The Truth About Antidepressants

February 18th, 2014

More and more the Chiropractic profession is being targeted to assist with referring patients for pychiatric type drugging. It is vital that you have the correct data in this area. The following video and article links should be of value to your patients’ and family’s safety.

Dr. Alf Garbutt, Editor

Part One:

iHealthTube.comAmerica Fooled: The Truth About Antidepressants: Part One

Part Two:

iHealthTube.comAmerica Fooled: The Truth About Antidepressants: Part Two

ACA Rehab Symposium – Las Vegas – Spring 2014

February 18th, 2014

The 15th Annual ACA Rehab Council Educational Symposium is scheduled to take place at the Paris Hotel & Casino in Las Vegas, NV on Friday, Feb. 28th, 2014 – Sunday, March 2nd, 2014.

If you are interested in a captivating weekend filled with excellent instruction on Rehab techniques, exposure to the latest in Rehab supplies and equipment, an exotic and fun filled locale, camaraderie with doctors who share your same interest in spinal and extremity rehabilitative procedures as well as receive 12 hours of license renewal credits in most states, look no further.

Featured speakers include Stuart McGill, PhD, professor of spine biomechanics at the University of Waterloo, ON, Canada, presenting his program on Training Maximum Performance which teaches the mechanism and techniques used with the fastest and strongest athletes. In addition, Lee Burton, PhD and Gray Cook, PT will be expounding on their 4 X 4 Matrix which explains the exercise strategy used by the Functional Movement Systems and Selective Functional Movement Assessment programs.

The time to register is now. Book your room at the Paris Casino Hotel by calling (877) 796-2096 and be sure to ask for the “ACA Rehab Council” rate at $159.00/night.

To register for the symposium, just click here to buy your ticket.

See you there,

Jerrold J. Simon, D.C.

Russian Step Up Exercise by Dr. Alfred Garbutt

February 18th, 2014

Standing Quadratus Lumborum Exercise and Stretch by Dr. Alfred Garbutt

February 17th, 2014

Soft Tissue Mobilization of Lumbar Multifidus by Dr. Alfred Garbutt

February 16th, 2014

New eBook Out By James Brantingham, DC, PhD

November 19th, 2013

Hip-Osteoarthritis-Book-445
Dr. James Brantingham just published a new e-book entitled Hip Osteoarthritis; Manipulative and Multimodal Therapy with Rehabilitation

Below is a statement about the eBook from the author to the ACA Rehab Council:

“I hope you saw my the recent article (in JACA) which discussed important and ground breaking research that I, and others have done – particularly on using HVLA grade 5 manipulation (& to a lesser degree mobilization) and exercise for Hip Osteoarthritis. Over 5 RCTs and many other studies have now demonstrated, that manipulative and multimodal therapy is effective in treatment of Hip Osteoarthritis.

Certainly this research could help you and other doctors who specialize in or take an Rehabilitation approach in treatment of many older patients, or younger patients (that have developed early Hip OA after trauma). This book also covers manual therapy research on Knee OA (particularly if it is co-morbid knee OA), and may help patients increase exercise or sports activity (for health or pleasure) but are seriously restricted because of lower extremity OA. Arthroscopic surgery is no longer recommended for common OA (with exceptions of course) so, this niche is not being offered and I believe we can help many of these suffering patients. I very much wish that chiropractic (my college when I was trained LACC now SCUHS) had taken rehabilitation more seriously (exercise and stretch among many other modalities are part and parcel of almost all of our lives).”

James W. Brantingham DC, PhD

The e-book can be purchased for $25.00 at Dr. Brantingham’s website: jamesbrantingham.com

Used OptoGait for Sale

November 12th, 2013

OptoGait: 50% of new price – used less than 10 times. New sells for $6,895.00
Contact: kimdchristensen@hotmail.com

Vote on the Proposed Colleges

November 12th, 2013

The recent ACA Rehab Council membership vote on the proposed two new sub specialty Colleges and their respective Bylaws passed by a wide margin. Specifically, the American College of MUA (ACMUA) and the American College of Clinical Electrodiagnosis (ACCE) have met voter approval as specialty Colleges under the auspices of the ACA Rehab Council by its membership. The final vote and approval process now needs to be brought before the ACA HOD (House of Delegates). Thanks to the authors of the ACMUA Bylaws, namely Drs. John Cerf, Walt Engle, Alf Garbutt and Craig Morris. Thanks also to the authors of the ACCE Bylaws, namely Drs. Gary Smith, Jeff Ross, Mike Schneider and George Petruska.

E-Voting Resolution Passes the ACA HOD

October 2nd, 2013

At last weekend’s ACA House of Delegate’s (HOD) Meeting held in Greeley, CO the HOD approved the proposed Rehab Council’s Resolution on e-voting (see below) which means that all future elections and membership votes can proceed electronically:

COUNCIL ON CHIROPRACTIC
PHYSIOLOGICAL THERAPEUTICS AND REHABILITATION
OF THE AMERICAN CHIROPRACTIC ASSOCIATION
CONSTITUTION AND BYLAWS

Resolution – Electronic Transmission

CURRENT:

ARTICLE VII                VOTING

B. At the discretion of the officers of the Council, when they feel it is in the best interest of the Council, the election of the officers will be by ballot at the annual meeting or by mail ballot.  If the election is by mail ballot, the ballot will be mailed to each member forty-five (45) days prior to the annual meeting, and all the ballots MUST be returned thirty (30) days prior to the meeting.  All ballots returned after that date will not be counted.  Only members in good standing are permitted to vote.

PROPOSED:

With respect to the Constitution and Bylaws of the American Chiropractic Association Council on Physiological Therapeutics and Rehabilitation, the use of the terms mail, written document and letter can be used interchangeably and have the same legal authority as the terms verified e-mail and electronic transmission.

Level 2 Functional Movement Seminar held in Las Vegas on Feb. 28th, 2014

September 9th, 2013

A Level 2 Functional Movement Systems Seminar is being held in Las Vegas at the Paris Hotel & Casino on Feb. 28th, 2014 from 8:00am – 5:00pm in conjunction with the 2014 ACA Rehab Symposium. Although not sponsored by the ACA Rehab Council, this Level 2 FMS Seminar will be held at the same location (Paris Hotel & Casino in Las Vegas) as our 2014 Rehab Symposium. The FMS Seminar date is 2/28/14, whereas the ACA Rehab Symposium dates are 3/1/14 – 3/2/14. To register for the FMS Seminar, log on to FunctionalMovement.com. More details of the FMS Seminar can be found below:

Level 2 Functional Movement Systems Seminar Description

This course is designed to enhance exercise professionals’ perspectives on improving fundamental movement patterns. The Functional Movement Screen will be reviewed and corrective exercise will be discussed based on movement dysfunction. The functional exercise progressions will be demonstrated and focus will be placed on how to utilize the FMS to properly prescribe and implement corrective strategy. More hands-on and practical information will be presented, using case studies and lab settings to show how the FMS can be used to provide a foundation for improvement in overall exercise programming. Objectives of this seminar:

  • Provide more insight into the implementation of the FMS into your training philosophy.
  • Enhance your ability to use the FMS to progress from corrective exercise to functional and traditional exercise.
  • Introduce other assessment techniques which complement the FMS.
  • Describe traditional and non-traditional strength and conditioning exercises and how they fit into the Functional Movement System.

To Register, log on at FunctionalMovement.com

Extremity Series By Dr. Jeff Tucker

May 30th, 2013

WHAT: Five one-day course series of practical hands-on training in corrective exercise/rehab taught by Dr. Jeffrey Tucker.

WHO: This class is open to DC’s, PT’s, AT’s & students (personal trainers need to speak to Dr. Tucker before enrolling).
Credits earned by both doctors and students at these courses may be used toward the ACA Rehab Diplomate credential (DACRB).

WHERE: Premiere Spine & Sport 4982 Cherry Ave. San Jose, CA 95118

WHEN: Saturdays from 8:00a.m to 7:00pm
Seminar: 8:00 a.m. – 7:00 p.m.
Includes two 15-min. breaks; (late morning & late afternoon)
Lunch: 1:45 p.m. to 2:30 p.m. Lunch provided by host

OBJECTIVES: Create specific rehabilitation and/or exercise programs

COST: Registration: 7:30 – 8:00 a.m. Doctor cost per course: $325 Registration Students cost per course $230 Registration Early Bird Registration – Register 30 days in advance & save $30 per course! Or Pay $1,295 for all 5 Courses (Save $330.00!)
Registration is limited to the first 40 registrations.
We cannot accept walk-ins without advance notice

CONTACT: Questions? Contact Course Chair: Dr. Jeffrey Tucker Email: DrJTucker@aol.com or Phone: (310) 339-0442 Phone: 1-310-444-9393

EXTREMITY SERIES:

June 8, 2013, Hip: This course in an application of diagnosis, assessment, and rehabilitation principles to common orthopedic conditions such as hamstring and groin sprains/strains, hip labral tears, pubic symphysis conditions. You will gain knowledge in functional anatomy and management of hip pain. It also covers open closed chain/functional movements, lower extremity functional-whole body exercises, as well as advanced issues in the objective measurement of soft tissue injury and specific stability ball exercises.

July 13, 2013, Knee & OA: This course presents rehabilitation for the management of osteoarthritis and the knee. Assessment of the knee and specific corrective exercises will be taught. Rehabilitation for common sports and industrial injuries will be presented. The functional anatomy and management of lower extremity pain will be taught. Open closed chain/functional movement, lower extremity functional-whole body exercises.

August 3, 2013, Ankle-Feet, plyometrics & balance training:  This is an in-depth course in the evaluation of gait and functional anatomy of the foot and ankle. Functional management and exercises of common sports and industrial injuries of the lower extremity pain are taught. Beginner to intermediate issues in the principles and protocols in balance & stabilization training, ball, band /tubing, & bodyweight training as it relates to the lower extremities.

September 7, 2013, Shoulder: This course provides an in-depth analysis to the upper quarter and shoulder functional anatomy and movement assessments. This is a workshop for shoulder rehabilitation (application of rehabilitation principles to common orthopedic conditions) using low load exercises, bands, free weights and kettlebells. Course goal is proficiency in the management of shoulder and upper extremity pain. Specific band exercise training will be taught.

Principles of the Suitcase Deadlift – Dr. Jeffrey Tucker

March 28th, 2013

Toe Touch Progression – Dr. Jeffrey Tucker

March 28th, 2013

Goblet Squat – Dr. Jeffrey Tucker

March 28th, 2013

Resolution of Recurrent Acute Episodes of a Chronic Lumbar Disc Herniation Utilizing Chiropractic Rehabilitation Procedures and a Multi-Modal Wellness Model of Care

March 28th, 2013

Peer Reviewed by the American Chiropractic Rehabilitation Board

Michael W. Mathesie, DC, CCSP, DABFP, DACRB*

*Chiropractor; Private Practice

10617 West Atlantic Boulevard
Coral Springs, Florida 33071
(954) 755-1434
Backman100@aol.com

Structured Abstract: A Retrospective Treatment/ Management Case Report

Objective: To document and describe a multi-modal treatment method approach, that can be utilized in resolving a case of long term recurrent exacerbations of a lumbar disc herniation, resulting in low back pain and sciatica in a 39 year old construction worker.

Methods: The review of the literature suggests numerous methods for the treatment of lumbar disc herniation; this is including: spinal manipulation, physical therapy methods, rehabilitation, NSAIDS, steroid epidural injections, and surgery. The methods used in this case include non pharmaceutical and non surgical methods available to the chiropractor. Nutritional advice included elimination of corn syrup and sugar drinks, an increase in water intake, a reduction of breads and grains, the addition of supplements (including niacin and omega 3 essential fatty acids) and a daily general supplement pack with enzymes. A heel lift was fit for the patient for an anatomical short right leg. During the passive phase of care, modalities including High Volt Electrical Muscle Stimulation @ 80-150Hz, Interferential Electrical Muscle Stimulation @ 1-10Hz, Ice, breathing exercises, and 910nm LASER, were utilized in the acute stages of treatment along with Chiropractic Spinal Manipulation for the first 8 visits. During the transitional phase of care Post Isometric Relaxation Muscle Energy Techniques progressing to Post Facilitation Stretch, Manual Therapy Soft Tissue Techniques, Foam Roll Maneuvers, Posture Stretches, Side Bridges Progression, Cat-Camel, Dead Bug and Quadruped Bracing Progressions, were introduced with continued 910nm Laser Therapy and PRN Chiropractic Spinal Manipulation over the next 9 visits. During the active phase of care, after a full functional assessment, the patient began a 20 minute cardiovascular training program and continued progressions of the previous transitional program exercises. Additional rehabilitation was initiated consisting of: Deep Neck Flexion, Push-ups, Scapulo-Thoracic Facilitation, McGill Curl Up Lumbar Stabilization Exercises, Cook Hip Lift Lumbar Stabilization, Side Bridge McGill Lumbar Stabilization Exercises, Prone Bridge McGill Lumbar Stabilization, Supine Bridges with Progressions to Gym Ball, Standing Lunges, Superman with Gym Ball, Bird Dog, Wall Squat with Gym Ball, and Balance Training on Rocker Board for an additional 10 visits, which were performed for a total of eight weeks. A one month follow-up visit occurred for a total of 28 visits. In this case, the visits were completed within a three month period.

Discussion: Considering that the cause of low back pain is so complex, it would not be efficient to limit the treatment option to one mode. In this case, the patient was brought through the passive, transitional, and active phases of chiropractic rehabilitation. The patient also followed simple nutritional recommendations for weight loss, general health, and to lower blood pressure, inflammation, triglycerides, and cholesterol levels. He was given a heel lift for an anatomical short leg, to balance the lumbar spine and improve a lumbar convexity. He improved his cardiovascular fitness in the office and at home, and was taught to strengthen his spinal stabilizing core while being treated with a 250 Watt peak power; this included a 2 Watt average power, and a 910nm wavelength LASER that would have the ability to reach the target tissue of the lumbar facet and discs.

Conclusion: The patient responded well with treatment in a two month time frame, and then with a one month follow- up. There was no longer any residual chronic low back pain or sciatic radiculopathy, which has not been able to be accomplished in nearly 20 years for this patient. A normal strength and flexibility level was reached, using referenced Physical Performance Ability Test Methods and Measurements. There was a near normal BMI accomplished from previous obesity, normal cholesterol  from previous hypercholesterolemia, normal glucose from borderline hyperglycemia, 33 pounds of weight loss, a decreased resting heart rate, and a decreased blood pressure. Common outcome assessment tools were utilized, and scores were dramatically improved including: Roland–Morris Low Back Pain and Disability Questionnaire (RMQ), Revised Oswestry Back Pain and Disability Questionnaire, and Health Status Questionnaire/SF-36/Rand 36.

Keywords: Lumbar Disc Herniation, Chiropractic Rehabilitation, 910nm Superpulsed Laser, Weight Loss, Heel Lift, Outcome Assessments, Chiropractic Spinal Manipulation

Introduction:

This case is an example of a common type of patient presenting to a chiropractic office, which includes: a nutrient deficient, obese, de-conditioned, early middle aged male physical laborer, with signs of pre-diabetes, hypercholesterolemia and elevated blood pressure. Along with a chief complaint of nearly 20 years of recurrent exacerbations of a lumbar disc herniation, resulting in chronic low back pain and acute episodes of sciatica. The objective, in this case, is to document and describe a wellness model of care using a multi-modal treatment method; an approach for a portal of entry chiropractor that could be utilized in resolving the presenting musculoskeletal conditions of the patient as well as the underlying additional health conditions that are co- morbidities affecting the healing process and the future health of the patient.

Case Report Presentation:

History of Present Illness (HPI) and Chief Complaint/ Symptoms: The patient entered the office explaining that at 8:30 AM he had bent over and lifted a small generator at a construction site, turned, and felt a pop in his lower back. He immediately felt pain in his lower back region, and it progressively got worse throughout the day. The pain eventually began to radiate to his right buttock and posterior thigh, his girlfriend had to drive him to the office. The symptoms remained to be constant; 100% of the time, they were severe in intensity, rated as an 8 to a 9 on a Quadruple Visual Analog Scale, with 8 being the best and 9 being the worst. His current and average pain levels were at a 9. The symptoms were further described as low back pain, from the bilateral ribs to the top of the crests, and then pain in the right butt cheek, under the butt cheek, and down the back of thigh stopping right before the back of the knee. The patient also described his back as being swollen. He said the pain he felt was sharp, dull, deep, burning and achy. The pain diagram filled in by the patient matched the description. He stated that lying on his back decreased the pain by a little, and putting weight on the right leg, including any movement, increased the pain. Prior to this episode, he has suffered from chronic low back pain, on and off, for 20 years, since high school sports. He also expressed, that he always feels stiffness and tightness in his body, even in the mid back region and neck, but those regions were not as painful in comparison to the pain he felt in his lower back. The patient revealed that 2 years ago he went to a pain doctor who ordered him a lumbar MRI; the patient brought in the results of the MRI for my review.

Activities of Daily Living Form revealed that there were no activities that could be performed except sedentary items and those not related to movement.

Outcome Assessment Forms, Red Flag and Risk Factor Assessments: These questionnaires were filled out to assess risks and set up baselines for future comparisons, and to determine levels of improvements; the results can be evaluated below in Table 1.

Past Medical History: The patient revealed a history of an appendix and tonsil surgery as a child: a broken right middle finger in high school, lacerated thumb requiring 20 stitches a few years ago, an automobile accident five years ago with no treatment, many traumas to the spine and extremities from high school sports, and he admitted to 8 episodes of this similar problem over the last 10 to 20 years. There was no other history of major illnesses, hospitalizations, or traumas revealed. His last physical examination was approximately two years ago, when he went to the pain doctor for pain medication and had injections. There was no blood work-up performed, according to the patient at that time, and he thinks it has been over 5 years since he’s had blood taken. Current Medication: He took 2 unknown pain pills from a co-worker this morning. For many years, he has been regularly taking two Motrin (400mg) every day, for his low back pain. Allergies: Pollen; Codeine; no other known allergies were listed.

Family History: The patient revealed that there was no heart disease, blood pressure conditions, cancer, or strokes in his immediate family. However, he revealed that his father has just been diagnosed with diabetes, and his father and mother both have high cholesterol. Since the patient had not had a blood work-up in over five years, further evaluation will occur regarding serum cholesterol and glucose levels.

Social/Occupational History: This patient is divorced, has an occasional two cigarettes a week, and consumes two alcoholic drinks a day with an occupation as a self employed carpenter/construction worker. His duties include construction, carpentry, form work, and framing which is often very strenuous. The highest level of education reached, is the completion of high school. The patient reveals that he does believe he has stress in his life, with some financial worries and trying to find work all the time, but not too high. He rarely takes a multi vitamin and often has fast food, processed food, and soda/sugar drinks at work all day. Prior to this injury, he had exercised less than moderately. He occasionally participates in other sports and activities, and he states that he usually does not get 6 to 9 hours of sleep each night.

Review of Systems: There were no symptoms of weakness, fatigue, fever, night sweats, weight loss, or any indication of vision, hearing, nasal, or throat disorders, coughing, difficulty breathing, chest discomfort, difficulty or loss of bladder or bowel control, rashes, numbness, major mental or hormonal disorders, or other blood, immune, or lymphatic abnormalities. However, he mentioned the feeling of pins and needles in his right leg. There was stuffiness mentioned for the nasal system, contributed to the allergies and construction dust, but there were no other additional symptoms noted to indicate additional organ dysfunction, except muscle/joint pain/back pain/stiffness was listed. However, this is part of the chief complaint, because he also has a chronic intermittent lower back condition.

Clinical Impression/Working Diagnosis: Based on the history, the patient most likely has a sprain/strain in the lumbar spine, with sciatic neuritis and possible disc herniation aggravation. A comprehensive examination will be performed to confirm this working diagnosis.

Physical Findings: This was a 39 year old, 5′ 11″, 225 pound, slightly disheveled appearance, endomorph body type, afebrile, Caucasian male with blood pressure of 138/89, and a pulse rate of 90 bpm with normal rate, rhythm and amplitude, and respiration rate of 19 breaths per minute. He would be considered obese based on the Body Mass Index calculation of (225 #/71 inches2) X 703 = 31.4 BMI. This would be considered within the “30 BMI and above” which would be the obese category; 18.5 to 24.9 would be normal category. Observation/Inspection of the skin, revealed no rashes or major scars of the head, neck, trunk, back, or extremities, except the hands, fingers, and forearms had multiple scars from working in construction. The fingernails were normal, there were no tattoos, no contusions, cuts, or discolorations noted on the spine or pelvis regions.

Percussion of the bony structures around the spine and pelvis, using a reflex hammer, revealed all normal findings except that the lower lumbar spinous processes were very tender when being struck with severe levels of increased pain. This was a suspicious finding, although hitting the painful areas would typically increase the pain, this level was more than would be expected.

Palpation/Inspection of the head, neck, trunk, back, and extremities (including skin, lymph nodes and thyroid gland) revealed all to be within normal limits except the bilateral lumbar paraspinals, and right quadratus lumborum were in spasm—rated at a 2— which is a spasm existing without provocation. Tenderness of this area would be graded as +4; thus, the patient complained of severe tenderness and withdraws immediately in response to the test pressure, and was unable to bear sustained pressure. The right Gluteals and piriformis muscles were in spasm, rated as a 1, which is triggered with movement or external pressure. These areas would be graded a +3 for tenderness, which is considerable tenderness, and withdraws momentarily in response to test pressure. The hamstring muscles were very tender to palpation, rated as a +2, which is moderately tender. The cervical paraspinal muscles revealed mild trigger points that were tender, graded as +1, which would be mildly tender or annoying.

Peripheral Vascular Evaluation consisted of auscultation of the carotid, subclavian, abdominal aorta, and femoral arteries for which there were no bruits heard. There was no swelling distally in the ankles or feet.

Specialized Testing consideration was appropriate at this point, because there was significant provocation upon percussion of the spinous processes of the lumbar spine, suggesting a possible fracture of the spinous processes, which could occur with some lifting injuries. This was considered in order to prevent further damage to the patient, from performing more strenuous testing. AP, lateral, left and right posterior oblique x-ray views of the lumbar spine, was taken on this patient before the exam was continued, in order to rule out the red flag of fracture of the spinous processes. The films did not reveal any fractures or other pathology; thus, the examination proceeded. The x-ray findings will be listed in a subsequent paragraph.

Range of motion of the cervical spine using dual inclinometer method reveals Flexion 45/50, extension 50/60, right lateral flexion 40/45, left lateral flexion 40/45, right rotation 65/85, and left rotation 70/85. There was no pain reported in the cervical spine, just stiffness. The lumbosacral spine ranges of motion were measured at flexion 30/65 (reached 24 inches from the toes) and pain in lumbar and right gluteal/posterior thigh, extension 10/30 with pain at lumbosacral region/right SI joint, and upper gluteal, right lateral flexion 10/25 right gluteal/hamstring pain, and left lateral flexion 20/25 with no increase in pain. Thoracic ranges of motion were flexion 40/60, right rotation 15/30, and left rotation 20/30. These movements increased low back pain. Range of motion of the hip joints, using goniometer revealed flexion to be 120/135 on the left and 50/135 on the right with both movements, resulted with increasing pain in the lower back and down the right posterior thigh. The Extension was 20/30 on the left and 10/30 on the right; both caused low back pain. Abduction and Adduction were too painful for him to complete. Internal rotation was 30/35 on the left and 25/35 on the right, with an increase in pain in the right gluteal. External rotation of the hip revealed 30/45 on the left and 20/45 on the right with increased pain in the right buttock with movement. Knee flexion was 115/135+ on the left and 105/135+ on the right. There was only a mild increase in low back pain upon knee flexion, no knee pain. The knee could be fully extended and there was obvious abnormal movement patterns noted in the spine.

Posture evaluation revealed: anterior head translation, a left head tilt, a high left shoulder, bilateral internally rotated shoulders, an increase in thoracic kyphosis, a high left ilium, mild left torso translation, a pendulous abdomen, and flattened Gluteals. Gait revealed a mild limp with the patient putting more weight on the left leg, no pronation of the feet, a mild right external rotation of the foot, and a slow cadence of gait were all noted.

Chiropractic evaluation, utilizing motion palpation of spinal joint play, was performed. Ligamentous fixations were noted at C1/C2, C5/C6 and C7/T1, T5/T6 and T12/L1, L4/L5, and Bilateral SI joints were fixated to a moderate degree. These fixations indicated kinesiopathology components of the subluxation complex. There was no crepitation or hypermobilities noted. No contusions were visually evident in these regions. There was obvious hypertrophy of the lower thoracic musculature and tenderness of the lumbar paraspinals as noted above, as well as additional right sided hypertrophy apparent from a lumbar spinal right convexity. There was also inflamed muscle tissue noted with mild edema, palpated along the paraspinals and right iliac crest.

Neurological Examination: The patient was oriented to time, place, and person. The mood was normal. A normal review of the cranial nerves was noted. Peripheral vascular system revealed normal skin temperature, and normal pulses of the upper and lower extremities. The Muscle tone in the upper and lower extremities was normal with no atrophy, fasciculations, spasticity, or flaccidity noted. Dermatome sensation to light, touch, and sharp stimulus was normal bilaterally along both upper and lower extremities (except S1 on the right would be considered hyperesthesia) because it was perceived as an increase in sensation compared to the left S1 dermatome, as well as the right L5 dermatome above, and S2 dermatome below. Muscle strength was 5/5 for all major upper and lower extremity muscle groups. Deep tendon reflexes of the upper and lower extremities were 2+, normal. Tandem Gait was difficult and not completed due to pain. Babinski’s Sign was absent with the toes going into plantar flexion. Rhomberg Sign was absent. Coordination testing of finger to nose was normal. Cerebral function was assessed with the patient being able to count backwards from 35 in intervals of 7. He was able to rapidly move his hand to his thigh, chest, and other hand. The girth of his left calf was 15 inches and the right calf was 15 inches.

Orthopedic Examination: In addition to the above findings, a musculoskeletal examination including inspection and palpation of the bilateral joints, bones, muscles, and tendons with stability/provocative testing revealed the following: Vertebral Basilar Artery Functional Maneuver was negative for vertebral artery insufficiency. Thoracic outlet syndrome testing was negative. Cervical foraminal compression, Maximum Compression, and Soto-Hall/forced flexion were all negative for any increase in cervical pain or radiation of pain. Shoulder depressor testing was negative but did cause a mild pulling sensation of the trapezius muscles, not pain. Jull’s Test with the patient asked to hold their head off the table for 10 seconds, resulted in chin jutting indicating weak deep neck flexors. An increase in intrathecal pressure caused an increase in lower lumbar spine pain. Straight Leg Raise Test caused an increase in low back pain bilaterally and also radiation to the right posterior thigh above the knee at 50° of right passive hip flexion. The hamstrings were shortened bilaterally with 70 degrees on the left and 50 degrees on the right. Bowstring Sign was negative bilaterally. Patrick’s Test was performed causing pain on the right side indication a possible right hip lesion and indicating very tight groin muscles bilaterally. Milgram’s Test was performed causing pain in the lower lumbar spine almost immediately and revealed very weak abdominals and/or hip flexors. Thomas’ Test revealed shortened Iliopsoas muscles bilaterally. Pelvic compression testing revealed pain in the right SI joint and surrounding regions. Nachlas’ Test caused pain in the right lumbosacral region and Sacroiliac Joint. Hibb’s Test revealed pain in the right SI joint and deep gluteal region when pushing away the right leg, also causing the left pelvis to rise, indicating piriformis shortening. There was no pain on the left Hibb’s Test. There was tight quadriceps muscles noted bilaterally with the patient unable to reach the heels to the buttocks with a passive stretch. Yeoman’s Test was positive on the right for SI joint pain. Kemp’s/Quadrant Test caused local low back pain and radiation of pain on the right when rotating the patient posteriorly on the right. Passive Scapula Approximation Test was negative for interscapula pain. There were no deformities, step offs, masses or instabilities noted.

X-rays: The views that were taken included the upright AP lumbopelvic, AP spot, lateral, and left and right posterior oblique x- ray views of the lumbar spine. As discussed previously, the physical exam was discontinued until fractures were ruled out and then the examination proceeded. The films did not reveal any fractures, on any of the projections, within any portion of the spinous processes or vertebral bodies. The AP lumbopelvis view revealed a lumbar convexity with an 11 degrees Cobb’s angle to the right, with a pelvic deficiency of 9 mm on the right side, measured at the heads of the femur, indicating an anatomical short leg on the right side. The L4/L5 and L5/S1 facets showed mild arthrosis. There was mild global left spinous rotation noted of the lumbar spine. The lateral projection revealed mild L5 disc space narrowing. The intervertebral foramens were patent. A mild loss in the lumbar lordosis is evident. Mild anterior spondylosis is evident on the vertebral bodies of L2/L3 and L5/S1. The oblique projections show no separation of the pars.

MRI: The patient brought in with him a copy of a lumbar spine MRI report, and compact disc from a local MRI Center dated 12/18/09, 15 months ago, which was ordered during his last episode of pain similar to this. The report written by a medical radiologist, who was considered reputable in the community, revealed a right paracentral herniation L5-S1 with loss of lumbar lordosis and a very mild dextroscoliosis. These findings were compared to the images and were accurate, thus the report was initialed.

No physical performance testing was attempted on this visit, to establish a baseline or weak link, because of the acute inflammatory phase or stage of the patient’s condition.

Diagnostic Impression/Assessment: This is an acute new injury over a pre-existing chronic weakness.

Primary Diagnoses:
1. 847.2-Lumbar Spine Sprain/Strain
2. 724.3-Sciatic Radiculitis/S1
3. 724.2-Lumbago
4. 728.85-Muscle Spasm; Piriformis
5. 739.3-Lumbar Joint; 739.4 SI Joint; Dysfunction/
Non-Allopathic Lesion/Subluxation Complex

Secondary Diagnoses:
1. 722.10-Lumbar Disc Herniation/L5
2. 739.2-Thoracic Joint Dysf./Non-Allopathic Lesion/ Subluxation Complex 3. 728.87 Muscle Weakness
4. 719.7-Difficulty Walking
5. 781.92-Abnormal Posture

Complicating Factors: The patient had co-morbidities noted; he was de-conditioned, had a pendulous abdomen, had a 9mm right short leg contributing to a mild right convex lumbar curvature, he was obese by at least 40 pounds, worked a laborious job, had an alcohol intake of two drinks per day, and occasionally smoked.

Prognosis: Fair. He has had this condition for many years, with on and off flare-ups every one to two years. He has never truly addressed the underlying weaknesses contributing to the problem. He works in a job that requires the use of his back. He has a confirmed L5 disc herniation that appears moderate in size. This condition could become more stable with proper methods applied. If he chose to follow my directions and treatment plan, this prognosis could be elevated.

Discussion, Decision Making, Treatment Goals and Initial Treatment Plan: The initial treatment plan was recommended to consist of short term, one to three weeks of ice with compression on the lumbar spine. This includes electrical stimulation of the lumbar spine and right piriformis/gluteal region to decrease pain and tissue swelling, starting with high volt galvanic at 80 to 150 Hz (encephalon release) and then after several visits, interferential at 1-10 Hz (endorphin release). He was instructed to wear an all elastic lumbar support brace for the next five days; it was to be worn only when moving and traveling places, and not when in bed or sitting at home. The brace is not rigid, but semi-flexible. He was required to return the back brace support to the office to assure he did not wear it past five days. The use of this brace was for short term only, to protect the injured area from re- injury while it was healing, to rest the injured tissue and to compress the injured tissue. At the same time, there was an attempt to prevent further weakness and disuse atrophy of the small spinal muscles of the spine. Also recommended, was LASER therapy to the lower lumbar region, L5 and SI joint, and right piriformis muscles for the reduction of pain, inflammation, and for the biostimulatory effects on the joint and soft tissue. To reach the facet and disc, which is at least 3.5cm to 5cm deep, a 910nm LASER must be used. Chiropractic Manipulative Treatment/Adjustments/Manipulation was recommended to the thoracolumbar region, lumbosacral and sacroiliac subluxation complex kinesiopathophysiological components as indicated during this initial stage of care. He was also given a soft tissue supplement pak, containing 660 mg of turmeric root extract, 705 mg of an enzyme blend of protease, amylase, papain, lipase, bromelain and others, quercetin, GABA, vitamin C, B-6, calcium, and magnesium for the inflammation and tissue repair. This would be taken as directed on the box and brochure given, and would immediately be stopped if any nausea occurred. If this occurs try to take it with food. The patient would then be re-evaluated within approximately 3 weeks unless indicated earlier or later. Treatment frequency would be three times a week, but he could be seen daily for the first few days in result of the severity of pain. He was treated on the day of this initial examination.

The clinician would be evaluating for improvement of symptoms and function. Short term treatment goals, by two to four weeks, will be a 50% decrease in the symptoms intensity, elimination of the majority of tissue swelling, the ability to sit, drive, and stand for more than one hour without an increase in pain, and the ability to walk without a limp, and to be able to perform basic functional testing maneuvers to assess his baseline. An additional goal for this patient was to lose 15 pounds in 30 days. He wanted to finally get rid of the chronic back pain that kept returning. The patient was concerned about his elevated blood pressure and wanted his cholesterol checked, and he agreed to listen to my recommendations. The patient would also utilize ice on the lumbar spine and right gluteal region with compression at home; applying a bag of crushed ice on a moist towel over the complaint area for 15 minutes, and then re-apply when the skin is normal to touch. The patient was given a requisition form to go to Quest Labs and have blood drawn for a comprehensive metabolic panel, thyroid panel, CBC, and Lipid Panel to evaluate the fatigue, thyroid, cholesterol levels, and glucose levels; it was done with the consideration of the borderline elevated blood pressure, obesity, and scores on the health status questionnaire.

This was an acute injury/condition with multiple components to the diagnoses. It required a low to moderate complexity of medical decision making, including the reviewing of diagnostic images and reports, low risk of morbidity, as well as the length of time spent face to face with the patient of over 75 minutes, with at least 25 minutes involving counseling. However this was regarding the options for him, including the referral for pharmaceutical intervention or epidural injection consultation, or the following up with a rehabilitation program with this office over the next 3 to 15 weeks. The risks of treatment and the risks of not getting treatment, were discussed with the patient and listed on the separate signed informed consent form, and the patient stated that he understood all elements and wanted to start the treatment plan that day.

Methods/Patient Management:

The patient was able to stand on the platform of a hi-lo table, and the table was then lowered to the prone position. Four adhesive electrode pads were attached to the four lead wires, and placed over the left and right L5 paraspinal/quadratus regions and the right upper and middle buttock. The high volt galvanic (HVG) (G0283) was set at 80-150 Hz for encephalon release and pain relief to slightly more than patient perception for 20 minutes. Ice (97010) was also applied to the same region with compression for no longer than 15 minutes to prevent an increased reaction of blood flow. After the ice and HVG therapy was complete, a 910nm 250W peak, 2W average power, superpulsed LASER device (S8948) was applied to the patient while in a side lying position at the right side of the interspinous space between L5/S1, the right top of the sacrum, the right SI joint, and the right piriformis muscle with 1344 Joules in a total area of 90 cm2 for a dose or energy density of 15 J/cm2 at the surface over 15 minutes. The use of ice prior to using LASER is often beneficial because less blood in the capillaries will allow better transmission of photons through the tissue. The patient was given an adjustment/spinal manipulation in the side posture position to the Left SI joint, and T11 fixations/subluxation complex. The right SI joint was too acute to manipulate on the initial visit. He tolerated the adjustment (98940) very well. The patient was fitted with an all elastic lumbosacral support brace to protect from re-injury, rest, and compress the lower back to assist in the reduction of swelling and pain. This is a loan to the patient to assure that he returns it and does not wear it for more than 5 days. He agreed to return it within the recommended time period. The patient was instructed not to wear it when sleeping or when sitting for long periods; he was only required to wear it when standing and walking. He understood that it was the goal to not have him become dependent on the brace, and would be utilized short term during the first phase/inflammatory phase. He was instructed to use ice at home with a moist towel on the skin, use a zip lock bag of crushed ice cubes on top of the wet towel for 15 minutes at a time, and then apply the ice again when the skin returns normal to touch (up to four times a day). The patient was given a three page handout on McKenzie self treatment/stretching and sciatica by Liebenson that he should read and attempt to put his body into the positions on the sheets. His breathing patterns were reviewed, also demonstrated and instructed him that while doing the exercises (even when standing or lying down) he must practice inhaling with his abdomen and ribs coming outward, and breathing out/exhaling with his abdomen and ribs coming inward; his shoulders and chest should not rise with breathing. It was explained to him that this could be a great exercise for him to start, and that it is not strenuous for his back and will help him have a head start when additional exercises begin in the weeks to come. The patient was instructed to return the next day. This treatment was performed for 4 visits over the next 7 days.

On the third visit the lab results came back. The results are available in Table 2. In addition to the soft tissue support vitamin/mineral/enzyme pak he was already taking. He was recommended to go to the health food store and purchase additional 100 mg capsules of niacin (B3) in the form of nicotinic acid. The patient was informed about the flush sensation which feels similar to a sunburn, but disappears in approximately 30 minutes. He should start with 100 mg three times a day for a week if tolerated. Then slowly titrate up to 500 mg three times a day. A slight flush, is the maximum he should feel. If it is more than that, he should back off. After three months, he should decrease the amount gradually and just include it in a multiple vitamin or other supplement packs or B-complex. This is to lower the triglycerides and increase his HDL levels and lower his LDL. He was also recommended to take 3000 mg of molecularly distilled Omega 3 essential fatty acids per day (in 1000 mg separate doses) to help lower triglycerides and possibly blood pressure, LDL cholesterol and increase HDL. He should increase his walnut and almond intake every day with at least a handful of each. Since he requested assistance with weight loss and fatigue; dietary recommendations included the complete elimination of all sugar drinks including electrolyte “ade” type, Cola, Iced Teas, and every other drink with sugar and corn syrup. No diet, energy, or vitamin water drinks, or artificial sweeteners were allowed either. He was instructed to drink as much water as he wants to for thirst. He may have plain green or black teas (cold or hot) with no sweeteners. He was able to use squeezed lemon in liquids. He may have two eggs for breakfast. He may also have a mixture of steel cut oats, shredded coconut, sliced almonds, walnuts, pecans, cinnamon, chia seeds, pumpkin seeds, and a banana with almond milk. He may have up to four servings of real beef/chicken/fish a day, but no processed cold cuts or jerky. He can have as much fresh or frozen vegetables (salads or steamed vegetables) as he wants to eat in a day, but can only use extra virgin olive oil, vinegar, lemon, Himalayan Salt, pepper, curry, hot sauce, or other seasonings on them. No other liquid dressings or oils were permitted. He may have one sweet potato or white potato a day if he wants and one serving of bread a day (two slices) if he must. For example, he can have a sandwich for lunch but not a full hero/hoagie roll. He may have four handfuls of fruit a day, (i.e. one whole fruit like an apple, orange, banana is each a handful, a big handful of blueberries is a handful) no more. He was permitted to cheat on his diet only one day a week (a Saturday night). Although this was a big change for him, he understood the parameters and promised to stick with it. He understood his lab results and understood that if the levels did not change in three months, he would need to see a medical doctor for pharmaceutical intervention. On the 5th visit over a 9 day span, the type of EMS was changed to interferential therapy. Interferential therapy (G0283) was applied with four adhesive electrode pads with the leads placed properly in a criss-cross pattern over the lower lumbar muscles/quadratus region and the upper gluteal/piriformis with most of the L5 region pain in the center of the pads vectors attempting to reach deeper in the tissue. The interferential machine was set to 1-10 Hz for endorphin release and continued pain relief, but also to increase circulation and reduce spasm, and set to patient comfort/tolerance for 20 minutes. Ice (97010) was also continued; to be applied to the same region with a compression wrap, but for only 15 minutes because of the tissue thickness and to prevent an increased reaction of blood flow. After the ice and interferential therapy application, a 910nm, 250W peak powered, 2W average powered LASER device (S8948) was applied to the lower lumbar/L5/and Right SI structures, delivering 1344 Joules in a total area of 90 cm2 for a dose or energy density of 15 J/cm2 at the surface over 15 minutes. He was given a side posture adjustment (98940) to the right and left SI joint fixations/subluxations, and supine adjustment to the lower thoracic segments. Light, passive range of motion was applied to the lower extremity to all muscles and all planes of his tolerance levels, and they were done to not aggravate the sciatica on the right, and just to relieve tension on the left side. He was instructed to try to walk a little more during the day and avoid sitting or lying down at all. He can continue to use ice at home as directed. This treatment was performed from the 5th to the 8th visit in slightly over two weeks. On his 6th visit, wall angel exercises were instructed, and performed to assist with the weak scapula stabilizers, tight pectoralis, and thoracic kyphosis. On the 7th visit, since his short right leg measurement was 9mm on the standing x-rays previously taken, he was given a 5mm heel lift to put into his right shoe. He walked around and did not have any problems with the lift. The patient is instructed to always remember to wear it in all his shoes. The pelvis appeared more balanced with the heel lift in the right shoe. On the 8th visit he was re-assessed/examined and functional and physical performance evaluations were performed, provocative tests were less severe regarding positive signs; some of the functional measurements and findings were noted in Table1, Table 2, and Table 3. The patient then began transitional care on the 9th visit to the 17th visit, for which the next goal was to continue with correct breathing patterns, stretching strategies, and stabilizing strategies. He continued to receive spinal adjustment/manipulations on a needed basis as well as the LASER therapy more regularly each visit. He continued on the diet and nutrition regimen, home exercises previously given, and additional ones. The transitional sessions consisted of breathing exercises for 6 to 8 minutes in the office, while stretching supine on a gym ball with the patient’s arms extended above his head, and then out to the sides stretching the pectoralis muscles and extending the thoracic hyperkyphosis. He was explained that with all exercises, the object is to never do a bad repetition to prevent creating a bad motor pattern. Stop at a bad rep and do more sets of fewer repetitions. Next the patient stood looking in the mirror (for awareness) holding perfect posture and abdominal hollowing with a “small foot” for 10 seconds at a time and this was repeated for three sets. He was then instructed to lay supine on a foam roll in the vertical position with arms to the side for 2 minutes and then up above the head for 2 minutes. He was then instructed to lay supine on a foam roll in the horizontal position and roll back and forth on the thoracic spine working the myofascial adhesions of the lower thoracic, and the hyperkyphosis of the upper back for 2 minutes. He was instructed that cavitation may occur and that would be fine. Next the Cat-Camel was performed for 6 to 8 minutes accentuating the correct breathing and reinforcing the tightening of the core, and assisting the form by holding the low back and abdomen for the patient and having him hold the positions. Quadruped Bracing:-on all fours-with chin tucked and neutral spine with a stiffened trunk/core using the “end cough contracted position” technique, and challenging the patient with perturbations when able, was performed. Next a Side Bridge on knees was held for 10 seconds each side for three sets. Then the Dead Bug Beginner: with arm above head, supine with same leg bent with foot on floor, other knee comes up and touches opposite hand coming from above, then switch, all while abdominal bracing and not holding the breath. 10 times three sets. Then Post Isometric Relaxation (PIR) was performed on the quads-hams-adductors- gastrocs-soleus-iliopsoas piriformis and gluteals, with the patient comfortable, with muscle passively lengthened to the slight resistance barrier, patient contracts the muscle with minimal effort against resistance for 10 seconds while breathing in, and then let out and relax. This was repeated 3 to 5 times until no new barrier was met for each group. In addition, Deep muscular manual therapy techniques of ischemic pressure, and stroking massage using the elbow, was applied to the right piriformis and gluteus muscles, and QL for up to 7 seconds. It was then released and repeated at different locations of the tightened trigger points of these muscles. The patient was explained that this deep pressure may be very painful and to not allow the level to pass their tolerance threshold. LASER therapy was applied on the right piriformis muscle, QL on the right and left trigger point areas at L4 and L5 region, and medial superior right SI joint region using a 910nm Superpulsed system, with a 250W peak and 2W average power to stimulates growth factors effecting gene expression, which is necessary for remodeling and formation of healthy tissue. This device also has the ability to penetrate deeper into the tissue because of its power density, wavelength, and delivery properties. 1344 Joules were delivered in a total area of 90 cm2 for a dose or energy density of 15 J/cm2 at the surface over 15 minutes. (S8948). He is recommended to attempt to do all of these routines and stretches gently at home. He was given a roll for the mid back to take home so he could work on the mid back at home. The patient was confident in doing the perfect form and repetition and was given my cell phone number for any questions. He should use ice as directed previously for any pain or flare-ups. At the 12th visit-no spinal adjustment was needed, and the patient was ready for additional intensity but still in the transitional phase of care. PNF techniques of Post-Facilitation Stretch (PFS) were initiated on the quads-hams/biceps femoris-gastrocs-soleus-iliopsoas-glutes and TFL/ITB. Care was used to assure patient comfort, and although he was instructed to contract with near maximum effort, pain should not increase past his average pain levels of 4. He promised not to go too hard with this stretch technique to avoid straining himself. The patient was then instructed to push against my body on each muscle treated, and breathe in slowly (respiratory synkinesis) while resisting on my count of 10 seconds, and have his eyes look (visual synkinesis) into the direction of his contraction. He then was told to completely relax and let go, as the muscle was stretched to the new barrier for 15-20 seconds, and he had his eyes look into the direction of the stretch. He relaxed for another 20-30 seconds and repeated each muscle 4 times. He continued then with breathing exercises for 6 to 8 minutes in the office, while stretching supine on a gym ball with the patient’s arms extended above his head, and then out to the sides stretching the pectoralis muscles and extending the thoracic hyperkyphosis. Again, the importance of proper breathing methods through the abdomen extending outward on inhaling, and that the ribs should come out laterally on inhaling and the shoulders should be relaxed with breathing and not be rising, were all reviewed. He was explained that with all exercises, the object is to never do a bad repetition, in order to prevent creating a bad motor pattern. Stop at a bad rep and do more sets of fewer repetitions. Next the patient stands looking in the mirror (for awareness) holding perfect posture and Abdominal Hollowing with small foot for 15 seconds at a time and this technique was repeated for three sets. This began with expected and unexpected perturbations while standing in this position. Then this was performed with the eyes of the patient closed, trying to assist him with proprioception, and balance while standing on two feet with awareness and perturbations trying to maintain the posture. He was then instructed to lay supine on a foam roll in the vertical position with arms to the side for 2 minutes, and then up above the head for 2 minutes. Next, He was instructed to lay supine on a foam roll in the horizontal position, and roll back and forth on the thoracic spine working the myofascial adhesions of the lower thoracic, and the hyperkyphosis of the upper back for 2 minutes. The patient also began rolling with perfect form, and breathing and bracing on the TFL to release some trigger points and tightness of this soft tissue for 2 minutes. Next the Cat-Camel was performed for 6 to 8 minutes accentuating the correct breathing, and reinforcing the tightening of the core as described previously. Quadruped Bracing was performed as described previously with expected and unexpected perturbations for 4 minutes. Next, a Side Bridge on the feet (instead of the knees) was held for 15 seconds each side for three sets. Dead Bug Second Progression was performed with the arm above head, supine with both knees at 90 degrees, other knee comes up and touches opposite hand coming from above, then switch, all while abdominal bracing and not holding breath, 10 times bilaterally; three sets. Deep muscular manual therapy techniques of ischemic pressure and stroking massage (using the elbow) was continued to be applied as previously described. LASER therapy was continued and performed as described above. A re-evaluation of previous positive maneuvers, as well as a reassessment of functional performance, was performed on the 17th visit of 03/09/11. Some of the results are included in Table1, Table 2, and Table 3. In addition, a Par-Q Form was filled out by the claimant to assess cardiovascular risks for which, allowed us to proceed with the YMCA 3 minute Bench Step Test. He was able to complete the assessment for which, the total visit took 2 hours to complete. On the 18th visit, 03/11/11-we began Active Care. The patient was instructed to continue to perform all the previous exercises at home during the off days. He is also asked to continue the cardio routine at home on his off day that was started today in the office, with the same level of intensity and time. He is also to attempt—with perfect form—the new exercises he was taught. The patient started at a 5 minute slow pace on the bicycle, and then increased the pace for 20 minutes maintaining his target heart rate of 142 bpm and then a 5 minute cool down. He was rated as below average on the YMCA 3 minute Bench Step Test on the assessment. Therefore, he was started at 60% for aerobic training for 20 minutes, and will be progressed up slowly to 80% for 20 minutes over the next several weeks as his fitness levels allow. The Karvonen Method Formula: (220 – age) – (RHR) X (% intensity) + (RHR) = HR target. This patient: 220 -39age = 181HRmax 181HRmax – 83HR rest =98 98 X 60% = 58.8 58.8 + 83HRrest = 141.8 HR target

By this time, the patient had mastered the Cat-Camel, Dead Bug, Mirror Image Posture, Side Bridging, Quadruped Bracing, Breathing Techniques, and has improved in his flexibility; he was able to explain that with all exercises, the object is to never do a bad repetition in order to not create a bad motor pattern. Stop at a bad rep and do more sets of fewer repetitions. He was instructed to continue this routine and use it as part of his warm up before entering the office, and also to perform this routine and all stretches daily. The active rehabilitation routine utilized is listed in Table 4. This rehabilitation routine was progressed slowly over each visit from the 18th visit to the 27th visit, with increased repetitions, sets, and/or resistance. It includes other increases in challenges such as, eyes being closed as indicated in the routine. He stretched and performed one hour of the exercises, and 20 minutes of cardio on his off days from this office, and used ice after all sessions for 15 minutes as previously directed. He was seen 3 visits a week of Monday, Wednesday and Friday until the 27th visit.
On the Final Evaluation, which was the 27th visit, the patient was discharged from active care and told to return in one month. He was stronger and thinner; had better posture and had nearly no back pain. At this point, it was deemed that he would do very well continuing to strengthen his back on his own. The patient should continue to perform all the exercises he was taught in this office, 3 times a week, as a home maintenance program. This would also include his cardio exercise as well. He was also prescribed a general multiple vitamin pack. This is in addition to the fish oil and niacin that he was still taking. He was no longer taking the soft tissue support pack for the last four weeks. He was instructed to reduce one fish oil capsule per day that he has been taking, because this new pack has one in it. He will reduce the niacin in four weeks, titrating down. He will visit his MD within the next four weeks, and have a complete physical and blood workup performed. He returned to work, and was recommended to return here in four weeks for a check-up to see how going back to work affected his back. He may also return to the office PRN (as needed) for any flare-ups, regressions, or reoccurrence of his lumbar condition. On the one month follow- up, the 28th visit, the patient was released and discharge. The patient has done a great job keeping up with the exercises. He looks great and he should return as needed for any tune-ups or flare-ups of any pain. If his condition deteriorates and functions decrease, if his symptoms reoccur, or after his home treatment fails to give relief, he may return for any nutrition purchases. The patient understood the importance of continuing the home plan of exercises with perfect form and proper breathing.

Results/Outcome of Care:

Table 1: Pain Assessment and Outcome Assessment Tools Summary of Results
02/01/11
1st visit
02/16/11
8th visit
03/09/11
17th visit
04/01/11
27th visit
05/02/11
28th visit
Key: *right now, average, best, worst listed, PF=Physical Function, BP=Bodily Pain, EF=Energy Fatigue
Quadruple Visual Analog Scale* 9,9,8,9 6,6,5,7 2,3,2,5 0,1,0,2
Health Status Questionnaire-(Rand)/SF 36 PF-60 PF-90
BP-57.5 BP-90
EF-40 EF-75
Roland-Morris Disability Questionnaire 18/24 11/24 6/24 1/24
Revised Oswestry Back Disability Quest. 39/50 22/50 13/50 5/50
Motrin Medication Intake 14x’s/week 2x’s/week 1x/week 0x’s/week

Table 2: Objective Findings or Measurements Summary
02/01/11
1st visit
02/16/11
8th visit
03/09/11
17th visit
04/01/11
27th visit
05/02/11
28th visit
Height 71 inches 71.75 inches
Weight 225 192 pounds
Blood Pressure 138/89 135/85 132/84 128/84
Resting Heart Rate 90bpm 83bpm 75bpm
Karvonen Calculation
at 60% and then 80%
HR Target
142 bpm
HR Target
160 bpm
BMI 31.4 26.22
Total Cholesterol 225/<200 190/<200
HDL 45/>46 55/>46
Triglycerides 235/<150 145/<150
LDL 160/<130 125/<130
Glucose 99mg/dl 85 mg/dl

Table 3: Physical Performance Ability Test Methods or Measurements:
02/01/11
1st visit
02/16/11
8th visit
03/09/11
17th visit
04/01/11
27th visit
05/02/11
28th visit
*Lumbar Spine Mobility Listed as Flexion, Extension, Lateral Bending Right, Lateral Bending Left (AMA normal values)
**Normal Values referenced from Rehabilitation of the Spine, A Practitioner’s Manual, 2nd Ed., Craig Liebenson, Lippincott Williams & Wilkins
YMCA 3 Minute Bench Step Test 116bpm; below average 101bpm above average
Lumbar Spine Mobility/ROM* 30, 10, 10,10 40, 15, 15, 20 45, 20, 20, 25 55, 25, 25, 25 60+, 25, 25, 25
Over Head Squat Test Score: 0; Fail; Pain Score: 1; Difficult Score 3
One Legged Standing Test Score: 0; Fail; 4 secs /open; 0 sec/closed Score: 1; Difficult; 15 secs /open; 6 secs /closed Score: 2; some compensation; 30 secs /open; 20 secs /closed
Lunge Test: Score: 1; Difficult Score: 1-2; Borderline Score: 3; No Compensation
Janda Hip Extension Test Score: 0; improper sequence; twisting/weak Score: 1; Weak Glute Score: 3; Correct Sequence/Normal Glute Max Strength
Janda Hip Abduction and Coordination Test Score: 1; Severe Hip Hike; ext. Rotation Score: 2; Overactive QL/Piriformis Score: 3; Normal
Side Bridge Endurance Test Score: 0; Pain; 10 secs Score:2-35 secs/no LBP/Compensation Score: 2; held 75 secs; slight compensation **/84.5 ave.
Sit and Reach Test Score: 2; 7 inch mark Score: 2; 9 inch mark Score: 3; 12 inch mark/10-16 mark
Trunk Flexor 2/50 10/50 35/50reps ; Ave. 27 +/- 14
Repetitive Arch Ups 6/50 15/50 30/50reps; Ave. 28 +/- 14
Squat Endurance/Repetitive 9/50 18/50 40/50reps; Ave. 37 +/- 12.5
Sorenson’s/Static Trunk 30/240 65/240 99/240sec; Ave. 97 +/- 56

Table 4: Active Care Rehabilitation Routine Performed with Continued Increase in Challenge:
Deep Neck Flexion Retraction of chin in the prone, seated or standing position to assist with forward head posture; with nodding the head without and then with resistance with a small gym ball and or head harness or band Sets of 10 to 20 reps to patient abilities
Push Ups On fists, chin tucked, neutral spine, protraction of shoulders, activate all stabilizers, feet dorsiflexed 5 reps; add reps, add rocking, rotation, and tripod
Scapulo-Thoracic Facilitation In the side lying position, activate scapula stabilizers, patient brings back scapula and shoulder to where the doctor directs Start with 10 reps each side and then increase
McGill Curl Up Lumbar Stabilization No head jutting, only perform after activation of abdominal bracing, breathing and bracing concurrently, hold and breath multiple times starting with the one leg bent, elbows on the floor, hand behind lumbar spine, upper spine moves only, no lumbar spine movement; progress to elbows off floor and/or both legs bent; then fingers curled next to ears, then adding trunk rotation. Start with 10 reps and increase to multiple sets of higher reps
Cook Hip Lift Lumbar Stabilization Supine; The focus should be on engaging the hip extensors. Pull one knee towards the chest as much as possible to engage the opposite hip extensors (as opposed to overusing the lumbar extensors) Hold 10 secs each side; increase secs held /sets
Side Bridge McGill Lumbar Side lying on feet (top in front) and propped up with forearm, square pelvis so no sag, abdominal brace 3 sets of 10 secs with Roll Over and increase
Prone Bridge McGill Lumbar Prone; propped up with both forearms, square pelvis so no sag, abdominal brace, chin tuck; progress from two feet to one foot, and lift other leg up and hold 3 sets of 10 secs and then increased over time
Supine Bridge Maintaining co-contraction including glut max, raising buttocks off the floor, then sacrum, lower lumbar, and upper lumbar spine. Then lower the spine down to the floor with the coccyx last to touch Hold 10 secs, longer; 2 legs to 1 leg, then ball
Superman On floor, both feet supporting on wall/floor, brace, keep spine neutral, extending the hips, not spine and lift arms up; both hands out, also sideways; hold 3 seconds/10 reps/3 sets Progress in hold time, reps, sets, and then to gym ball
Gym Ball Lumbar Extension Lay prone on ball, feet on floor, torso hanging off; lumbar extensions, 3 sets of 10 reps, hold each rep for 3 secs. Progress in reps and sets and hold time
Bird Dog Quadruped; chin tuck, breath, brace and hold, check for abnormal external rotation of hip and lumbar hyperextension, should be neutral then one arm/other leg; hold 3 secs; progress to under touches/ball 3 sets of 10; increase sets, reps, hold time; touches
Standing Lunges Patient steps forward onto Stability Trainer-(green-firm then blue and then black) with perfect erect posture; knee &hip at 90 degrees, then returns to stand; alternate legs; progress to weights on shoulders 3 sets of 15; progress in sets/ reps/colors/lb’s
Wall Squat with Gym Ball Abdominal Brace; Stand with back, shoulders, and head even and straight, leaning against the ball and look straight ahead. Keep shoulders relaxed and feet 1 foot away from the ball and a shoulder’s width apart. Keep head straight, roll down the wall with the ball, lowering the buttocks toward the floor until the thighs are almost parallel to the floor. Hold this position for 10 seconds. Make sure to tighten the thigh muscles while slowly sliding back up to the starting position. 3 sets of 10; progress with time in lowered position, sets, reps, and dumbbells on shoulders
Balance Training on Rocker Board Small foot and subtalar neutral maintained, abdominal hollowing, patient should maintain controlled rocking on the board with ankle joint without bending at the waist; start with 3 minutes and increase. Progressing to multiple angles eyes closed and round board

Discussion/Opinion:

The fact that obesity contributes to higher levels of inflammation and to causing additional abnormal forces on the motor and biomechanical systems, cannot be ignored. A leg length deficiency contributes to uneven forces on the spine structure; often a convexity of the lumbar spine on the same side; and in many cases should be progressively leveled to prevent or slow down the process of boney deformation, osteophytes and syndesmophytes. Joint and tissue mobility and flexibility is the foundation of any rehabilitation protocol and must be attained in order to progress into restoring stability to a weakened and unstable lumbar spine. Chiropractic Manipulative Treatment/Chiropractic Adjustments/Spinal Manipulation is the most researched mode of treatment for low back pain. This of course is the staple of the practice of chiropractic in restoring joint mobility and reduction of the kinesiopathophysiological component of the subluxation complex. Proper functional testing and measurements are key components to the documentation process. This testing and measuring will validate that conservative chiropractic rehabilitation protocols is cost effective with outcomes that not only produce resolution of the abnormal spinal condition, and progress a patient to normal status compared with referenced normal data, but also for the resolution of systemic health conditions that if ignored may require the inveterate use of medications. These outcomes will then possibly confirm that chiropractors are more than qualified to be primary care physicians, not only on health plans but on workers’ compensation plans, including wellness models of healthcare. Nutritional supplementation and cardiovascular fitness is also imperative when attempting to improve a patient’s general health. Proper circulation to the soft tissue with oxygen and micro and macronutrients is required for any successful rehabilitation and conditioning protocol. Finally, with the advances in technology, there are LASER devices which are FDA cleared in the United States that are available with a 910nm wavelength that have the ability to penetrate into the deeper target tissues of the spine with adequate power density to initiate the biostimulatory effects and accelerate the healing process. The practicing chiropractor, depending on his or her practice style, philosophy of practice, state regulatory practice acts, and education have the ability to utilize more than one modality to assist the patient to become well, not just in the spine, but the whole body, and without the need of pharmaceuticals.

Limitations:

This clinical case study did not have a post MRI performed after the treatment was finished. This would have been beneficial to access if the chiropractic manipulation/adjustment, rehabilitation protocols, and laser therapy assisted in the reduction of protrusion size. Thus, resulting in the beneficial results that were seen or if it was just from the improved stability, mobility,
strength and global alignment. Since this patient was self paying for his treatment, ordering another MRI in a pain-free subject may have been difficult. There are also limitations in general when treating this type of chronic condition, because of the amount of treatment time required each visit to accomplish the goal. The typical physician or therapist does not always get reimbursed by third party payers adequately for the hour or more that these visits actually lasted to make it financially feasible to perform on all patients. Furthermore, instead of being impressed with the provider, the third party payer may interpret the amount of effort by the provider as overutilization, making the documentation of the case much more important. Dedicating an hour of time one on one with the patient can be very difficult in a typical practice, which is why so many therapists and physicians often utilize more passive modalities which do not require constant attendance, but do not usually give a long lasting result.

Conclusion:

In general terms, case reports should not be generalized beyond the context of a particular case for a larger population of patients. Also, the natural progression of a condition or dysfunction may also explain the results experienced in patient care. This case study submitted, that happened to have stellar results for only one patient with long term reoccurring low back pain and sciatic radiculitis from a documented disc herniation, will hopefully stimulate more large scale studies and utilize multi-mode procedures instead of a single mode procedure. Most of these types of case studies attempt to establish the “best” single treatment; however, the “best” treatment may actually be performing everything that will restore the patient to whole body full function and wellness, not just treating the pain or the assumed source of pain.

Acknowledgements:

This case study was completed in part for the purpose of a requirement for board certification by the American Chiropractic Rehabilitation Board. The learning process and the assistance from the instructors such a George Petruska, DC was invaluable to me. The professionalism of the testing process and the staff and members of the ACRB was an example for all to follow. I am grateful for the opportunity to be a part of it.

Funding sources and potential conflicts of interest:

No funding sources or conflicts of interest were reported for this study.

References:

  1. Cassidy J D, Research Associate, Department of Orthopedics, University Hospital, University of Sockatchervan. An overview of the problem of low back pain D.C. Tracts1989; 1:345-356.
  2. Meade T W, Dyers S, Browne W, Townsend J, Frank A 0.Low back pain of mechanical origin: randomized comparison of chiropractic and hospital outpatient treatment. British Medical Journal 1590; 256:1431-1437.
  3. Deyo R A, Tsui-WI YJ. Descriptive Epidemiology of low back pain and its related medical care in the United States. Spine 1587; 12:246-268.
  4. Gilbert Jr, et al. Clinical trial of common treatments for low back pain in family practice, British Medical Journal 1585; 291:791-754.
  5. Cherkin D C, Mackornack F A, Berg A 0. Managing low back pain – a comparison of the beliefs and behaviors of family physicians and chiropractors. Western Journal of Medicine 1388; 149:475-480.
  6. Biering-Soiensen F. Physical measurements as risk indicators for low back trouble over a one-year period. Spine 1589; 9:106.
  7. Mayer T G, Gatechel R J, Kishino N, et al. Objective assessment of spine functioning following industrial injury; a prospective study with comparison group and one-year follow-up. Spine 1985; 10:482-453.
  8. K D Christensen. Rehabilitation guidelines for chiropractic. Chiropractic Rehabilitation Association 1992; l (edition):3-4.
  9. Mayer T G, Smith, Keeley J. Mooney V. Quantification of lumbar function; part II: sagittal plan trunk strength in chronic low back pain patients. Spine 1985; 10:765-772.
  10. Beimborn D S, Morrisey M C. A review of the literature related too trunk muscle performance. Spine 1988; 13:655660.
  11. Jinkins J R, Whittemore A R, Bradley W G. The anatomic basis of vertebrogenic pain and the autonomic syndrome associated with lumbar disc extrusion. American Journal of Neuroradiology 1989; 152:1277-1289.
  12. Hiering-Sorensen F. Physical measurements as risk indicator for low back trouble over a one-year period. Spine 1989; 9:106.
  13. Hochschuler S Rehabilitation of the Spine: science and practice St. Louis MI Mosby 1993
  14. Liebenson C. Rehabilitation of the spine: a practitioner’s manual. Baltimore: Williams & Wilkins, 1995.
  15. Studde D. Spinal Rehabilitation Stamford, Conn. Appleton & Lange 1999
  16. 1996 peer reviewed journal publication “Physiotherapy-Rehab Guidelines for the Chiropractic Profession” from the Council on Physiological Therapeutics and Rehabilitation authored by Dr. K.D. Christensen, D.C., C.C.S.P., D.A.C.R.B.
  17. Richardson J Clinical Orthopedic Physical Therapy Philadelphia, Pa Saunders 1994
  18. Pettibon B Spinal Biomechanics Tacoma, WA Pettibon Biomechanics Institute Inc. 1989
  19. Jaskoviak PJ, Schafer RC. Applied physiotherapy: microcurrent therapy. J Chiropr 1993; 381-400.
  20. Andrews Physical Rehabilitation of the Injured Athlete Philadelphia, Pa Saunders 1991
  21. Magee D. Orthopedic Physical Assessment: second edition Philadelphia, Pa Saunders 1992
  22. Christensen KD. Chiropractic Rehabilitation: Protocols, vol. 1. Ridgefield, WA: Chiropractic Rehabilitation Association, 1991.
  23. Williams MH. Beyond Training Champaign, Ill Leisure Press 1989
  24. Christensen KD. Clinical Biomechanics. Roanoke, VA: Foot Levelers, Inc. 1984:171-268.
  25. Christensen KD. Clinical Chiropractic Orthopedics. Roanoke, VA: Foot Levelers, Inc. 1984:171-268.
  26. Hellerbrandt FA, Krikorvian AM. Cross education. J Appl Phys 1950;2.-446-452.
  27. Yeomans S. Clinical Application of Outcome Assessment. Stamford, Conn. Appelton & Lange 2000
  28. Gray H. Gray’s anatomy. 15th ed. (T.P. Pick, B. Howden, ed.). New York: Crown Publishers, 1977:259-266.
  29. McGill Stuart Low Back Disorders Human Kinetics 2002
  30. Liebenson C. Rehabilitation of the spine: a practitioner’s manual. Baltimore: Williams & Wilkins, 2005
  31. Morris C Low back Syndromes Mcgraw Hill 2005
  32. Haldeman S Principals of Practice Mcgraw Hill 2006
  33. Baechile & Earle Essentials of Strength Training and Conditioning Human Kinetics: NSCA 2008
  34. Cook Gray Movement On Target Publications 2010
  35. Hode L, Tuner J., The New Laser Therapy Handbook, Prima Books AB, Grangesburg, Sweden, 2010
  36. Karu, Tiina, Ten Lectures on Basic Science of Laser Phototherapy, Prima Books AB, Grangesburg, Sweden, 2007
  37. http://www.cdc.gov/healthyweight/assessing/bmi/adult_bmi/index.html#Interpreted
  38. BenEliyahu DJ., Magnetic resonance imaging and clinical follow-up: study of 27 patients receiving chiropractic care for cervical and lumbar disc herniations, J Manipulative Physiol Ther., 1996 Nov-Dec;19(9):597-606
  39. Wilco C. H. Jacobs, Maurits van Tulder, et al., Surgery versus conservative management of sciatica due to a lumbar herniated disc: a systematic review Eur Spine J. 2011 April; 20(4): 513–522. Published online 2010 October 15.
  40. Hahne, Andrew J., Ford, Jon J., McMeeken, Joan M., Conservative management of lumbar disc herniation with associated radiculopathy: a systematic review, Spine (2010) Volume: 35, Issue: 11, Pages: E488-E504

Rehab Council Bylaws Amendment Vote Scheduled for Monday, Jan. 21st, 2013

January 17th, 2013

If you are an active ACA Rehab Council member in good standing, on Monday, Jan. 21st, 2013, you will be receiving an e-mail from Josh Damon, Corporate Affairs Assistant of the ACA, with respect to the proposed ACA Rehab Council Bylaws Amendment, Article XVIII (the proposed Amendment and the Rationale for this Amendment can be found below. The Rationale is in italics). The Bylaws Amendment has the full support of your Rehab Council Executive Committee and has been reviewed by our Rehab Council Liaison, Dr. Kelli Pearson, as well as ACA Legal Counsel Tom Daly. In addition, it has been approved as written (see below) by ACA Bylaws Chairperson Dr. Karen Konarski-Hart and past ACA Bylaws Chairperson, Dr. David Herd.

The e-mail from Josh will have a link that you will be able to click on in order to cast your “yes” or “no” vote. Only active ACA Rehab Council members who are in good standing and have paid their 2013 dues are eligible to vote. Thank you for taking the time to cast your vote.


Proposed ACA Rehab Council Article XVIII – Establishment of a College

“In accordance with its objective to promote scientific research directly related to all aspects
of physiologic therapeutics and rehabilitation with particular attention directed towards
chiropractic and multi- disciplinary network approach, the ACA Rehab Council President
may, upon a two-thirds (2/3) majority vote of the members at a regular or special meeting
called for that purpose, appoint a College which will be governed by its own Bylaws which
will not be in conflict with the Rehab Council Bylaws or those rules and regulations set
forth by the ACA, and which will consist of a group of chiropractic doctors with a specific
academic and clinical focus that can be viewed as complementary to the specialty of
rehabilitation. The College shall aid in providing scientific, academic and clinical guidance
and research to the ACA Rehabilitation Council complementary to the field of rehabilitation.”

ACRB Rehab Review 2013 – Pennsburg, PA

January 5th, 2013

Course & Registration Form

Register for an ACRB Rehab Review scheduled on one of two weekends; either Jan. 19th & 20th, 2013 or Feb. 2nd & 3rd, 2013. Both reviews are held in Pennsburg, PA.

For questions, contact Gene at 610-304-8471.

ACRB Rehabilitation Review Series 2 Day Program

2791 Geryville Pike Pennsburg,
PA 18073 (215) 679-3419

Come prepare with us with a comprehensive review and mock oral exam!
ACRB Certified Lead Instructors:
Chad Buhol DC DACRB
George Petrusksa DC, DACRB
Gene Serafim DC DACRB

Area Hotels

Hampton Inn Quakertown
1915 John Fries Highway, Quakertown, PA
hamptoninn.com

Comfort Inn & Suite
1905 John Fries Highway Quakertown, PA 18951
(215) 538-3000

Holiday Inn Express Hotel & Suites Quakertown
1918 John Fries Highway Quakertown, PA 18951
(215) 529-7979
hiexpress.com

Respond to Eugeneserafim@yahoo.com to ensure availability, Cost $299. for 12 hour module. ACRB credit available upon request. Questions; contact Gene 6103048471

Topics to be covered include:

  • Establishing Baselines for local muscle endurance, aerobic potential, flexibility and more
  • Strength progressions and regressions
  • Acute, Subacute and Chronic protocols and phases of healing
  • The abridged Certified Strength and Conditioning Program
  • Functional Analysis systems including the FMS, SFMA, MAG 7 and 4×4 Matrix
  • Muscle Energy Techniques
  • Neuromobilization
  • Functional Anatomy
  • Condition Specific Protocols
  • Outcomes Assessments Review
  • Sparing Strategies
  • Postural Syndromes
  • Qualitative vs. Quantitative analysis
  • Mock Skills and Comprehensive Exams

Rehab of the Lumbar Spine

January 5th, 2013

When: Feb. 9th & 10th, 2013
Where: Rocky Hill, CT

Become Board Certified in Rehabilitation

12 module program satisfying the lecture/workshop requirement leading to Diplomate Status in the

American Chiropractic Rehabilitation Board®
February 9th and 10th, 2013
Rehabilitation of the Lumbar Spine
Connecticut Chiropractic Association
2257 Silas Deane Highway
Rocky Hill, Ct. 60067

This module presents the best available evidence to support evaluation, rehabilitation and implementation principles for treating the lumbar spine. Static posture analysis, lower body stretching, as well as functional anatomy and the management of low back pain will be taught. An introduction to basic rehabilitation principles, advanced assessment of motor control, and body weight exercises will also be offered.

Chad Buohl, DC, DACRB
Eugene Seraphim, DC, DACRB
Mitchell B. Green, DC, DACRB
George Petruska, DC, DACRB

To register, contact NYCC Post Graduate Department at (800) 434-3955 ext. 132, or online at www.nyccpostgrad.com. Cost is $299 per module ($349 when paid less than 7 days prior to the first seminar date of the month). For course and program information, contact Mitch Green, DC, DACRB at (212) 269-0300. Contact the ACRB for additional online material and testing requirements at info@acrb.org.

License Renewal: Appropriate applications relating to credit hours for license renewal in selected states have been executed for these programs. For information regarding these applications, please contact the NYCC Postgraduate Department at 800 -434-3955. The presence of a speaker or an exhibitor at a NYCC-sponsored or co-sponsored program does not represent an endorsement by NYCC, nor is the presence of a product at a NYCC-sponsored program to be construed as a product endorsement or a testimonial by NYCC as to the quality of the product.

Dr. Jeff Tucker’s 2013 Rehab Seminar Series in Alameda, CA

December 6th, 2012

Description: Functional assessments and exercise are used as treatment of acute and chronic pain. The use of exercise is part of case management strategies and continues to be in the forefront of appropriate and safe use. Practitioners will learn assessments that will guide your corrective exercise selection and help you in the management in patients’ care.

Instructor: Jeffrey Tucker, DC, Diplomate American Chiropractic Rehabilitation Board. ACA Rehab Chiropractor of the year 2012.

Audiences: Chiropractors, Physical Therapists, Personal Trainers, students of same

Download the PDF

ACA Rehab Council President’s Report

November 29th, 2012

Jerrold Simon, DC, DACRB

Excellence is our Goal

In about a month we will all be starting a new year. Each of us will bring our own set of aspirations, hopes desires and goals with us as that new year unfolds. As far as the ACA Rehab Council is concerned, we’ve already established our goal for 2013 which can be summarized in one word, “EXCELLENCE”.

Since its founding approx. 20 years ago, the Rehab Council has followed its path along a proud tradition of principled leadership and service to its members. Unlike some of the other Councils within the ACA, the Rehab Council is not fraught with internal problems, divisiveness and argumentation. We as a Council know and understand that though we may sometimes disagree with each other, we all agree that our Council is made stronger, more productive and more responsive to our members when we work together in unity, cooperation and mutual respect for each other. We are also blessed with an associated Rehab Board, the ACRB, who works with our Council in mutual regard to maintain a joint approach which focuses on the promotion of the common good of our Council members and Diplomate holders. In short, in the words of Dr. George Petruska, here at the Rehab Council, “We don’t do smack and we don’t tolerate those who do.”

This year, the ACA Rehab Council elected its new Executive Committee. After six years of distinguished service to the Rehab Council as its President, Dr. George Petruska now carries the mantle of Past President. However, he remains a viable member of the Rehab Council as Chairman of the Symposium Vendor Procurement Committee. Because of Dr. Petruska and others like him, our annual symposium continues to grow in stature, attendance and academics as one of the leaders in post graduate education in the field of Rehabilitation.

Dr. Alfred Garbutt has been voted in as Vice President of the ACA Rehab Council. Besides filling in for the President in the event of his absence, Dr. Garbutt continues to edit the Journal of the North American Rehab Specialist while also maintaining the Council website found on the web at www.ccptr.org. Both the Journal and the website continue to grow in influence while helping to keep the Rehab Council member and Diplomate apprised of the latest research in the field of rehabilitation while also informing the Rehab Council member on postgraduate opportunities and the various goings on of the Rehab Council.

Our newest member to the Rehab Council Executive Committee is Dr. Jeff Tucker. For those of you who have had the pleasure of listening to him lecture, you know that Dr. Tucker is “a wealth of practical rehab oriented knowledge.” In addition, he is well known and well regarded in the field of rehabilitation with connections in academia that help to keep our Council at the cutting edge of the science of rehabilitation. Dr. Tucker has now taken on the duties of Secretary/Treasurer. It’s no wonder he has been chosen for this duty. With his successful practice and educational lecture series combined with his family business of owning and operating many successful Southern California restaurants, our Rehab Council Account couldn’t be in better hands.

Our Rehab Council also has the benefit of the many years of experience of Past President Dr. Don Fedoryk and his assistant Dr. Mitch Green as Convention Chair and Co-Chair respectively. More than any other persons, these Rehab Council members have been instrumental in attracting the best speakers in the field of rehab while coordinating one of the best run Specialty Council Symposiums in the American Chiropractic Association. It is no wonder why the ACA often praises the Rehab Council at their annual HOD meetings and during the annual NCLC (National Chiropractic Legislative Conference) Washington, D.C. meetings.

As of this year, the ACA Rehab Council has also added four advisors to assist the Rehab Council Executive Committee in carrying out its duties. Lee Burton, PhD, ATC, CSCS will assist the Executive Committee in educating Council members as to the importance of functional movement analysis. Craig Morris, DC, DACRB will act as an exceptional resource with respect the association between lower back syndromes and spinal rehabilitation. Michael Schneider, DC, PT, PhD will provide insight with respect to a rehabilitation suite which incorporates physical therapy modalities as well as licensed Physical Therapists. And finally, Kim Christiansen, DC, DACRB, as the Founder of the ACA Council on Rehabilitation, will provide a historical perspective necessary for a focal vision essential to the continued growth of our Rehab Council. We will also profit from the continued assistance of our Liaison, Kelly Pearson, DC, DABCO, who provides an invaluable link between the Rehab Council and the ACA Board of Governors and other Executive Leaders in the American Chiropractic Association.

Finally, all of us can be proud of the Rehab Council’s commitment to excellence with respect to our ever growing, mindfully relevant and increasingly pertinent annual Rehab Symposiums. The 2013 Rehab Symposium will take place at the Walt Disney Swan Resort in Orlando on April 19th – 21st and is shaping up to be the BEST yet. Howard Israel, DDS, PhD will present recent research on TMJ inflammatory & degenerative disorders. Jeff Spencer, MA, DC will address body holism as the key link in resolving difficult musculoskeletal problems. Thomas Michaud will present an overview of the latest research evaluating 3-D motion during the gait cycle relating this to improved examination and treatment techniques. And Michael Schneider, DC, PhD together with Sean Mathers, DC, DPT, DACRB, CSCS will address principles of post-surgical rehabilitation protocols of the spine, shoulder and knee.

The Rehab Council is also committed to expanding its purview and its scientific basis. With this in mind the Executive Committee called for and received majority vote approval by the membership to include the IBE (International Board of Electrodiagnosis) as a recognized certifying organization under the auspices of the ACA Rehab Council and the discerning eye of the ACRB. This is in keeping with the medical model which has incorporated its Electrodiagnosis Board under the auspices of the Physical Medicine and Rehabilitation Board.

In short, as your President, I continue to seek membership suggestions and input to help us reach our goal of Excellence. Ultimately, it is you, our members, who will continue to propel our growth as a Council in meeting and exceeding expectations as the leader in chiropractic physiological therapeutics and rehabilitation.
In chiropractic service,

Jerrold J. Simon, DC, DACRB

President, ACA Rehab Council

New Rehab Diplomate Program Starting Oct. 6 & 7th in Westford, MA

August 29th, 2012

Become Board Certified in Rehabilitation

12 module program satisfying the course requirement leading to Diplomate Status in the
American Chiropractic Rehabilitation Board®

Starting October 6 and 7th, 2012 and continuing monthly at the

Westford Regency Inn & Conference Center Westford, MA 01886 ~ (978) 692-8200

Enjoy the benefits of certification!!!

  • Join the fastest growing chiropractic specialty and transform your practice immediately
  • Hands on training! Learn in depth analysis, evaluation and appropriately prescribe corrective exercise and movement protocols
  • The recognition of a nationally accredited specialty by attorneys, insurance companies and fellow DCs
  • Catapult your practice into a higher realm of service.
  • Learn to initiate, manage and document patient care utilizing rehab protocols and guidelines and therefore effectively insulate your practice from Post Payment Audits!!
  • George Petruska, DC, DACRB ~ Lead instructor
  • Mitchell B. Green, DC, DACRB ~ Associate Instructor
  • Chad Buohl, DC, DACRB ~ Associate Instructor
  • Eugene Seraphim, DC, DACRB ~ Associate Instructor

To register, contact NYCC Post Graduate Department at (800) 434-3955 ext. 132. Cost is $299 per module ($349 when paid less than 14 days prior to the first seminar date of the month). For course and program information, contact Mitch Green, DC, DACRB at (212) 269-0300. Contact the ACRB for additional online material and testing requirements at info@acrb.org . Please contact NYCC Post Graduate Dept at 800-434-3955.

This program is co-sponsored by the Massachusetts Chiropractic Society and New York Chiropractic College. Appropriate applications relating to credit hours for license renewal in selected states have been executed for these classes.  license **renewal in selected states has been executed for these programs. Please contact NYCC Post Graduate Dept at 800-434-3955

New Rehab Certification Program beginning in October 2012

July 18th, 2012

Become Board Certified in Rehabilitation

12 module program satisfying the course requirement leading to Diplomate Status in the

American Chiropractic Rehabilitation Board®

Starting October 6 and 7th, 2012 and continuing monthly at the

Westford Regency Hotel – Westford, MA 01886

$299.99/module Ph (978)692-8200

Enjoy the benefits of certification!!!

  • Join the fastest growing chiropractic specialty and transform your practice immediately
  • Hands on training! Learn in depth analysis, evaluation and appropriately prescribe corrective exercise and movement protocols
  • The recognition of a nationally accredited specialty by attorneys, insurance companies and fellow DCs
  • Catapult your practice into a higher realm of service.
  • Learn to initiate, manage and document patient care utilizing rehab protocols and guidelines and therefore effectively insulate your practice from Post Payment Audits!!

George Petruska, DC, DACRB Lead instructor
Mitchell B. Green, DC, DACRB Associate instructor
Chad Buohl, DC, DACRB Associate Instructor
Eugene Seraphim, DC, DACRB Associate Instructor

To register, contact NYCC Post Graduate Department at (800) 434-3955 ext. 132. Cost is $299 per module ($349 when paid less than 14 days prior to the first seminar date of the month). For course and program information, contact Mitch Green, DC, DACRB at (212) 269-0300. Contact the ACRB for additional online material and testing requirements at info@acrb.org. these programs. Please contact NYCC Post Graduate Dept at 800-434-3955

* This program is co-sponsored by the Mass. Chiropractic Society and New York Chiropractic College. Appropriate applications relating to credit hours for license renewal in selected states have been executed for these classes. license

** Renewal in selected states has been executed for these programs. Please contact NYCC Post Graduate Dept at 800-434-3955

New Cold Laser Regulations in California

July 12th, 2012

To our California Rehab Council Members:

For those of you who use cold lasers in your practice please go to the following link to become aware of the new regulations just adopted by the California Board of Chiropractic Examiners in regards to the use of lasers.

http://www.chiro.ca.gov/res/docs/pdf/Regulations/Laser%20Regs%2006-19-12.pdf

Dr. Vera Wins National Championship

July 12th, 2012


Dr. Luis C. Vera, President of the IBE (an independent certifying organization under the auspices of the ACA Rehab Council) won the Gold Medal at the 2012 AAU U.S. National Championships. More than 4,000 participants and spectators from around the country recently attended the Amateur Athletic Union’s 2012 National Karate Championships which was held July 2-7, 2012 in St. Charles, Illinois.

Dr. Luis Vera, chiropractic neurologist & electromyographer (and President of the International Board of Electrodiagnosis – IBE) from Regional Chiropractic Group in Orlando, FL has returned to the competition arena after being retired for nearly 12 years from the sport. He has been involved in the martial arts for over 28 years and competed in the 2012 Florida AAU District State Championships earlier this March, which served as the AAU National Karate Championships Qualifier, and obtained the gold medal. As a result he qualified, as number one in the state of Florida, for the U.S. Nationals and then competed this past week in the 2012 AAU National Championships, Black Belt Kata division. After the scores were tabulated, he won the gold medal and the respective title of AAU U.S. National Champion.

He is now expected to attend the 2012 World Karate Champions this December as the U.S. representative. Congratulations to Dr. Vera and good luck at the upcoming world championships!

Alternative to Toxic Psychiatry

June 21st, 2012

Introduction to the Alternative to Meds Center

Do you encounter patients that continue to have mood problems, despite being on psychiatric meds that are supposed to alleviate these issues? Have you ever felt that a patient’s well-being and attitude have been adversely affected by a welling meaning doc casually prescribing anti-depressants or anxiety medicine? Have you ever wondered if some of the most commonly prescribed medicines–psychotropic pharmaceuticals–may be doing more harm to your patients than good? The truth is that the majority of psychiatric medications prescribed today, as self-described by manufacturers, have an unknown mechanism of action. This means, that even the creators of these potent substances, these molecules that enter into and directly bind onto neurons within our patients’ brains–do not understand exactly how they work. And the psychiatric texts themselves often recommend switching various psychotropic meds randomly, until the least amount of side affects are obtained.

The recent epidemic of prescribing anti-depressants, anti-anxiety, and anti-psychotic meds, has been fueled by profit-seeking pharmaceutical companies, managed care constraints, and over-burdened primary care docs. The result has been many people who may have been medicated unnecessarily, often for longer periods of time than recommended. And what is becoming more and more common, is that chronic use of these psychotropic causes undesirable long-term side effects. Additionally, once an individual desires to be rid of the psychotropics, there are true physiologic as well as psychological barriers towards their withdrawal.

One class of the psychiatric meds that causes some of the worst issues for patients are benzodiazapines. These medicines were designed to treat acute anxiety and temporarily aid sleep; but unfortunately they are often prescribed for months or years–causing side-effects, and more chronic problems than they were meant to address. Perhaps worst of all, the sufferer of chronic anxiety, often has an accumulation of neurotoxins including heavy metals that are over-stimulating their nervous system. This is what may have led to the initial use of the medication, and while the benzos may numb some of the patient’s initial discomfort, they do nothing to eliminate these underlying toxins.

Withdrawal from these medications can present with extreme anxiety, protracted withdrawal symptoms, and even seizures. This is the most common class of medications we address, as unsupported withdrawal can be virtually impossible. Our methods are diverse on this particular class of medication, but include careful taper techniques, removal of neurotoxins that have accumulated in the persons system due to the drug and from environmental sources, neurochemical support using natural substances, peer support, and the benefit of many therapies designed to promote relaxation including massage, acupuncture, meditation and sauna.

If you have you ever wished your patients could be rid of psychiatric medicines, returned to you with a clean system and naturally balanced neurochemistry, there is a solution. There does exist a viable alternative to toxic psychiatry. The Alternative to Meds Center is a licensed residential mental health facility that specializes in eliminating environmental toxins, and restoring optimal neural-chemistry while the patient is gently withdrawn from psychiatric medications. We are located in Sedona, Arizona.


To discover more about The Alternative to Meds Center, please visit MedicationWithdrawal.com or Call (800) 301-3753.

Anterior Hip Pain in a Preprofessional Ballet Dancer

June 21st, 2012

By Mitchell B. Green, D.C.

Background

No one can deny the beauty and grace of a ballet dancer performing on stage, but dancers present a special challenge to the chiropractic rehabilitation specialist. Because ballet goes “against” the body’s natural tendencies, years of training in ballet can exact a toll that may prove to be deleterious to the dancer’s musculoskeletal system; not only is the dancer at risk for short term injury, but long-term damage requiring consistent and specific treatment may also be a possibility. The injured dancer deserves a practitioner who is competent in differential diagnosis: it is imperative to be able to identify not only the damaged structures at the site of pain, but also the functional movement patterns that are potentially the underlying cause of the condition. When special populations such as classical ballet dancers present for treatment, it is critical to be familiar with the wide variation of “normal” that is possible. Most dancers, for example, can perform hip flexion in the supine position well beyond the widely accepted 90 degree norm. Yet, due to pain, an injured dancer might achieve only 90 degrees. While this might be a normal finding for the non-dancing general population, it would definitely not be normal in the ballet dancer. Therefore, the clinician needs to accurately interpret data based on the variations present within a given population and proceed accordingly. In addition, the practitioner should be able to rule out more serious injuries that require immediate medical attention. Also, the physician needs to be well acquainted and comfortable with a wide range of both passive and active rehab modalities and techniques. They should be well versed in methods to enhance both the dancer’s basic and more complex array of movements.

Case Presentation

SDG is an 18 year-old female pre-professional ballet dancer who presented for evaluation and treatment. She was referred by her ballet instructor for chronic hip pain that plagued her on and off over the past year. She also reported occasional mild lower back pain that had occurred infrequently over the past several years. Her dance routine is quite intensive. Including classes and rehearsals, her training usually runs for 5-6 hours, 6 days per week. She revealed in consultation that the front of her left hip had been painful off and on for about 12 months. However, she also indicated that she could not recall any specific event, episode or injury that initiated her first bout of pain. Her one visit to the family internist regarding this problem, approximately 6 weeks prior to our initial consultation, resulted in a referral for an MRI examination of the left hip. The examination was negative for abnormality, disease, dislocation or fracture; therefore, a referral to physical therapy was prescribed. In addition, she also received a prescription for 400 mg of ibuprofen, three times per day for 7 days. She was seen by the physical therapist on three occasions and
received massage therapy, ultrasound and advice on stretching. She described the results of her physical therapy as minimally productive. SDG denied contralateral lower extremity or thoracic pain. She also further denied cervical pain. There was no correlative indication of familial history and the review of systems was negative.

SDG presented as a bright, well nourished Caucasian teenager. Physical examination revealed her height to be 5’4″ and weight 107lbs. Her basal temperature was 98.4 and her blood pressure on the left side was 100/72 and her resting heart rate was 67 bpm.

Upon examination, all orthopedic tests (Kemp’s, Lasegue’s, Gaenslaen’s and Goldthwaite’s tests) were negative. Deep tendon reflexes were +2 right and left for the Achilles and
patella. Manual muscle testing was 5/5 bilaterally for the quadriceps and hamstrings. Dorsi and plantar flexion were equal bilaterally. Pathological reflexes were absent. Range of motion tests of the lower back, hips, knees and ankles revealed only slight loss of motion in the right ankle (18 of 22.4 degrees). Palpation revealed mild/moderate hypertonicity in the erector spinae, quadratus lumborum and piriformis bilaterally; however, it was worse on the left.

SDG’s initial QVAS for the left hip was 6/10 and 2/10 for the lower back. Her Oswestry rating was 6% indicating minimal to no disability. Her lower extremity functional scale
was 87.5%. At the time of her transition to active care her QVAS was 2-3/10 demonstrating a minimum of 50% improvement.

The patient was treated palliatively 5 times over the course of a 2 week period with diversified joint manipulation to the spine and left hip. Cox flexion-distraction was utilized for the lower lumbar spine.1 Interferential muscle stimulation was applied over the anterior superior left hip for pain control. She was transitioned to an active rehabilitative program after the 5th session and treated for an additional 6 weeks. See the following sections for treatment details. SDG was treated for a total of 17 visits.

Discussion

As with any other patient, the attending clinician must rule out serious disease and injury in the dancer that might be categorized as urgent and require further medical intervention. Once a case has been accepted, the next step is to help reduce pain as soon as possible: this is accomplished using modalities that have been agreed upon by the doctor and patient. Liebenson, et al. point out that 50% of patients were found to be significantly better within 4 visits or two weeks of starting chiropractic care; 75% were better by 12 visits.2

During the initial phase, care for the dancer resembled that of other populations. This included following PRICE protocols until a measure of stability emerged.3 Unfortunately, many patients leave care before true rehabilitation has commenced; this leaves them at risk to suffer repeated injurious episodes. Dancers are a particularly driven group, sometimes to the point of obsession: they often state that the work they do in class, rehearsals and performance is “rehab enough.” They typically resist sitting out of a class even during this initial phase of care. This is a particularly unenlightened position that can lead to a more severe injury and resultant disability. As Sonia Rafferty, M.Sc., points out, “the concept of rest intervals is significantly absent in dance pedagogy.”4 Hopefully, the practitioner can help to change this by expressing and continually reinforcing to the injured patient the various principles of healing and rehabilitation.

For those who do continue with care, the real challenge begins. SDG had minimal range of motion issues. In fact, except for her minimal loss of right ankle mobility, she presented as extremely flexible with excellent posture. She exceeded expectations in the one-legged balance testing with eyes open and closed. So the question was: bow could she be challenged her in an active rehab program that would also help her improve as an elite classical dancer? The goal was to help prevent injury, but also possibly enhance an already superb performance ability.

The course of treatment chosen was largely based on Sensory Motor Stimulation (SMS). According to Liebenson, “SMS can be beneficially used as a part of any exercise program because it helps to improve muscle coordination and motor programming or regulation and it increases the speed of activation of a muscle. It was used originally to improve the unstable ankle after an injury; however it can be used for a variety of conditions. Chronic back pain syndromes are one of the most important indications. Better control of the trunk, improved activation of the gluteal muscles and thus better control of the pelvis is achieved.”5

“Balance training using unstable surfaces such as Thera Band Stability Trainers and Rocker I Wobble Boards are increasing in popularity both in rehabilitation and sports performance. In addition, balance training has been shown to be beneficial in preventing injuries across the lifespan, from athletes to older adults.

German researchers published a systematic review of the efficacy of balance training for neuromuscular control and performance enhancement in the Journal of Athletic Training.
20 randomized clinical trials of balance training met their inclusion criteria for the review. As with many systematic reviews, the authors noted a lack of methodological quality and conflicting findings between studies. Nonetheless, they were able to make some conclusions:

  • Balance training is effective at improving static postural sway and dynamic balance in both athletes and non-athletes.
  • Balance exercises are recommended for postural and neuromuscular improvements, particularly for rehabilitation and preventive purposes.
  • To improve strength, jumping or sports performance other interventions such as strength training are more effective than balance training.
  • Longer balance training durations of 6 to 12 weeks seem more effective than shorter 4 week durations.”6

Functional Training and Rehabilitation

The first phase of active rehabilitation for SDG consisted of floor based exercises: these were primarily used for improving stability of the lower back, and helped limber the spine and pelvis. She was taught and quickly learned cat-camel (cow), quadruped leg reach and bird dog maneuvers. The overhead squat, side bridges, planks and various supine bridges were added to her regimen, as recommended by Stuart McGill in his book, Low Back Disorders: Evidence-Based Prevention and Rehabilitation.1 Additionally, there was utilization of a moderately packed foam roll to release the appropriate region from contracture.

While performing these maneuvers care was taken to observe, point out and correct basic dysfunctional movement patterns. This was done by bringing these patterns to her attention, with the use of verbal prompting for correction. In SDG’s case it was noted that her left thigh abducted when moving into hip extension, indicating hyperactivity of the iliotibial band on the left. This also confirmed inhibition of the left gluteus maximus, as well as possible weakness or inhibition of the gluteus medius on the same side.

It was also noted that she had considerable trouble with the overhead squat. SDG was graded as a l on Gray Cook’s FMS scoring scale 0-3.8 This was due to a bilaterally tight gasctrocnemius/soleus complex and right ankle restriction with resultant hyper hip flexor activity. To facilitate better movement control, a half foam roll measuring 4″ was placed under her heels to improve the maneuver. Over the course of treatment that heel elevation was gradually reduced. It is interesting to note that dancers are actually taught a variation
of a squat from early training: the plie’. This dance movement is taught with the feet in four possible positions. The grand plie’ (full descending movement) in second position is the only plie’ that does NOT require the dancer to elevate their heels. This is because less knee flexion occurs during the movement, putting less tension on the gasctrocnemius/soleus complex. As a result, there is greater elongation in the calf and the heels are able to remain on the floor. The hips are as close to full turnout as possible (90 degrees of external
rotation) for each plie’ regardless of foot position. When performing a squat, SDG was instructed to externally rotate her hips to 45 degrees (instead of 90 degrees as when performing a plie): this improved her biomechanics somewhat.

The above protocol was followed twice weekly for two weeks, which served as a prelude to all future rehab sessions. On the fourth visit, SDG had progressed to 1 set of 5 cat/camels, 8 quadruped leg reaches each side alternating, 8 bird dogs each side alternating, and (3) sets of 6 reps of squat variations: overhead, elevated split, and goblet squats. The goblet squat was utilized to encourage greater ankle mobility. During this period of time SDG reported little to no discomfort in her left hip and was eager to proceed o the next phase of active rehabilitation.

At the start of week 5 of care and week 3 of active rehab, SDG performed one legged balance exercises on the floor, bilaterally, for 120 seconds. Then she proceeded to each successive Thera Band stabilizer pad, in order of ascending difficulty. She progressed from green to blue and finally to black. She had to perform at each level for 90 seconds with her eyes open before transitioning to the next, increasingly unstable surface. SDG was also introduced to small foot positioning, at first passively, followed by active assist, and finally active self-induction.

Throughout the course of her remaining care she began all her SMS sessions with 6 minutes of rocker board activity. At that point, different balletic moves were blended into SDG’s active care.

While standing on each Thera Band exercise pad, SDG was instructed to perform 5 slow degage movements bilaterally, to the front, side and back. Degage is performed by keeping the leg straight and lifting the foot. She was encouraged to keep her standing and elevated hip in turnout to assist in strengthening the associated muscles and thus, support her ballet work. Additional movements performed while alternating with one leg on a Thera Band stabilizer that became part of her rehabilitation included: (1) Fondu, which is described as lowering the body while on one leg, (2) Battement, which is the raising of a leg into the air and bringing it down again, with both knees straight, and (3), Developpe which refers to
the leg being drawn to the knee of the supporting leg before being slowly extended to an open position and held for control. The hips should be kept level and square to the
direction the dancer is facing.9

SDG was introduced to the round board during the last week of her rehabilitation. At that point two different levels of difficulty were employed. In addition to any combination of the

above movements performed on the Therapads, she also performed an arabesque on the round board. On the last day of our work together, SDG performed all of the different balletic movements discussed, on unsteady surfaces. She added 5’ plies to each arabesque on the round board, and she was asked to hold for a 5 count on the last plie.

At the end of the last visit she reported no pain and had returned to fully engage in all aspects of her ballet studies. Her exiting Lower Extremity Functional Scale was rated at
100%.

Conclusion

The integration of active rehab principles to the patient’s goals is paramount to a successful outcome. This case illustrates how active rehab care can help a classical ballet dancer
return to performance, while correcting and strengthening cardinal movements. It also points out the necessity for developing and understanding a body of information not necessarily applicable to the general population. The implications of principle based, functional rehabilitation and its application to other specialized populations should prove to be very exciting for the chiropractic rehabilitation specialist.

Competing Interests

The author reports no competing interests.

Written consent was obtained from the patient for publication of this report.


Bibliography

1 Cox, James M. Low Back Pain Mechanism, Diagnosis and Treatment. Williams and Wilkins. (1999) Print. Pp.273-343.
2 Liebenson, Craig. Rehabilitation of the Spine: A Practitioner’s Manual. Philadelphia: Lippincott, Williams, and Wilkins. (2007) Print.
3 Hyde, Thomas E. and Gengenbach, Marianne S. Conservative Management of Sports Injuries. Sudbury, Ma. Jones and Bartlett, 2007. Print.
4 Rafferty, Sonia. Considerations for integrating fitness into Dance Training. Journal of Dance Medicine and Science, Vol.14, Number 2, (2010)
5 Liebenson, Craig. Rehabilitation of the Spine: A Practitioner’s Manual. Philadelphia: Lippincott, Williams, and Wilkins. (2007) Print.
6 www.hygenicblog.com/2011/07/01/systematic -review-supports­ Balance -training. Web.
7 McGill, Stuart. Low Back Disorders: Evidence based Prevention and Rehabilitation. Human Kinetics, (2002). Print p. 221-229.
8 Cook, Gray. Movement: Functional Movement Systems, Screening­ Assessment-Corrective Strategies. On Target Publications. (2010) Print. p. 81
9 www.balletterms.org. Web.

Familial predisposition in cervicogenic disequilibrium, as it relates to functional disturbances and somatotype, A Case Study

June 21st, 2012

By Dr. Eugene Serafim

Paper Outline

Abstract;

Dizziness is a nonspecific term that means various things to various people. It falls under a greater category of vertigo, but for our purposes we will concentrate on the subcategory of disequilibrium. This paper will review the origins, testing procedures as well as common disturbances of the physiologic and neurological systems that affect balance and contribute to disequilibrium. We will further concentrate on the familial link between structure and function of the cervical spine, and it’s pathogenesis of cervical disequilibrium in a mother and daughter case study.

Background

Dizziness has a variety of meanings, but it is most often used as a means of describing unsteadiness. Notwithstanding layman’s terms; more specific identifiers are required, including: lightheadedness, pre-syncope, disequilibrium and vertigo. The diagnostic triage must include a thorough history, specialized testing, orthopedic and neurological workup to discern the specific symptom, correct diagnosis and optimal treatment. Allopathic medicine has traditionally addressed these symptoms pharmaceutically; however, a chiropractic/ rehab approach is successful in addressing the underlying structural root cause1. In this case study I cited; a mother/daughter case, both patients benefited from an approach using chiropractic and rehabilitation techniques. While this is not an exhaustive study, these cases provide an insight into the inherited structural or physiological etiology of disequilibrium.

Discussion

In discussing balance and the loss of it (disequilibrium) we must start with reviewing the components that would affect it. Balance is accomplished through various systems that integrate in the cerebellum. Proprioception, vestibular, visual sensory input, and tactile sources combine to facilitate balance and coordination. Proprioception in the cervical spine provides sensory afferent input, which contributes to coordination of the eyes, head, and body.

Proprioception in the cervical spine is controlled by a variety of reflexes that include; the cervico-collic, the tonic neck reflex, and the cervico-occular reflex. Bolton states (Bolton, 1998); the first reflex stabilizes the head and integrates with the vestibulo-collic reflex (where the neck muscles are acted upon from the semi-circular canals). The tonic neck reflex is a asymmetrical reflex present in newborns, that controls the tonic activity of the limbs2. In discussing the tonic reflex, research by Hikosaka and Maeda (1973) documented the association of neck afferents originating at the dorsal roots and cervical facets at level C2/C3 and the vestibular nuclei3. These reflexes communicate with the vestibulo-ocular reflex.

When sensory input is interrupted, it causes a disparity in perceived information received from the vestibular, cervical proprioceptive or visual systems disequilibrium results.4 Research conducted by Dejong and Dejong further support this data.5

There are a number of differentials that should be excluded, before a diagnosis of cervicogenic disequilibrium can be assigned. Some diagnoses include; Benign Paroxysmal Positional Vertigo, Ménière’s disease, and Vertebrobasilar insufficiency.

Discerning between terminologies patients use to describe dizziness is another important aspect in evaluating a patient with unsteadiness. They include; presyncope, disequilibrium, vertigo, dystaxia, ataxia and light headedness. To further complicate matters, in its slang form, dizziness has been used to describe those that lack mentation.

Key words

Vertigo, cervical disequilibrium, lightheadedness, presyncope, dystaxia, ataxia, proprioception, cervico-collic, the tonic neck reflex and the cervical-ocular reflex

Introduction

Dizziness—in general—is widely complained of and can have a component in virtually any medical condition. For our purposes we will only consider one symptom of dizziness; cervical disequilibrium. The diagnosis of cervicogenic disequilibrium is largely one of exclusion; thus, one should strive to rule out diseases of the inner ear(vestibule-cochlear apparatus), vertebral arteries and the spinal canal . Special attention must be paid to patients with a post traumatic onset. In those cases; vertebral artery compression and dissection, spinal stenosis, Cerebral Spinal Fluid leak, and of course whiplash should be ruled out, or referred to the appropriate provider before initiating a rehab protocol.

Evaluation of any disease begins with a thorough history; treating cervicogenic disequilibrium must include a detailed history. Special interest would include: the onset, duration, trauma, description, intensity, mechanism, previous treatment, cause, previous history, aggravating Factors(positional relation), relieving factors, environmental related triggers, previous episodes, effects on ADL’s, and functional deficits.

Outcome assessments provide a qualitative baseline to allow for accurate case management. They also measure pain, disability, and psycho-social status. Questionnaires that measure pain would include; Visual analog scale, McGill, and Pain drawing. For disability; Neck disability index, The Dizziness Handicap Inventory, The Henry Ford Headache Disability Inventory (HDI ), Activities-specific Balance Confidence scale (Powell), Somatic Perception and PARQ. Psychosocial assessment would include Beck and SCL-90-R.

Orthopedic, Functional, and neurological testing must be combined to comprehensively evaluate a patient with cervicogenic disequilibrium. The orthopedic testing that would be appropriate would include:

  • Jackson’s, Bakodys,
  • Cervical distraction,
  • Berrie-Lou,
  • Deklines,
  • Maignes,
  • Dix-Hallpike maneuver,
  • Barany-caloric test,
  • Hoffman’s sign,
  • Rhombergs,
  • The Vertebral artery test,
  • Rapid alternating movement (diadochokinesis),
  • Lhermitte’s,
  • Saccadic and smooth pursuits eye movements

Functional testing would include;

  • Berg balance scale
  • The Clinical Test for Sensory Interaction in Balance
  • Postural analysis and Gait analysis,
  • Platform stabilometry7
  • Cervical flexion test8
  • Jull’s cervical cranial test(to quantify)9
  • T4-T8 mobility test Wall Angel10
  • Respiration11
  • Hautant’s test12
  • Rotating stool test13

Neurologic testing would include cranial nerves (especially auditory), pathologic reflexes, deep tendon reflexes, sensory dermatomes as well as gait and station. Diseases of the brainstem (central lesion) affecting the vestibule-cochlear nerve will too affect adjacent cranial nerves (VII and IX).

Physical examination should focus on the vitals, with special attention being paid to the Vitals and Auscultation exam to rule out arrhythmias, stenosis, prolapsed, or congestive issues. Blood pressures should be assessed bilaterally as well, going from sitting to standing and laying down to standing.

Specialized testing for dizziness should rule out:

  • T.I.A
  • Vetebrobasilar insufficiency
  • Menierre’s disease
  • Benign paroxysmal positional vertigo (BPPV)
  • Myelopathy

Such specialized testing could include but not be limited to:

  • Rotary chair testing
  • Trans-cranial Doppler sonography
  • MRI angiogram 14
  • ENG(caloric)
  • Audiometry
  • CSF leakage, hypoglycemia, as well as cardiovascular disorders. , ,
  • Cervical and cranial MRI’s.
  • Electrolyte Panel- disturbance of the acid base balance could lead to dizziness15
  • Coagulation Profile and Lipids-to evaluate vertebra-basilar disorders16
  • Serology-to rule out infectious diseases including syphilis and Lyme’s17

Case report 1

A 76 year old woman reported with a chief complaint of sub-occipital neck pain, head ache, and stiffness complicated by dizziness that is position aggravated. She notices it the most while flexing her head forward to putt during golf. It presents intermittently, and its duration can last anywhere from 3 days to 3 weeks. She reports suffering from the stiffness and dizziness for the better part of her adult life. Her sedentary computer occupation worsens her neck pain and stiffness. Movement of the head (especially ballistic) seems to increase her unsteadiness. She experiences feelings of movement from side to side and denies spinning (disequilibrium). She denies any tinnitus or obvious hearing deficit. These problems limit her daily living activities when the unsteadiness is at its worst (difficulty standing). She is also disabled from playing golf during these episodes. She had not sought treatment for this problem in the past. Disability indexes were assigned including:

  • Neck disability index(46%[moderate}),
  • Dizziness Handicap Inventory
  • The Henry Ford Headache Disability Inventory (HDI )(10 on the emotional subscale and 25 on the functional subscale),
  • Activities-specific Balance Confidence scale(Powel)rated at 75% episodically
  • PARQ (cleared)
  • Red Flags (yes to over 50 and 70 years old).

Psychosocial assessment included

  • Beck(10 not depressed or mildly)
  • Modified Somatic perception questionnaire(13high level of somatic complaint)

The patient could not relate, or report any family or social history that would apply to her complaint. The clinical impression was Ataxia, disequilibrium, and cervical spasm. Her working diagnosis was cervical disequilibrium related to functional disturbance.

Her evaluation was as follows; Vitals 5’9”, 128 lbs, 130/86 R, 128/80 L(B/L B.P.), (pulse)50 bpm, 99.0 F,(temp.), 15 breaths per min(resp.). No change in B.P. found in sit to stand or lye to stand.

Auscultation of the carotids and Inferior vena cava were normal. Observation showed a well formed, aware and alert 76 year old female. Percussion reveals tender paravertebral musculature at the occiput, cervico-thoracic junction, and the lumbo- sacral junction. Palpation reveals myo-facial trigger points at the occiput, levator scapulae, SCM’s, lumbar erector spinae, and gastrocs/soleus. All findings were B/L. Cervical spine X-ray examination confirmed a decreased cervical spine lordodic curve and generalized spondylosis C3-T1. Cervical ROM was found to be minimally limited in right lateral flexion, extension, and right rotation. Lumbar ROM was minimally limited in flexion and B/L lateral bending.

Postural analysis yielded; rounded shoulders, anterior lean, anterior head carriage, head tilt to the left, decreased cervical lordodic curve, dowagers hump, decreased lumbar lordotic curve, and posterior pelvic tilt. Chiropractic examination revealed shortened/facilitated SCM’s, levator Scapulae, scapular retractors, hamstrings, and gastroc/soleus complex. Lengthened/inhibited muscles included Cervical and lumbar erectors, longus coli, knee flexors, and pectoralis. Subluxation complexes were found at Occiput (inferior) C2 (right rot. restriction) T1 right lat flex restriction) L4 left rotation restriction and a right PI pelvis.

Examination began with a neurological exam including; cranial nerves (within normal), sensory dermatomes (within normal), pathological reflexes(absent) and deep tendon reflexes(+2/5 upper and lower B/L). Orthopedic examination consisted of Cervical compression(negative with pain), Jackson’s(negative with pain), Cervical distraction(negative), Berrie-Lou(negative), Deklines(negative), Maignes(negative), Dix-Hallpike maneuver(positive), Hoffman’s sign(absent), Rhombergs(positive), The Vertebral artery test(negative), Rapid alternating movement [(diadochokinesis)negative], Lhermitte’s(negative), saccadic and smooth pursuits eye movements(negative) and the swivel chair test(negative) . During Functional testing chin pointing was observed in the supine neck flexion test, disequilibrium with the sit to stand test worsening towards the 5th repetition, a medium fall risk (35/56) on the Berg standing18 , Clinical testing of sensory interaction for balance19 failing the 5th condition (eyes closed on unstable surface) within 5 seconds, gait analysis ataxia was noted with a wide stance being used. Functional analysis of respiration revealed paroxysmal breathing patterns. One legged standing (failed at 6 sec R 4 sec L). Other functional activity testing revealed scapular winging and altered scapular abduction. No specialized testing was performed at the time as no underlying pathology was suspected. The patient’s primary diagnosis was Layered syndrome, her secondary diagnosis was cervical disequilibrium and her tertiary diagnosis was cervalgia. Complicating factors included subluxation complex (full spine),cervical spondylosis, myofascial pain syndrome, altered gait, muscle weakness, muscle imbalance, and diminished proprioception.

Treatment consisted of passive care for the initial 2 weeks of care that included electro-therapies, soft tissue work, and manipulation 3 times a week. After the acute care thresholds were passed, transitional care was provided for an additional 6 weeks. It included facilitated stretching techniques, myofascial trigger point therapy, and non weight bearing short foot protocol on balance pads and pelvic stabilization protocols. Active care was initiated next, and included weight bearing Proprioceptive protocols, postural retraining (passive and active) as well as home exercises. The active care lasted 12 weeks at a frequency of 3 times a week.

Outcomes were measured at 2 week intervals and dictated the transition of care. Her Disability indexes improved consistently. Post 4 weeks [(neck disability index20 32%, The Henry Ford Headache Disability Inventory21 (HDI) (10 on the emotional subscale and 15 on the functional subscale), Activities-specific Balance Confidence scale222 (ABCl) rated at 50%. ABC assessment was most profoundly influenced by the active phase of rehab (25% at 6th week of active care). Other benchmarks for advancing stages of care included performance of orthopedic and functional testing.

Initial 2 weeks 4 weeks 6 weeks 8 weeks 12 weeks
NDI 42% 44% 35% 26% 14% 10%
HDI(emotional/functional) 20/26 18/18 16/16 10/16 8/10 8/10
DHI(physical /emotional/functional) 22/12/18 18/12/14 16/10/14 12/8/10 8/8/10 8/6/10
ABCI 24% 28% 32% 45% 55% 55%
Berg 35/56 35/56 40/56 50/56 50/56 52/56
1 leg bal. 10 sec R 6 sec L 8 sec R 14 sec L 15 sec R 22 sec L 25sec R 33sec L 40 sec R 38sec L 40 sec R 46 sec L

At the completion of her 12 week rehab protocol, the patient was able to perform Rhomberg’s with an acceptable level of sway, and their one legged balance had improved from 6 sec. to 72 sec. R, performance of functional activity improved in the neck flexion test, improved breathing patterns and the squat (improved forward lean). Postural analysis showed a marked decrease in the upper cross syndrome. She complied with her home exercise protocol as well as the sparing strategies issued for her work. At that point she was released from active care and was told to return PRN.

Case Study 2

A female 42 year old related family member (to the first patient) presents with a similar complaint of suboccipital neck pain, dizziness and headaches with a 14 year duration. Her complain has no vector of injury or known causative factor. She suffers from her pain and unsteadiness intermittently, and it persists for weeks at a time. She admits to an average of one attack per month, and relates her problem to work and emotional stress. Her work is a sedentary office position, she is an entrepreneur. She describes her dizziness as an unsteady feeling, a sensation of movement from side to side. This is exacerbated with rapid head movements and laying to sitting. It is an intense sensation which severely affects/limits her daily life. She denied any hearing difficulties or ringing in the ears. Outcome assessment in the form of Neck disability index [54%(moderate)], Pain disability questionnaire (60/180 ), The Henry Ford Headache Disability Inventory (HDI )(14 on the emotional subscale and 20 on the functional subscale), Activities-specific Balance Confidence scale(ABCl) 23rated at 36% and PARQ(all no’s) were performed during an episode. Family history was relevant due to the obvious similarities to her mother’s complaint. All other familial and social factors were denied. She had not seen any other provider for this problem. The clinical impression was postural overuse, psycho-somatic pain, dysmetria, and disequilibrium.

Her evaluation was as follows; Vitals 5’11”, 147 lbs, 146/72 R, 140/78 L(B/L B.P.), (pulse)72 bpm, 97.0 F,(temp.), 15 breaths per min(resp.). No change in B.P. found in sit to stand or lye to stand. Auscultation of the carotids and Inferior vena cava were normal. Observation revealed a well formed but distressed 42 y.o. woman. Percussion to the spine reveals tender musculature at the occiput, cervico-thoracic junction and the lumbo- sacral junction. Palpation showed active myo-facial trigger points at the occiput levator scapulae, SCM’s, rhomboids, lumbar erector spinae, psoas and plantar muscles. All findings were B/L with the exception of the L lateral head tilt. Cervical spine X-ray examination confirmed a “military spine” and mild spondylosis C5-C7. ; Cervical ROM was found to be minimally limited in right lateral flexion, extension and right rotation. Lumbar ROM was minimally limited in extension and mildly in flexion. Postural examination revealed forward head carriage with a left head tilt and rounded shoulders. Chiropractic exam showed shortened SCM’s, levator scapulae, upper trapezius, pectorals, anterior deltoids, psoas and hamstrings. Segmental dysfunction was noted as follows; Occiput (inferior) C2 (right rot. restriction) C6 and C7 right lat flex restriction) L5 left rotation restriction and a anterior sacrum.

During neurological examination she showed no pathologic reflexes, all deep tendon reflexes were +2/5 B/L, cranial nerve examination was within normal limits and sensory dermatomes were intact. Orthopedically she tested positive to Dix-Hallpike maneuver and Rhombergs. Previously mentioned testing was performed and found to be negative. Functional testing included ;chin pointing observed on curl up, disequilibrium with the sit to stand test worsening towards the 2nd repetition, a medium fall risk(35/56) on the Berg standing24, Clinical testing of sensory interaction for balance25 failing the 5th and 6th condition(eyes closed on unstable surface and under the dome ) within 5 seconds. Gait analysis showed toeing out. Functional analysis of respiration revealed paroxysmal breathing patterns. Scapular winging and altered scapular abduction were noted in the push up and shoulder abduction respectively.

Primary diagnosis was Upper Cross syndrome, Secondary diagnosis was Cervical disequilibrium and Tertiary diagnosis was Cervalgia. Her complicating factors included: psycho-somatic stress, myofascial pain syndrome, subluxation complex, muscle imbalance, muscle weakness, diminished proprioception and altered gait.

Acute care included management of myofascial pain through electrotherapies, trigger point compression, spray and stretch techniques, PIR stretching diversified CMT as well as contrast treatment. Transitional care focused on patient reactivation, and included gait training, PNF stretching, pelvic stabilization, scapular stabilization, postural retraining, and sparing strategies at home and work. Active care included isometric to isotonic strengthening and closed chain kinematics (from supine to prone, to quadruped then seated to standing). We also provided Ergonomic analysis, coping strategies (to address the bio-psycho-social aspect and limit chronicity) and a home stretching and strengthening routine.

Treatment was initiated at a 3x a week frequency; passive care lasted 3 weeks. Transitional care was rendered at 2x’s per week (2 weeks) and active rehab was 2x’s per week (6 weeks). Outcome measures were given every 2 weeks, and were compared to clinical benchmarks to progress the patient through the phases of care. Her pain and disability showed improvement subjectively, and on the Neck disability index they improved on the 4th week assessment (35%). Her disequilibrium and headaches, did not respond until the 4th week of active rehab. At the end of her treatment protocol her outcome assessments were: Neck disability index[20%(moderate)], Pain disability questionnaire (30/180 ), The Henry Ford Headache Disability Inventory (HDI )4 on the emotional subscale and 10 on the functional subscale), and the Activities-specific Balance Confidence scale(ABCl)26rated at 65%(administered during an episode). Repeated Functional testing confirmed her improvement with a low fall risk(45/56) on the Berg standing27, Clinical testing of sensory interaction for balance28 failing the 5th and 6th condition(eyes closed on unstable surface and under the dome )after 35 seconds, and improved posture and gait( improved head and shoulder carriage and no toeing out on gait. She was released to PRN care, and was instructed to return if her symptoms reappear.

Initial 2 weeks 4 weeks 6 weeks 8 weeks 12 weeks
NDI 52% 44% 35% 26% 24% 20%
HDI(emotional/functional) 14/20 10/18 10/16 10/16 8/10 4/10
DHI(physical /emotional/functional) 22/12/18 18/12/14 16/10/14 12/8/10 8/8/10 8/6/10
ABCI 36% 41% 53% 55% 59% 65%
Berg 22/56 26/56 43/56 46/56 50/56 50/56
1 leg bal. 6 sec R 4 sec L 8 sec R 7 sec L 33 sec R 22 sec L 59 sec R 55 sec L 40 sec R 56 sec L 72 sec R 66 sec L

Treatment protocols and benchmarks

The patients’ short term goals included: stretching shortened facilitated muscles and activating inhibited muscles (PIR), decreasing myofascial trigger points, improving subluxation complex, instruct positions of comfort, and decreasing pain.

The Intermediate goals centered around early reactivation include: postural re-education, stretching shortened facilitated muscles, activating inhibited muscles (PNF, Flex building), improve proprioception (non weight bearing), improve core stabilization (via breathing techniques), monitor and track progress via outcome assessment, and rule out vestibular dysfunction. Considering the patient’s complicating factors, we initiated sparing strategies according to the patients A.D.L.’s.

Long term goals would include home/self care activities, and Stage 1 active rehab-Core and postural stabilization; They enhance disequilibrium through improving faulty mechanics/postural imbalances, propriosensory retraining, a system of exercises that utilize balance boards, balance beams, rocker boards, wobble boards, and balance shoes29. Increased Proprioceptive input (weight bearing), improved coordination/integration of the vestibular, ocular and tactile sources of balance (via closed chain kinematics, unstable surfaces). Stage 2 active rehab-Endurance training, improves aerobic potential (brisk walk, HIIT30). Stage 3 active rehab-Strength training includes isometric protocols to improve functional reserve of strength in the postural muscles. Hettinger-Mueller protocols are instituted to create static strength at 2/3 maximum contraction, then they are graduated to multiple angles; Isotonic strength is the next progression31, D.A.P.R.E. protocol is used. The adaptation in the D.A.P.R.E. protocol makes it ideal for the rehab setting32. Stage 4 active rehab-home protocol includes self care, which is administered in the form of a home exercise routine that includes stabilization exercise, postural training, and applicable muscle lengthening procedures.

Discussion

The similarities in these cases are by no means a quantitative measure of the effects of functional disturbances on the balance and stabilization systems of the body. They do however, provide a basis for further testing and a qualitative example of structure as it relates to function. The link between these two cases—while not genetic—still shared many of the postural and altered movement patterns. The shared link in these cases is the upper cervical dysfunction. Hulse has shown the relationship between upper cervical joint dysfunction and disequilibrium, and recommends an integrated approach.33 The aforementioned etiologies can prompt disturbances in the cerebellar integration of sensory afferents of cervical proprioception, as nociception can contribute to dysafferentation from the zygapophyseal joints.34

Chiropractic care and the rehab mindset in treating cervicogenic disequilibrium, is custom tailored to identify and address the root causes of this issue, and equally suited to alleviate the contributing factors. The advantage over other types of providers would be in the ability to treat, diagnose, and monitor simultaneously. The last of which is pivotal, as the complaint can constantly change when the treatment is implemented. The practitioner must be ready for an immediate unexpected reaction, therefore it is imperative that the practitioner rule out more sinister etiologies before instituting a conservative care program. In addition, one must be equipped with the diagnostic triage required in a working diagnosis. The distinction between central and peripheral lesions causing vertigo/dizziness must be accurately deduced and is a major differential in case management, that would determine conservative care vs. further investigation and outside referral.

Conclusion

Dizziness, and more specifically cervicogenic disequilibrium, is a complex and multifaceted issue with a very high prevalence. It is concluded that 23-30% of adults have experienced at least one episode of dizziness, and 3.5% of adults experience a chronic recurrent episode greater than a one-year duration by age 6535. Familial similarities (body-type, psycho-somatic stress and postural stress) can sometimes predispose a patient to functional disturbances. Disequilibrium can commonly be related to cervical dysfunction36, and manipulation is a safe37 and effective3839 way of restoring cervical function. The correct diagnosis along with a diversified approach that concentrates on addressing joint dysfunction, soft tissue changes, and functional disturbances can correct such issues. The rehab mindset including outcome assessment tools are essential in monitoring progress, establishing benchmarks, and justifying changes in the clinical protocols. Self care and stress management are other valuable tools in maintaining positive results.

Powell LE, Myers AM. The activities-specific balance confidence
(ABC) scale. / Gerontol. 1995;50A:M23-M34.


1 Hulse M, Holzl M. [The efficiency of spinal manipulation in otorhinolaryngology. A retrospective long-term study.]
2 Bolton, P, (1998). The somatosensory system of the neck and its effects on the central nervous system. J. Manip. & Physiol. Therapy., 21 (8): 553-563.
3 Hikosaka O & Maeda M, (1973). Cervical effects on abducens motor neurons and their interaction with vestibulo-ocular reflex. Exp. Brain Res.,18: 512-539
4 D. Boyling, G. Grieve & G. Jull, (2004). Grieve’s modern manual therapy: the vertebral column. Elsevier, 463pp.
5 De Jong P, De Jong M, Cohen B, Jongkees L. Ataxia and nystagmus induced by injection of local anesthetics in the neck. Ann Neurol, 1, 240-246, 1977
6 Shumway-Cook A, Horak FB. Assessing the influence of sensory interaction on balance: Suggestions from the field. Phys Ther. 1986; 1584-1550.
7 A.Bastos Evaluation of patients with dizziness and normal electronystagmography using Stabilometry. Rev Bras Otorhinolaryngology. V.71, n.3, 305-10, may/jun. 2005
8 C. Liebenson (Ed), Rehabilitation of the Spine. A Practitioner’s Manual. Lippincott Williams & Wilkins Philadelphia, Pennsylvania: 2007, 870 pp.
9 C. Liebenson (Ed), Rehabilitation of the Spine. A Practitioner’s Manual. Lippincott Williams & Wilkins Philadelphia, Pennsylvania: 2007, 872 pp.
10 C. Liebenson (Ed), Rehabilitation of the Spine. A Practitioner’s Manual. Lippincott Williams & Wilkins Philadelphia, Pennsylvania: 2007, 864 pp.
11 C. Liebenson (Ed), Rehabilitation of the Spine. A Practitioner’s Manual. Lippincott Williams & Wilkins Philadelphia, Pennsylvania: 2007, 862pp.
12 Lewit K. Manipulative Therapy in the Rehabilitation of the Motor System. Boston: Butterworths, 1985.
13 Fitz-Ritson D. Assessment of cervicogenic vertigo. J Manipulative Physiol Ther 1991; 14(3):193-198.
14 Rigmor M, et al. Magnetic Resonance Imaging Assessment of the Alar Ligaments in Whiplash Injuries A Case-Control Study. SPINE Volume 33, Number 18, pp 2012–2016, 2008
15 Labtestsonline. American Association for Clinical Chemistry. October 13, 2011 .
16 Merkmanuals online. E.A. Giraldo, MD. The Merk Manual for Professionals. April, 2007
17 Merkmanuals online. D.L. Tucci, MD. The Merk Manual for Professionals. January 2009
18 Berg KO, Wood-Dauphinée S, Williams JI & Maki B (1992). Measuring balance in the elderly: validation of an instrument. Canadian Journal of Public Health, 83 (Suppl 2): S7-S11.
19 Shumway-Cook A, Horak FB. Assessing the influence of sensory interaction on balance: Suggestions from the field. Phys Ther. 1986; 1584-1550.
20 Vernon H, Mior S. The Neck Disability Index: A study of reliability and validity. J Manipulative Physiol Ther 1991;14:409-415, Copyright Vernon H and Hagino C, 1990.
21 Jacobson GP, Ramadan NM, et al. The Henry Ford Hospital headache disability inventory (HDI). Neurology 1994; 44:837-842.
22 Powell, LE & Myers AM. The Activities-specific Balance Confidence (ABC) Scale. J Gerontol Med Sci 1995; 50(1): M28-34
23 Powell, LE & Myers AM. The Activities-specific Balance Confidence (ABC) Scale. J Gerontol
Med Sci 1995; 50(1): M28-34
24 Berg KO, Wood-Dauphinée S, Williams JI & Maki B (1992). Measuring balance in the elderly: validation of an instrument. Canadian Journal of Public Health, 83 (Suppl 2): S7-S11.
25 Shumway-Cook A, Horak FB. Assessing the influence of sensory interaction on balance: Suggestions from the field. Phys Ther. 1986; 1584-1550.
26 Powell, LE & Myers AM. The Activities-specific Balance Confidence (ABC) Scale. J Gerontol
Med Sci 1995; 50(1): M28-34
27 Berg KO, Maki BE, Williams JI, Holliday PJ, Wood-Dauphinee SL. Clinical and laboratory measures of postural balance in an elderly population. Arch Phys Med Rehab.1992; 73: lO73-lO8O.
28 Shumway-Cook A, Horak FB. Assessing the influence of sensory interaction on balance: suggestion from the field. Phys Ther. 1986;66: 1548-1550
29 Murphy, Donald, and Craig Liebenson. “Chiropractic Rehabilitation in the Treatment of Dizziness.” Dynamic Chiropractic. 1983. Web. 17 Nov. 2011. .
30 Tabata I, Nishimura K, Kouzaki M, et al. (1996). “Effects of moderate-intensity endurance and high-intensity intermittent training on anaerobic capacity and VO2max”. Med Sci Sports Exerc 28 (10): 1327–30
31 Hettinger, T., and E.A. Muller 1953. Muscle strength and training. 15:111-26
32 T.Beacham & R. Earle. Essentials of Strength and Conditioning. Champaign: Human Kinetics. 2008. 536pp
33 Hulse M. Disequilibrium, caused by a functional disturbance of the upper cervical spine. Clinical aspects and differential diagnosis. Man Med 1983; 1:18-23.
34 Biemond A, De Jong JMBV. On cervical nystagmus and related disorders. Brain 1969; 92:437-458.
35 Ojala, M (1989). Etiology of dizziness: a neurological and neuro-otological study. Helsinki, University of Helsinki, Academic Dissertation.
36 Hulse M. Disequilibrium, caused by a functional disturbance of the upper cervical spine. Clinical aspects and differential diagnosis. Man Med 1983; 1:18-23.
37 Haldeman S, Kohlbeck FJ, McGregor M (1999) Risk factors and precipitating neck movements causing vertebrobasilar artery dissection after cervical trauma and spinal manipulation. Spine 24(8):785-94.
38 Spitzer WO, Skovron ML, et al. (1995) Scientific Monograph of the Quebec Task Force on Whiplash-associated Disorders: redefining Whiplash and its Management. Spine 1995; 20:8S.
39 Coulter ID, Hurwitz EL et al. (1996) the Appropriateness of Manipulation and Mobilization of the Cervical Spine. Santa Monica, California: RAND, Document NO. MR-781-CR.

Official Ballot

June 21st, 2012

The attached official ballot for ACA Rehab Council executive officers for the term 2013-2016 has been mailed out by the ACA Corporate Secretary, William O’Connell, to all current ACA Rehab Council members. If you have not yet received one, please call the ACA (attention Lavinia Mosher) at Ph. 703-475-3325 or simply use the attached ballot and mail it back to the ACA (see attached addressed envelope) to be received by or before 5:00pm on June 18th, 2012. Thank you.

Rehab Council Official Ballot – 2012
Rehab Council Official Ballot – Return Envelope

Elections of ACA Rehab Council officers – 2013

May 15th, 2012

In accordance with the Bylaws of the ACA Rehab Council and the master Bylaws of the American Chiropractic Association (ACA), the ACA Rehab Council Executive Officer’s Candidate Nominating Committee has chosen the chiropractic doctors listed below as candidates for the offices of President, Vice President and Secretary/Treasurer of the ACA Rehab Council for the 2013 – 2016 three year term. All candidates must be current in their membership dues with respect to both the American Chiropractic Association and ACA Rehab Council and according to the ACA Rehab Council Bylaws must be a member in good standing in the Rehab Council for a minimum of two (2) years prior to election and must have served on a Rehab Council Committee, or as a state representative for at least two (2) years. In addition, in order to run for the office of President, a Rehab Council member must have met the above requirements and must have served a minimum of two (2) years on the Executive Committee:

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

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

EHR Questionnaire

April 23rd, 2012

Dr. Terry Shaw, Past President of the American Chiropractic Rehab Board, would like your input on your experience with Electronic Health Records (EHR). Please respond to the following questionnaire and e-mail your responses back to Dr. Terry Shaw at: TWShawDC@hotmail.com or you may fax him at FAX (217) 224-5941.

EHR Questionnaire

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