our Rehab Council Liaison, Dr. Kelli Pearson, as well as ACA Legal Counsel Tom Daly. In addition, it has been approved as written (see below) by ACA Bylaws Chairperson Dr. Karen Konarski-Hart and past ACA Bylaws Chairperson, Dr. David Herd.
The e-mail from Josh will have a link that you will be able to click on in order to cast your “yes” or “no” vote. Only active ACA Rehab Council members who are in good standing and have paid their 2013 dues are eligible to vote. Thank you for taking the time to cast your vote.
Proposed ACA Rehab Council Article XVIII – Establishment of a College
“In accordance with its objective to promote scientific research directly related to all aspects
of physiologic therapeutics and rehabilitation with particular attention directed towards
chiropractic and multi- disciplinary network approach, the ACA Rehab Council President
may, upon a two-thirds (2/3) majority vote of the members at a regular or special meeting
called for that purpose, appoint a College which will be governed by its own Bylaws which
will not be in conflict with the Rehab Council Bylaws or those rules and regulations set
forth by the ACA, and which will consist of a group of chiropractic doctors with a specific
academic and clinical focus that can be viewed as complementary to the specialty of
rehabilitation. The College shall aid in providing scientific, academic and clinical guidance
and research to the ACA Rehabilitation Council complementary to the field of rehabilitation.”
Register for an ACRB Rehab Review scheduled on one of two weekends; either Jan. 19th & 20th, 2013 or Feb. 2nd & 3rd, 2013. Both reviews are held in Pennsburg, PA.
For questions, contact Gene at 610-304-8471.
ACRB Rehabilitation Review Series 2 Day Program
2791 Geryville Pike Pennsburg,
PA 18073 (215) 679-3419
Come prepare with us with a comprehensive review and mock oral exam!
ACRB Certified Lead Instructors:
Chad Buhol DC DACRB
George Petrusksa DC, DACRB
Gene Serafim DC DACRB
Hampton Inn Quakertown
￼1915 John Fries Highway, Quakertown, PA
Comfort Inn & Suite
1905 John Fries Highway Quakertown, PA 18951
Holiday Inn Express Hotel & Suites Quakertown
1918 John Fries Highway Quakertown, PA 18951
Respond to Eugeneserafim@yahoo.com to ensure availability, Cost $299. for 12 hour module. ACRB credit available upon request. Questions; contact Gene 6103048471
Topics to be covered include:
- Establishing Baselines for local muscle endurance, aerobic potential, flexibility and more
- Strength progressions and regressions
- Acute, Subacute and Chronic protocols and phases of healing
- The abridged Certified Strength and Conditioning Program
- Functional Analysis systems including the FMS, SFMA, MAG 7 and 4×4 Matrix
- Muscle Energy Techniques
- Functional Anatomy
- Condition Specific Protocols
- Outcomes Assessments Review
- Sparing Strategies
- Postural Syndromes
- Qualitative vs. Quantitative analysis
- Mock Skills and Comprehensive Exams
When: Feb. 9th & 10th, 2013
Where: Rocky Hill, CT
Become Board Certified in Rehabilitation
12 module program satisfying the lecture/workshop requirement leading to Diplomate Status in the
American Chiropractic Rehabilitation Board®
February 9th and 10th, 2013
Rehabilitation of the Lumbar Spine
Connecticut Chiropractic Association
2257 Silas Deane Highway
Rocky Hill, Ct. 60067
This module presents the best available evidence to support evaluation, rehabilitation and implementation principles for treating the lumbar spine. Static posture analysis, lower body stretching, as well as functional anatomy and the management of low back pain will be taught. An introduction to basic rehabilitation principles, advanced assessment of motor control, and body weight exercises will also be offered.
Chad Buohl, DC, DACRB
Eugene Seraphim, DC, DACRB
Mitchell B. Green, DC, DACRB
George Petruska, DC, DACRB
To register, contact NYCC Post Graduate Department at (800) 434-3955 ext. 132, or online at www.nyccpostgrad.com. Cost is $299 per module ($349 when paid less than 7 days prior to the first seminar date of the month). For course and program information, contact Mitch Green, DC, DACRB at (212) 269-0300. Contact the ACRB for additional online material and testing requirements at email@example.com.
License Renewal: Appropriate applications relating to credit hours for license renewal in selected states have been executed for these programs. For information regarding these applications, please contact the NYCC Postgraduate Department at 800 -434-3955. The presence of a speaker or an exhibitor at a NYCC-sponsored or co-sponsored program does not represent an endorsement by NYCC, nor is the presence of a product at a NYCC-sponsored program to be construed as a product endorsement or a testimonial by NYCC as to the quality of the product.
Description: Functional assessments and exercise are used as treatment of acute and chronic pain. The use of exercise is part of case management strategies and continues to be in the forefront of appropriate and safe use. Practitioners will learn assessments that will guide your corrective exercise selection and help you in the management in patients’ care.
Instructor: Jeffrey Tucker, DC, Diplomate American Chiropractic Rehabilitation Board. ACA Rehab Chiropractor of the year 2012.
Audiences: Chiropractors, Physical Therapists, Personal Trainers, students of same