American Chiropractic Association Rehab Council

Modern Spine Care – Craig Liebenson, DC

August 1st, 2010

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Dynamic Neuromuscular Stabilization (DNS) According to Kolar – Course A

August 1st, 2010

Dates: Nov. 12-14, 2010
Athletes’ Performance – Phoenix, AZ

ISCRS Members Receive a $125 Discount!

Presented by – Craig Liebenson, D.C. L.A. Sports and Spine Los Angeles, CA
DNS Seminar Registration Info:
Fee: $950
craigliebensondc@gmail.com

Location
Athletes’ Performance International 2629 E. Rose Garden Lane
Phoenix, AZ
www.athletesperformance.com

Limited Enrollment Course. This program will sell out!

Registration

Call LA Sports & Spine (310) 470-2909
Fee: $950 ($300 non-refundable)
Discounts:
- ISCRS members www.clinicalrehabspecialists.com – $125
- Students – $100 o Early-Bird – June 1 – $100
CEU’s applied for PTs, ATCs, NSCA, & DCs (Additional Fee may apply for CEU application – varies by state) • Questions: craigliebensondc@gmail.com

Schedule

9-5 Friday/9-5 Saturday/8:30-3 Sunday

Hotel

Residence Inn Phoenix Desert View at Mayo Clinic, 5665 E. Mayo Boulevard, Phoenix, AZ, 85054, (480) 563-1500
Group Rate: LA Sports & Spine
$89.00/night guaranteed through July 30
Final room hold released October 1
Faculty Pavel Kolar, PT, Paed. Dr., Ph.D. – Day 1 only Alena Kobesova, MD, PhD – DNS instructor – Prague School Martina Jezkova, PT – DNS instructor – Prague School Clare Frank, DPT – Local certified DNS instructor Kathryn Kumagai, DPT – Local certified DNS instructor

COURSE OBJECTIVES

Demonstrate an understanding of the basic principles of developmental kinesiology with an emphasis on development during the first year of life.
Describe the relationship between development during the first year of life and pathology of the locomotor system in adulthood.
Demonstrate understanding of new terminology such as functional joint centration, punctum fixum, punctum mobile and the integrated stabilizing system of the spine.
Demonstrate a basic understanding of the principles of reflex locomotion: locomotor patterns – stepping and support function and stimulation zones.
Evaluate and correct poor respiratory patterns. Assess the integrated stabilizing system of the spine both visually and utilizing dynamic functional tests. Perform the basic techniques for reflex locomotion, i.e. reflex turning 1 & 2, and reflex creeping: initial positioning and anticipated movements, key zones and their vectors.
Integrate corrective exercises based on the DNS functional tests and developmental positions used in reflex locomotion. Clarify how DNS corrective exercises can integrate with other exercise strategies.
Provide basic clinical management explanation for clinicians to better integrate the DNS approach in their regular practice, including patient educat

A certificate of completion will be awarded upon completion of Course A.

OPTIONAL EXAMINATION

Participants who would like to participate in the educational track towards becoming a certified practitioner can take this exam for an additional fee of $150. The test will consist of 50 multiple choice questions. Participants are required to return the test to the local instructor within a month after the course Upon successful completion and passing of the test, a Certificate of ACHIEVEMENT from Prague School of Rehabilitation will be awarded.

Testimonials

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

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

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

“Reflex locomotion stimulation and the theory behind gives you an understanding of how problems arise and at the same time a tool for correction.” – Teddy Fohlmann, Chiropractor and member of multidisciplinary “back team” in Esbjerg,Denmark:

“Pavel’s approach to treating conditions by addressing the CNS first and understanding the body’s natural adaptive patterns has given me a unique prespective in treating injury pathology. I have a much greater appreciation of the CNS and human development playing significant role’s in the body’s postural adaptive patterns. Since having completed his course, I feel like I have implemented a more effective global approach in my treatment plans with the athletes I work with.” PJ Mainville, ATC, Minor League Rehab / Athletic Training Coordinator Arizona Diamondbacks

“You get a good model of explanation for the function of the locomotor system, and tools for examination and treatment of the chronic and hypermobile patient. These are the patients lacking central stability, that has tried rehab. Unsuccessfully in the past” – Mogens Frost, GP and member of multidisciplinary “back team” in Grindsted, Denmark

“Through very specific positions and stimulation points the patient learn to activate the deep stabilising muscles, enabeling voluntary control to develop before more advanced training is started. When this basic step is lacking failure of rehabilitation is seen. Simply an ingenious technique. – Grethe Jensen, Physiotherapist and member of multidisciplinary “back team” in Grindsted. Denmark

“I have always sought results, and you certainly get them using this technique” – Ida Nørgaard, Chiropractor & MSc., London.

Core Training: The Dangers of What Our Patients Think They Know

August 1st, 2010

Craig Liebenson

Introduction

Abdominal or “core” training is becoming more popular all the time. Traditional sit-ups are still in vogue, but may in fact be dangerous for the back. Modern biomechanics verifies the importance of the abdominal wall, but suggests it is functional, coordinated action of the kinetic chain linkage system from pelvis to rib cage that is most crucial. Train is best when the entire orchestra is trained rather than isolating individual muscles. The diaphragm, pelvic floor, oblique abdominals, transverse abdominus, rectus abdominus, as well as the lumbar spine musculature should all participate in a well coordinated manner.

The dangers of the sit-up

The sit-up places high compressive load on the disc, involving 3350 N of force (McGill 2006, 2007). According to McGill the safe limit for an acute-subacute low back pain patient is approximately 3000N. The sit-up usually involves a posterior pelvic tilt which unnecessarily elevates disc load (Hickey and Hukins 1980). It is frequently performed early in the morning, which is a time of great risk due to increased intra-discal pressure (Adams 1985).

Isolation vs Integration

Spine stability is greatly enhanced by co-contraction (or co-activation) of antagonistic trunk muscles (Cholewicki and McGill 1996). Co-contractions increase spinal compressive load, as much as 12%-18% or 440N, but they increase spinal stability even more by 36% – 64% or 2925N (Granata 2000). They have been shown to occur during most daily activities (Marras 1990). This mechanism is present to such an extent that without co-contractions the spinal column is unstable even in upright postures! (Gardner-Morse 1998).

Poor motor control of the “core” muscles has been found to be correlated to back pain. Research at Yale University have shown that a specific motor control signature of delayed agonist-antagonistic muscle activation predicts which asymptomatic people will later develop low back pain (LBP) (Cholewicki 2005). What researchers found were longer muscle response latencies to perturbation in the “at risk” group than in healthy control subjects.

Inappropriate muscle activation patterns during seemingly trivial tasks (only 60 Newtons of force) such as bending over to pick up a pencil can compromise spine stability and potentiate buckling of the passive ligamentous restraints (Anderson 1990). Certain times of the day such as in the morning or after prolonged sitting render the spine so unstable that if “surprised” by trivial load an injury can be precipitated (Adams 1995).

Paul Hodges and colleagues from Australia have shown that delayed activation of the transverse abdominus muscle during arm or leg movements distinguishes between LBP patients and asymptomatic individuals (Hodges 1998, 1999). However, according to Canadian scientists focusing on a single muscle is like focusing on a single guy wire (Kavcic 2004). Research in Pr. Stuart McGill’s laboratory at the University of Waterloo in Canada has found that the entire orchestra of muscles is responsible for spinal stability (Kavcic 2004). They demonstrated that different muscles played greater or lesser roles depending on the activity/exercise and that no single muscle can be considered ‘the stabilizer of the spine”.

How Should Functionl Core Training Occur?

Proper Breathing

If spine stability is compromised when one is gasping for air the natural result will be low back injury (e.g. a deconditioned person shoveling snow). McGill demonstrated a loss of control of the “neutral spine posture” during weight lifting under challenging aerobic circumstances (McGill 1995).

For all abdominal exercises it is important that the patient is cued to maintain normal respiration.

The Exhalation Position of the Rib Cage

Kolar (2007) has recommended that to achieve stronger co-activation of abdominal wall the anterior rib cage should be depressed into a similar position as occurs with atctive exhalation. Raising the ribs up is synchronized with the inhalation phase of respiration and will inhibit the normal postural function of the diaghragm. It is noted that the thoraco-lumbar (T/L) junction is hyperlordotic and the diaphragm is oblique in this position (see figure 1). Ideally, a depressed (e.g. caudal) anterior chest position is facilitated which is the “exhalation” position. In this case the T/L junction is more neutral and the diaghragm is “centrated” in a horizontal position (see figure 2). The “exhalation” position is believed to be facilitory of the abdominal wall since active exhalation is produced by the abdominal muscles.

Fig1 Fig2

Bracing the Core

Co-contractions have been shown to occur automatically in response to unexpected or sudden loading and to have a stabilizing effect (Lavender 1989, Marras 1987). Stokes (2000) has described how there are basically two mechanisms by which this co-activation occurs. One is a voluntary pre-contraction to stiffen the spinal column when faced with unexpected perturbations. The second is an involuntary, reflex contraction of the muscles quick enough to prevent instability following either expected or unexpected perturbations (Cresswell 1994, Lavender 1989, Marras 1987, Stokes 2000, Wilder 1996).

Performing an abdominal brace (AB) is very simple. The patient should pretend they are about to be pushed or hit and they will “automatically’ brace.

Neutral Spine Posture

The ideal spine posture is the same as occurs when standing upright – neutral lumbar lordosis. Many patients perform a posterior pelvic tilt which actually places the lumbo-sacral spine in flexion and thus can potentially harm the disc via end-range loading in flexion. The “neutral zone is the inner region of a joint’s range of motion (ROM) where minimal resistance to motion is encountered” (Panjabi 1992). According to McGill (2006) “Because ligaments are not recruited when lordosis is preserved, nor is the disc bent, it appears that the annulus is at low risk for failure.”.

Training the Core

After breathing and bracing are trained with good lumbar spine posture during such exercises as dying bugs, bird-dog, curl-ups, and side bridges. The patient is ready to take on more rigorous challenges. One of the most common mechanisms of injury is lumbar torsion. Controlling lumbar torsion is thus helpful for those patients who play tennis, golf, hockey, baseball, soccer, and any other sport involving bending and twisting.

The “stir the pot” exercise is an excellent way to train control of lumbar rotation (Reynolds 2009)(figure 3).

If you can perfrom forward plank with stability, progress to this exercise
Tighten your core to stiffen your trunk
Move the ball side to side & in circles by small movements from your shoulders
Progress by performing on your toes with legs straight.
Progress further by placing your toes on a Bosu.

Conclusion

Abdominal exercises are utilized for cosmetic and therapeutic purposes. There are a number of myths which should be unmasked about this subject regarding sit-ups, morning exercise, the posterior pelvic tilt, the transverse abdominus, exhaling with exertion, etc.. The 4 pillars of core training described in this article should be incorporated into all abdominal training. The dying bug is an excellent starting point to “groove” healthy motor patterns. This should be seen as a first step, but not an end in itself. Progressions to side support, quadruped, and most importantly upright (squat, lunge, push, and pull) positions is essential to ensure sufficient stability in the lumbar spine during participation in job demands, activities of daily living, as well as sports and recreational activities.

References:

Adams, M.A., Dolan, P. 1995. Recent advances in lumbar spine mechanics and their clinical significance, Clin Biomech 10: 3‑19.

Adams, M.A., Hutton, W.C. 1985. Gradual disc prolapse, Spine 10: 524‑531.

Andersson GBJ, Winters JM 1990. Role of muscle in postural tasks: spinal loading and postural stability. In Winters JM, Woo SL-Y (eds) Multiple Muscle Systems, Springer-Verlag, New York Ch 23 p 375-395.

Cholewicki J, Silfies SP, Shah RA, et al. 2005. Delayed trunk muscle reflex responses increase the risk of low back injuries. Spine. 30(23):2614-20

Cholewicki J, Panjabi MM, Khachatryan A 1997. Stabilizing function of the trunk flexor-extensor muscles around a neutral spine posture. Spine 22: 2207-2212.

Cholewicki, J., and McGill, S.M. 1996. Mechanical stability of the in vivo lumbar spine: Implications for injury and chronic low back pain, Clin Biomech 11(1):1-15.

Cresswell AG, Oddsson L, Thorstensson A 1994. The influence of sudden perturbations on trunk muscle activity and intraabdominal pressure while standing. Exp Brain Res 98:336–41.

Granata KP, Marras WS 2000. Cost-benefit of muscle cocontraction in protecting against spinal instability. Spine 25:1398-1404.

Hickey DS, Hukins DWL 1980. Relation between the structure of the annulus fibrosis and the function and failure of the intervertebral disc. Spine 5:106-116.

Hodges PW, Richardson CA 1998. Delayed postural contraction of the transverse abdominus associated with movement of the lower limb in people with low back pain. J Spinal Disord 11:46-56.

Hodges PW, Richardson CA 1999. Altered trunk muscle recruitment in people with low back pain with upper limb movements at different speeds. Arch Phys Med Rehabili 80:1005-1012.

Kavcic N. Grenier S, McGill SM 2004. Determining the stabilizing role of individual torso muscles during rehabilitation exercises. Spine 29:1254-1265.

Kolar P 2007. Facilitation of agonist-antagonist co-activation by reflex stimulation methods in Rehabilitation of the Spine: A Practitioner’s Manual, Liebenson C (ed). Lippincott/Williams and Wilkins, Philadelphia.

Lavender SA, Mirka GA, Schoenmarklin RW, Sommerich CM, Sudhakar LR, Marras WS 1989. The effects of preview and task symmetry on trunk muscle response to sudden loading. Human Factors 31: 101-115.

Liebenson C. Functional Stability Training in Rehabilitation of the Spine: A Practitioner’s Manual. Lippincott/Williams & Wilkins (2^nd ed), Philadelphia 2007.

Marras WS, Mirka GA 1990. Muscle activities during asymmetric trunk angular accelerations. J Orthop Res 8:824-32.

Marras WS, Rangarajulu SL, Lavender SA 1987. Trunk loading and expectation. Ergonomics 30:551–62.

McGill SM 2007. Lumbar Spine Stability: Mechanism of Injury and Restabilization in Rehabilitation of the Spine: A Practitioner’s Manual, Liebenson C (ed). Lippincott/Williams and Wilkins, Philadelphia.

McGill SM 2006. Ultimate back fitness and performance (2^nd edition).Wabunu .

McGill,S.M., Sharratt,M.T., Seguin,J.P. 1995. Loads on the spinal tissues during simultaneous lifting and ventilatory challenge, Ergonomics 38: 1772-1792.

Panjabi MM 1992. The stabilizing system of the spine. Part 1. Function, dysfunction, adaptation, and enhancement. J Spinal Disorders 5:383-389.

Reynolds G. NY TIMES JUNE 17, 2009 “Is Your Ab Workout Hurting Your Back?”

http://well.blogs.nytimes.com/2009/06/17/core-myths/

Stokes IAF, Gardner-Morse M, Henry SM, Badger GJ 2000. Decrease in Trunk Muscular Response to Perturbation With Preactivation of Lumbar Spinal Musculature. Spine 25:1957-1964.

Wilder DG, Aleksiev AR, Magnusson ML, Pope MH, Spratt KF, Goel VK 1996. Muscular response to sudden load. A tool to evaluate fatigue and rehabilitation. Spine 21:2628–39.

Figure Legend:

Inhalation position of the sternum and anterior-inferior chest wall
Exhalation position of the sternum and anterior-inferior chest wall
The abdominal brace
Dying bug
Dying bug with small hand weight
Marching on foam roll with medicine ball in hands
The overhead arm reach on a foam roll
Medicine ball trunk twist

Advance Your Rehab Diplomate: Add a Medicolegal Subspecialty

August 1st, 2010

Leanne N. Cupon, DC, DACRB, DABFP

You have to agree that within our rehab diplomate core requirements, there is a paucity of advanced education in forensics (the application of medical facts to legal issues and/or proceedings).

The forensics syllabus was formulated prior to 2000 and there was a concerted effort not to reinvent educational requirements that had been transcripted through recognized diplomate programs, but rather to utilize those hours (advanced standing toward core requirements) and to supplement where appropriate. Advanced (rehab) standing, completion of forensic educational requirements (only 136 hours; most online at www.ChiroCredit.com) and passing the forensics‑specific examination lead to certification as a forensic professional (DABFP).

An example of forensic certification would be as follows: Since you are a DACRB, you would identify yourself as a forensic professional concentrating in rehabilitation in legal matters.

Forensic training focuses on areas that enhance the diplomate’s ability to increase revenue sources through knowledge, training, skill and experience in Federal Rules of Evidence (FRE); disability determination systems or programs, impairment rating systems, independent medical examinations (IMEs), functional (work) capacity and physical assessment (Federal) systems, return to work and fitness for duty (DOT) assessment, fraud and abuse investigation, compliance issues, post payment audits, ethics issues, documentation formulation, informed consent and/or expert witness activities.

Council on Forensic Sciences (CFS) endorses the Objective Scientists Model for forensic examination, expert evidence based on the Reference Manual of Scientific Evidence, the American Board of Independent Medical Examiners’ protocol for IMEs, the American Medical Association’s Guides to the Evaluation of Permanent Impairment 4th‑6th editions for impairment ratings, the National Association for Disability Evaluating Professionals’ (NADEP) and CFS protocol for Functional Capacity Evaluation (FCE), and the professional policies of the American College of Medical Quality (ACMQ) and the American Chiropractic Association.

Membership in the ACA Council of Forensic Sciences is open to all ACA members interested in learning more about medicolegal issues.

For more information on CFS, visit forensic-sciences.com or contact Leanne Cupon, DC, DACRB at (770) 740‑1999 or drlcupon@ix.netcom.com.

For information on the forensics diplomate program (DABFP), contact Steve Baker, DC, at (520) 323‑2888 or sbaker@rinconchiropractic.com

In-Office Rehab and Balance Training

August 1st, 2010

Dr. Jeffrey Tucker, DC

The doctors that I get to teach, and those that I meet who include exercise therapy in their practice appear to create better client satisfaction and experience better patient retention.

Patients enjoy the participation in their care that exercise therapy provides. More than thirty-five years ago, when I was a teenager, going to the gym and working out was for kids and parents who already had an active lifestyle. The typical ‘old school’ gym program included a ten minute bike or treadmill warm up, a 40-50 minute strength training regime—usually in a muscle group split, and then on “off-days,” 20-30 minutes of cardio. Today’s ‘new school’ exercise programs consists of foam roll therapy (self myofascial release) for 10 minutes, stretching of overactive muscles for 5-10 minutes, core stability exercises for 5-10 minutes, balance training for 5 minutes, reactive training and speed, agility and quickness training for 5-10 minutes, intense strength training for 20-25 minutes, metabolic/cardiovascular training for 10-15 minutes and 5 minutes for cooling down.

Many clients that come to us may already be doing any or all of these exercise strategies on their own at home or in the gym. My role as a rehab specialist is to write corrective exercise programs, teach clients how to perform the exercises and guide them into progressions that help eliminate pain.

Additional therapeutic goals may include injury prevention, decreased body fat, increased lean muscle mass, increased strength, increased endurance, increased flexibility, and enhanced performance. You can have a very successful exercise practice in your office using Therabands, especially the ones with handles, a barbell, dumbbells, kettlebells, a sturdy exercise bench that inclines, a swiss ball, a wobble board, or rocker board, or bosu.

I break up each of the “new school” categories of exercise in my in-office treatment sessions. After the acute care phase, I start by training clients in the use of the 3-foot-by-6-inch wide foam roll. This method of self myofascial release is used to inhibit overactive muscles. Holding pressure on the tender areas of tissue (trigger points) for a sustained period of time, usually 30 seconds per tender point, can diminish trigger point activity.

Patients are expected to use the foam roll at home on their own. This is followed by a session where I teach clients how to stretch. Following use of the foam roll, the application of a lengthening technique (static stretching) resets the muscle lengths and provides for optimal length-tension relationships. Once patients are foam rolling and stretching at home, the subsequent in-office session is used to teach isolated strengthening exercises. This session time is used to teach clients how to isolate and exercise a particular muscle. For example, a common underactive muscle is the gluteus medius.

The side lying hip abduction exercise would be taught to increase the force production capabilities through concentric-eccentric muscle actions. Isolated exercises focus on the muscles of the body that have synergistic function of the stabilization and mobilization
system.

Additional sessions are required to train clients in integrated dynamic strengthening exercises. This will ensure an increase in intra- and intermuscular coordination, endurance strength and optimal force-couple relationships that will produce proper arthrokinematics.

An important exercise therapy often overlooked by clinicians, is that prior to resistance training, balance training should be performed, because it has preconditioning effects on strength training. Our everyday clients face the challenges of keeping balance to perform activities such as playing with their children or grandchildren, walking on uneven surfaces
or even taking a walk in their neighborhood.

‘New school’ exercise programs realize balance is a skill-related component of physical fitness. It is important to incorporate balance training in every client’s corrective exercise program as an integrated component to a comprehensive training regimen.

Balance can be influenced by many factors. As we age, our ability to balance or maintain postural control decreases. Watch seniors maneuver steps and stairs. Those who lack the ability to decelerate and control their center of gravity have a significant risk potential of a devastating fall. Prior injuries, especially after ankle sprains, ligamentous injuries to the knee, and low back pain can also decrease an individual’s ability to balance.

A joint dysfunction in the ankle, knee, shoulder, or low back can lead to muscle inhibition. An acute joint injury may cause joint swelling, which results in an interruption in the internal communication process of the body–sensory input from receptors such as articular, ligamentous, and muscular mechanoreceptors to the central nervous system. In turn, this changes our proprioceptive capabilities. When sensory input to the central nervous system is altered, our movement system may become imbalanced. Repetitive recruitment of the wrong muscle fibers, in the same ROM/Plane of motion and at the same speed, creates tissue overload and eventual injury. Consequentially, this can lead to neuromuscular inefficiency, resulting in decreased balance and postural instability.

Recovery from injury needs to include repairing faulty movement patterns (alterations in stability) and correcting inefficient neuromuscular control. Through balance training, the central nervous system can be exercised to change and improve a lack of joint stabilization that is causing functional instability.

Don’t forget to address balance as a component of a training program. Balance training may be used not only for reconditioning clients post injury, but also as a preventative measure to increase postural stability and reduce the chances of injury.

In Part Two of this article I will write a corrective exercise program for balance training.

Reprinted from an article published in the CCA Journal Feb 2010

About the Author:

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

For more information, please visit: www.drjeffreytucker.com

To learn more about rehabilitation in your practice come to the 2010 Annual Rehab Symposium, March 5 – 7 at the Westin Los Angeles Airport Hotel in Los Angeles, CA. Group rate at the Westin is $109.00/night. Please call the Westin Hotel at (310) 216-5858 to make your reservations. Any questions about the upcoming Rehab Symposium, call program co-ordinator, Dr. Don Fedoryk at (908) 722-9075 or e-mail him at RehabDC18@aol.com.

Please check the ACA Rehab Council’s newly formatted website at: www.ccptr.org

Dynamic Neuromuscular Stabilization (DNS) Introduction & Adjustive Technique

August 1st, 2010

neuro

Dynamic Neuromuscular Stabilization (DNS) Skills Workshop

August 1st, 2010

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Dynamic Neuromuscular Stabilization (DNS) According to Kolar – Course “C”

August 1st, 2010

Functional Action, Inc.
Presents

Dates: November 6-9, 2010
Sunrise Hotel at Redondo Beach Harbor
400 N. Harbor Drive, Redondo Beach, CA 90277
www.bestwestern-sunrise.com

Pavel Kolar, Paed Dr., PhD
Magdalena Jezková, PT
Alena Kobesova, MD, PhD
Craig E. Morris DC
Clare Frank, DPT

Course attendees will gain further insights regarding the introductory understanding of:

Deeper principles of developmental kinesiology.
Additional reflex stimulation positions
Complex management of DNS cases DNS case management of specific disorders
Greater Depth in functional stabilization of the spine & correction of poor stereotypical respiration.
Critical principles of reflex locomotion: locomotor patterns, stepping forward & support function, support/stimulating zones.

Workshop Timetable

Saturday Nov 6, 2009
09.00 – 10.30 Workshop
10.30 – 11.00 Coffee break
11.00 – 12.30 Workshop
12.30 – 13.30 Lunch
13:30 – 15:00 Workshop
15:00 – 15:30 Coffee break
15:30 – 17:00 Workshop

Sunday Nov 7, 2009
09:00 – 10:30 Workshop
10:30 – 11:00 Coffee break
11:00 – 12:30 Workshop
12:30 – 13:30 Lunch
13:30 – 15:00 Workshop
15:00 – 15:30 Coffee break
15:30 – 17:00 Workshop

Monday Nov 8, 2009
09.00 – 10.30 Workshop
10.30 – 11.00 Coffee break
11.00 – 12.30 Workshop
12.30 – 13.30 Lunch
13.30 – 15.00 Workshop
15.00 – 15.30 Coffee break
15.30 – 17.00 Workshop

Tuesday Nov 9, 2009
09:00 – 10:30 Workshop
10:30 – 11:00 Coffee break
11:00 – 12:30 Workshop
12:30 – 13:30 Lunch
13:30 – 15:00 Workshop
15:00 – 15:30 Coffee break
15:30 – 17:00 Workshop

Enrollment Fee:
Early-Bird Discount: $995 USD* [ ]
Registration After Aug 1: $1,095 USD* [ ]
Examination Fee** $150 USD

*$500 non-refundable **Please note: The examination fee is elective for workshop registrants. However, successful completion of the examination component is a pre-requisite for admission into the Course D workshop to qualify to become a “Certified DNS Clinician”. Please see the DNS/Prague School website (www.rehabps.com) for detailed explanation of DNS certification.

Registration for this course is limited due to the hands-on nature of the course.
Please register at the F.A.I. website at www.rehabfai.com

Hotel Accommodations

FAI has negotiated a discounted room rate of $119/night for our courses at the Sunrise Hotel Best at Redondo Beach Harbor. Please call +1-310-376-0746 to register and ask for the DNS-FAI course room discount rate. There is free parking to all attendees. Book your room ASAP, as this popular hotel fills quickly.

Dynamic Neuromuscular Stabilization (DNS) According to Kolar – Course “B”

August 1st, 2010

Functional Action, Inc.
Presents
Dates: November 6-9, 2010
Sunrise Hotel at Redondo Beach Harbor
400 N. Harbor Drive, Redondo Beach, CA 90277
www.bestwestern-sunrise.com

Pavel Kolar, Paed Dr. PhD
Magdalena Jezková PT
Alena Kobesova, MD, PhD
Craig E. Morris DC
Clare Frank, DPT

Course attendees will gain further insights regarding the introductory understanding of:

The basic principles of developmental kinesiology.
Development during the first year of life: stabilization of the spine in the sagittal plane, development of the phasic movements coupled with trunk rotation.
The relationship between development during the first year of life & locomotor system pathology in adulthood.
The reflex consequences following central neural programs during the first year of life. Functional stabilization of the spine & correction of poor stereotypical respiration.
New terminology such as functional joint centration/decentration, punctum fixum, and the integrated stabilizing system of the spine.
In addition, posture will be discussed from a developmental point of view.
Critical principles of reflex locomotion: locomotor patterns, stepping forward & support function, support/stimulating zones.

Workshop Timetable

Saturday, October 23, 2010
09.00 – 10.30 Workshop
10.30 – 11.00 Coffee break
11.00 – 12.30 Workshop
12.30 – 13.30 Lunch
13:30 – 15:00 Workshop
15:00 – 15:30 Coffee break
15:30 – 17:00 Workshop

Sunday October 24, 2010
09:00 – 10:30 Workshop
10:30 – 11:00 Coffee break
11:00 – 12:30 Workshop
12:30 – 13:30 Lunch
13:30 – 15:00 Workshop
15:00 – 15:30 Coffee break
15:30 – 17:00 Workshop

Saturday October 30, 2010
09.00 – 10.30 Workshop
10.30 – 11.00 Coffee break
11.00 – 12.30 Workshop
12.30 – 13.30 Lunch
13.30 – 15.00 Workshop
15.00 – 15.30 Coffee break
15.30 – 17.00 Workshop

Sunday October 31, 2010
09:00 – 10:30 Workshop
10:30 – 11:00 Coffee break
11:00 – 12:30 Workshop
12:30 – 13:30 Lunch
13:30 – 15:00 Workshop
15:00 – 15:30 Coffee break
15:30 – 17:00 Workshop

Enrollment Fee:
Early-Bird Discount: $995 USD* [ ]
Registration After Aug 1: $1,095 USD* [ ]
Examination Fee** $150 USD

*$500 non-refundable **Please note: The examination fee is elective for workshop registrants. However, successful completion of the examination component is a pre-requisite for admission into the Course D workshop to qualify to become a “Certified DNS Clinician”. Please see the DNS/Prague School website (www.rehabps.com) for detailed explanation of DNS certification.

Registration for this course is limited due to the hands-on nature of the course.
Please register at the F.A.I. website at www.rehabfai.com

Hotel Accommodations

Dynamic Neuromuscular Stabilization (DNS) According to Kolar – Course “A”

August 1st, 2010

Functional Action, Inc.
Presents

Dates: October 23-24 & 30-31, 2010 Sunrise Hotel at Redondo Beach Harbor 400 N. Harbor Drive, Redondo Beach, CA 90277

Course attendees will have a clear understanding of:

The basic principles of developmental kinesiology.
Development during the first year of life: stabilization of the spine in the sagittal plane, development of the phasic movements coupled with trunk rotation.
The relationship between development during the first year of life & locomotor system pathology in adulthood.
The reflex consequences following central neural programs during the first year of life.
Functional stabilization of the spine & correction of poor stereotypical respiration.
New terminology such as functional joint centration/decentration, punctum fixum, and the integrated stabilizing system of the spine.
In addition, posture will be discussed from a developmental point of view.
Critical principles of reflex locomotion: locomotor patterns, stepping forward & support function, support/stimulating zones.

Course attendees will possess:

Skills to utilize critical functional tests to evaluate the integrated stabilizing system of the spine. Skills for evaluation of breathing stereotypes.

Course Description

Much attention has been given in recent years to the development, maintenance and decline of functional stability of the locomotor system. Indeed, emerging research has proven the existence of the deep, or core, stabilizing muscles and their impact in controlling safe joint motion. This is especially true for the joints of the spinal column, where the complexity of the biomechanical and neurophysiological demands is phenomenal. With the increased understanding of functional stability have arisen new theories regarding the etiology of functional pathology and also of effective treatment methods to restore stability. Unfortunately, these techniques have yielded less than satisfactory results for many frustrated clinicians in search of more effective and long-lasting results. Some functional stabilization methods, although based on sound principles, have been criticized as impractical.

Course Instructors

Craig E. Morris, D.C., DACRB, CSCS
Dr. Morris is the Director of the F.I.R.S.T. Health clinic in Torrance, California, where he has practiced for 27 years. He is a Clinical Professor at Cleveland Chiropractic College, Los Angeles. He has studied rehabilitation and manual medical techniques extensively at Charles University Hospital in Prague, Czech Republic and is the first DC DNS Certified Instructor in North America. He studied extensively with the late Professor Vladimir Janda, assisting him in many of his courses internationally. A popular instructor in both lecture and work shopping, Dr. Morris teaches courses around the world. He is the editor and a multi-chapter author of “Low Back Syndromes: Integrated Clinical Management”, a leading multi-professional textbook published by McGraw-Hill. In addition to rehabilitation, he specializes in sports injuries and medico-legal issues.

Magdalena Jezková, P.T.
Dr. Šafarová graduated from Charles University Dept of Physical Therapy and specializes in rehabilitation of locomotor system dysfunction. She is a senior physiotherapist of the Physical Therapy Department at the Motol Hospital in Prague. She is a certified Vojta therapist and has trained and worked with Professor Kolar and Dr. Kobesova at the rehabilitation department for several years, where she treats both adults and children. She regularly instructs both medical and physiotherapy students at the hospital. Fluent in English, Ms. Jezkova has served as an assistant skills instructor for several of Professor Kolar’s courses for international clinical groups who come to study in Prague, in addition to lecturing on his methods internationally. She resides in Prague with her husband and three children.

Workshop Timetable

Enrollment Fee:
Regular Fee: $1,095 USD* [ ]
Early Bird Discount**: $995 USD* [ ]
Examination Fee*** $100 USD

* $500 non-refundable ** Registration/Payment completed by June 1, 2010 ***Please note: The examination fee is elective for workshop registrants. However, successful completion of the examination component is a pre-requisite for admission into the Course D workshop to qualify to become a “Certified DNS Clinician”. Please see the DNS/Prague School website (www.rehabps.com) for detailed explanation of DNS certification.

Registration for this course is limited due to the hands-on nature of the course.
Please register at the F.A.I. website at www.rehabfai.com

“Dynamic Neuromuscular Stabilization (DNS) is a critically is a critically important inclusion within Murdoch University’s Postgraduate Certificate and Diploma Courses in Musculoskeletal Rehabilitation. I would highly recommend this course to doctors interested in expanding their clinical skills and scope of practice, especially in the fields of rehabilitation, sports chiropractic and chronic pain disorders.” – John Sweeney, AM, DC, FACC, FICC, Past-President, World Federation of Chiropractic
“DNS training has helped broaden my ability to understand and assess neuromuscular conditions at a deeper level while adding a treatment approach that has improved my effectiveness with my current cases and expanded my ability to treat patients that were untreatable by previous methods.” – Dave Juehring, DC, DACRB, Director, Palmer College Rehabilitation Clinics & Residency Program, Davenport, IA

“After studying the diagnostic and manual therapeutic methods of Professor Pavel Kolar, I am increasingly convinced of the critical importance of this approach.” -Rocco Guerriero, B.Sc. D.C. FCCSS(c) FCCRS(c) FCCO(c), Associate Professor, Canadian Memorial Chiropractic College, Coordinator of the Department of Rehabilitative and Assessment Services
“Every chiropractor and chiropractic student needs to know this information.” – Kim Christensen, DC, CCSP. DACRB, CSCS, Portland, OR.

Dynamic Neuromuscular Stabilization (DNS) According to Kolar – Course “A”

August 1st, 2010

Functional Action, Inc.
Presents

Dates: August 7-8 & 14-15, 2010 Sunrise Hotel at Redondo Beach Harbor 400 N. Harbor Drive, Redondo Beach, CA 90277

Course attendees will have a clear understanding of:

The basic principles of developmental kinesiology. Development during the first year of life: stabilization of the spine in the sagittal plane, development of the phasic movements coupled with trunk rotation. The relationship between development during the first year of life & locomotor system pathology in adulthood. The reflex consequences following central neural programs during the first year of life. Functional stabilization of the spine & correction of poor stereotypical respiration. New terminology such as functional joint centration/decentration, punctum fixum, and the integrated stabilizing system of the spine. In addition, posture will be discussed from a developmental point of view. Critical principles of reflex locomotion: locomotor patterns, stepping forward & support function, support/stimulating zones.

Course attendees will possess:

Skills to utilize critical functional tests to evaluate the integrated stabilizing system of the spine. Skills for evaluation of breathing stereotypes.

Course Description

Course Instructors

Petra Valouchova, P.T., Ph.D.
Dr. Valouchova is a physiotherapist at the Rehabilitation Department, University Hospital Motol, School of Medicine, Charles University, Prague, Czech Republic. She earned her degree in physiotherapy at Palacky University in Oloumoc, Czech Republic. She subsequently earned her Ph.D. in biomechanics at the same institution.Dr. Valouchova is an instructor of neurological manual medicine and rehabilitation at the 2nd Medical School and also the Physiotherapy School, Charles University, Prague. She also organizes courses for international groups of clinicians travel to the Czech Republic to study the “Prague School” methods.
Dr. Valouchova successfully completed the Czech Reflex Locomotion Training Course, which covers the theoretical and practical methods of the founder of Reflex Locomotion, the late Professor Vaclav Vojta. Dr. Valouchova has additional training in pediatric and sports rehabilitation. An elite athlete herself, she has competed in and won numerous international team step fitness competitions.
Workshop Timetable

Sunday August 8, 2010
09.00 – 10.30 Workshop
10.30 – 11.00 Coffee break
11.00 – 12.30 Workshop
12.30 – 13.30 Lunch
13:30 – 15:00 Workshop
15:00 – 15:30 Coffee break
15:30 – 17:00 Workshop

Sunday August 15, 2010
09:00 – 10:30 Workshop
10:30 – 11:00 Coffee break
11:00 – 12:30 Workshop
12:30 – 13:30 Lunch
13:30 – 15:00 Workshop
15:00 – 15:30 Coffee break
15:30 – 17:00 Workshop

Saturday August 7, 2010
09.00 – 10.30 Workshop
10.30 – 11.00 Coffee break
11.00 – 12.30 Workshop
12.30 – 13.30 Lunch
13.30 – 15.00 Workshop
15.00 – 15.30 Coffee break
15.30 – 17.00 Workshop

Saturday August 14, 2010
09:00 – 10:30 Workshop
10:30 – 11:00 Coffee break
11:00 – 12:30 Workshop
12:30 – 13:30 Lunch
13:30 – 15:00 Workshop
15:00 – 15:30 Coffee break
15:30 – 17:00 Workshop

Enrollment Fee:
Regular Fee: $1,095 USD*
Early Bird Discount**: $995 USD*
Examination Fee*** $100 USD

* $500 non-refundable ** Registration/Payment completed by June 1, 2010 ***Please note: The examination fee is elective for workshop registrants. However, successful completion of the examination component is a pre-requisite for admission into the Course D workshop to qualify to become a “Certified DNS Clinician”. Please see the DNS/Prague School website (www.rehabps.com) for detailed explanation of DNS certification.

Registration for this course is limited due to the hands-on nature of the course. Please register at the F.A.I. website at www.rehabfai.com

“Dynamic Neuromuscular Stabilization (DNS) is a critically is a critically important inclusion within Murdoch University’s Postgraduate Certificate and Diploma Courses in Musculoskeletal Rehabilitation. I would highly recommend this course to doctors interested in expanding their clinical skills and scope of practice, especially in the fields of rehabilitation, sports chiropractic and chronic pain disorders.” – John Sweeney, AM, DC, FACC, FICC, Past-President, World Federation of Chiropractic
“DNS training has helped broaden my ability to understand and assess neuromuscular conditions at a deeper level while adding a treatment approach that has improved my effectiveness with my current cases and expanded my ability to treat patients that were untreatable by previous methods.” – Dave Juehring, DC, DACRB, Director, Palmer College Rehabilitation Clinics & Residency Program, Davenport, IA
“After studying the diagnostic and manual therapeutic methods of Professor Pavel Kolar, I am increasingly convinced of the critical importance of this approach.” -Rocco Guerriero, B.Sc. D.C. FCCSS(c) FCCRS(c) FCCO(c), Associate Professor, Canadian Memorial Chiropractic College, Coordinator of the Department of Rehabilitative and Assessment Services
“Every chiropractor and chiropractic student needs to know this information.” – Kim Christensen, DC, CCSP. DACRB, CSCS, Portland, OR.

Dynamic Neuromuscular Stabilization (DNS) Skills Workshop

August 1st, 2010

neuro View Flyer

2010 F.A.I. Schedule

August 1st, 2010

Functional Action, Inc.

Please review the 2010 schedule, which includes continuing education hours, and share it with your friends
and colleagues. We hope to see you in 2010!

March 6-7, 2010 — Redondo Beach – Morris/Faye Course (8 hours DNS Intro /4 hours Adj Technique) Instructors: Craig E. Morris, D.C., DACRB, Leonard J. Faye D.C., F.C.C.S.S. (C) Hon, F.I.C.C.

April 24-25, 2010 – San Diego – Morris/Faye Course (8 hours DNS Intro /4 hours Adj Technique) Instructors: Craig E. Morris, D.C., DACRB, Leonard J. Faye D.C., F.C.C.S.S. (C) Hon, F.I.C.C.

May 1-2, 2010 – Redondo Beach – Morris/Faye Course (8 hours DNS Intro /4 hours Adj Technique) Instructors: Craig E. Morris, D.C., DACRB, Leonard J. Faye D.C., F.C.C.S.S. (C) Hon, F.I.C.C.

May 22-23, 2010 — Davenport – Morris/Faye Course (8 hours DNS Intro /4 hours Adj Technique) Instructors: Craig E. Morris, D.C., DACRB, Leonard J. Faye D.C., F.C.C.S.S. (C) Hon, F.I.C.C.

June 4-6, 2010 — Naarden DNS Basic “A” Course (3-day)
Instructors: Instructors: Craig E. Morris, D.C., DACRB & Martina Jezkova, P.T.

July 17-18, 2010 — Redondo Beach – DNS Skills/Review Courses (2 days) Instructors: Lucie Oplova, P.T. & Craig E. Morris, D.C., DACRB

August 7-8 & 14-15 Redondo Beach – DNS Basic “A” Course (4 day) Instructors: Petra Valouchova, P.T., Ph.D & Craig E. Morris, D.C., DACRB

August 20-22, 2010 — Davenport, Iowa DNS Basic “A” Course (4 day) Instructors: Craig E. Morris, D.C., DACRB & Petra Valouchova, P.T., Ph.D

October 9-10, 2010 – Redondo Beach Morris/Faye Course (8 hours DNS Intro /4 hours Adj Technique) Instructors: Craig E. Morris, D.C., DACRB, Leonard J. Faye D.C., F.C.C.S.S. (C) Hon, F.I.C.C.

October 23-24 & 30-31 Redondo Beach – DNS Basic “A” Course (4 days) Instructors: Craig E. Morris, D.C., DACRB & Marcela Safarova, P.T., Ph.D

November 6-9, 2010 — Redondo Beach — DNS Basic “B” Course (4 days):
Instructors: Pavel Kolar, P.T., Paed. Dr., Ph.D – DNS Founder (Days 3 and 4 only), Alena Kobesova, M.D., Ph.D., Craig E. Morris, D.C., DACRB, CSCS, Martina Jezkova, P.T., Clare Frank, D.P.T, MS.

November 6-9, 2010 — Redondo Beach — DNS Intermediary Course “C” (4 days):
Instructors: Pavel Kolar, P.T., Paed. Dr., Ph.D – DNS Founder (Days 3 and 4 only), Alena Kobesova, M.D., Ph.D., Craig E. Morris, D.C., DACRB, CSCS, Martina Jezkova, P.T., Clare Frank, D.P.T, MS.

Please visit the FAI website at www.rehabfai.com (registration protected by PayPal)

A Review of Mindfulness

August 1st, 2010

By Maria A. Perri, D.C., D.A.C.R.B.

The American Academy of Family Physicians has estimated that up to two-thirds of all office visits to family doctors are for stress-related symptoms. Research over the last 2 decades has indicated that up to 60% of all HMO visits are made by people with no diagnosable disorder–the “worried well” (Sobel)–and that many of these presenting symptoms are related to the patient’s psychosocial functioning–things such as depression, anxiety, social isolation, overwork, etc. (Kroenke & Mangelsdorff ). At least one third of cardiology patients presenting with chest pain who have normal or near normal coronary arteries have been found to be suffering from panic disorder (Kusher).

Are you interested in improving your ability to co-manage your neuro-musculoskeletal patient’s who also suffer from these all pervasive psychosocial issues? The important question, “How do you alter your treatment protocols for special populations?” is asked during the skills section of the ACRB’s Oral Practical Examination. Those taking the test are asked detailed questions about the rehab program they would create for a geriatric or pediatric patient or for an elite athlete. How would you answer this question today if your patient’s condition was stress related? Do you presently have the skill set to effectively participate in the co-management of patients with high blood pressure, colitis, sleep disturbances, depression or anxiety disorders? A large percentage of your patients with NMS related complaints are also suffering with many stress related ailments. When you begin to delve into their history you will find that a majority of your patients have an “Upper Stress Syndrome”; Hypertonicity of the amygdala and adrenal glands and Inhibition of the diaphragm and pre-frontal cortex (Perri, 2010 – I just made this up!) Seriously, as Chiropractors, I believe we can do more for these patients than give a good referral.

At the annual ACRC’s Conference held this past March in LA, I presented a brief introduction to mindfulness and the neurobiology of well-being. Simply put, mindfulness is a way of focusing attention in the present moment and being fully present with the intension of experiencing rather than judging. Practicing mindfulness is recommended for anyone in a helping profession as it can lead to enhanced listening skills and a greater sense of health and well-being for the practitioner. Exposing patients to the concept of mindfulness can give them invaluable self care tools to better manage pain as well as stress with greater ease.

Many of us can recall times when we have experienced moments of mindfulness. Time stood still, our awareness was peaked and we were totally in the moment. When asked about these moments several in our group recounted unforgettable moments of near death experiences or readiness for winning a competition. All of us could also recall too many times when we were on automatic pilot; experiences of driving, eating, showering and (oh should we admit it) taking a patient’s history. During these moments we zone out and experience a time lapse so that when we come back to awareness we cannot recall what happened while we were “away”. These experiences are the antithesis of mindfulness.

There is a way to have moments of total presence more often and it is simple – practice! In fact, research has shown over the last 30+ years that the way we focus our attention can create actual structural changes in the brain that are measurable and reproducible. Dan Siegel describes in his groundbreaking book The Mindful Brain: The Neurobiology of Well-being the way mindfulness practice creates structural changes in the pre- frontal cortex and what effects these changes have on behavior, health and the experience of well-being.

Siegel describes the first function of the pre-frontal cortex as auto regulation of the autonomic nervous system. Patients with anxiety, high blood pressure, digestive disturbances or sleeping disorders can benefit greatly from a calmed sympathetic nervous system and a para-sympathetic nervous system that is supported and balanced.

Recent research has shown that mindful practices influence pain modulation and may be valuable in the treatment of central sensitization and chronic pain. Montreal University researchers from the lab of Pierre Rainville, PhD found that meditators experienced an 18% reduction in pain sensitivity compared to their non-meditating counterparts.

Building on this earlier study, researchers have found that Zen meditation can decrease sensitivity to pain by thickening brain matter. They measured thermal pain sensitivity of 17 seasoned meditators and compared them to that of 18 people who haven’t practiced any form of meditation or other relaxation techniques such as yoga.

The researchers placed a heated plate on the calf of participants and used Magnetic Resonance Imaging (MRI) to conduct brain scans. The results? Meditators had significantly thicker anterior cingulate, a region of the brain known for pain and emotion regulation. And with this thickening of the brain, pain sensitivity was decreased. The entire study can be found in a special edition of the American Psychological Association’s Journal Emotion.

The Center for Mindfulness in Medicine, Health Care, and Society at the University of Massachusetts Medical School is a visionary force and global leader in mind-body medicine. For thirty years, they have pioneered the integration of mindfulness meditation and other mindfulness-based approaches in mainstream medicine and healthcare. This includes patient care, research, academic medical and professional education, and into the broader society through diverse outreach and public service initiatives.

More than 18,000 patients have completed their 8 week Stress Reduction Program spearheaded by Jon Kabat Zinn called the MBSR (Mindfulness Based Stress Reduction) program. In addition, over 4,000 physicians as well as other healthcare providers have referred their patients to this program with exceptional results. Thousands of people worldwide have entered similar programs offered by practitioners trained by senior staff members at The Center for Mindfulness.

Their work over three decades has shown consistent, reliable, and reproducible demonstrations of major and clinically relevant reductions in medical and psychological symptoms across a wide range of medical diagnoses. This includes many different chronic pain conditions [Kabat-Zinn, 1982; Kabat-Zinn, Lipworth and Burney, 1985; Kabat-Zinn et al, 1986] as well as other medical diagnoses. [Kabat-Zinn and Chapman-Waldrop, 1988] Gains were also recorded in medical patients with a secondary diagnosis of anxiety and/or panic disorders. [Kabat-Zinn et al, 1992; Miller et al, 1995] A reduction of symptoms was shown over the eight weeks of MBSR intervention. The most significant finding is the maintenance of these changes in some cases for up to four years of follow-up.

Duke Integrative Medicine in Raleigh, North Carolina offers the 8 week Mindfulness Based Stress Reduction Program. The majority of people who complete the course report:

Lasting decrease in physical and psychological symptoms
An increase in ability to relax
Reduction in pain levels and an enhanced ability to cope with chronic pain that may be permanent
Greater energy and enthusiasm for life
Improved self-esteem
An ability to cope more effectively with both short and long-term stressful situations.

The new wave in progressive healthcare is called “integrative, participatory medicine”. It is a cooperative model of healthcare that encourages and expects active involvement by all connected parties (patients, caregivers, healthcare professionals, etc.) as integral to the full continuum of care. As early as 1946, The World Health Organization defined optimal health as “more than the absence of disease, involving mental, physical and social well-being.” Surprisingly familiar to what I learned on the first day of philosophy class in Chiropractic school. Duke University’s Department of Integrative Medicine offers the model below depicting the essential role of mindfulness in overall health and well being.

mindfulness

There is power and empowerment in participatory, integrative medicine. By adopting practices of mindfulness, patients can collaborate with providers to restore their own health, wholeness and balance and harmony within.

Duke Integrative Medicine

SUMMARY

How to integrate mindfulness into your Chiropractic practice:

The pace of our lives is so fast with constant demands and never ending to do lists. Sometimes our well-intentioned, well documented, evidence based rehab program is just another thing on a patient’s never-ending list.

Even our patients with “balanced” and happy lives often take time for exercise, but rarely make time to really relax the mind and body and just “be”.

Mindfulness exercises are so easy to do and regular practice can produce profound health benefits. The instructions are very simple:

Sit in a dignified position with a lengthened spine
Focus on your breath
Stay present

When thoughts arise as they inevitably do, return your focus back to the breath

There are many ways to practice mindfulness:

formal sitting practice/Walking meditation
Yoga/Tai Chi/Running (mindfully)
Centering prayer
Mundane activities done mindfully like walking the dog or washing dishes

If you are interested in learning mindfulness yourself or integrating mindfulness into your treatment approach I have several suggestions that will help you get started.

Learn more about the Mindfulness Based Stress Reduction Program at UMass Medical School by visiting www.umassmed.edu/cfm/
Visit www.Dukeintegrativemedicine.org to see a state of the art integrated program with mindfulness as the core operating principle
Read these books:
1. THE MINDFUL BRAIN –THE NEUROBIOLOGY OF WELL-BEING by Daniel Siegel MD
2. HEAL THYSELF by Saki Santorelli (director of The Center for Mindfulness in Medicine, Health Care, and Society)
Go to SoundsTrue.com – for free podcasts, books, audio & on line courses from the leaders: Zinn, Kornfield, Thich Nhat Hanh, Chodrin, Siegel and so many more
Join the Natl Inst. for Clinical Application of Behavior Medicine and explore their many related offerings: www.nicabm.com
Find a MBSR instructor in your area. Offer the 8 week course through your practice (and take it yourself).

The practice of mindfulness has a profoundly positive influence in my life, both personally and professionally. It is my intention to continue to share the depth and the wealth of this ancient knowledge, art and more recent science with our Rehab group. I hope that it inspires you and expands your skills to provide active care with the functional goal of well-being.

I leave you with the words of Sandy Wells, the founder of The Institute for Mindful Living:

Mindfulness is a way of learning to relate directly to your own experience with acceptance. It is a way to take charge of your life by developing the capacity to pay attention, moment-by-moment, without judgment, to the continuous stream of your experience.

It is a way of doing something for yourself that no one else can do for you — to consciously and systematically work with your own mind and learn to alleviate stress, pain, illness, and to relate to the challenges and demands of everyday life with awareness.

It is a way to develop sensitivity to all aspects of self: body and mind, heart and soul, and to restore within yourself a balanced sense of health and well-being.
Sandra Wells
The Institute for Mindful Living

Bibliography — Peer Reviewed Papers

Kabat-Zinn, J. An out-patient program in Behavioral Medicine for chronic pain patients based on the practice of mindfulness meditation: Theoretical considerations and preliminary results. Gen. Hosp. Psychiatry (1982) 4:33-47.

Kabat-Zinn, J., Lipworth, L. and Burney, R. The clinical use of mindfulness meditation for the self-regulation of chronic pain. J. Behav. Med. (1985) 8:163-190.

Kabat-Zinn, J., Lipworth, L., Burney, R. and Sellers, W. Four year follow-up of a meditation-based program for the self-regulation of chronic pain: Treatment outcomes and compliance. Clin.J.Pain (1986) 2:159-173.

Kabat-Zinn, J. and Chapman-Waldrop, A. Compliance with an outpatient stress reduction program: rates and predictors of completion. J.Behav. Med. (1988) 11:333-352.

Ockene, J., Sorensen, G., Kabat-Zinn, J., Ockene, I.S., and Donnelly, G. Benefits and costs of lifestyle change to reduce risk of chronic disease. Preventive Medicine, (1988) 17:224-234.

Bernhard, J., Kristeller, J. and Kabat-Zinn, J. Effectiveness of relaxation and visualization techniques as a adjunct to phototherapy and photochemotherapy of psoriasis. J. Am. Acad. Dermatol. (1988) 19:572-73.

Ockene, J.K., Ockene, I.S., Kabat-Zinn, J., Greene, H.L., and Frid, D. Teaching risk-factor counseling skills to medical students, house staff, and fellows. Am. J. Prevent. Med. (1990)6 (#2): 35-42.

Kabat-Zinn, J., Massion, A.O., Kristeller, J., Peterson, L.G., Fletcher, K., Pbert, L., Linderking, W., Santorelli, S.F. Effectiveness of a meditation-based stress reduction program in the treatment of anxiety disorders. Am. J Psychiatry (1992) 149:936-943.

Miller, J., Fletcher, K. and Kabat-Zinn, J. Three-year follow-up and clinical implications of a mindfulness-based stress reduction intervention in the treatment of anxiety disorders. Gen. Hosp. Psychiatry (1995) 17:192-200.

Massion, A.O., Teas, J., Hebert, J.R., Wertheimer, M.D., and Kabat-Zinn, J. Meditation, melatonin, and breast/prostate cancer: Hypothesis and preliminary data. Medical Hypotheses(1995) 44:39-46.

Kabat-Zinn, J. Chapman, A, and Salmon, P. The relationship of cognitive and somatic components of anxiety to patient preference for alternative relaxation techniques. Mind/ Body Medicine (1997) 2:101-109.

Kabat-Zinn, J., Wheeler, E., Light, T., Skillings, A., Scharf, M.S., Cropley, T. G., Hosmer, D., and Bernhard, J. Influence of a mindfulness-based stress reduction intervention on rates of skin clearing in patients with moderate to severe psoriasis undergoing phototherapy (UVB) and photochemotherapy (PUVA) Psychosomat Med (1998) 60: 625-632.

Saxe, G., Hebert, J., Carmody, J., Kabat-Zinn, J., Rosenzweig, P., Jarzobski, D., Reed, G., and Blute, R. Can Diet, in conjunction with Stress Reduction, Affect the Rate of Increase in Prostate-specific Antigen After Biochemical Recurrence of Prostate Cancer? J. of Urology, In Press, 2001.

Abstracts and Poster Sessions

Kabat-Zinn, J. and Burney, R. (1981) The clinical use of awareness meditation in the self-regulation of chronic pain. Pain Supplement 1, p.S273 (abs). Poster presented at III World Congress on Pain, Edinburgh, August, 1981.

Kabat-Zinn, J., Lipworth, L., Sellers, W., Brew, M., and Burney, R. Reproducibility and four year follow-up of a training program in mindfulness mediation for the self-regulation of chronic pain. Pain Supplement 2 pg.S303 (1984) (abs).Poster presented at IV World Congress on Pain, Seattle, Sept, 1984.

Kabat-Zinn, J., Beall, B. and Rippe, J. A systematic mental training program based on mindfulness meditation to optimize performance in collegiate and olympic rowers. Poster presented at VI World Congress in Sport Psychology, Copenhagen, Denmark, June, 1985.

Bath, J., Alfred, H. Powell, P., Cohen, A., Baker., S. and Kabat-Zinn, J. Patient Education: Relaxation training via videotape reduces cramping in patients undergoing chronic hemodialysis. Paper presented at APHA, Washington, D.C., Nov.18, 1985.

Kabat-Zinn, J., Goleman, D., and Chapman-Waldrop, A. Relationship of cognitive and somatic components of anxiety and depression to patient preference for alternative relaxation techniques. Poster presented at SBM, San Francisco, March 1986.

Kabat-Zinn, J. Sellers, W. and Santorelli, S. Symptom reduction in medical patients following stress management training. Poster presented at AABT Meetings, Chicago, Nov. 15, 1986.

Kabat-Zinn, J. and Chapman-Waldrop, A. Compliance with physician referral for stress management training. Poster presented at AABT Meetings, Chicago, Nov. 15, 1986.

Kabat-Zinn, J. Six-month hospital visit cost reductions in medical patients following self-regulatory training. Poster presented at SBM, Washington D.C. March 22, 1987.

Chapman-Waldrop, A. and Kabat-Zinn, J. SCL-90-R symptom profiles for seven diagnostic categories of medical patients. Poster presented at SBM, Washington, D.C., March 21, 1987.

Chapman-Waldrop, A. and Kabat-Zinn, J. Patient evaluation of multiple relaxation techniques: relationship to compliance and treatment outcome. Poster presented at SBM, Washington, D.C., March 22, 1987.

Kabat-Zinn, J. and Chapman-Waldrop, A. Compliance with physician referral for cognitive/behavioral intervention in chronic pain patients. Pain Suppl 4, pg. S170 1987.

Kabat-Zinn, J., Tarbell, S., French, C., Santorelli, S., Dubois, J., Curley, F., Pratter, M., and Irwin, R. Functional status of patients with COPD following a behavioral pulmonary rehabilitation program. Poster presented at SBM Meetings, Boston, April 29 (1988).

Frid, D., Ockene, J., Kabat-Zinn, J., Tarbell, S., and Doefler, L. Training primary care physicians in behavioral medicine: graduate medical education. Paper presented at SBM Meetings, Boston, April 30 (1988).

Kabat-Zinn, J. The clinical uses of mindfulness in behavioral medicine. Paper presented at AABT Meetings, Washington D.C., November 5, 1989.

Curley, F.J., French, C.L., Tarbell, S., Kabat-Zinn, J., and Irwin, R.S. Do patients perceive and cope with dyspnea similarly to pain? Paper presented at the American Thoracic Society Meetings, Boston, May 21, 1990.

Weinberger, J., McLeod, C., McClelland, D., Santorelli, S.F., and Kabat-Zinn, J. Motivational change following a meditation-based stress reduction program for medical outpatients. Poster presented at the lst International Congress of Behavioral Medicine, Uppsala, Sweden, June 28, 1990.

Kristeller, J., Peterson, L., Massion, A., Pbert, L., Miller, J., and Kabat-Zinn, J. Mindfulness-based stress reduction in the treatment of anxiety disorders: effectiveness and limitations. Poster presented at the lst International Congress of Behavioral Medicine, Uppsala, Sweden, June 28, 1990.

Kabat-Zinn, J., Mumford, G., Levi-Alvares, D., Santorelli, S., and Skillings, A. A mindfulness-meditation based stress reduction clinic for low-income inner city residents: outcomes and receptivity. Poster presented at the 14th annual meeting of the Society of Behavioral Medicine, San Francisco, March 11, 1993.

Miller, J., Fletcher, K., and Kabat-Zinn, J. Effectiveness of a meditation-based stress reduction intervention in the treatment of anxiety disorders: Three-year follow-up. Poster presented at Society of Behavioral Medicine, San Francisco, March 11, 1993.

Kabat-Zinn, J. Some clinical and social applications of Buddhist mindfulness meditation in mainstream medicine and health care. Paper presented, First International Congress on Health Psychology, Tokyo, Japan, July 28, 1993.

Kabat-Zinn, J. Mindfulness: What it is and what it isn’t, and its value in mainstream medicine, health care, and daily living. Paper presented at International Symposium on the Comparative and Psychological Study of Meditation, Makuhari, Japan, August 2, 1993.

Kabat-Zinn, J. A fifteen-year experience using mindfulness meditation and yoga in the mainstream of medicine and health care. Paper presented at the Society of Behavioral Medicine Annual Meeting, Boston, April 14, 1994, and at the American Psychosomatic Society Annual Meeting, Boston, April 14, 1994.

Other Researchers

Sobe,DS. Rethinking Medicine: Improving Health Outcomes with Cost-Effective Psychosocial Interventions. Psychosomatic Medicine (1995) 57:234-44

Kroenke, K, Mangelsdorff, AD. Common Symptoms in Ambulatory Care: Incidence, Evaluation, Therapy and Outcome. Am J Med (1989) 86:262-266
Beitman BD, Mukerji V, Lamberti JW, Schmid L, DeRosear L, Kushner M, Flaker G, Basha I. Panic disorder in patients with chest pain and angiographically normal coronary arteries. Am J Cardiol (1990) 15:1048
Kaplan, HK, Goldenberg, DL, and Galvin-Nadeau, M. The impact of a meditation-based stress reduction program on fibromyalgia. Gen Hosp. Psychiatry (1993) 15:284-289.

Goldenberg, DL, Kaplin, KH, Nadeau, MG, et al. A controlled study of a stress reduction, cognitive-behavorial treatment program in fibromyalgia. Musculoskeletal Pain (1994) 2:53-66.

Teasdale, JD, Segal, ZV, and Williams, JMC. How does cognitive therapy prevent depressive relapse and why should attentional control (mindfulness) help? Behav Res Ther (1995)33:25-29.

Astin, JA. Stress Reduction through mindfulness meditation: Effects of psychosocial symptomatology, sense of control, and spiritual experiences. Psychother Psychosom (1997) 66:97-106.

Roth, B and Creaser, T. Mindfulness meditation-based stress reduction: Experience with a bilingual inner-city program. The Nurse Practitioner (1997) 22:150-176.

Shapiro, SL, Schwartz, GE, and Bonner, G. Effects of mindfulness-based stress reduction on medical and premedical students. J Behav Med (1998) 1:93-98.

Shapiro, SL and Schwartz, GE. Mindfulness in medical education: Fostering the health of physicians and medical practice. Integrative Med (1998) 21:581-599.

Shaprio, SL and Schwartz, GE. The role of intention in self-regulation: Toward intentional systemic mindfulness. In Boekaerts, M., Pintrich, PR, and Zeidner, M (Eds) Handbook of Self-Regulation, Academic Press, New York (1999, in press).

Randolph, PD, Caldera YM, Tacone AM et al. The long-term combined effects of medical treatment and a mindfulness-based behavorial program for the multidisciplinary management of chronic pain in West Texas. Pain Digest (1999)9:103-112.

Teasdale, JD. Metacognition, mindfulness and the modification of mood disorders. Clin Psychol Psychother (1999) 6:146-155.

Epstein, R.M. Mindful Practice. JAMA (1999) 262:833-839.

Marlatt, G A, and Kristeller, J. Mindfulness and Meditation. In: Miller, WR (Ed), Integrating spirituality into treatment(1999) 67-84.

Teasdale, JD, Segal, ZV, Williams MG, Ridgeway, VA, Soulsby, JM, Lau, MA. Prevention of Relapse/Recurrence in Major Depression by Mindfulness-Based Cognitive Therapy. J. of Consulting and Clinical Psychology (2000) 68:615-623.

Speca, M, Carlson, LE, Goodey, E, Angen, M. A randomized, wait-list controlled clinical trial: the effect of a mindfulness-based stress reduction program on mood and symptoms of stress in cancer outpatients. Psychosom Med (2000) 62:613-622.

Mills, N, Allen, J. Mindfulness of movement as a coping strategy in multiple sclerosis: a pilot study. Gen Hosp Psychiatry (2000) 22:425-431.

Williams JMG, Teasdale JD, Segal ZV and Soulsby J. Mindfulness-based cognitive therapy reduces overgeneral autobiographical memory in formerly depressed patients. J Abnorm Psychol (2001).

Rehab Workshops Leading to Diplomate Certification

August 1st, 2010

rehab-diplomate

Standing Tall as Rehab Specialists

November 19th, 2009

Congratulations to the ACA Rehab Council for its vision in the creation of this Journal. Thank you to Dr. Petruska and Dr. Simon for their leadership and Dr. Garbutt for his dedication to this cause.

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

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

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

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

K.D. Christensen DC, CCSP, DACRB

Achieving Lumbar Stabilization Through Chiropractic/Rehabilitation After Radiofrequency Neurolysis: Retrospective Case Report Of A Recovering Drug Addict With Lumbar Fact Syndrome; Degenerative Disc Disorder; And Herniated Lumbar Disc.

November 16th, 2009

Kent C. Long, D.C.

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

ABSTRACT

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

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

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

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

KEYWORDS

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

INTRODUCTION

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

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

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

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

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

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

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

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

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

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

CASE REPORT

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

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

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

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

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

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

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

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

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

Flexibility Tests	Result	% of Normal
Sit and Reach	- 9 cm	Poor
Trunk Extension	15	Poor
Repetitive Tests
Repetitive Squat	40 reps	100+%
Repetitive Sit Up	25 reps	86%
Repetitive Arch Up	9 reps	35%
Endurance Tests
Static Abdominal Hold	55 sec	73%
Static Back Endurance	12 sec	14%
Horizontal Side Bridge	40R 43L	43%R 44%L

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

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

Flexibility Tests	Result	% of Normal
Sit and Reach	+ 12 cm	Good
Trunk Extension	30	Good
Strength Tests
Repetitive Squat	45 reps	100%+
Repetitive Sit Up	50+ reps	100%+
Repetitive Arch Up	50+ reps	100%+
Endurance Tests
Static Abdominal Hold	90 sec	100%+
Static Back Endurance	120 sec	100%+
Horizontal Side Bridge	100 R 110 L	100%+ R 100%+ L

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

DISCUSSION

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

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

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

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

CONCLUSION

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

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28. Fairbank J, Davies J, et al. The Oswestry Low Back Pain Disability Questionnaire. Physiotherapy, 1980, 66 (18), 271-273

29. Hudson-Cook N, Tomes-Nicholson K. The Revised Oswestry Low Back Pain Disability Questionnaire. Thesis, Anglo-European College of Chiropractic, 1988

30. Klassen AC, Berman ME. Medical care for headaches. A consumer survey. Cephalgia 1991:11 (supp 11) 85-86.

31. Biering-Sorensen F. Physical measurements as risk indicators for low back trouble over a one-year period. Spine 1984; 9: 106-119.

32. Luoto S, Hiliovaara M, Hurri H, Alaranta H. Static back endurance and the risk of low back pain. Clin Biomech 1995; 10: 323-324.

Chiropractic Rehabilitation and Its Influence On Daily Chiropractic Practice

November 16th, 2009

Spiro N. Comis, DC
Durham, NC

E-mail: spiro_c@yahoo.com

Recovery from illness or injury demands a specific plan of care to insure adequate results and the best outcomes available for the patient. Injuries take time to heal but may not always heal correctly or as well as possible leaving the patient to often suffer persistent recurring problems and at times unnecessary physical limitations that could easily have been avoided by choosing a more thoughtful course of care. It should always be the physician’s hope that the recovery will be full and speedy and that maximum gains are made in the final recovery. Far too often the decision to ignore an active rehabilitation plan is made due to cost factors. At times the benefit of a carefully laid out rehab plan can be unfortunately underestimated, sacrificing benefits to lower cost. To help insure premium care it becomes the duty of the trusted physician to see that quality care is applied. Health care providers must come to understand that saving money with shortcuts might often do more harm than we would intend.

“Everyone wants to cut costs. But what if saving my life is expensive” As the title demonstrates, the article in Slate points out a very real fear of cost containment thinking and the debate on effective care vs. overspending when not necessary.⁽¹⁾ As cost containment becomes even a bigger issue in our healthcare system the demand to quantify our results in Chiropractic will determine the fate of what we do in our care plans. As research points out that the combination of spinal manipulation and exercise is a cost effective physical treatment for back pain in primary care, we in chiropractic must be prepared to offer rehabilitation as part of our patient care plans.⁽²⁾

We now understand that the best recovery from injury must include a rehabilitation plan that includes manipulation and some form of exercise. There is always the question of overutilization to consider so it is important to understand the benefits vs. the costs in these matters. It is noted in the study that exercise alone is not as effective as manipulation alone but in combination there is additional benefit for the patient.⁽³⁾

Attempts at bed rest compared to being active demonstrate that there is more harm to inactivity and so it is evident that staying active during the recovery is in the best interest of the patient.⁽⁴⁾ The principles of chiropractic rehab also recognize that active rehabilitative care promotes the best recovery.

The concern over safety with manipulation in the presence of disc protrusions has been argued, generally in an attempt to limit care from the chiropractor. Research is demonstrating that active spinal manipulation vs. simulated manipulation demonstrates more effect. Even with sciatica present, the evidence is mounting that puts manipulation in a better position regarding patient treatment and in the interest of both results and patient safety. Better results utilizing manipulation quells the argument that manipulation does harm.⁽⁵⁾

In the evaluation of the patient’s condition, further evidence collection is possible utilizing additional in-office diagnostic methods, such as electrodiagnostic testing. The benefits of pre and post evaluation are an excellent aid in setting treatment goals and clearly document both patient care needs and benefits following care. (6) “Electro diagnostic testing can provide the primary care provider the data needed to make an informed decision regarding advanced imaging studies and to institute appropriate therapy or to intelligently refer a patient for follow-up.”⁽⁷⁾ Dynamic surface EMG studies help demonstrate functional asymmetries, muscle control, spasm and quality of the muscle tone. It also demonstrates agonist / antagonist relationships and flexion relaxation phenomenon which helps define pathophysiologic dissymmetry, guarding and muscle inhibition. These values also aid in the evaluation of permanent impairment. There is more work that needs to be done to add validation to the routine use of SEMG but it’s value is unquestionable as it stands.⁽⁸⁾

As part of the chiropractic rehab programs it is a main concern to bring the most fruitful choices of treatment to the patient care plan. The selection of which rehab procedures and exercise we utilize are based on our treatment goals and stem from our examination and evaluation of the patient. Postural, pathological and structural concerns will help develop a plan of care. An effective evaluation and an understanding of the biophysics will help build a foundation for our rehabilitation treatment methods. The level of injury and disability will define many of our treatment parameters. Our goals will always be to reach active care as quickly as possible and to avoid lingering in a passive care mode.

Spinal manipulation will always be our primary tool as it accentuates normal spinal function and the return to normal physiology that is needed and essential for a full and proper recovery. Understanding the principles of chiropractic rehabilitation helps us to enhance the initial benefit of spinal manipulation alone. This care compliments the adjustment and adds greater benefit to the patient’s recovery.

Avoiding the patient’s fear of pain and helping the patient return to activity is a primary goal of the chiropractic rehabilitation specialist. Aggressive exercise will act to bring positive feedback to the patient and help the confidence level for future activity and a quicker and longer lasting return to health.⁽⁹⁾ Stabilization exercise will help if the need is indicated by instability.⁽¹⁰⁾ Chronic lower back pain without instability will not respond to stability exercise and a more comprehensive program of exercise will be indicated. There are a great number of patients that do respond to spinal stability training. Segmental instability may be due to weakness, degenerative disease, loss of passive tension and injury.⁽¹¹⁾ Exercises like bridges and planks are spinal stability enhancers. Pelvic tilt training and holding a mid, “safety zone”, posture are helpful training and lead to less pain while the patients learn a safer way to move about and they can become more active quicker.

SEMG testing is helpful in detecting muscle activity during training. Testing demonstrates there is increased muscle activity when exercise is done on an unstable surface. This adds a dynamic component to the activity of the muscles and increases the benefit.⁽¹²⁾ Because sports skills are often performed off balance, greater core stability provides a foundation for greater force production in the extremities. Balance can be improved by training and, therefore, help benefit the athlete.⁽¹³⁾ I have learned that the use of a balance board in the chiropractic office is invaluable.

Aerobic fitness also adds to the benefits of better spinal health. The addition of aerobic exercise to the treatment plan will help to improve the patient’s health. Maximal oxygen consumption was lower in women with lower back pain. Exercise will help to improve strength and endurance and increase general activity levels.⁽¹⁴⁾ With the addition of aerobics the patient will be more active and recovery will be enhanced. The addition of aerobic exercise to the chiropractic rehabilitative plan should be included.⁽¹⁵⁾ Before beginning strenuous activity a Par-Q form will be helpful in ruling out contraindications.

The addition of a Swiss ball to the chiropractic rehabilitation regiment to aid in the patient’s recovery from injuries or back problems or pain offers many opportunities for the chiropractor to employ specific exercise protocols and programs that deal directly with stability and functional development, including balance, strengthening and proprioceptive training and enhancement.⁽¹⁶⁾ This tool is a great asset in accomplishing many basic rehabilitation principles. In my own experience there is added benefit of patient compliance as it is fun and easy to learn and patients can do these exercises at home. I have been very surprised at how well the Swiss ball has been utilized by my patients of all ages and backgrounds.

In addition to spinal manipulation the utilization of mobilization and McKenzie Techniques bring even more to the table for treatment options that can be utilized by the chiropractor. Clinical evidence supporting McKenzie therapy is very positive.⁽¹⁷⁾ McKenzie protocols offers one more tool that will help relieve the suffering experienced by many that seek care from a chiropractor.

The more information that the chiropractic practitioner has with respect to treatment options and techniques that supplement spinal manipulation and brings patients more positive outcomes sooner and better and directly leads to a full recovery only help our profession in general. That is why it is important to learn chiropractic rehabilitation skills. The information being taught in today’s chiropractic rehabilitation courses are just that; great information that will influence quicker and longer lasting results and that are also cost effective.

1. Beam, Christopher. “Your Money or Your Health.” Slate June 26, 2009: Print.
2. Beam, “Back pain exercise and manipulation randomized trial.” BMJ 329(2004): 1287. Print.
3. Beam, “Back pain exercise and manipulation randomized trial.” BMJ 329(2004): 1377. Print.
4. Hagen, Hilde, Jamtvedt, Winnem, KB, G, G, MF. “The Cochrane review of advice to stay active as a single treatment for low back pain and sciatica.” Spine 15; 27(16)(2002): 1736-41. Print.
5. Santilli, Beghi, Fiucci, V, E, S. “Chiropractic manipulation in the treatment of acute back pain and sciatica with disc protrusion: a randomized double-blind clinical trial of active and simulated spinal manipulations.” Spine 6(2006): 131-7. Print.
6. Morningstar, MW. “Improvement of lower extremity electrodiagnostic findings following a trial of spinal manipulation and motion-based therapy.” Chiropr Osteopat 14:20(2006): Print.
7. Iannelli, Humphreys, Triano, G, CR, JJ. “Electrodiagnostic testing in back and extremity pain..” Manipulative Physil Ther. 6(1993): 401-10. Print.
8. Ritvanen, Zaproudian, Nissen, Leinonen, Hanninen, T, N, M, V, O. “Dynamic surface electromyographic responses in chronic low back pain treated by traditional bone setting and conventional physical therapy..” Manipulative Physiol Ther. 30(1)(2007): 31-7. Print.
9. Cohen, Rainville, I, J. “Aggressive exercise as treatment for chronic low back pain.” Sports Med. 32(1)(2002): 75-82. Print.
10. Koumantakis, Watson, Oldham, GA, PJ, JA. “Trunk muscle stabilization training plus general exercise versus general exercise only: randomized controlled trial of patients with recurrent low back pain.” Phys. Ther. 85(3)(2005): 209-25. Print.
11. Mannion, Helbling, Pulkovski, Sprott, AF, D, N, H. “Spinal segmental stabilisation exercises for chronic low back pain: programme adherence and it’s influence on clinical outcome.” Eur Spine J. July (2009): Epub ahead of print. Print.
12. Kolber, Beekhuizen, MJ, K. “Lumbar Stabilization: An evidence-based approach for the Athlete with low back pain.” Strength and Conditioning Journal: 29(2007): 26-37. Print.
13. Norwood, Anderson, Gaetz, JT, GS, MB. “Electromyographic Activity of the Trunk Stabilizers Durhing Stable and Unsstable Bench Press.” Journal Strength Conditioning Res. 22(2)(2007): 343-347. Print.
14. Willardson, J. “Core Stability Training.” Journal Strength Conditioning Res. 21(2007): 979-85. Print.
15. Hoch, Young, Press, AZ, J, J. “Aerobic fitness in women with chronic discogenic nonradicular low back pain.” American Journal Physical Med. Rehabil 85(2006): 607-13. Print.
16. Lehman, Hoda, Oliver, GJ, W, S. “Trunk muscle activity during bridging exercises on and off a Swiss ball.” Chiropractic Osteopat. July (2005): 14. Print.
17. Busanich, Verscheure, BM, SD. “Does McKenzie therapy improve outcomes for back pain?” Journal Athletic Trainer 41(1)(2006): 117-9. Print.

Weight Lifting Modifications for Shoulder Tendonitis & Impingement Syndrome

November 16th, 2009

Dr. Jeffrey Tucker
11600 Wilshire Blvd. #412
Los Angeles, CA 90025
310-473-2911
www.DrJeffreyTucker.com

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Dynamic Neuromuscular Stabilization Seminar – Arizona

November 15th, 2009

Dynamic Neuromuscular Stabilization (DNS) According to Kolar – Course A

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

ISCRS Members Receive a $100 Discount

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

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

Location
Physiotherapy Associates
1025 E. Broadway Rd. #10

Misc

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

Faculty

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

COURSE OBJECTIVES

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

Testimonials

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

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

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

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

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

Brett Winchester, DC DACRB, Troy , MO

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

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

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

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

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

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

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

Ida Nørgaard, Chiropractor & MSc., London

Pennsylvania Rehab Program

November 15th, 2009

George K. Petruska DC, DACRB presents

2009-2010 Chiropractic Rehab Diplomate Series

Pennsburg – Pennsylvania

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

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

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

Download the registration form here

COURSE BEGINS OCTOBER 17, 2009

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

Outline

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

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

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

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

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

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

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

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

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

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

August 14, 2010
Forms; Nutrition; Performance Enhancement.

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

Download the registration form here

New Council News

November 3rd, 2009

here is some council news i just got…

Dynamic Neuromuscular Stabilization Seminars – Redondo Beach, CA

November 3rd, 2009

Dynamic Neuromuscular Stabilization (DNS) According to Kolar – Course “A”

Dates: Saturday – Monday, November 7-9, 2009 (9:00-12:30 & 13:30-17:00)

SUNRISE HOTEL AT REDONDO BEACH HARBOR 400 N. HARBOR DRIVE, REDONDO BEACH, CA 90277

Pavel Kolar, Paed. Dr.
PhD Magdalena Lepšikova, P.T.
Alena Kobesova, M.D.
PhD Craig E. Morris, D.C., DACRB

Download the registration form here or signup online at Functional Action.

Course Goals

Course attendees will have a clear understanding of:

The basic principles of developmental kinesiology.
Development during the first year of life: stabilization of the spine in the sagittal plane, development of the phasic movements coupled with trunk rotation.
The relationship between development during the first year of life & locomotor system pathology in adulthood.
The reflex consequences following central neural programs during the first year of life.
Functional stabilization of the spine & correction of poor stereotypical respiration.
New terminology such as functional joint centration/decentration, punctum fixum, and the integrated stabilizing system of the spine. In addition, posture will be discussed from a developmental point of view.
Critical principles of reflex locomotion: Locomotor patterns, stepping forward & support function, support/stimulating zones.
Course attendees will possess:
Skills to utilize critical functional tests to evaluate the integrated stabilizing system of the spine.
Skills for evaluation of breathing stereotypes.

Course Description

Course Instructors

Asst. Prof. Pavel Kolar, Paed. Dr., PhD
Professor Kolar is a physiotherapist by training, with advanced traind in pediatrick management and a PhD in physiology. His instructors, Professor Karel Lewit and the late Professors Vaclav Vojte and Vladimir Janda, profoundly influenced him in his approach. He is the Director of the Rehabilitation Department, University Hospital Motol, School of Medicine, Charles University, Prague, Czech Republic. This is the largest hospital in Central Europe, with 4,000 beds. He also acts as an adviser to the Director of the Hospital.

Professor Kolar is renowned for his work in rehabilitation, in addition to his treatment of celebrities in the world of sports, politics and entertainment. He has been appointed team clinician for the Czech Olympic teams, Davis Cup tennis teams and national ice hockey teams. He gained wide recognition for his treatment of former Czech President Vaclav Havel, which included traveling the President’s personal clinician when he went abroad. Professor Kolar has taught his methods in Europe, North America and Australia. He is also a member of interdisciplinary team at the Orthopedic Unit at the hospital. This concerns evaluation of children suffering form cerebral palsy and poor posture resulting in orthopedic deformities and indications for surgical treatment. His work is highly appreciated by orthopedists, who consider his opinion to be very important for surgical indications. Professor Kolar resides in Prague with his wife and three children.

Alena Kobesova, M.D., PhD
Dr. Kobesova is a neurologist who specializes in manual medicine and rehabilitation at the Rehabilitation Department, University Hospital Motol, School of Medicine, Charles University, Prague, Czech Republic. She is a certified instructor in Manual Medicine in the Czech Republic. She has studied extensively with Professor Karel Lewit, an international authority in manual medicine for more than 5 decades and the founder of the renowned “Prague School of Manual Medicine”. In conjunction with Professor Lewit, she has produced a four-volume instruction video demonstrating “Prague School” therapeutic soft tissue mobilization and relaxation techniques.

Dr. Kobesova is an instructor of neurological manual medicine and rehabilitation at the 2nd Medical School and also the Physiotherapy School, Charles University, Prague. She also organizes courses for international groups of clinicians travel to the Czech Republic to study the “Prague School” methods. Specializing in the treatment of patients suffering from various neurological disorders, Dr. Kobesova is a member of interdisciplinary team, which cares for patients suffering from hereditary motor and sensory neuropathy (HMSN – Charcot Marie Tooth). She recently published an article in the peer-reviewed journal, Czech rehabilitation journal “REHABILITACE” describing the complex treatment of the patients with HMSN.

Dr. Kobesova successfully completed the Czech Reflex Locomotion Training Course, which covers the theoretical and practical methods of the founder of Reflex Locomotion, the late Professor Vaclav Vojta. Professor Kolar studied with Professor Vojta and bases much of his work on Vojta’s principles.An emerging leader in the field of manual medicine and rehabilitation, Dr. Kobesova has served as the lead instructor in manual medicine and rehabilitation courses on three continents. She is very experienced in Professor Kolar’s methods, having assisted him in his courses for the past four years. Because Professor Kolar is not fully fluent in English, Dr. Kobesova also serves as his interpreter during the lecture portion of the course.

Dr. Kobesova resides in Prague with her husband and two sons.

Craig E. Morris, D.C., DACRB
Professor Morris is a 1981 graduate of Cleveland Chiropractic College, LA. He has practiced in Torrance, CA for over 25 years. Dr. Morris is a Clinical Professor at Cleveland Chiropractic College, Los Angeles. He has lectured and conducted clinical workshops at academic institutions in North America, Europe, Asia, Australia and South America. Dr. Morris has also studied extensively with Professor Karel Lewit and the late Professor Vladimir Janda of the Department of Rehabilitation and Manual Medicine, Charles University, Prague, Czech Republic. He co-instructed courses internationally with Professor Janda in North America and Europe. Dr. Morris is the editor of the text, “Low Back Syndromes, Integrated Clinical Management” (McGraw-Hill), a leading multidisciplinary text for the management of low back disorders. He resides in Redondo Beach, California with his wife and they have four adult children and one grandson.

Magdalena Lepsikova, P.T.
Ms. Lepsikova is a clinical physiotherapist at the Physical Therapy Department at Motol Hospital, 2nd medical Faculty in Prague, where she works with Asst. Professor Kolar and Dr. Kobesova. She specializes in rehabilitation of locomotor system dysfunction. She also serves as a lecturer, where she regularly instructs both medical and physiotherapy students. She is trained as a Vojta therapist and also as a DNS therapist. A very popular and effective instructor, she has taught DNS courses around the world. She resides in Prague with her husband and daughter.

Dynamic Neuromuscular Stabilization (DNS) According to Kolar – Course “B”

Dates: November 7-9, 2009

Sunrise Hotel at Redondo Beach Harbor
400 N. Harbor Drive, Redondo Beach, CA 90277

Download the registration form here or signup online at Functional Action.

Course attendees will gain further insights regarding the introductory understanding of:

The basic principles of developmental kinesiology.
Development during the first year of life: stabilization of the spine in the sagittal plane, development of the phasic movements coupled with trunk rotation.
The relationship between development during the first year of life & locomotor system pathology in adulthood.
The reflex consequences following central neural programs during the first year of life.
Functional stabilization of the spine & correction of poor stereotypical respiration.
New terminology such as functional joint centration/decentration, punctum fixum, and the integrated stabilizing system of the spine. In addition, posture will be discussed from a developmental point of view.
Critical principles of reflex locomotion: locomotor patterns, stepping forward & support function, support/stimulating zones.

Course attendees will possess:

Skills to utilize critical functional tests to evaluate the integrated stabilizing system of the spine.
Skills for evaluation of breathing stereotypes.
Expansion of reflex locomotion positions and their clinical application.

Course Description

It is during this period that a new method of intrinsic locomotor system stabilization has arisen to dramatically gain the attention of rehabilitation specialists. Pavel Kolar, PaedDr. has indeed spawned a new manual approach to activate the “Integrated Stabilizing System” and achieve exciting levels of improved function in a remarkably brief period. Based upon the scientific principles of developmental kinesiology, the neurophysiological aspects of the maturing locomotor system on which the internationally renowned “Prague School of Manual Medicine and Rehabilitation” was established, he has expanded the scope of clinical options in an exciting new direction. Attendees to the course will be introduced to these methods.
Course “B” of the DNS Certification series completes the introductory principles and skills. It is designed to present the clinician with a better understanding of the critical cornerstones of DNS after the introductory “A” course material has been completed. Because of the complexity of the DNS principles and skill set, and also the uniqueness of each course and instructor, clinicians typically attend multiple “A” courses and “B” courses, building additional understanding and technique expertise with each course. Attendees will be introduced to additional reflex locomotion positions during this course, expanding on what was taught during the introductory “A” course!

Course Instructors

Pavel Kolar, P.T., Paed. Dr., PhD – DNS Founder
Dr. Pavel Kolar is a PT and Paediatric specialist who has expanded the developmental kinesiology approach of Vojta’s Reflex Locomotion methods, designed primarily for neurological disorders, to be utilized for chronic pain and dysfunction, in addition to ATHLETIC OPTIMIZATION (utilized prior to athletics to improve athleticism). He traveled as the private physician for Czech president Vaclav Havel, and a host of international celebrities have flown to Prague for treatment with him. His methods promote reflex activation of the abdominal wall, deep back extensors, diaphragm & pelvic floor as part of an overall approach to improved locomotor system function. Dr. Kolar is a former world class gymnast & is the treating clinician for the Czech Davis Cup, Soccer, Ice Hockey & Olympic teams as well as a variety of international sports superstars. Asst. Professor Kolar will be instructing on the 2nd & 3rd days of this course.

Alena Kobesova, M.D.
Dr. Kobesova is a certified instructor in Manual Medicine in the Czech Republic. She has studied extensively with Professor Karel Lewit, an international authority in manual medicine for more than 5 decades and the founder of the renowned “Prague School of Manual Medicine”. In conjunction with Professor Lewit, she has produced a four-volume instruction video demonstrating “Prague School” therapeutic soft tissue mobilization and relaxation techniques.

Craig E. Morris, D.C., DACRB, CSCS
Dr. Craig E. Morris is the Director of the F.I.R.S.T. Health clinic in Torrance since 1982. He is a Professor at Cleveland Chiropractic College, L.A. and Board-Certified in Chiropractic Rehabilitation. He is the editor and an author of “Low Back Syndromes: Integrated Clinical Management”, a leading multi-professional textbook. In addition to his “Prague-School”-based international rehabilitation recognition, he specializes in sports injury management and medico-legal issues.

Magdalena Lepsikova, P.T.
Ms. Lepsikova is a treating physiotherapist at Motol Hospital in Prague, where she works with Asst. Professor Kolar and Dr. Kobesova. She is trained as a Vojta therapist and also as a DNS therapist. A very popular and effective instructor, she has taught DNS courses around the world. She resides in Prague with her husband and daughter.

The Functional Approach

July 26th, 2003

by K.D. Christensen DC, CCSP, DACRB

Selecting the ideal exercises for patients with back conditions requires judgment based on clinical experience and scientific evidence. There are several approaches to rehabilitation, and many different types of exercises are available; however, patients have a limited amount of time, willingness, and enthusiasm to exercise. Therefore, we must always try to give our patients the most effective exercises for their condition. But, what are the “best” exercises for Chiropractic patients?

Selection Criteria

The best exercises for a specific problem are those that will be rapidly effective, easy to learn and perform, and are safe; that is, they don’t worsen the current condition or aggravate other problems. The exercises must help the patient to regain normal alignment and easy, natural movement. And the end result should include a decreased chance of similar, recurring problems.

A successful and appropriate rehabilitative program for the back and/or neck can be designed without the use of expensive, joint-specific equipment. While rehab type machines can be very useful, current active care concepts consider such equipment not an absolute requirement. In fact, the low-tech approach can be very effective for the treatment of most spinal conditions. Additional personnel, fancy equipment, more office space, and extra time are not always necessary. With an understanding of normal spinal function, knowledge of the involved muscles, and some updating of exercise concepts, doctors of Chiropractic can effectively rehab their patients with timely in-office instruction and patient performance followed by simple home exercise procedures .

Specific Adaptation to Imposed Demands

The “SAID” concept is one of the underlying tenets of the strength and conditioning field. [1] It describes the observation that our bodies will predictably change in response to the demands that are placed on them. If we frequently perform aerobic activities, then our lungs, hearts, and muscles become more efficient at taking in and processing oxygen. When we spend more time in activities requiring force and providing resistance, our bodies become stronger. And, if we practice balance and coordination skills, we improve our ability to function easier on unstable surfaces (such as on an incline, rolling ship or a pair of skates). In fact, these improvements in our abilities are quite specific, and we become better at doing whatever it is that we do most often.

It has taken quite a while for those specialists in the treatment of spinal problems to incorporate the SAID concept into neck and back rehab programs. Recently, some of us have begun to use the same thought processes to design spinal exercises that we have used for decades to determine appropriate x-ray positions. As Chiropractors, we do recognize that the spine functions very differently when it is not weight-bearing. We now know that an ideal way to help our patients return to normal function is with exercises that imitate as closely as possible the real conditions under which the spine must function day after day. That certainly must include the specific stress of gravity in the upright position.

Kinetic Chain Exercises

When the spine is bearing weight it is part of a closed kinetic chain. This is the manner in which we use the joints and connective tissue of the spine during most daily and sports activities, and it requires the co-contraction of accessory and stabilizing muscles. Weaker or injured muscles can be quickly strengthened with the additional use of isotonic resistance to stimulate increases in strength. Isotonic resistance can come from a machine, from weights, from elastic tubing, or just using the weight of the body. Perhaps more important than the equipment used is whether the spinal support structures are also exercised in an open or a closed-chain position.

Open-chain exercises for the spine are done non-weight bearing, while either lying on the ground or immersed in water (which removes much of the effect of gravity). Both floor-based and water-based exercises have some specific usefulness, primarily during the acute stage.

A good example of this is a study comparing closed vs. open kinetic chain exercises for the training of the thigh muscles. Augustsson et al. wanted to improve their subjects’ vertical jump height. [2] Two groups exercised twice a week at maximal resistance – one group doing closed-chain exercises (barbell squats), and the other working on the knee extension and hip adduction weight machines (open-chain exercising). At the end of six weeks both groups had gained considerable strength, but the closed-chain exercisers were the only ones who improved significantly in the vertical jump. Since jumping is a closed-chain activity, the SAID concept tells us to expect that closed-chain exercising will likely be more effective.

Functional Position Exercise

We know that the functional origins and insertions of many muscles change when changing position from standing to lying down. Certainly the proprioceptive input from receptors in the muscles, connective tissues, and joint capsules is very different between the two positions. This is why it is also important to bring neck and back rehab exercises closer to real-life positions, and it explains why patients make rapid progress when they are taught to exercise in a functional (upright) position.

Patients initially may need to exercise when lying down. However, continual floor-based exercises do not train muscles and joints to function in upright functional postures. The neurological patterns that are developed on the floor or in a pool may not resolve problems encountered in upright activities. Generally, continually learning new skills and habits on the floor doesn’t translate to better functioning during upright activities And, some patients don’t like to get down onto the floor to exercise, anyway.

By staying up off the floor, exercising in a weight-bearing position is actually easier for most patients. In addition to being more focused and practical, upright exercising trains and strengthens the spine to perform better in everyday activities. Patients accept the idea of doing exercises that clearly prepare them for better function during normal activities of daily life.

How to Spot a “Sham” Exercise

When investigators want to test treatments, they always require a “control” group, which is given a treatment that is known to be ineffective. A 1998 study on back pain published in the respected journal Spine taught several popular low back exercises to the control group. As with other studies, the researchers found no improvement using these exercises. [3] The six exercises considered a “sham” treatment included: knee-to-chest stretches, partial sit-ups (”ab crunches”), pelvic tilts, hamstring stretches, “cat and camel”, and side leg lifts. The problem with these and most other commonly recommended back exercises is that the joints, discs, muscles, and connective tissues are not bearing weight during the exercise; therefore, the movements performed while exercising do not prepare or retrain these structures for daily activities. On the other hand, exercises performed with the spine upright (standing or sitting) against resistance specifically train and condition all involved structures to work together smoothly. Thus, effective exercises are ones that are performed upright, in a closed kinetic chain.

The Value of Balance Exercises

For many athletes (whether recreational or competitive), it is important to regain the fine neurological control necessary for accurate spinal and full body performance. This means that about five to ten minutes of each workout should be spent exercising while standing on one leg, with the eyes closed, while standing on a mini-tramp, or using a special rocker board. The advantage of these balance exercises is seen when athletic patients return to sports activities and can perform at high levels without consciously having to protect their backs. Back exercises done on a rocker board or while standing on one leg can be more useful than those done on a gym ball, since the entire body is in a closed-chain position during the exercises. The stabilizing muscles, the co-contractors, and the antagonist muscles all have to coordinate with the major movers during movements that are performed during closed-chain exercising. This makes these types of exercises very valuable in the long run, particularly for competitive athletes.

Functional Alignment

Many chronic spinal problems develop secondary to an imbalance in weight-bearing alignment of the lower extremities. In fact, lower extremity misalignments — such as leg length discrepancies and pronation problems — are frequently associated with chronic pelvis and low back symptoms. [4] Any of these that are present will need to be addressed in order to resolve the patient’s current symptoms and to prevent future back problems. The use of adjustments, exercises, and custom, flexible orthotics for the lower extremities is especially critical when a functional approach is taken. The effects of weight bearing and the alignment of the kinetic chain must be considered.

Conclusion

Selecting the best exercise approach for each patient’s back problem is important. A well-designed exercise program allows the doctor of Chiropractic to provide cost-efficient, yet very effective rehabilitative care. Exercises performed with the spine upright (standing or sitting) specifically train and condition all the involved structures to work together smoothly. The end result is a more effective rehab component and patients who make a rapid response to their Chiropractic care. Except for brief periods in patients who are acute, caution must be heeded for continual exercises that don’t place patients in real-life, functional positions. While this may require a change in standard procedures, it is consistent with Chiropractic philosophy and treatment approaches. When you persist with this, you will experience dramatic improvements in patient outcomes.

References

1. Fleck SJ, Kraemer WJ. Designing Resistance Training Programs. Champaign, IL: Human Kinetics, 1987.

2. Augustsson J et al. Weight training of the thigh muscles using closed vs. open kinetic chain exercises: a comparison of performance enhancement. J Orthop Sports Phys Therap 1998; 27:3-8.

3. Snook SJ et al. Reduction of chronic nonspecific low back pain through the control of early morning lumbar flexion — a randomized controlled trial. Spine 1998; 23:2601-2607.

4. Rothbart BA, Estabrook L. Excessive pronation: a major biomechanical determinant in the development of chondromalacia and pelvic lists. J Manip Physiol Therap 1988; 11:373-379.

Adjunctive Therapies to the Adjustment The Diabetic Patient and Improving Quality of Life

July 26th, 2003

by K.D. Christensen DC, CCSP, DACRB

Type II diabetes or non-insulin dependant diabetes mellitus (NIDDM) affects millions of our patients. The condition usually develops after age forty, and many patients who present for treatment of musculoskeletal or neurological conditions may actually be experiencing complications from uncontrolled blood glucose levels. As potentially debilitating as this condition can be, it is unfortunate that as many as half of those with diabetes are unaware of their condition. (1) Being familiar with the disease process will allow the healthcare provider to function as an important member of any treatment team.

Signs, Causes, Complications

The classic signs of the Type II diabetic are:

Over weight
Hypertensive
Inactive

Type II diabetes usually results from decreasing tissue insulin sensitivity and degeneration of pancreatic Beta cells, related to a high carbohydrate diet and inactivity. The result is a chain of pathological processes involving mobilization and deposition of fat. The worst complication is vascular destruction because of atherosclerotic plaquing. As peripheral blood vessels become blocked, especially in those that supply nerves, characteristic changes occur in the feet and ankles.

Improving Quality of Life

The triad of peripheral neuropathy, neuropathic joint destruction (Charcot joint), and increased weight gain requires direct intervention by a structure-conscious healthcare provider. Although the chiropractor may not directly treat the diabetic condition, using some simple techniques will improve the quality of life for any diabetic patient:

• Increase patient activity level

• Monitor diet and supplements

• Protect and support the feet

Obviously, the number one goal is to control the blood sugar level. In Type II this may require oral hypoglycemic medications, but treatment will be far more effective if the patient is able to improve diet and increase activity, without adding additional stress to the feet and ankles.

Even patients without diabetes find it hard to exercise regularly when they are in pain. Chiropractic care increases the patient’s ability to establish an exercise regimen which is necessary to maintain healthy body weight. Furthermore, exercise is therapeutic. “During exercise, insulin need is diminished,” Souza observes. “This is due to the enhanced insulin binding at receptor sites, so that glucose uptake is increased without an increase in insulin (insulin demand reduced).” (2)

Excessive chronic hunger, thirst and urination (polyphagia, polydipsia, and polyuria) mean your patients will struggle with their diet. Despite the blood being full of ample fuel, the cells which need it don’t have access to it. The signals to eat and drink are truly false alarms. The function of insulin and its balance with other hormones that control glycemic metabolism depends on sufficient levels of chromium and potassium. Thiazide diuretics, used to control hypertension for example, decrease serum potassium and beta blockers may raise lipid levels. An attempt to correct hyperlipidemia with niacin can increase insulin resistance.

Foot Concerns

Any disease that impairs sensation of joint receptors predisposes the articulations to microtrauma and joint derangement, resulting in Charcot joints. Diabetic arthropathy affects the feet and ankles predominantly, and although diabetics may report tingling or burning in their feet, true sensation actually decreases. Especially for the diabetic, it is very important to ensure normal articulations in the feet.

First, subluxations are responsible for the severe joint destruction which occurs. Although destruction can happen anywhere, the tarsals and distal metatarsals are most susceptible. The arches of the feet should be supported to maintain proper alignment. Secondly, misalignments can cause pressure sores, which are slow to heal and are easily infected.

The American Orthopaedic Foot and Ankle Society (AOFAS) (3) makes the following foot-care recommendations:

Make frequent visual inspection to compensate for the loss of sensation.
Never walk barefoot.
Check inside shoes for foreign objects.

Orthotic Support

Use custom-made, flexible orthotics to help cushion the foot and provide shock protection to the joints. Avoid over-the-counter, rigid, and hard plastic insoles.

Research on magnetic inserts suggests a positive effect on diabetic-related distal neuropathy. Weintraub reports that despite “the uncertainty regarding the precise mechanism of this novel approach, the results are impressive and suggest that a legitimacy exits for magnetotherapy as a safe and unique therapy in neuropathic diabetic foot pain.” (4) Speculation as to how or why these positive changes occur currently centers around gradient changes in the Na-K-ATPase system of sensory nerve endings or the induction of a change in the C-fiber firing patterns which are known to be adaptive.

In response to demands from doctors who were already providing spinal/pelvic stabilization for their patients, there is now a line of flexible, custom-made orthotics which include magnet therapy. Not only do these scientifically designed orthotics help stabilize the body’s overall structure by providing a symmetrical foundation, enhancing shock-absorption capacity, and improving the sensory-motor responses, they also provide the potential positive benefits of magnetic therapy. Orthotics are a fundamental part of any treatment plan aimed at increasing the patient’s activity level and getting him or her back on their feet.

There are other specialty orthotics without magnets. These orthotics are specifically designed to support foot and ankle articulations in the diabetic, while providing a level foundation for the pelvis and spine. Built-in gentle orthotic correction protects the feet from possible pressure sores and provides a very high level of comfort.

So, even though you may not treat the diabetic condition directly, your efforts to minimize the damaging effects of this disease will add quality to the life of your patient, while you function as a vital member of the healthcare team.

References

1. Harris MI. Undiagnosed NIDDM: clinical and public health issues. Diabetes Care 1993; 16:642-652.

2. Souza TA. Differential Diagnosis for the Chiropractor: Protocols and Algorithms. Gaithersburg, MD: Aspen Publishers, Inc; 1997:705-710.

3. N.A. The diabetic foot. AOFAS Online. Revised March 24, 1999: www.aofas.org/diabetic.html.

4. Weintraub MI. Magnetic bio-stimulation in painful diabetic peripheral neuropathy: a novel intervention — a randomized, double-placebo crossover study. Am J Pain Mgmt 1999; 9(1):8-17.

Stiffness, Pain, and Sleep Following Exercise

July 26th, 2003

by K.D. Christensen DC, CCSP, DACRB

Post-exercise Stiffness

It is to be expected that many rehab patients experience stiff, painful, slow-functioning leg muscles after an exercise, and myoglobinemia has been reported in many endurance activities. Hansen et al. determined the degree of leakage of myoglobin and other muscle proteins into the circulation during various types of muscular activity. 1 Sixteen highly-trained marathon runners, aged 19-44 years, were examined, along with nine nonrunners of similar age, and six rowers aged 15-24 years. All subjects were men. The runners trained for 100 km to 350 km per week, and had maximal oxygen uptake values of 72-90 ml oxygen per minute per kilogram of body weight. The nonrunners had maximal oxygen uptake values of about 40 ml, and the rowers’ values were at 60-75 ml. Four runners were examined after running 17-27 km on a hilly course at a mean rate of 17.4 km per hour. Six runners and six nonrunners were compared during and after a noncompetitive test run of 27 km or 12 km, respectively. Runners also participated in 15 km and 30 km events. The rowers were examined after hard rowing for 1 1/2 hours.

Runners returned from the 17 km to 27 km race with plasma-free hemoglobin values of 2.4-10 mole/L. High transferrin iron-binding capacity and low haptoglobin values also were noted. The runners received iron daily and had normal serum iron levels. All the runners had abnormally high serum myoglobin values immediately after the race. Minimal myoglobinuria was observed for 24 hours. No runner had significant proteinuria. Serum lactic dehydrogenase, creatinine kinase, and alkaline phosphatase values were increased. Nonrunners had a greater increase in serum myoglobin levels than did the runners. Most runners had increased values of serum creatinine kinase B after the competitive run, in contrast to those values after noncompetitive runs or rowing. The rowers had elevations of serum enzymes and serum myoglobin similar to those seen in the runners. Free plasma hemoglobin was present in all the rowers.

Both distance running and rowing damage skeletal muscle cells. The myopathic condition resolves within 24 hours except for soreness in leg muscles. The changes after competitive running are consistent with some leakage of muscle proteins from myocardial cells. Neither myoglobinemia nor hemoglobinemia appears to explain adequately the iron deficiency that occurs in athletes.

This study makes a careful comparison of the biochemical damage sustained by muscle in athletes and nonathletes after running, and in rowers after rowing. The fact that protein leaks from the muscles of rowers makes a traumatic explanation unlikely. This phenomenon is possible after endurance exercise within the clinic. Nutritional intervention is helpful.

Exercise-Induced Soreness

Acute soreness develops during exercise and is related by Abraham 2 to stress-induced ischemia. Pain occurs when exercise is intense enough to produce muscle ischemia and the muscle cannot remove metabolic waste products such as lactic acid and potassium quickly enough. Critical concentrations of these substances can stimulate pain, which continues until exercise intensity is reduced or work ceases, both of which result in increased blood flow.

Delayed muscle soreness develops 24-48 hours after exercise. It has been attributed to torn tissues, spasm and the strain placed on the elastic component of muscle by eccentric work. Increases in urinary myoglobin excretion have been associated with exercise-induced muscle soreness, but they may also follow exercise when soreness does not develop. The relationship between exercise-induced muscle soreness and urinary hydroxyproline excretion can be compared. Significant correlation is apparent between the time of maximum hydroxyproline excretion and the day when the most soreness is reported. Delayed soreness appears to be linked to an irritation of the connective tissue in muscles.

Exercise-Delayed Soreness

Exercise that uses untrained muscles results in delayed muscle soreness 3 and increased muscle enzyme activities in untrained individuals. 4 Tiidus 5 examined the time course of these effects and the importance of the intensity and duration of exercise in untrained individuals of both sexes, aged 20-45 years. All exercised less than once a week. A dynamic leg extension apparatus was used. Six persons performed sets of up to ten contractions to establish the time course of post-exercise serum enzyme changes and muscle soreness. Twenty-one subjects then performed exercise at various intensities and durations at ten-day intervals.

The most severe muscle soreness and the highest serum creatine phosphokinase (CPK), lactic dehydrogenase, and glutamic oxaloacetic transaminase activities occurred 48 hours and 8 to 24 hours after exercise, respectively, in the pilot study. Increasing intensities and durations of exercise resulted in corresponding increases in enzyme activities and muscle soreness. High-intensity, brief exercise led to greater enzyme activities and more muscle soreness than low-intensity exercise of long duration. The serum CPK activity correlated significantly with the change of degree of muscle soreness.

The findings suggest that exercise-induced muscle damage leads to leakage of muscle enzyme into the blood and physiologic reactions to the muscle damage that result in a sensation of muscle soreness. Studies in rate have shown myofibrillar disruption, macrophage and fibroblast accumulation, and necrosis in exercised muscles in association with serum enzyme elevations. The exercise-induced changes may be casually related to delayed muscle soreness. What is important is that the enzyme elevation and subjective symptoms of soreness are signals of profound cellular change, which includes cellular disruption, fibroblastic change, and necrosis.

Sleep and Exercise

Slow-wave sleep (SWS) has been suggested to be a restorative phase of sleep, and exercise has been hypothesized to create a demand for SWS proportional to energy expenditure. Bunnell 6 used a quantified submaximal exercise procedure, carried out to volitional exhaustion, to test the exercise-SWS hypothesis. Measures of total caloric expenditure permitted comparisons on individual energy costs and changes in SWS. Five women and four men, aged 21-30 years, participated in the study.

All were moderately active, but none engaged in vigorous physical training. Four patients typically exercised regularly. Recordings were made on adaptation and baseline nights and for two nights after an afternoon exercise bout in which the subjects walked on a treadmill for fifty-minute periods at 50% to 70% of maximal oxygen uptake to the point of volitional exhaustion.

The duration of SWS before the onset of rapid eye movement (REM) sleep increased markedly on the exercise night. Moderate increases in stage 4 sleep and total SWS were observed. An increased latency to first REM onset and decreased duration of the first REM period were also found. Initial REM cycle length decreased. The increases in SWS before the onset of REM sleep averaged twenty-four minutes in women and six minutes in men. In women, this increase correlated with total caloric expenditure during exercise with a coefficient of 0.85. Heart rate and cardiac output during sleep were significantly increased on the exercise night. A significant fall in nocturnal urinary cortisol excretion followed exercise.

The findings suggest that exhaustive exercise affects sleep primarily in the early part of the night. An increase in SWS pressure is observed, at the expense of REM sleep. The increase in SWS in the first non-REM period is consistently greater in women than in men. Any explanation of the increase in SWS after exhaustive exercise must take into account the apparently greater effect of exercise intensity, compared with caloric expenditure itself. An explanation that holds that SWS reflects primarily neural functioning seems to account for the changes in both SWS and REM sleep.

The metabolic and biochemical alterations induced by vigorous exercise have not been identified precisely. It is of some interest that in rats swum to exhaustion there is a 15% increase in whole brain serotonin and a 20% drop in norepinephrine levels. Whether this pattern is reduplicated or paralleled in the higher vertebrates remains to be seen. The main points are well documented: slow wave sleep is increased early on, REM sleep is decreased, and the effect is greater in women than in men.

References

1. Hansen KN, Bjerre-Knudsen J, Brodthagen U, Jordal R, Paulev PE. Muscle cell leakage due to long-distance training. Eur J Appl Physiol Occup Physiol 1982; 48(2):177-188.

2. Abraham WM. Physician Sportsmed 1979; 7(Oct):57-60.

3. Ernst E. Does post-exercise massage treatment reduce delayed onset muscle soreness? A systematic review. Br J Sports Med 1998; 32(3):212-214.

4. Vincent HK, Vincent KR. The effect of training status on the serum creatine kinase response, soreness and muscle function following resistance exercise. Int J Sports Med 1997; 18(6):431-437.

5. Tiidus PM, Ianuzzo CD. Effects of intensity and duration of muscular exercise on delayed soreness and serum enzyme activities. Sci Sports Exerc 1983; 15(6):461-465.

6. Bunnell DE, Bevier W, Horvath SM. Effects of exhaustive exercise on the sleep of men and women. Psychophysiology 1983; 20(1):50-58.

Managing Shoulder Sprain/Strain Injuries

July 26th, 2003

by K.D. Christensen DC, CCSP, DACRB

The various shoulder problems seen by doctors of Chiropractic can be due to one or more of the manifestations of rotator cuff dysfunction. This is generally a biomechanical continuum which begins with dysfunction of the rotator cuff muscles and may progress to rotator cuff syndrome, supraspinatus tendinitis, impingement syndrome, subdeltoid and subacromial bursitis, calcific shoulder bursitis, and even cases of frozen shoulder and bicipital tendinitis. In most cases, there is no direct, acute injury.

Because it is a very mobile joint with little stability in certain positions, the soft tissues of the shoulder region can be injured during athletic and recreational activities, at work, or in a fall. Every acute sprain and strain injury to the shoulder needs an accurate evaluation, treatment and rehabilitation, if future problems are to be avoided. Chronic instability is a real possibility after an injury, since the surrounding muscles and connective tissues are the true source of shoulder joint stability.

Shoulder Function

The shoulder is made up of several joints that must function together smoothly to provide the extreme mobility which is possible, and is necessary for many activities. The shoulder joint complex includes the sternoclavicular joint, the acromioclavicular joint, the glenohumeral joint, and the scapulothoracic articulation (a pseudojoint). The upper thoracic spine should also be considered a major contributor to shoulder motion, especially during overhead reaching (when reach is extended as the spine tilts away from the shoulder), and during throwing. [1] The connective and muscular tissues that support and move these joints will need to be assessed, so that support can be provided for the healing of any injured tissues. Eventually, rehabilitation of all injured tissues will be necessary, in order to regain full function.

There are many connective tissues in these joints which can be injured, resulting in a shoulder sprain. The sternoclavicular joint is the only point at which the shoulder girdle is firmly attached to the axial skeleton. The ligaments involved there are the sternoclavicular and costoclavicular. The acromioclavicular (AC) joint is held in place by the coracoclavicular and acromioclavicular ligaments. A thick capsule composed of several ligaments secures the humerus into the labrum of the glenohumeral joint. The scapulothoracic “joint” has muscular connections only; there are no ligamentous attachments.

Any of the numerous muscles and tendons that contribute to the movement and coordinated stability of these joints can become strained in a shoulder injury. The main muscles associated with the shoulder include: the trapezius, latissimus dorsi, pectoralis major, deltoid, rotator cuff (SITS muscles), serratus anterior, and the biceps and triceps muscles. Manual testing can often quickly identify which of these muscles are weakened and painful upon contraction after an injury.

Mechanics of Shoulder Injury

While injuries can be quite individual and complex, several common shoulder injury patterns have been identified: [2]

Blow to the anterior shoulder – can cause ligamentous tears resulting in dislocation.
Fall onto top of shoulder – may cause a ligamentous tear resulting in AC joint separation.
Fall on an outstretched arm – can result in AC separation, posterior dislocation, labrum or rotator cuff tear.
Arm forced into external rotation and abduction – anterior dislocation and/or labrum tear.
Sudden traction to the arm – momentary subluxation or brachial plexus traction injury.
Sudden pain during activity or lifting – consider rupture of muscle/tendon or labrum tear.
Rehabilitation of Shoulder Sprain Injuries

Significant damage to one or more of the connective tissues of the shoulder can result in joint instability and chronic dislocations. Treatment of Grade 3 or moderate-to-severe Grade 2 sprains will include some external support (sling or taping) and restricted activities. Once the ligaments have undergone sufficient early repair, controlled passive motion to include PNF routines can help to prevent the formation of adhesions (scarring in areas of movement). Resistance exercises are introduced to stimulate a stronger repair and to assist in the remodeling process. Isometric patterns are progressed to various forms of resistance exercise, based on the patient’s tolerance for joint motion. For athletes, regaining full stability may require advanced forms of exercise in the functional phase of rehabilitation, such as proprioceptive training and plyometrics. These maneuvers help to re-coordinate the sensory receptors and motor controls at the spinal cord (non-thinking) levels. [3]

Rehabilitation of Shoulder Strain Injuries

Injured muscles and tendons of the shoulder girdle may need a brief period of support and restricted activity, but controlled re-strengthening should be initiated early. Elastic tubing is a safe and effective method of providing progressive resistance exercises. [4] A very easy and effective program starts with a consistent exercise routine using surgical tubing equipment in the basic forward-back-in-out directions (flexion, extension, abduction, adduction) making certain speed is pain free. This is initially performed within a limited, pain-free range of motion, building to full range as pain subsides. As tolerated, additional shoulder exercises should be performed as indicated, including internal / external rotation, horizontal abduction / adduction and the various complex PNF patterns. This inexpensive rehabilitative program should initially be practiced under supervision to ensure proper performance.

Once good exercise mechanics and control are demonstrated, a self-directed program of home exercises is appropriate. As with sprain injuries, shoulder strains in athletes may require more specific, sports-performance exercises, such as eccentrics and plyometrics. Specific sports skills (such as throwing) may also need to be retrained.

A factor that is too frequently overlooked is the influence of posture on shoulder girdle function. Reports by Hertling and Kessler [5] and Hammer [6] support the need to evaluate the patient for specific postural distortions, such as thoracic kyphosis and cervical anterior translation (causing a “forward head”). An additional complicating postural factor can be the alignment of the scapula on the thoracic cage – when the shoulder is “rolled forward” (protracted). Correction of these chronic alignment faults will significantly reduce the biomechanical stress on muscular support for the shoulder.

Outcome Management

Outcomes assessment is the collection and recording of information relative to health processe, whereas, outcomes management uses outcome information in a way that enhances patient care. With the dawning, of the “era of accountability,” there are new social mandates directed toward health care providers and health-related facilities. Measurements of quality, satisfaction, efficacy, and effectiveness now serve as essential elements for health care decisions and matters of health policy. The two common outcome assessments in regards to shoulder management available to chiropractors include:

Shoulder Injury Self-Assessment of Function Questionnaire

This is a 15 item ADL tool from American Shoulder and Elbow . The patient fills out the questionnaire. A score of 0 is considered normal whereas scores approaching 60 represent disability.

Shoulder pain and Disability Index (SPADI)

This is a 13 point questionnaire measuring pain and disability. The Scale has been
shown responsive to improved and worsened change over time and treatment.

Both of these questionnaires require permission from the copyright owners to utilize which has been obtained and available. (See OutcomesAssessment.org).

Conclusion

An appropriate and progressive active rehab program should be started early in the treatment of patients with shoulder sprain and strain injuries, generally after ligaments and connective tissues have repaired sufficiently. Simple, yet effective rehab techniques are available, none of which require expensive equipment or great time commitments. A closely monitored home exercise program using exercise tubing is recommended, since this allows the doctor of Chiropractic to provide cost-efficient, yet very effective and specific rehabilitative care. Outcome assessment monitoring is a simple way to document curative progress and treatment during recovery.

The most important aspect is to recognize and address the biomechanical alignment problems and postural factors that are frequently associated with shoulder injuries. This entails screening the patient for forward head and flexed (kyphotic) torso postures. In addition, protracted (forward) shoulders change the angle of the scapula and compress the rotator cuff further. Failure to recognize these complicating factors will result in a patient with recurring shoulder complaints. When the shoulder girdle is properly aligned on the torso, the complex mechanism of the shoulder will be more likely to function optimally.

References

1. Nordin M, Frankel VH. Basic Biomechanics of the Musculoskeletal System, 2nd. ed. Philadelphia: Lea & Febiger; 1989. 235.

2. Souza TA. Differential Diagnosis for the Chiropractor. Gaithersburg: Aspen Pubs; 1997. 145.

3. Kibler WB, et al. Functional Rehabilitation of Sports and Musculoskeletal Injuries. Gaithersburg: Aspen Pubs; 1998. 157.

4. Roy S, Irvin R. Sports Medicine: Prevention, Evaluation, Management, and Rehabilitation. Englewood Cliffs: Prentice-Hall; 1983. 195.

5. Hertling D, Kessler RM. Management of Common Musculoskeletal Disorders, 2nd. ed. Philadelphia: JB Lippincott; 1990. 177.

6. Hammer WI. Functional Soft Tissue Examination and Treatment by Manual Methods. Gaithersburg: Aspen Pubs; 1991. 31.

Adjunctive Therapies to the Adjustment Preventing Leg Injuries

July 26th, 2003

by K.D. Christensen DC, CCSP, DACRB

Leg injuries (to the ankles, lower leg, knees, and hip and thigh) affect many athletes, both competitive and recreational. These injuries can interfere significantly with sports enjoyment and performance levels, and they occasionally will end participation completely. Excessive pronation and poor shock absorption have been found to be an underlying cause or a contributing factor for many leg injuries. (1) Custom-fitted orthotics can help to improve pedal biomechanics, reduce the extent of pronation, and prevent many activity-related leg injuries.

One recent study looked at the foot biomechanics of athletes who reported a recent foot or leg injury (iliotibial band syndrome, Achilles tendinitis, stress fracture of the tibia, tibial periostitis, or plantar fascitis), and compared them to an uninjured control group. (2) The researchers determined that those athletes with more foot pronation had a much greater statistical probability of sustaining one of these five leg injuries. This helps us understand how providing appropriate orthotic support to patients who are involved in sport or recreational activities can lower their likelihood of developing leg injuries.

Hip and Thigh Injuries

Many injuries experienced at the hip and thigh develop from poor biomechanics and gait asymmetry, especially when running. Smooth coordination of the muscles that provide balance and support for the pelvis is needed for optimum performance. This includes the hamstring muscles and the hip adductor muscles (groin strains), in addition to the iliotibial band. When there is a biomechanical deficit from the feet and ankles, abnormal motions (such as excessive internal rotation of the entire leg) will predispose to pulls and strains of these support muscles. The hamstrings (comprised of the biceps femoris, semimembranosus, and semitendinosus muscles) are a good example.

Hamstring muscles. During running, the hamstrings are most active during the last 25% of the swing phase, and the first 50% of the stance phase. (3) This initial 50% of stance phase consists of heel strike and maximum pronation. The hamstring muscles function to control the knee and ankle at heel strike and to help absorb some of the impact. A recent study has shown a significant decrease in electromyographic activity in the hamstrings when wearing orthotics. (4) In fact, these investigators found that the biceps femoris (which is the most frequently injured of the three hamstring muscles) (5) had the greatest decrease in activity of all muscles tested, including the tibialis anterior, the medial gastrocnemius, and the medial and lateral vastus muscles. The scientists in this study theorized that the additional support from the orthotics helped the hamstrings to control the position of the calcaneus and knee, and to absorb some of the shock of heel strike.

Knee Injuries

Except for direct injuries from contact or forced overstretch, most knee problems develop from poor biomechanics and overuse of muscles and tendons. Many of these injuries are associated with foot pronation and can be prevented by using orthotics during sports activities.

Anterior cruciate ligament (ACL). Epidemiology and frequency studies have now demonstrated that the vast majority of acute tears of the ACL occur without any contact or direct trauma to the athlete’s knee. (6) Eighty-one percent of athletes with injury to the ACL recalled the moment of injury as having their tibia in internal rotation. (7) It is the torque, or twisting forces imposed on the knee joint that cause some ACLs to rupture. Some athletes have knee joints that are more susceptible to these torque forces, and excessively pronating feet transmit more rotational force into the knee joints.

A recent study by Beckett et al. retrospectively reviewed a group of athletes with acute, non-traumatic ACL ruptures (arthroscopically-proven), and compared them to a matched control group. These researchers found excessive pronation of the foot and collapse of the arch during weight-bearing in the injured subjects, and they proposed this finding as the mechanism of injury. (8)

In their study, Beckett et al. reviewed the biomechanics of the foot and ankle, and described how arch collapse and excessive pronation cause abnormal internal (medial) tibial rotation that “pre-loads” the anterior cruciate ligament. Normally, subtalar joint pronation and internal rotation of the tibia occur only during the initial, contact phase of gait. If pronation continues beyond the contact phase, the tibia remains internally rotated. This abnormal tibial rotation transmits excessive forces upward in the kinetic chain to the knee joint. This theory is supported by Copland’s work, which found that passive tibial rotation was statistically greater in hyperpronators than in nonpronators. (9) Another study found that ruptures of the ACL in female athletes (many of whom are at a high risk for ACL rupture) were directly correlated with the amount of arch collapse and hyperpronation. (10)

Patellofemoral pain. Pain and injury at the front of the knee can be due to patellar tendinitis and/or rubbing of the patella in the femoral groove. Both of these conditions can be caused by poor foot biomechanics and are easily prevented with the use of orthotics that reduce pronation. Prolonged time in pronation causes excessive internal rotation of the tibia, impeding its normal external rotation during gait progression in the stance phase. (11) This excessive internal tibial rotation transmits abnormal forces upward in the kinetic chain and produces medial knee stresses, force vector changes of the quadriceps mechanism, and lateral tracking of the patella. (12) One study found that the use of soft corrective orthotics was very effective in reducing patellofemoral pain, and preventing recurrence. (13)

Lower Leg Injuries

Excessive movements of the tibia can cause injury to many of the structures in the lower leg. The muscles and tendons in the shin, the Achilles tendon, and even the bones of the lower leg are all at risk from excessive pronation. Studies have demonstrated a significant decrease in tibial internal rotation (14) and on pronation velocity (15) when using orthotics, which will help to prevent injuries to this area.

Shin splints. A chronic tendinitis affecting either the anterior or posterior tibialis muscle can present as “shin splints.” (16) The anterior tibialis tendon is stressed when the foot is unable to adequately absorb the forces of foot deceleration at or after foot strike, while the posterior tibialis tendon develops micro-tears from attempting to stabilize excessive foot pronation. (17) Therefore, orthotics can reduce the likelihood of developing shin splint injuries.

Stress fractures. Repetitive biomechanical stresses are often accentuated by inherent imbalances or asymmetries, such as hyperpronation. An example is the increased frequency of stress fractures found in the feet and lower legs of military recruits with low arches and flat feet. (18) The hyperpronating foot tends to develop stress fractures more frequently in the collapsed metatarsals and in the tibia. (19, 20) Orthotic support for the arches that includes pronation correction at the heel (a medial or “varus” wedge) will decrease the torque forces on the bones of the foot and leg and prevent the development of stress reactions. And, of course the additional shock absorption found in modern orthotics is an additional preventive factor.

Foot and Ankle Injuries

Orthotic support is most obviously able to help prevent leg injuries that affect the foot and ankle. Many injuries of this region have been found to be caused by hyperpronation, and orthotics are recommended for the associated poor shock absorption and arch collapse. These include injuries such as ankle inversion sprains (21), heel spurs and plantar fascitis, metatarsalgia, and even sesamoiditis (which can become a frank fracture). (22)

Conclusion

Excessive pronation and/or poor shock absorption have been shown to be an associated or causative factor in many leg injuries — from the foot itself, up the lower leg to the knee, thigh, and hip. Many of these conditions can be prevented with custom-fitted orthotics. The investigation of foot biomechanics is a good idea in all patients, especially for those who are recreationally active. Competitive athletes must have regular evaluations of the alignment and function of their feet, in order to avoid potentially disabling injuries. Additional preventive measures include wearing well-designed and constructed shoes. Recommending orthotics may help prevent not just arch breakdown and biomechanical foot problems, but numerous other injuries to the lower extremities as well.

References

1. Dahle LK et al. Visual assessment of foot type and relationship of foot type to lower extremity injury. J Orthop Sports Phys Ther 1991; 14:70-74.

2. Busseuil C et al. Rearfoot-forefoot orientation and traumatic risk for runners. Foot Ankle Intl 1998; 19:32-37.

3. Mack RP. AAOS Symposium on the Foot and Leg in Running Sports. St. Louis: Mosby; 1982.

4. Nawoczenski DA, Ludewig PM. Electromyographic effects of foot orthotics on selected lower extremity muscles during running. Arch Phys Med Rehabil 1999; 80:540-544.

5. Garrett WE. Muscle strain injuries. Am J Sports Med 1996; 24:S2-8.

6. McNair PJ, Marshall RN, Matheson JA. Important features associated with acute anterior cruciate ligament injury. NZ Medical Journal 1990; 14:537-539.

7. Arnold HA et al. Natural history of the anterior cruciate ligament. Am J Sports Med 1979; 7:305-313.

8. Beckett ME et al. Incidence of hyperpronation in the ACL injured knee: a clinical perspective. J Athl Train 1992; 27:58-62.

9. Copland JA. Rotation motion of the knee: a comparison of normal and pronating subjects. J Orthop Sports Phys Ther 1989; 10:366-369.

10. Loudon JK. The relationship between static posture and ACL injury in female athletes. J Orthop Sports Phys Ther 1996; 24:91-97.

11. Zappala GG, Taffel CB, Scuderi GR. Rehabilitation of patellofemoral joint disorders. Orthop Clin North Am 1992; 23:555-566.

12. Tiberio D. The effect of excessive subtalar joint pronation on patellofemoral mechanics: a theoretical model. J Ortho Sports Phys Therap 1987; 9:160-165.

13. Eng JJ, Pierrynowski MR. Evaluation of soft foot orthotics in the treatment of patellofemoral pain syndrome. Phys Ther 1993; 73:62-70.

14. Nawoczenski DA, Cook TM, Saltzman CL. The effect of foot orthotics on three-dimensional kinematics of the leg and rearfoot during running. J Orthop Sports Phys Ther 1995; 21:317-327.

15. Eng JJ, Pierrynowski MR. The effect of soft orthotics on three-dimensional lower limb kinematics during walking and running. Phys Ther 1994; 74:836-844.

16. Souza TA. Differential Diagnosis for the Chiropractor. Gaithersburg: Aspen Pubs; 1998. 313.

17. Roy S, Irvin R. Sports Medicine: Prevention, Evaluation, Management, and Rehabilitation. Englewood Cliffs: Prentice-Hall; 1983. 434, 438.

18. Simkin A, et al. Combined effect of foot arch structure and an orthotic device on stress fractures. Foot Ankle 1989; 10:25-29.

19. Subotnick SI, ed. Sports Medicine of the Lower Extremity. New York: Churchill Livingstone; 1989. 164.

20. Michaud TC. Recurrent lower tibial stress fracture in a long-distance runner: a case report. Chirop Sports Med 1988; 2:78-87.

21. Heiser JR. Rehabilitation of lower extremity athletic injuries. Contemp Podiat Phys 1992; Aug:20-27.

22. Hartley A. Practical Joint Assessment: A Sports Medicine Manual. St. Louis: Mosby Yearbook; 1991. 571.

Osteoporosis and Spinal Exercise

July 26th, 2003

by K.D. Christensen DC, CCSP, DACRB

With an aging and sedentary population, osteoporosis and its complications are affecting greater numbers of our patients. Initially, there is a reduction in bone mass (osteopenia), which is considered a universal phenomenon of aging. However, when the condition progresses to osteoporosis, bone strength is compromised, and fractures develop with trivial (or no) trauma. These fractures may affect the extremities, the hip, and the spine. While calcium intake and diet are very important, and hormone status is a major contributing factor, physical activity and exercise have been shown to provide significant protection from osteoporosis [1] and fractures. [2] As doctors of chiropractic, we have a duty to identify those patients who are at risk of fracture, and to provide exercise recommendations that will decrease that risk. And, very importantly, we can tailor their exercises to prevent the spinal complications of osteoporosis, such as kyphosis, vertebral wedging, and compression fractures.

Benefits of Exercise to Bone

As recalled from the principle known as Wolff’s Law, bone density and strength are a function of the magnitude and direction of the mechanical stresses that act on bone. Assuming the availability of necessary nutrients, stimulus to the osteoblasts results in a net gain in bone mass. Exercise is a form of repetitive loading that facilitates osteoblastic activity, thereby helping to maintain a positive balance between bone formation and bone resorption. [3] Even the very moderate amount of exercise that is recommended for general wellness (a minimum of 30 minutes on most days) is helpful in preventing osteoporosis. [4]

Exercise Types

Aerobic/endurance. Two of the most commonly recommended forms of exercise for the elderly are walking and swimming. While improved aerobic capacity is good for the cardiopulmonary system and is generally beneficial for most older patients, we mustn’t expect any skeletal improvement. Bone mineral density can be increased by walking, but only when it is done above the anaerobic threshold. [5] It is unlikely that most older women will be willing to walk at this intensity, especially those who have been sedentary. Women who participate in a regular swimming program have no significant difference in bone mass from women who don’t swim. [6] This is also true of a standard “weightbearing, water-based exercise program” (aquacise). [7]

Impact/weightbearing. In order to create sufficient stimulus to increase bone density, exercise needs to be weightbearing and have some impact. This doesn’t mean jumping off of chairs, but can be as simple as step-training (10 minutes stepping up and down from an 8 inch high step). [8] Caution should be used when recommending impact exercise to elderly patients, and orthotics with good support and shock absorption may need to be considered. Certainly, excellent shoewear is important.

In general, exercises are effective when done in an upright, weight-bearing position, since the entire body is in a closed-chain position during the training. The stabilizing muscles, the co-contractors, and the antagonist muscles all learn to coordinate with the major movers during movements that are performed during closed chain exercising (Fig. 1). This makes these types of exercises very valuable for the elderly — not just for increasing bone density, but also for preventing stumbles and falls.

Resistance/strength. Resistance training has been found to be safe and quite effective in increasing strength and function in the elderly. [9] Older patients make similar relative, but smaller absolute, strength gains when compared with younger adults. Weight training in a submaximal controlled, supervised situation can also preserve [10] and even increase [11] bone deposition. Strength training recommendations should be an integral part of chiropractic treatment for older and osteoporotic patients. Exercise tubing is an excellent tool for strength training of the elderly, since the risks of injury are minimized, and a spotter or expensive equipment is not needed (Fig. 2).

Spinal Osteoporosis

As doctors of chiropractic, we often encounter osteopenia and osteoporosis on our patients’ spinal x-rays. Of course, by the time changes are visible on x-ray, substantial bone loss has already occurred. The most common fractures due to osteoporosis are vertebral fractures, and yet less than a third of all vertebral fractures are clinically diagnosed. [12] Needless to say, these skeletal changes can have a significant impact on posture and our ability to handle subluxation complexes. Specific, corrective exercises should be recommended in order to relieve the postural strain on the spine and to prevent further wedging and compression fractures. Avoiding exercise is the worst approach to an aging patient with osteoporosis. Back strengthening exercise constitutes a powerful intervention for reducing pain and increasing functional capacity.

An important caveat must be addressed when designing an exercise program for patients with osteoporosis. Most importantly, the exercises should not worsen a patient’s condition. And this is certainly possible, since some of the commonly used back exercises may cause more fractures. For patients with spinal osteoporosis, the most harmful activity is that which places an anterior load on the vertebral bodies. Patient education must emphasize the dangers of lifting in flexion, and of performing flexion exercises. In fact, one exercise study [13] found an increase in new vertebral deformities when postmenopausal women performed flexion exercises (such as forward stretches and abdominal curls), while those who performed only spinal extension exercises had a significant reduction in the number of vertebral compressions.

Corrective Spinal Exercises

Spinal osteoporosis is often associated with poor postural support, specifically an increase in the thoracic kyphosis. This posture is secondary to many decades of flexed activities, and may be compounded by poor posture habits and tendencies to “slump.” One important factor in chiropractic treatment is the correction of any loss of the normal upright alignment of the pelvis and spine. In addition to general strengthening and coordination exercises, all patients (and especially the elderly) should be shown corrective exercises that are specific for the postural imbalances they have developed. The thoracic kyphosis of estrogen-deficient women has been found to be directly correlated with weakness of the back extensor muscles, [14] and increasing the back extensor strength has been shown to decrease the kyphosis. [15] In this instance, when the torso is carried flexed forward, the patient will need to retrain the extensor muscles of the spine with isotonic resistance exercises. As stated previously, this is most effective when done in an upright, weightbearing position.

Conclusion

A well-designed exercise program can improve posture, help to reduce bone loss, and prevent fractures, while also reducing symptoms. Exercises performed with the spine upright (standing or sitting) can specifically train and condition all the involved structures to work together smoothly. For some elderly patients, orthotic support will be necessary to reduce shock and ensure correct alignment of the lower extremities during weightbearing exercises such as walking. The end result is an effective rehab component for osteoporosis and aging patients who will make a rapid response to their chiropractic care. Now we understand how important it is for our exercise recommendations to provide for strengthening of the spinal support mechanisms to prevent kyphosis and compression fractures in our elderly patients.

References

1. Chien MY, Wu YT, Hsu AT et al. Efficacy of a 24-week aerobic exercise program for osteopenic postmenopausal women. Calcif Tissue Int. 2000; 67:443-448.

2. Campbell AJ, Robertson MC, Gardner MM et al. Randomised controlled trial of a general practice programme of home based exercise to prevent falls in elderly women. Br Med J. 1997; 315:1065-1069.

3. Pirnay FM. Bone mineral content and physical activity. Int J Sports Med. 1987; 8:331-335.

4. US Dept. of Health and Human Services. Physical Activity and Health: A Report of the Surgeon General. Atlanta: 1996.

5. Hatori M, Hasegawa A, Adachi H et al. The effects of walking at the anaerobic threshold level on vertebral bone loss in postmenopausal women. Calcif Tissue Int. 1993; 52:411-414.

6. Orwoll ES, Ferar J, Oviatt SK et al. The relationship of swimming exercise to bone mass in men and women. Arch Intern Med. 1989; 149:2197-2200.

7. Bravo G, Gauthier P, Roy PM et al. A weight-bearing, water-based exercise program for osteopenic women: its impact on bone, functional fitness, and well-being. Arch Phys Med Rehabil. 1997; 78:1375-1380.

8. Chien MY, Wu YT, Hsu AT et al. Efficacy of a 24-week aerobic exercise program for osteopenic postmenopausal women. Calcif Tissue Int. 2000; 67:443-448.

9. Fiatarone MA, Marks EC, Ryan ND et al. High-intensity strength training in nonagenarians: effects on skeletal muscle. JAMA. 1990; 263:3029-3034.

10. Nelson ME, Fiatarone MA, Morganti CM et al. Effects of high-intensity strength training on multiple risk factors for osteoporotic fractures. JAMA. 1994; 272:1909-1914.

11. Kerr D, Ackland T, Maslen B et al. Resistance training over 2 years increases bone mass in calcium-replete postmenopausal women. J Bone Miner Res. 2001; 16:175-181.

12. Ross PD. Clinical consequences of vertebral fractures. Am J Med. 1997; 103:30S-43S.

13. Sinaki M, Mikkelsen BA. Postmenopausal spinal osteoporosis: flexion versus extension exercises. Arch Phys Med Rehabil. 1984; 65:593-596.

14. Sinaki M, Itoi E, Rogers JW et al. Correlation of back extensor strength with thoracic kyphosis and lumbar lordosis in estrogen-deficient women. Am J Phys Med Rehabil. 1996; 75:370-374.

15. Itoi E, Sinake M. Effect of back-strengthening exercise on posture in healthy women 49 to 65 years of age. Mayo Clin Proc. 1994; 69:1054-1059.

About The Author

Kim D. Christensen, DC, CCSP, DACRB, is codirector of the SportsMedicine & Rehab Clinics of Washington, and current president of the American Chiropractic Association Rehab Council. He can be reached at Chiropractic Rehabilitation Association, 18604 NW 64th Avenue, Ridgefield, WA 98642 or via email: kimdchristensen@hotmail.com.

[captions for illustrations]

Fig. 1. Hip extension exercise

Fig. 2. Exercise tubing: an ideal tool for elderly/osteoporotic patients

Lower Extremity Rehab for the Elderly

July 26th, 2003

by K.D. Christensen DC, CCSP, DACRB

When a patient over the age of sixty needs to regain strength in an injured lower extremity, or when an elderly woman needs to build bone mass to prevent hip fractures, a question arises. What exercises are appropriate, safe, and effective? Won’t exercising this older patient make the problem worse? As caring doctors of Chiropractic, the last thing we want to do for our older patients is to increase their pain or add to their disability.

While there are very important special considerations when planning exercises for a patient over sixty, the benefits far outweigh the risks. In fact, it would be a distinct advantage for every person over the age of sixty to be under the care of a Chiropractor who can advise and provide guidance regarding the most effective forms of exercising. What follows is a review of the concerns we must address, and some solutions when we need to start an elderly patient on a lower extremity rehab program.

Rehab Concerns in the Elderly

Because the lower extremities bear the weight of the entire body, eventually some imbalance or mis-step will result in the need for a rehab program. There are several areas where older patients differ from the younger population, however. These special concerns include weaker bones, problems with blood flow, joint degeneration, and age-related weakness. Let’s look at each of these problem areas, and then we’ll see what the experts say.

Osteoporosis. With aging comes a loss of bone mass in many people, especially post-menopausal women. We don’t want to place an elderly patient in a situation that could cause a hip or leg fracture, or a vertebral compression fracture. Even recommending a walking program may expose elderly patients to a higher risk of ankle fractures, since what is normally a simple ankle sprain becomes a comminuted fracture when the bones are osteoporotic. A well-organized study of elderly women found a much higher incidence of thoracic compression fracture after five years of performing exercises that placed the spine in flexion. [1] This means that many of the standard exercises we use, such as knees to chest, and abdominal crunches should be modified or possibly even eliminated in the elderly population.

Hypertension/atherosclerosis. Hardening and constriction of the arteries cause a decrease in blood flow, especially to the extremities. The heart responds by increasing the blood pressure, trying to force the blood through the restricted areas. When resting measurements are consistently above 140 mmHg (systolic) and/or 90 mmHg (diastolic), the person has hypertension. Elderly patients entering the office may already be on medication to control their high blood pressure, especially in the higher age ranges. While the drugs do decrease the likelihood of strokes and heart attacks, many patients are still hesitant to exercise, and they become even more sedentary. There is now good evidence that exercise is not contra-indicated, and is actually beneficial for patients taking blood pressure medications. [2] We’ve got to consider what type of exercising is least likely to further increase blood pressure, since we don’t want to cause a heart attack or stroke.

Osteoarthrosis. Degenerative arthritis is one of the most common musculoskeletal disorders in older adults, causing significant amounts of physical disability. Osteoarthrosis afflicts an estimated 20 million Americans, with the knee being the most commonly affected weightbearing joint. [3] In addition to pain with movement, the involved joint(s) lose flexibility and strength. Also found is a loss of proprioception, which may be a contributor to impaired balance. [4] Exercises for the elderly must avoid increasing painful movements, yet improve flexibility, strength, and balance. Contrary to what is commonly believed, moderate exercise does not increase the risk for osteoarthrosis or exacerbate it; rather, it has been found to improve function and reduce pain. [5]

Deconditioning/low muscle mass. As we age, we become more sedentary. National surveys reveal that 70% or more of older adults do not engage in any regular exercise. [6] This compounds the previously identified loss of strength and muscle mass, and increase in body fat that is normally seen in aging. In fact, this change in body composition is tied to many factors, including poor nutrition, decreased physical activity, increased disability and disuse, type II muscle fiber atrophy, and drug side effects.

Benefits of Elder Exercise

The American Geriatrics Society recently reviewed the literature that demonstrates the wide range of benefits that are obtained when older patients exercise. [7] There is now a wealth of data that supports the value of resistance exercise in the geriatric population. Improvements are seen in weight and body composition, decreased falls, improved balance, better psychological health, less frailty and improved function. With exercise, the resting blood pressure lowers, and there is a reduction in the risk of all-cause mortality. [8] Studies have shown that the stronger the back and leg muscles are, the higher the bone density is in the region. [9] These benefits are so widespread, they overwhelm the few detrimental concerns, and encourage us to recommend resistance exercise to older patients who need lower extremity rehab.

Solutions

First, flexion exercises may have to be avoided, in order to decrease the likelihood of compression fractures in the spine for some elderly patients. In fact, exercises that strengthen the back extensor muscles can decrease the thoracic kyphosis seen in many older women. [10] Repetitive impact stresses needs to be reduced without sacrificing the benefits of repetitive motion for the cardiovascular system. Swimming or water exercise is perhaps one of the ideal repetitive exercise options. Distance walking can cause repetitive overuse complaints. These can be minimized with the use of shoe inserts or custom orthotics made of viscoelastic materials. [11] If a lower extremity joint or muscle is acutely inflamed (with joint effusion), an initial period of relative rest with cryotherapy may be needed. During this period, though, exercise of the opposite leg should be encouraged. Vigorous exercise of the uninvolved contralateral leg muscles will produce a neurological stimulus in the injured side (called the “cross-over effect”), and helps to prevent atrophy. [12]

Isometric exercises may increase the systolic blood pressure; therefore, isotonic or “dynamic” exercises are the better choice. [13] Elastic resistance tubing is an excellent method to provide dynamic exercise strengthening without the need for machines or heavy weights. Older adults may have difficulty getting to and figuring out complex machines. They may not be able to handle heavy weights and barbells. Studies have shown that a home-based program using elastic tubing can provide significant gains in lower extremity strength and improvements in gait. [14] These exercises can be done standing or sitting.

ACSM/NSCA Guidelines

Two major organizations – the American College of Sports Medicine (ACSM) [15] and the National Strength and Conditioning Association (NSCA) [16] have both published recommendations to be followed when advising older adults to exercise. Both state that aerobic and resistance exercise for older populations is generally safe and can be very effective, both for treating specific problems as well as avoiding general disability. These guidelines encourage the use of regular physical activity, along with specific exercising to improve endurance, strength, and proprioception. Current research has found that even high-intensity training of frail men and women in their 90s is safe and leads to significant gains in muscle strength and functional mobility. [17]

Conclusion

An appropriate and progressive rehab program should be started early in the treatment of all patients with lower extremity injuries and problems. [18] Selecting the best exercise approach for an older patient is not difficult, but does require some special considerations. A review of the patient’s health history is necessary, in order to identify any complicating or restricting factors. Using the factors described above, an effective lower extremity rehab program can be easily designed for an elderly patient. A closely monitored home exercise program allows the doctor of Chiropractic to provide cost-efficient, yet very effective, rehabilitation care for patients of all ages.

References

1. Sinaki M, Mikkelsen BA. Postmenopausal spinal osteoporosis: flexion vs. extension exercises. Arch Phys Med Rehabil 1984; 65:593-596.

2. LaFontaine T. Resistance training for patients with hypertension. Strength & Conditioning 1997; 19:5-7.

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Leanne N. Cupon, DC, DACRB, DABFP

Dr. Jeffrey Tucker, DC

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Course attendees will gain further insights regarding the introductory understanding of:

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Functional Action, Inc. Presents

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Functional Action, Inc.

By Maria A. Perri, D.C., D.A.C.R.B.

SUMMARY

Bibliography — Peer Reviewed Papers

Abstracts and Poster Sessions

Other Researchers

Kent C. Long, D.C.

ABSTRACT

KEYWORDS

INTRODUCTION

CASE REPORT

DISCUSSION

CONCLUSION

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Dynamic Neuromuscular Stabilization (DNS) According to Kolar – Course A

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Dynamic Neuromuscular Stabilization (DNS) According to Kolar – Course “A”

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Dynamic Neuromuscular Stabilization (DNS) According to Kolar – Course “B”

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by K.D. Christensen DC, CCSP, DACRB

Selection Criteria

Specific Adaptation to Imposed Demands

Kinetic Chain Exercises

Functional Position Exercise

How to Spot a “Sham” Exercise

The Value of Balance Exercises

Functional Alignment

Conclusion

References

by K.D. Christensen DC, CCSP, DACRB

Signs, Causes, Complications

Improving Quality of Life

Foot Concerns

Orthotic Support

References

by K.D. Christensen DC, CCSP, DACRB

Post-exercise Stiffness

Exercise-Induced Soreness

Exercise-Delayed Soreness

Sleep and Exercise

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Functional Action, Inc.
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Functional Action, Inc.
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