American Chiropractic Association Rehab Council

Standing Tall as Rehab Specialists

November 19th, 2009

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

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

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

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

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

K.D. Christensen DC, CCSP, DACRB

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

November 16th, 2009

Kent C. Long, D.C.

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

ABSTRACT

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

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

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

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

KEYWORDS

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

INTRODUCTION

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

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

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

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

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

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

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

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

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

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

CASE REPORT

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

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

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

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

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

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

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

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

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

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

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

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

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

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

DISCUSSION

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

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

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

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

CONCLUSION

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

REFERENCES:

1. Carey TS, Evans AT, Hadler NM, Lieberman G, Kalsbeek WD, Jackman AM, Fryer JG and McNutt RA. Acute severe low back pain: A population-based study of prevalence and care-seeking. Spine 21:339-344, 1996

2. Frymoyer JW, Cats-Baril W. Predictors of low back pain disability. Clinical Orthopedics and Related Research 221:89-98, 1987

3. VonKorff & Saunders. The course of back pain in primary care. Spine 1996; vol 21(24): 2833-2839.

4. Jayson. Presidential Address. Why does acute back pain become chronic? Spine 1997; vol 22(10)

5. Holbrook TL, Grazier K, Kelsey JL, Stauffer RN. The frequency of occurrence, impact and cost of selected musculoskeletal conditions in the United States. American Academy of Orthopaedic Surgeons, Chicago, IL, 1984

6. Waddell G. Epidemiology review: The epidemiology and cost of back pain. The Annex to the Clinical Standards Advisory Group’s Report on Back Pain. London: HSMO, May 1994

7. Waddell G. The Back Pain Revolution. Edinburgh: Churchill Livingstone, 1998.

8. Dreyfuss P, Halbrook B, Pauza K, Joshi A, Mclarty J, Bogduk N. Efficacy and validity of radiofrequency neurotomy for chronic lumbar zygapopysial joint pain. Spine 2000 May 15; 25(10): 1270-7.

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

10. Windsor RE. Radiofrequency lumbar zygapophysial (facet) join denervation: a preliminary report of a new concept. Pain Physician. 2003 Jan; 6(1): 119-23.

11. Hyun JK, Lee JY, Lee SJ, Jeon JY. Asymmetric atrophy of multifidus muscle in patients with unilateral lumbosacral radiculopathy. Spine. 2007 Oct 1; 32(21): E598-602.

12. Hodges P, Holm AK, Hansson T, Holm S. Rapid atrophy of the lumbar multifidus follows experimental disc or nerve root injury. Spine. 2006 Dec 1; 31(25): 2926-33.

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

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

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

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

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

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

19. Hides JA, Richardson CA, Jull GA. Multifidus muscle recovery is not automatic after resolution of acute, first-episode low back pain. Spine. 1996 Dec 1; 21(23): 2763-9.

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

21. MacDonald DA, Moseley GL, Hodges PW. The lumbar multifidus: does the evidence support clinical beliefs? Man Ther. 2006 Nov; 11(4): 254-63.

22. Ward SR, Kim CW, Eng CM, Gottschalk LJ 4th, Tomiya A, Garfin SR, Lieber RL. Architectural analysis and intraoperative measurements demonstrate the unique design of the multifidus muscle for lumbar spine stability. J Bone Joint Surg Am. 2009 Jan;91(1):176-85.

23. Kladny B, Fischer FC, Haase I. Evaluation of specific stabilizing exercise int eht treatment of low back pain and lumbar disk disease in outpatient rehabilitation. Z Orthop Ihre Grenzgeb. 2003 Jul-Aug; 141(4): 401-5.

24. Hides JA, Jull GA, Richardson CA. Long term effects of specific stabilizing exercises for first-episode low back pain. Spine. 2001 Jun 1:26(11):E243-8.

25. Ng JK, Richardson CA, Jull GA. Electromyographic amplitude and frequency changes in the iliocostalis lumborum and multifidus muscles during a trunk holding test. Phys Ther. 1997 Sept;77(9):954-61.

26. Danneels LA, Vanderstraeten GG, Cambier DC, Witvrouw EE, Bougois J, Dankaerts W, De Cuyper HJ. Effects of three different training modalities on the cross sectional area of the lumbar multifidus muscle in patients with chronic low back pain. Br J Sports Med. 2001 Jun;35(3):186-91.

27. Von Korff M., Deyo RA, Cherkin D, Barlow W. Back pain in primary care: Outcomes at 1 year. Spine, 1993, 18, 855-862. Oswestry Disability Index

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

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

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

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

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

Chiropractic Rehabilitation and Its Influence On Daily Chiropractic Practice

November 16th, 2009

Spiro N. Comis, DC
Durham, NC

E-mail: spiro_c@yahoo.com

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Weight Lifting Modifications for Shoulder Tendonitis & Impingement Syndrome

November 16th, 2009

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Dynamic Neuromuscular Stabilization Seminar – Arizona

November 15th, 2009

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

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

ISCRS Members Receive a $100 Discount

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

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

Location
Physiotherapy Associates
1025 E. Broadway Rd. #10

Misc

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

Faculty

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

COURSE OBJECTIVES

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

Testimonials

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

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

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

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

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

Brett Winchester, DC DACRB, Troy , MO

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

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

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

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

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

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

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

Ida Nørgaard, Chiropractor & MSc., London

Pennsylvania Rehab Program

November 15th, 2009

George K. Petruska DC, DACRB presents

2009-2010 Chiropractic Rehab Diplomate Series

Pennsburg – Pennsylvania

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

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

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

Download the registration form here

COURSE BEGINS OCTOBER 17, 2009

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

Outline

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

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

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

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

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

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

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

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

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

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

August 14, 2010
Forms; Nutrition; Performance Enhancement.

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

Download the registration form here

New Council News

November 3rd, 2009

here is some council news i just got…

Dynamic Neuromuscular Stabilization Seminars – Redondo Beach, CA

November 3rd, 2009

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

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

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

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

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

Course Goals

Course attendees will have a clear understanding of:

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

Course Description

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

Course Instructors

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

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

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

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

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

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

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

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

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

Dates: November 7-9, 2009

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

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

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

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

Course attendees will possess:

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

Course Description

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

Course Instructors

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

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

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

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

The Functional Approach

July 26th, 2003

by K.D. Christensen DC, CCSP, DACRB

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

Selection Criteria

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

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

Specific Adaptation to Imposed Demands

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

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

Kinetic Chain Exercises

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

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

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

Functional Position Exercise

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

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

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

How to Spot a “Sham” Exercise

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

The Value of Balance Exercises

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

Functional Alignment

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

Conclusion

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

References

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

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

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

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

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

July 26th, 2003

by K.D. Christensen DC, CCSP, DACRB

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

Signs, Causes, Complications

The classic signs of the Type II diabetic are:

Over weight
Hypertensive
Inactive

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

Improving Quality of Life

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

• Increase patient activity level

• Monitor diet and supplements

• Protect and support the feet

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

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

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

Foot Concerns

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

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

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

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

Orthotic Support

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

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

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

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

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

References

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

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

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

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

Stiffness, Pain, and Sleep Following Exercise

July 26th, 2003

by K.D. Christensen DC, CCSP, DACRB

Post-exercise Stiffness

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

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

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

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

Exercise-Induced Soreness

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

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

Exercise-Delayed Soreness

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

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

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

Sleep and Exercise

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

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

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

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

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

References

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

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

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

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

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

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

Managing Shoulder Sprain/Strain Injuries

July 26th, 2003

by K.D. Christensen DC, CCSP, DACRB

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

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

Shoulder Function

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

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

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

Mechanics of Shoulder Injury

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

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

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

Rehabilitation of Shoulder Strain Injuries

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

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

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

Outcome Management

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

Shoulder Injury Self-Assessment of Function Questionnaire

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

Shoulder pain and Disability Index (SPADI)

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

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

Conclusion

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

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

References

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

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

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

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

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

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

Adjunctive Therapies to the Adjustment Preventing Leg Injuries

July 26th, 2003

by K.D. Christensen DC, CCSP, DACRB

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

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

Hip and Thigh Injuries

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

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

Knee Injuries

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

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

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

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

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

Lower Leg Injuries

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

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

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

Foot and Ankle Injuries

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

Conclusion

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

References

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Osteoporosis and Spinal Exercise

July 26th, 2003

by K.D. Christensen DC, CCSP, DACRB

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

Benefits of Exercise to Bone

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

Exercise Types

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

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

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

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

Spinal Osteoporosis

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

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

Corrective Spinal Exercises

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

Conclusion

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

References

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

About The Author

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

[captions for illustrations]

Fig. 1. Hip extension exercise

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

Lower Extremity Rehab for the Elderly

July 26th, 2003

by K.D. Christensen DC, CCSP, DACRB

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

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

Rehab Concerns in the Elderly

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

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

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

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

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

Benefits of Elder Exercise

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

Solutions

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

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

ACSM/NSCA Guidelines

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

Conclusion

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

References

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

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

3. Lawrence RC et al. Estimates of the prevalence of arthritis and selected musculoskeletal disorders in the United States. Arthritis Rheum 1998; 41:778-799.

4. Wegener L, Kisner C, Nichols D. Static and dynamic balance responses in persons with bilateral knee osteoarthritis. J Orthop Sports Phys Ther 1997; 25:13-18.

5. Casper J, Berg K. Effects of exercise on osteoarthritis: a review. J Strength Condition Res 1998; 12:120-125.

6. Clark DO. Racial and educational differences in physical activity among older adults. Gerontologist 1995; 35:472-480.

7. Christmas C, Andersen RA. Exercise and older patients: guidelines for the clinician. J Am Geriatr Soc 2000; 48:318-324.

8. Blair SN et al. Influences of cardiorespiratory fitness and other precursors on cardiovascular disease and all-cause mortality in men and women. JAMA 1996; 276:205-210.

9. Sinaki M, Offord KP. Physical activity in postmenopausal women: effect on back muscle strength and bone mineral density. Arch Phys Med Rehabil 1988; 69:277-80.

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

11. Schwellnus MP et al. Prevention of common overuse injuries by the use of shock absorbing insoles. Am J Sports Med 1990; 18:636-641.

12. Hertling D, Kessler RM. Management of Common Musculoskeletal Disorders. 2nd ed. Philadelphia: JB Lippincott; 1990. 334.

13. American College of Sports Medicine. Exercise prescription for special populations. In: Guidelines for Exercise Testing and Prescription. 1991. 166.

14. Jette AM et al. Exercise- it’s never too late: the strong-for-life program. Am J Publ Health 1999; 89:66-71.

15. American College of Sports Medicine. Exercise and physical activity for older adults. Med Sci Sports Exerc 1998; 30:992-1008.

16. Pearson D et al. The national strength and conditioning association’s basic guidelines for the resistance training of athletes. Strength & Conditioning J 2000; 22(4):14-27.

17. Fiatarone MA et al. High-intensity strength training in nonagenarians: effects on skeletal muscle. JAMA 1990; 263(22):3029-3034.

18. Kibler WB et al. Functional Rehabilitation of Sports and Musculoskeletal Injuries. Gaithersburg, MD: Aspen Publishers; 1998. 252.

Warm-Up and Stretching Procedures

July 26th, 2003

by K.D. Christensen DC, CCSP, DACRB

A majority of patients involved in rehabilitation — athletes and non-athletes alike — perform some type of preliminary physical activity or warm-up procedure, especially if a strenuous workout is expected. Warming up provides numerous benefits. An accelerated metabolic rate promotes the efficient use of substrates needed to provide energy for physical activity. A rise in muscle temperature reduces the internal viscosity of muscle protoplasm, enhancing the mechanical efficiency of moving muscles. Recent research indicates that mild warm-up exercise could inhibit the development of intracellular acidosis during subsequent intense exercise. 1 Muscle contraction is more rapid and forceful when muscle temperature is slightly higher than body temperature. An elevated body temperature stimulates vasodilation, increasing blood flow through the vascular bed of muscle tissue and increasing substrate delivery.

An adequate warm-up appears to minimize the risk of injury to the muscles, tendons, ligaments, and other connective tissues, possibly because of improved elasticity from blood saturation. 2 Therefore, the most common static stretch procedures before warming up must be reconsidered. A warm-up may also reduce the incidence of subendocardial ischemia and improve blood pressure response to exercise. It is clear that a warm-up should precede participation in any type of vigorous rehab activity.

Types of Warm-Up

Any effective type of warm-up should produce increased muscle temperature. Passive warm-up raises the body temperature by some external means a hot shower, for example). A general or nonspecific warm-up involves active motion of major muscle groups, as in simple calisthenics. Specific warm-up focuses on the neuromuscular regions to be used in the anticipated exercise (a rehearsal of the exercise event taking place), making this method the most effective for rehab patients. The intensity and duration of warm-up should be individualized according to the patient’s physical capabilities. A rectal temperature rise of 1° to 2° C seems adequate and is usually accompanied by the onset of sweating in normal environmental conditions. Too intense a warm-up should not be done too far in advance of exercise, as the body temperature returns to normal after about 45 minutes of rest. Some believe that the benefits of warming up may be related in part to psychologic factors.

Warm-up before exercise is a generally accepted practice. 3 Genovely et al. 4 examined the effects of prolonged warm-up exercise at 40% and 68% of maximal aerobic capacity (below and above anaerobic threshold, respectively) on maximal performance in five men who were active regularly but were not highly trained. Maximal performance, consisting of two 40-second bouts of maximal pedaling against a 5.5-kg resistance, was tested without warm-up exercise.

The two bouts of maximal exercise, separated by a five-minute rest period, were found to be reproducible for work output and peak blood lactate level. Below anaerobic threshold, warm-up exercise significantly increased core temperature with no rise in the steady-state blood lactate level. It did not contribute to improved maximal performance. Above anaerobic threshold, warm-up exercise led to significant increases in both core temperature and steady-state blood lactate level; work output and peak blood lactate concentration on maximal exercise were significantly reduced.

Task-specific, prolonged warm-up exercise below anaerobic threshold does not contribute to improved maximal performance, while warm-up exercise above the anaerobic threshold impairs maximal performance. This probably is due to glycogen depletion in fat-twitch muscle fibers, which in turn may have contributed to decreased lactate production. These findings apply to short-term maximal exercise in a setting in which the psychologic aspects of testing are rigidly controlled.

In recent years more flexibility exercises are included in most warm-ups. The warm-up should be exercise specific, and the type of drills used should prepare the patient for the skills they will use. The warming up should not be exhausting and should prepare the patient both physically and mentally for their rehabilitative events.

Static Stretching Exercise

The 1999 study by Johansson et al. suggests that pre-exercise static stretching “has no preventive effect on the muscular soreness, tenderness and force loss that follows heavy eccentric exercise.” 5 Shrier 6 and Pope et al. 7 conclude that stretching before exercise does not reduce the risk of exercise-related injury. Dominguez 8 believes that stretching, particularly static stretching, is itself a significant cause of injuries. The hurdler’s stretch and the plow, in which the patient is supine with the legs raised up and over the head so the feet touch the ground behind the shoulders, are specific examples of static stretching exercises deemed to be harmful. He does favor a 15 minute warm-up of gentle range-of-motion exercises (ROM) for individuals who perform explosive activities, but advises most to merely start slowly and finish with a gentle cool-down, bending and rotating the hips, knees, ankles, and shoulders. The benefits associated with stretching are attributed to active, controlled exercises, not static stretching itself.

Dominguez 9 also believes that, rather than seeking flexibility, most should attempt to develop dynamic ranges of motion. The ability to actively control joints through the full range of motion can be promoted by a combination of gentle flexing, extending, sideways bending, and rotation. A good overall program should develop range of motion, strength, power, endurance, balance, and motor control. Nothing more than oversized rubber bands (rehab tubing), balls, teeterboards, and balance beams is needed. Dominguez feels there is much room for creativity as clinicians apply general techniques to individual needs.

Flexibility Exercise

In the past few years static flexibility exercises have gained a great deal of popularity. However, many clinicians have gone beyond this and are using proprioceptive neuromuscular facilitation (PNF) techniques to increase flexibility. Warnings began to appear in the literature that some of the exercises may actually be harmful. “Bouncing could tear a muscle.” “Stretch the muscle and not the tendon.” “Hurdler’s stretch can damage the medial aspect of the knee.” “The plow is bad for the cervical spine.” “The ballet stretch is dangerous.” However, most believe that flexibility done in moderation, when the muscles are warmed up, can be beneficial. There are obviously some exercises that should be avoided. Attempts should be made in general to stretch muscle bellies and not tendons. This can be done by slightly relaxing the joints which the stretched muscles pass over. Never stretch a cold muscle. Most of the flexibility program should be done at the end of a rehab program.

Surberg 10 points out that there is an optimal level of flexibility that allows efficient movement while reducing the risk of certain types of injury. Attainment of this level of flexibility usually is a goal of rehab conditioning programs. The first step after certain injuries is achievement of normal ROM. Flexibility or ROM can be increased by reducing the resistance of agonist muscle groups, or by increasing the strength of opposing muscles. Decreasing the resistance of an agonist muscle group can be accomplished by lengthening connective tissues or by relaxing the myotatic reflex. Certain PNF methods may increase the strength of opposing muscles, whereas others influence agonist muscle groups. Flexibility or ROM exercises include passive or active, and combined active and passive, movements. Passive movements involve guiding a body part through an ROM with or without a prolonged stretch at the end of the movement. Active ROM involves the slow movement of an extremity of body part until resistance precludes further movement. Several variations in these methods exist.

References

1. Kato Y, Ikata T et al. Effects of specific warm-up at various intensities on energy metabolism during subsequent exercise. J Sports Med Phys Fitness 2000; 40(2):126-130.

2. Shellock FG. Physician Sportsmed 1983; 11(Oct):134-139.

3. American College of Sports Medicine position stand. The recommended quantity and quality of exercise for developing and maintaining cardiorespiratory and muscular fitness, and flexibility in healthy adults. Med Sci Sports Exerc 1998; 30(6):975-991.

4. Genovely H, Stamford BA. Effects of prolonged warm-up exercise above and below anaerobic threshold on maximal performance. Eur J Applied Physiol 1982; 48(Apr):323-330.

5. Johansson PH, Lindstrom L et al. The effects of preexercise stretching on muscular soreness, tenderness and force loss following heavy eccentric exercise. Scand J Med Sci Sports 1999; 9(4):219-225.

6. Shrier I. Stretching before exercise does not reduce the risk of local muscle injury: a critical review of the clinical and basic science literature. Clin J Sport Med 1999; 9(4):221-227.

7. Pope RP, Herbert RD, et al. A randomized trial of preexercise stretching for prevention of lower-limb injury. Med Sci Sports Exerc 2000; 32(2):271-277.

8. Shyne K. Physician Sportsmed 1982; 10(Sept):137-140.

9. CRA. Chiropractic Rehabilitation Standards Manual. Chiropractic Rehabilitation Association, 1989.

10. Surberg PR. Athletic Training 1983; 18(Spr):37-40.

Adjunctive Therapies to the Adjustment High-Heeled Shoes and Musculoskeletal Problems

July 26th, 2003

by K.D. Christensen DC, CCSP, DACRB

Looking good is what counts most! At least, that is what one might conclude, faced with the popularity of high-heeled fashion footwear. Ironically, a recent survey of 620 women established that the majority were dissatisfied with their dress shoes because they hurt their feet, even though most had paid between $50 and $200 per pair. Furthermore, women have about 90% of the nearly 800,000 annual surgeries for neuromas, bunions, and hammer toes. (1) There is a clear link between the types of shoes worn and the development of abnormal foot conditions.

Spotting a high heel is an easy task; convincing patients not to wear them is another story. This information should help you make a strong and logical appeal. Additionally, custom-made shoes — which combine fit, fashion, and the postural support of custom orthotics — are now available, so you can offer a sensible solution.

Forefoot Compression Injuries

A neuroma, also called interdigital neuritis, results from compression of a plantar nerve or a bursa between two metatarsals. The resulting inflammation and fibrosis can diminish both nerve and vascular flow, resulting in a burning sensation that extends into the toes. The most common area involved is between the third and fourth metatarsals but may occur at any site of compression. “A three-inch heel creates seven times more stress on the forefoot than a one-inch heel.” (1)

Brantingham et al. reported the results of a clinical trial involving twenty-nine patients suffering from Morton’s neuroma. The average pre-treatment history of foot pain was nineteen months. All patients received a series of foot manipulations, with the number of treatments ranging from three to twenty-six. The manipulations included mobilization of the metatarsal and MTP joints, forefoot mobilization relative to the rearfoot, ankle mobilization, and specific adjustments of the cuboid and cuneiforms. Additionally, twenty-three (80%) of the patients were fitted with orthotics to control excessive movements and hyperpronation. A follow up, three months after treatment, established that 83% reported moderate to excellent relief of their pain. (2) Adjustments that restore the articulations, combined with flexible orthotics that maintain the corrections, provide a true long-term solution in many cases, but high heels (higher than two inches) are nearly impossible to properly fit with orthotics.

Shoe Styles and Biomechanics

Although the Brantingham et al. study did not comment on modifying footwear, a long history of studies have attempted to link shoe style with altered biomechanics, necessary for the development of these common conditions among women. (3-5) Some of the earliest studies that compared gait in low-heel and high-heel shoes were performed by Schwartz et al. They reported changes in the distribution of weight in the forefoot with a shift away from the fifth metatarsal head in high-heel shoes. (6) Increased weight distribution over the third and fourth metatarsals, combined with the compressive toe box common to most high-heel shoes, is a logical mechanism for the development of a neuroma. Considering that 59% of women surveyed report wearing high-heel shoes at least one to eight hours a day, unless the underlying stress is removed by changing shoe styles, the symptoms associated with neuromas are likely to return. (7)

Loss of Arch Integrity

The same biomechanical derangement responsible for neuroma can cause a hallux valgus and bunion formation. In this condition, one or more of the foot’s three arches has often collapsed or lost integrity, which changes normal toeing off and weight transfer in the forefoot. Lateral deviation of the proximal first phalanx changes the direction of muscle attachments on the great toe. Contraction of these muscles leads to abnormal abduction of the phalanx and the cycle of deviation continues.

An early clue that the patient is losing integrity of the transverse arch is excessive callus formation directly under any of the metatarsal heads, but especially two through four. This is the body’s attempt to lift and pad the fallen structures. Metatarsal corrections built into flexible, custom orthotics can lift the metatarsals from the bases and remove the pressure from the metatarsal heads.

Rearfoot Conditions

Wearing heels also concentrates abnormal forces on the ankle and rearfoot, relative to the forefoot. The tibiotalar joint “is a tightly interlocked joint exposed to extreme mechanical conditions during single limb support” and is susceptible to repetitive, traumatic forces. (8) Anyone who has seen an inexperienced high-heel walker knows exactly what repetitive microtrauma is. The integrity of this joint is ensured by tension produced as the wedge-shaped talus is secured between the malleoli. However, the forced plantarflexion associated with high-heel use decreases the degree of tension, because of the shape of the wedge (wider anteriorly).

Although slight, this loss of tension decreases the optimal biomechanical relationship. According to Kapandji, “there is only a single position of articular congruence for the subtalar joint, i.e. the median position. The foot is then straight without any inversion or eversion and it is the position adopted by a normal foot lying flat on a horizontal plane…” He continues, “this neutral position, where the articular surfaces are kept together by the force of gravity, and not by the ligaments, is stable and can be maintained for a long time owing to the congruence of the articular surfaces. All other positions are unstable and are associated with a variable degree of articular incongruence.” (8)

In extreme cases, the plantarflexion associated with heels may be responsible for injuries as serious as inversion sprains. Remember also, that because of the lack of muscular attachments, the talus is nourished only by a weak blood supply, accompanying ligaments. “Thus it has a barely adequate arterial supply under normal conditions.” (8) This is an unfortunate situation for a bone faced with remodeling in response to repetitive microtraumas.

Conclusion

Whether or not your patient turns an ankle, heels disrupt gait and posture for the entire body. In their study of varying heel heights, Gastwirth et al. make the following observation: “Proximal symptomatology associated with wearing high heels, such as knee, hip and back problems, may in part be related to [a] restriction of subtalar joint pronation. The subtalar joint pronation that normally occurs at heel strike aids in shock absorption. If this pronation is limited, an increased shock wave must be absorbed by the joints proximal to the foot.” (9)

If your female patients continue to wear their high-heeled shoes, despite your best recommendations, it isn’t your fault if you cannot “cure” their every ache and pain,. However, because fashion is still in fashion, your patients will want an alternative to high heels. According to at least one study, it is not necessary to wear completely flat shoes. Only heel heights greater than 5 cm (2 inches) significantly influenced lower extremity mechanics and gait. (10) That may be a compromise that many of your fashion-conscious patients could live with.

References

1. The low down on high heels. AOFAS Online (www.aofas.org/highheels.htm).

2. Brantingham JW et al. Chiropractic management of Morton’s metatarsalgia (Morton’s neuroma): a review of 29 patients. Chiropractic Technique 1994; 6(2):61-66.

3. Craigmile DA. Incidence, origin and prevention of certain foot defects. Br Med J 1953; 2:749.

4. Feinberg H. Women’s fashion shoes. JAPA 1969; 59:360.

5. Gorecki GA. Shoe related foot problems and public health. JAPA 1978; 68:245.

6. Schwartz RP, Heath AL, Misiek W. The influence of the shoe on gait. J Bone Joint Surg 1935; 17:406.

7. The Gallup Organization, Inc. Women’s Attitudes and Usage of High Heel Shoes. August, 1986.

8. Kapandji IA. The Physiology of the Joints (5th ed.). New York: Churchill Livingstone Inc. 1989:148-206.

9. Gastwirth BW, et al. An electrodynographic study of foot function in shoes of varying heel heights. J Am Podiatric Med Assoc 1991; 81:463-472.

10. Ebbeling CJ, et al. Lower extremity mechanics and energy cost of walking in high-heeled shoes. JOSPT 1994; 19:190-196.

Rehabilitation of Running Injuries

July 22nd, 2003

by K.D. Christensen DC, CCSP, DACRB

As the number of participants in recreational and competitive running continues to increase, so does the number of Chiropractic patients who need treatment for running-associated injuries. Some researchers have estimated that up to 60% of runners will experience an injury that will limit their activities. [1] While some of these injuries are due to actual trauma, the vast majority fall into the category of overuse syndromes. In these cases, the runner pushed beyond the capabilities of the musculoskeletal system.

Overuse/Microtrauma

Most running injuries are not due to a recent acute injury, but have developed gradually, over a period of weeks or months. These “overuse” or “misuse” conditions are due to excessive and/or repetitive motion. The end result is a microtrauma injury – the body is unable to keep up with the repair and re-strengthening needs, so the tissue begins to fail and becomes symptomatic. If it is not very painful (or if the pain is eliminated by pain-killing drugs), the runner continues to run; eventually complete failure, such as a stress fracture or ligament tear, will result. The causes of these types of injuries are often categorized into extrinsic and intrinsic sources (Table 1). [2]

Extrinsic factors. Causes of microtrauma injuries that are outside of the runner are often the easiest to modify, and should be addressed immediately in treatment. Extrinsic factors include: the training program (such as mileage per week, number of speed or hill workouts, recent mileage increases, and amount of rest time); running surfaces (such as asphalt, artificial track, or natural trails); and equipment (design and materials of running shoes). Modifications in the running routine (such as less mileage on more forgiving surfaces) and newer, better shoes should be introduced at the start of the rehab program for any running injury. One extrinsic source of problems that is often overlooked is the forced pronation and “environmental” leg length discrepancy due to repetitive running on a banked surface, such as along the sides of roads that have with a pronounced slant for water run-off. [3]

Intrinsic factors. The individual variables associated with overuse injuries are either muscle imbalances or structural alignment problems. These factors are more difficult to modify, but a good rehab program should be able to make significant progress once the problem has been identified. In fact, this is actually the most difficult part – recognizing the intrinsic source of the runner’s symptoms. A well-designed examination is necessary to investigate the structural, biomechanical, and dynamic aspects, searching for evidence of muscle imbalances, misalignments, and dysfunctions. Often there are several intrinsic factors that combine to interfere with a runner’s musculoskeletal efficiency and to limit performance. When the runner tries to push harder, the system breaks down and becomes symptomatic.

This type of categorization, however, is overly simplified. When a runner has good alignment and muscle balance, even a strenuous training program is well tolerated. Runners with biomechanical problems, however, can’t withstand even a moderate training program without developing various types of overuse injuries. A change in running surface or shoes may bring out the fact that a runner has an underlying foot or leg alignment problem that had previously gone unrecognized. In other words, the intrinsic and extrinsic factors are closely intertwined, and both contribute significantly to most running injuries.

Implementing Rehab for Runners

First the extrinsic factors must be addressed. This entails changing the training program to decrease stress, selecting different running surfaces, and upgrading the runner’s shoes. Then, all involved intrinsic factors need to be evaluated, and any problem areas are treated. This will often include support for structural alignment and biomechanical improprieties.

Muscle imbalance. Muscle imbalance inhibits normal joint function and limits the functional range of motion. Improving the flexibility of shortened and tight muscles from many miles of running is often necessary. Slow, sustained stretching must be performed regularly. Stretching is possibly most effective when the muscles are warm (at the end of a run). Stretching and gentle, passive movement of involved joints should also be initiated soon after an injury, in order to improve flexibility and prevent adhesions. If an injury is very acute, an initial period of relative rest with cryotherapy may be needed. During this period, though, exercise of the opposite leg should be encouraged. Vigorous exercise of the uninvolved contralateral leg muscles produces a neurological stimulus in the injured muscles (called the “cross-over effect”), and helps to prevent atrophy. [4]

Weaker or injured muscles can be safely strengthened with the use of controlled isotonic resistance exercises. The resistance can come from a machine, from weights, from elastic tubing, or just using the weight of the body. Possibly more important than the equipment used is whether the exercise is done in an open or a closed chain position. The muscles and joints of the leg form part of a closed kinetic chain when the foot is fixed (usually on the ground). Exercises performed in this position mimic the way we use the leg during most daily and sports activities, as they require the co-contraction of accessory and stabilizing muscles.

Alignment problems. Knees, hips, ankles and feet all must be in proper alignment during the repetitive striding performed during running. The arches of the foot are particularly important for providing a combined strength and flexibility to support the stress of body weight during running. Interestingly, the arches are seldom symptomatic in the earlier stages of biomechanical stress, and they are capable of tolerating extreme stresses for long periods before breaking down and failing. This strength is also a weakness, since many foot failures seem to come on suddenly, when they actually have been developing for a long time.

Biomechanics. The structures and the functioning of the foot, ankle, and knee are all exposed to greater stresses during running. The most important biomechanical action during running is the timing and amount of pronation at the foot and ankle. If there is too much pronation, or if the foot stays in pronation too long (prolonged pronation), the biomechanics of gait are altered, and running is less efficient. [5] Excessive pronation also increases the internal rotation of the tibia, placing additional stress on the knee. [6] When running is a dominant component of the recreational choices of an individual, the natural biomechanics must be able to sustain these higher forces.

Current Research

A recent retrospective study looked back at the foot biomechanics of running athletes who reported recent foot and leg overuse problems, and compared them to a control group of uninjured runners. [7] The researchers (three M.D.s and a Ph.D. who work with many athletes and runners) wanted to determine whether excessive pronation (measured while weightbearing) correlated with the likelihood of developing various types of “overload” sports injuries. Specifically, the researchers looked at runners who had needed treatment for iliotibial band syndrome, Achilles tendinitis, stress fracture of the tibia, tibial periostitis, and plantar fascitis.

The amount of pronation during standing and while running at “regular speed” was determined by measuring the angles of the footprints of sixty six injured runners and 216 matched, uninjured control runners. The results are consistent with several other studies that have taken a slightly different approach, but have arrived at similar conclusions. The investigators found a significant correlation: Those athletes with more pronation had a much greater likelihood of having sustained one of the overuse athletic injuries. And they found that the amount of pronation seen in the static weightbearing footprint was more predictive than the footprint obtained during running. This reinforces the value of checking the alignment of our running patients’ feet in the standing position.

Shoe Inserts and Orthotics for Runners

A shoe insert made of viscoelastic material will help decrease the amount of stress on the feet, legs, and back during running. [8] If there is either excessive pronation or a high-arched foot, additional calcaneal and medial arch support will often need to be supplied by an orthotic.

Biomechanical efficiency. Orthotics have been found to be very useful in the long-term improvement of running biomechanics. [9] While there is still controversy regarding exactly how and why orthotics are so useful, [10,11] there is solid empirical evidence of their benefits to runners, for both treatment and prevention of overuse injuries. [12]

Shock absorption. Running exposes the joints, muscles, and connective tissues to high levels of repetitive stress. For patients with any tendency to develop overuse injuries, additional dispersion of these ground reaction forces is an important part of their treatment and rehabilitation. Even healthy young athletes who expose their knees to frequent pounding (runners, ball players, etc.) should be supplied with shock-absorbing insoles to decrease the stress transmitted from the feet into their knee and hip joints.

Conclusion

Overuse injuries in runners are a good example of the individual interacting strenuously with the environment. Problems can arise from either the environment (extrinsic factors) or the individual’s biomechanics (intrinsic factors). Rehabilitation needs to consider both sources of structural stress and strain, and then apply cost-effective treatments. Immediate treatment will include modifications of training and improvements in muscle balance – stretching of tight muscles and strengthening of weakened areas. For long-term improvement, biomechanical alignment problems will need to be addressed – often with the addition of custom-fitted sport orthotics. Failure to recognize these intrinsic complicating factors will result in a patient with recurring, and possibly variable complaints. A comprehensive approach to rehabilitation of running injuries provides the best hope for many years of recreational enjoyment.

References

1. Jacobs SJ, Berson BL. Injuries to runners: a study of entrants to a 10,000 meter race. Am J Sports Med 1986; 14:151-155.

2. Lysholm J, Wiklander J. Injuries in runners. Am J Sports Med 1987; 15:168-171.

3. Subotnick SI. ed. Sports Medicine of the Lower Extremity. New York: Churchill Livingstone, 1989:193.

4. Hertling D, Kessler RM. Management of Common Musculoskeletal Disorders (2nd ed.) Philadelphia: JB Lippincott, 1990:334.

5. Martin PE, Morgan DW. Biomechanical considerations for economical walking and running. Med Sci Sports Exerc 1992; 24:467-474.

6. Coplan JA. Rotational motion of the knee: a comparison of normal and pronating subjects. J Orthop Sports Phys Ther 1989; 11:366-369.

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

8. Schwellnus MP, Jordaan G, Noakes TD. Prevention of common overuse injuries by the use of shock absorbing insoles. Am J Sports Med 1990, 18:636-641.

9. Gross ML, Napoli RC. Treatment of lower extremity injuries with orthotic shoe inserts. Sports Med 1993; 15:66-70.

10. Nigg BM, Nurse MA, Stefanyshyn DJ. Shoe inserts and orthotics for sport and physical activities. Med Sci Sports Exerc 1999; 31:S421-428.

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

12. Gross NL, Davlin LB, Evanski PM. Effectiveness of orthotic shoe inserts in the long-distance runner. Am J Sports Med 1991; 19:409-412.

CAUSES OF MICROTRAUMA INJURIES
Extrinsic Factors	Intrinsic Factors
training program	muscle imbalance
running surfaces	structural alignment
equipment (shoes)	biomechanical function

Rehabilitation of the Hip

July 22nd, 2003

by K.D. Christensen DC, CCSP, DACRB

By virtue of its deep-socketed bony anatomy, the hip is a very stable joint. The intrinsic stability of the hip joint is further enhanced by a very thick joint capsule reinforced by strong spiral ligaments, and several powerful groups of muscles. [1] It is injured much less commonly than joints such as the shoulder, knee, and ankle; [2] however, since hip problems can be very disabling, it is vital to have a treatment and rehabilitation program which can return patients to full function. Simple daily activities such as walking down stairs, getting to the bathroom, and even turning in bed can be difficult for a patient with a hip problem. Athletes, both the highly competitive and the recreational, can be put out of commission by pain in or around the hip joint. This is because the hip forms a vital link in the lower extremity kinetic chain — transferring ground-reaction forces from the legs to the trunk during gait. While some hip problems are due to trauma, many conditions are secondary to overuse or misuse. Osteoarthritis of the hip joint is often an end-result, following years of improper biomechanics and dysfunction.

Most hip problems seen by doctors of Chiropractic have developed gradually, over a period of weeks, months, or even years. Common examples include: trochanteric bursitis, recurrent muscle strains (hamstrings, adductors), piriformis syndrome, snapping hip, and chronic degenerative changes (hip joint DJD). A successful and appropriate exercise program for the hip does not require expensive, joint-specific equipment. In fact, the low-tech approach can be very effective for the treatment of most hip conditions. With an understanding of normal hip joint function, knowledge of the involved muscles, and simple home exercise equipment, doctors of Chiropractic can readily help their patients with hip complaints.

How to Rehab the Hip

Stretching and passive motion. For some hip problems, improving the flexibility of short and tight muscles is necessary. Muscle imbalance inhibits normal joint function and limits the functional range of motion. Frequent, gentle and sustained stretching of specific muscle groups should be demonstrated to the patient, who can usually start the stretching immediately, even in the early stages after an injury. Slow, passive movements of the joint should also be initiated soon after an injury, in order to prevent the formation of adhesions. If an injury is very acute (with muscle swelling), an initial period of relative rest with cryotherapy may be needed. During this period, though, exercise of the opposite leg should be encouraged. Vigorous exercise of the contralateral leg muscles produces a neurological stimulus in the injured muscles (called the “cross-over effect”), which helps to prevent atrophy. [3] This is most easily done by “single-leg cycling” on a stationary bike or water exercise using the non-injured leg.

Piriformis syndrome and trochanteric bursitis are the two hip conditions which benefit from specific stretching exercises. In both of these, tight muscles contribute to an overuse condition which irritates sensitive tissues. Piriformis syndrome develops when a tight piriformis muscle inflames the sciatic nerve, causing posterior hip aching along with paresthesiae down the back of the leg, in the sciatic distribution. Since the piriformis is an external rotator of the hip, treatment must include inward rotation stretches for the piriformis muscle. Complete Chiropractic care will also encompass corrections of subluxations and biomechanical faults of the pelvis, as well as predisposing factors — such as an anatomically short leg and/or foot pronation. [4] Trochanteric bursitis causes pain at the lateral aspect of the hip, where a shortened iliotibial band crosses over the greater trochanter, irritating the protective bursa. Localized pain in this area, along with a positive Ober’s test, indicates the need for stretches to lengthen this long segment of connective tissue. Again, correction of abnormal biomechanics, such as leg length discrepancies, must be part of the treatment [5], and foot orthotics may be needed. [6]

Isotonic resistance exercise. Weaker or injured muscles can be quickly strengthened with the use of isotonic resistance exercises. The resistance can come from a machine, from weights, from elastic tubing, or just using the weight of the body. Since the hip functions as part of a closed kinetic chain during most daily and sports activities, weight-bearing exercises which require the co-contraction of accessory and stabilizing muscles can be most effective. Open-chain exercising (done with the foot and lower leg freely moving) are most helpful in the early stages of hip rehab, to reduce the stress on the surrounding muscles.

Open chain exercising can be started very early with a symptomatic hip, since it doesn’t require the musculoskeletal structures to bear the weight of the body. The easiest method is to extend the entire leg against the resistance of elastic tubing. This can also be accomplished with the knee bent and in a sitting or recumbent position with the tubing attached around the thigh. Initial exercising should be done with a limited amount of movement — within a “pain-free” range of motion. These exercises are particularly useful for patients who have an injured muscle, or a chronic muscle imbalance, which can develop into a “snapping hip” syndrome. Surprisingly, strengthening of the muscle and tendon involved in a “snapping” hip (such as the tensor fascia lata, iliopsoas, or biceps femoris muscles) is reported as more useful than stretching for resolving the snapping. [7] Rehab for degenerative arthritis of the hip should also start with open chain exercising, since the joint is more safely exercised when the damaged cartilage is not bearing weight directly. As the patient progresses, additional resistance can safely be supplied with heavier tubing.

Weight-bearing strengthening exercises, with the foot on the floor, should be included when an athlete is preparing to return to sports activities. Examples of closed chain exercises include partial squats, lunges (forward, back, and to the side), and step-ups or stair-climbing. Initially, body weight will be sufficient. Resistance can be gradually and progressively increased with the use of hand weights or a weight bar. A closed chain exercise which is available at many gyms is the leg press machine; however, this machine does not re-train the co-contraction of accessory hip support muscles as fully as weight-bearing exercises do.

Proprioception and coordination. It is important for athletes (whether recreational or competitive), to regain the fine neurological control necessary for accurate hip and lower extremity movements. Stimuli from articular and muscle mechanoreceptors must be modulated with efferent responses to maintain “dynamic joint stability.” [8] This means that some time (five to ten minutes each day) should be spent exercising while standing on one leg, with the eyes closed, while standing on a mini-tramp, or using a rocker board. The advantage of these balance exercises is seen when patients return to sports activities and can perform at high levels without consciously having to protect their hip or leg. Rocker board exercises are especially necessary for injuries, but can also help patients who have degenerative arthritis of the hip to gain improved function.

Plyometric exercise. Advanced exercises designed to develop explosive power and eccentric responses of the hip muscles are needed to re-establish the rapid responses necessary for good performance in many sports. Building strength during the eccentric (lengthening) phase of contraction and overloading the stretch response with plyometric exercises are often the missing component in recurrent hip muscle strains. Plyometric exercises include jumping with rapid returns, “bounding” style of running, and dropping off a box and quickly jumping up as high as possible. These types of exercises are part of the final phase of rehab for all athletes who hope to return to full function after a hip injury. Sedentary patients and those who do not need to develop this level of specialized muscle contractions usually do not need to progress into this part of hip rehab.

Functional alignment. Many of the chronic and overuse hip problems seen by doctors of Chiropractic develop secondary to an imbalance in weight-bearing alignment of the lower extremities. Alignment problems will need to be addressed in order to resolve the patient’s current symptoms and to prevent hip arthritis. Leg length discrepancies and foot pronation problems are frequently found in association with trochanteric bursitis, iliotibial band syndrome, and piriformis syndrome. Studies have found that osteoarthritis is much more common in the hip joint of a longer leg. [9] Recurrent muscle strains, especially hamstring and groin pulls, often occur secondary to an asymmetry in structural alignment. The use of custom-fitted orthotics and/or heel lifts is frequently a necessary part of a comprehensive hip rehab program.

Shock absorption. Asymmetrical loss of joint space is evidence of degenerative change at the joint surfaces and erosion of cartilage. In addition to proper nutrient support, additional dispersion of ground reaction forces will be necessary by providing shock-absorbing insoles. Many recreational athletes can avoid developing hip problems when they are fitted with orthotics which support the feet and ankles, and limit the forces on the hip joints. Shock absorbing orthotic supports provide almost immediate symptom relief for many patients with chronic, degenerative hip symptoms.

Conclusion

An appropriate and progressive rehab program should be started early in the treatment of patients with hip complaints and sports injuries. [10] Several rehab techniques are available, none of which require expensive equipment or great time commitments. Selecting the best exercise approach for each patient’s hip problem is not difficult. A closely monitored home exercise program allows the doctor of Chiropractic to provide cost-efficient, yet very effective rehabilitation care.

Since biomechanical alignment problems are frequently found in association with chronic hip complaints, patients must be screened for excessive pronation and/or leg length discrepancies. Failure to recognize these complicating factors will result in patients with recurring hip complaints, or symptoms that vary in location due to the effects of the underlying biomechanical stress. When the lower extremities are properly aligned, the muscles are strengthened and lengthened, and the hip joints work smoothly, patients will be able to enjoy the benefits of independent mobility well into their elder years.

References

1. Hertling D, Kessler RM. Management of Common Musculoskeletal Disorders (2nd ed.). Philadelphia: JB Lippincott, 1990:280.

2. Geraci MC. Rehabilitation of the hip, pelvis, and thigh. In: Kibler WB, ed. Functional Rehabilitation of Sports and Musculoskeletal Injuries. Gaithersburg, MD: Aspen Publishers, 1998:216.

3. Hertling D, Kessler RM. Management of Common Musculoskeletal Disorders (2nd ed.). Philadelphia: JB Lippincott, 1990:334.

4. Souza TA. Differential Diagnosis for the Chiropractor: Protocols and Algorithms. Gaithersburg: Aspen Publishers, 1998:134.

5. Souza TA. Differential Diagnosis for the Chiropractor: Protocols and Algorithms. Gaithersburg: Aspen Publishers, 1998:263.

6. Subotnick SI. Sports Medicine of the Lower Extremity. New York: Churchill Livingstone 1989:312.

7. Souza TA. Differential Diagnosis for the Chiropractor: Protocols and Algorithms. Gaithersburg: Aspen Publishers, 1998:265.

8. Laskowski ER, Newcomer-Aney K, Smith J. Refining rehabilitation with proprioception training. Phys Sports Med 1997; 25:89-102.

9. Friberg O. Clinical symptoms and biomechanics of lumbar spine and hip joint in leg length inequality. Spine 1983; 8:643-645.

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

Adjunctive Therapies to the Adjustment Functional Re-Training and Spinal Support

July 22nd, 2003

by K.D. Christensen DC, CCSP, DACRB

Choosing the best exercises for patients with back problems requires judgment based on clinical experience and scientific evidence. There are many approaches to rehabilitation, and lots of different types of exercises are available, but patients have a limited amount of time (and willingness) to exercise. Therefore, we must always try to give our patients the most effective exercises for their condition. But, what are the “best” exercises for chiropractic patients?

Exercise Selection

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

A successful and appropriate exercise program for the back and/or neck may not require expensive, joint-specific equipment. While high-tech machines are very useful and helpful particularly in the research lab, current rehab concepts recognizes the value of the low-tech approach. In fact, the low-tech approach can be very effective for the treatment of most spinal conditions. Additional personnel, high-tech equipment, more office space are usually not essential for general results but may be helpful in various situations. With an understanding of normal spinal function, knowledge of the involved muscles, and some updating of exercise concepts, doctors of chiropractic can effectively rehab their patients with simple exercise equipment.

Specific Adaptation to Imposed Demands

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

It has taken quite a while for those who specialize in the treatment of the spine to incorporate this idea into neck and back rehab programs. Recently, some of us have begun to use the same thought processes to design spinal exercises that we have used for decades to determine appropriate x-ray positions. As chiropractors, we do recognize that the spine functions very differently when it is not weight-bearing. We now know that a method to help our patients return to normal function is with exercises that mimic as closely as possible the real conditions under which the spine must function day after day. That generally will include the specific stress of gravity in the upright position or functional posture.

Closed Kinetic Chain

The spine is part of a closed kinetic chain when it is bearing weight. This is the manner in which we use the joints and connective tissue of the spine during most daily and sports activities, and it requires the co-contraction of accessory and stabilizing muscles. Weaker or injured muscles can be quickly strengthened with the additional use of isotonic resistance to stimulate increases in strength. Isotonic resistance can come from a machine, from weights, from elastic tubing, or just using the weight of the body. Also important is whether the spinal support structures are exercised in an open or a closed chain position. Open-chain exercises for the spine are done non-weight bearing, while either lying on the ground or immersed in water (which removes much of the effect of gravity). Both floor-based and water-based exercises have usefulness, especially during the acute stage. However, there may be a difference in functional end results.

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

Exercising the Spine in a Functional Position

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

Patients may need during the acute phase of recovery to exercise when lying down. Floor-based exercises train muscles and joints to begin to accept function in normal posture. The neurological patterns that are developed on the floor or in a pool assist in improving upright activities. However, learning new skills and habits on the floor may not translate to better functioning during all upright activities. The time and effort patients spend on open chain exercises is prepatory to more functional patterns and generally is not all that should be provided.

Exercising in a weight-bearing position is generally accepted by most patients. In addition to being focused and practical, upright exercising trains and strengthens the spine to perform in everyday activities. Patients recognized the value of doing exercises that clearly prepare them for better function during normal activities of daily life.

Exercises for Back Pain

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

Proprioception and Balance

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

Functional Alignment

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

Conclusion

Selecting the best exercise approach for each patient’s back problem is important. A well-designed exercise program allows the doctor of chiropractic to provide cost-efficient, yet very effective rehabilitation care. Exercises performed with the spine functional will ultimately specifically train and condition all the involved structures to work together smoothly. The end result is a more effective rehab component and patients who make a rapid response to their chiropractic care. When you persist with this, you will experience dramatic improvements in patient outcomes.

References

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

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

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

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

Adjunctive Therapies to the Adjustment Pelvic Unleveling

July 22nd, 2003

by K.D. Christensen DC, CCSP, DACRB

The most useful method for determining pelvic unleveling is to examine the patient in normal, upright posture. Much of the confusion surrounding this topic is then eliminated, and treatment decisions are simplified. Whenever we check a patient on the treatment table, whether prone or supine, errors of positioning are introduced (and are very difficult to exclude). Measurements of pelvic balance obtained in the non-weight bearing position have been found to be very unreliable. (1) In a relaxed, upright posture, these confounding factors are no longer a factor. Accurate clinical and radiographic determinations are then possible, (2) and effective chiropractic care can proceed.

Determining Anatomical Source

When evidence of pelvic unleveling has been identified in the standing position, efficient treatment depends on the anatomical source of the misalignment. Either the pelvis or the lower extremities must be the cause of the biomechanical imbalance. If the pelvis is the source, then treatment will need to be directed to this region. When the cause is in the lower extremities, successful care can be expected only with evaluation and correct treatment of the foot, ankle, or leg asymmetry. Since the lower extremities provide the foundation and support for the pelvis during standing and walking, it is not surprising that they can have a profound effect on the alignment of the pelvis (and the spine, as well).

Determination of Causal Factors

Whether the pelvic unleveling originates in the pelvis or in the lower extremities, there are only two possibilities — the cause must be an anatomical asymmetry, or a functional imbalance. Anatomical sources include growth asymmetries, anomalies, and post-fracture discrepancies. Functional problems encompass subluxations and biomechanical imbalances. Since these two categories are treated very differently, they must be separately identified. Here are the details of these two causes in the two regions:

In the Pelvis

Anatomical asymmetry. A very small percentage of patients will demonstrate pelvic unleveling due to a growth asymmetry or an old fracture of an ilium. The innominate bones can develop with a substantial difference in height, although this is rare. Luckily, it also is the least likely of the categories under discussion to cause symptoms. For sedentary patients, an ischial lift (a wedge under the “sit-bone” of the smaller side) can prevent problems from developing when seated for long periods of time. For most patients, standard chiropractic care of biomechanical problems in the spine and pelvis is sufficient.

Functional imbalance. Much more common in the pelvis is a biomechanical source of pelvic unleveling, with sacroiliac joint subluxations. This condition can be caused by work postures, recreational habits, or just a broken-down chair at home. Muscle imbalances are frequently part of this syndrome, with weakness of the hip extensor muscles being most common. Tightness of a psoas muscle, or shortening of the hamstrings from excessive sitting can also contribute to pelvic unleveling. An “antalgic” posture in response to acute pain and inflammation of the lower spinal joints often results in a difference in height of the iliac crests.

Treatment should include specific stretches targeted to shortened muscles, with strengthening and stabilizing exercises for weak or poorly coordinated muscles. Careful, specific adjustments of the pelvis and lumbar spine are necessary, in order to regain normal pelvic biomechanics and full function of the region.

In the Lower Extremities

Anatomical asymmetry. Some patients have a difference in the anatomical components of the lower extremities that results in pelvic unleveling. This may be due to a fracture of the tibia or femur, which healed with persisting shortness. Much more likely is a simple growth asymmetry. In fact, it is quite amazing that most of us have no significant difference in the length of our legs. Somehow, most legs grow to an equal length at adulthood. Those that end up with a difference in length over 9 mm. (measured while standing) have a higher incidence of low back pain. (3) Athletes and those who spend a lot of time on their feet may develop chronic symptoms with 5 mm. or just 3 mm. of discrepancy. (4)

Functional imbalance. The most commonly seen cause of pelvic unleveling is loss of support from the lower extremity — from the foot, in particular, due to collapse of the medial arch. When the arch drops (excessive pronation), the leg rotates medially, and the femur head drops, causing an unlevel pelvis. Excessive pronation may occur from a young age, through lack of development of the arch; but most commonly it occurs in later years, when the ligaments that support the arches undergo plastic deformation. Since this process usually happens gradually, over many years, there is often no significant foot pain. The patient with this condition begins to develop chronic low back and pelvis problems, but doesn’t describe any foot symptoms. Therefore, the doctor of chiropractic must always have an index of suspicion, and include a lower extremity postural exam in the evaluation of most new patients. Whenever there is evidence of pelvic unleveling, investigation of the feet and ankles, along with inspection of shoe wear patterns, is necessary.

Lift vs. Orthotic

It is very important to recognize the functional short leg, since providing a lift instead of an orthotic is likely to perpetuate the associated sacroiliac subluxations. (5) And there is no reliable information on the radiographs to differentiate these conditions. A pelvic tilt, a lower sacral base, and a femur head discrepancy indicate a lower extremity source, but not whether it is an anatomical or a functional short leg. The clinical postural exam with lower extremity screening is the only way to make this determination. If there is any doubt, the safest approach is to fit the patient with flexible, custom-made orthotics, initially. If there is a persisting pelvic tilt after wearing the orthotics for several weeks and receiving chiropractic adjustments, a heel lift can then easily be added to the orthotic for complete correction.

Conclusion

Once pelvic unleveling has been found in a patient, effective treatment can be planned. The first step is to differentiate whether the source of the imbalance is in the pelvis or the lower extremities. This may require accurate, standing radiographs taken without projectional distortion. Then, a determination of anatomical asymmetry or functional imbalance will help guide treatment. Most commonly, the lower extremities are not providing the necessary support for the pelvis. In many cases, orthotic support for foot pronation, knee rotation, or femur angulation is needed. Those few patients with a true anatomical leg length discrepancy will need to be supplied with the appropriate lift. The additional time required to determine the source of the pelvic unleveling will be repaid in more effective chiropractic care, and adjustments that last. The gratitude of patients who have finally found a doctor who is interested enough to individualize their treatment will help build a tremendous practice. This level of service ensures a great future for chiropractic, no matter what the insurance companies say or do.

References

1. Woerman AL, Binder-MacLeod SA. Leg length discrepancy assessment: accuracy and precision in five clinical methods of evaluation. J Orthop Sports Phys Therap 1984; 5:230-238.

2. Friberg O et al. Accuracy and precision of clinical estimation of leg length inequality and lumbar scoliosis: comparison of clinical and radiological measurements. Int Disabil Studies 1988; 10:49-53.

3. Giles LGF, Taylor JR. Low back pain associated with leg length inequality. Spine 1981; 6:510-511.

4. Subotnick SI. Limb length discrepancies of the lower extremity; the short leg syndrome. J Orthop Sports Phys Therap 1981; 3:11-16.

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

Adjunctive Therapies to the Adjustment Ligament and Muscle Stress

July 22nd, 2003

by K.D. Christensen DC, CCSP, DACRB

Muscles and ligaments are normally exposed to stress throughout life. Their structure is such that they respond and adapt to the usual amount of stress exposure. Damage occurs when the muscle or connective tissue is exposed to higher than usual stress levels. This can be a single, sudden excessive stress, or the result of repetitive stress to the muscle or ligament. In either case, the doctor of chiropractic must determine how the damage occurred, and then make appropriate recommendations to help the body heal the injury and to prevent a recurrence.

Problems can also develop when these tissues are not exposed to sufficient regular stress to maintain functional health. It’s important to recognize that there is a “continuum,” or spectrum of usual stress to the tissues in the body, and that categorizing a patient’s level of use helps in the planning of treatment and exercise regimens.

The Continuum of Use

What we usually consider to be normal use is in the mid-range of the use continuum. At one far end is paralysis, when the skeletal muscles and ligaments are completely unused. Close to paralysis is immobilization, such as in a cast or with bedrest. The difference between these is that paralysis lacks a neurological stimulus, called “tone,” which is present in immobilized (yet still neurologically intact) muscles and skeletal ligaments. (1) Next is sedentarism, when the ligaments and muscles are used only minimally. Unfortunately, this condition is becoming more common in all age groups in our rich, advanced society, which has so many labor-saving devices. Normal use can vary widely, but requires the intermittent and regular exercise and use of all muscles and ligaments. Those who are employed in active (usually blue-collar) jobs and people who engage in regular, active recreational pursuits fall into the strenuous use category. And then there are the athletes, who are always trying to improve and push their limits by specifically building and strengthening their muscular and skeletal ligament tissues. They are at the far end of the continuum, demonstrating the body’s response to progressive overload.

Paralysis. When the muscles and ligaments are not used at all, their functional properties rapidly diminish. The combination of muscle atrophy and ligament stiffening produces joints which do not function smoothly or easily. In some cases, the complete lack of use causes calcium to infiltrate into the soft tissues, resulting in heterotopic ossification. (2)

Immobilization. When a joint or extremity has been immobilized, atrophy sets in rapidly. The muscles shrink and the ligaments get stiffer and weaker. In fact, within a month, an immobilized muscle will lose up to one half its normal size. (3) After just one week of immobilization, a 20% decline in muscle strength has been measured! (4) Ligaments which have been immobilized for two months have been found to have only about half of their functional strength and resistance to stretch and injury. (5)

Sedentarism. In today’s society, we are able to avoid most physical efforts which were previously necessary to put food on the table and keep our homes warm. As a matter of fact, most of our patients no longer have to perform any significant physical labor. The result is several problems: overweight, de-conditioning, hypertension, and poor fitness in general. One in three Americans is clinically obese (defined as 20% or more above normal weight), and more than half are overweight. (6) This new reality causes problems for doctors of chiropractic who attempt to return patients to all capabilities; they find that many of their patients are too out of shape to maintain normal spinal function. Among other terms, this condition has very appropriately been called the “disuse syndrome.” (7)

Normal use. Throughout most of our existence, humans have needed to perform a variety of physical activities every day. Some strength was needed, as was a certain amount of flexibility and endurance. This began to change when the Industrial Revolution required certain repetitive movements, and now has been modified by our labor-saving inventions over the past century.

Strenuous use. By exercising regularly and participating in recreational sports, some of our patients work their ligaments and muscles harder than most. Some occupations place more than the usual stress on the feet, legs, and spine of some patients. This is beneficial, so long as the use does not exceed the body’s response to the stress. However, these are the patients who are susceptible to repetitive injuries, due to ongoing, stressful use which eventually overcomes the ability to strengthen muscle and ligaments.

Progressive overload. Athletes who push their bodies to continuously improve their performance take advantage of our innate ability to respond to stress by building strength. In response to gradually increasing loads, the muscles and ligaments strengthen and improve their function. (8) Many factors must be considered when designing and implementing these types of programs, so that injury can be avoided. (9)

Overuse and Damage

The muscles and ligaments in any of the above categories can be overused and damaged. Less stress is needed to cause injury to tissues in the lower use end of the continuum. After several days of immobilization, or when someone has been on bedrest or is a couch potato, even mildly strenuous effort can be too much. Fitness protects from some injuries, especially overuse conditions of the spine. Athletes who are regularly pushing their muscles and ligaments are most likely to end up with either overuse or acute injuries. There are two major categories of excessive stress to ligaments and muscles — repetitive use (chronic, over time), and sudden injury (strain or sprain) with tissue tearing.

Repetitive overwhelm. As discussed above, when the muscles and ligaments are stressed, they respond by repairing and strengthening. In some cases, however, the physical stress occurs so frequently that this process is overcome, resulting in damage. Examples include: runners who quickly increase their mileage, workers who are placed in a new position which requires repetitive movement or bending, and athletes who practice throwing to the point that they injure their shoulders. Even someone taking up walking after years of standing on rigid flooring can quickly overwhelm the foot’s ability to strengthen, developing plastic deformation of the plantar fascia with arch collapse.

Acute injury. Of course, trauma to a ligament or muscle is a single episode of stress which causes damage. When a muscle or ligament is torn, there is immediate pain, followed by swelling and loss of function. Around the spine, this is often a complex injury, since it is inevitable that several layers of both muscles and connective tissues will have been damaged (a “strain/sprain” injury). Understanding of the healing response is necessary for good management of acute injuries to muscles and ligaments, wherever their location.

Healing Response

Whether damaged by repetitive overuse or by acute injury, muscles and ligaments will heal most rapidly and completely when they are treated properly. A brief period of “relative rest” is important; the amount depending on the extent of injury. This may require one to four days of immobilization of the damaged region, followed by gradual reintroduction of movement and activity. (10) Then reactivation is necessary; this usually requires specific exercise instruction and expert guidance. The patient should be encouraged to return to the level of pre-injury, and then advised on preventing further injury, either by providing additional response time or by improving muscle strength and balance (or both). Occasionally, ligaments become damaged and deformed to the point that full repair is not possible. In these cases modification of stress may be necessary, either through changes in activities or through the use of supports, such as knee braces or custom foot orthotics.

Conclusion

It is vitally important to understand the status of a patient’s muscle and ligament tissues prior to injury. And then it’s also necessary to realize how these tissues became overwhelmed: Was it an acute injury, or can a history of repetitive insult be elicited? Once the doctor of chiropractic has the information for the “start point” and an understanding of the method of stress damage, the treatment can proceed rapidly. This is what separates caring doctors of chiropractic from those providers who prescribe drugs or bedrest for ligament and muscle injuries.

References

1. Schafer RC. Clinical Biomechanics: Musculoskeletal Action and Reactions, 2nd ed. Baltimore: Williams & Wilkins; 1987.163.

2. Resnick D, Niwayama G. Diagnosis of Bone and Joint Disorders, 2nd ed. Philadelphia: WB Saunders; 1988.3127.

3. Guyton AC. Textbook of Medical Physiology, 5th ed. Philadelphia: WB Saunders; 1976.145.

4. Noonan TJ, Garrett WE. Muscle strain injury: diagnosis and treatment. J Am Acad Orthop Surg 1999; 7:262-269.

5. Noyes FR. Functional properties of knee ligaments and alterations induced by immobilization. Clin Ortho Rel Res 1977; 123:210-242.

6. [NA]. Update: prevalence of overweight among children, adolescents, and adults — United States, 1988-1994. MMWR Morbid Mortal Wkly Rep 1997; 46:199-202.

7. Bortz WM II. The disuse syndrome. West J Med 1984; 141:691-694.

8. Frank C, Amiel D, et al. Normal ligament properties and ligament healing. Clin Ortho Rel Res 1985; 196:15-25.

9. Baechle TR. Essentials of Strength Training and Conditioning. Champaign: Human Kinetics, 1994.

10. Jarvinen MJ, Lehto MUK. The effects of early mobilisation and immobilisation on the healing process following muscle injuries. Sports Med 1993; 15:78-89.

Adjunctive Therapies to the Adjustment Improving Proprioceptive Balance with Orthotic Support

July 22nd, 2003

by K.D. Christensen DC, CCSP, DACRB

Recently published research has shown that custom orthotic support can help improve structural alignment (1), balance (2), gait (3), and athletic performance. (4) This is quite an extensive list of benefits. How can all of these claims be justified from the use of a single adjunctive therapy?

There is a reason so many changes (both in physical function and in symptoms) are reported with the use of custom-fitted orthotics. This large universe of improvements is due primarily to the sense of proprioception — one of the most important neurological systems of the body. A quick review of the mechanisms and components of proprioception will help us comprehend how patients can demonstrate such a large variety of improvements. Being able to explain this to patients (using simpler terms, of course) will help them understand the reasons you are recommending they wear in-shoe orthotics.

Specialized Sensory Organs

Proprioception is defined as “sensing the motion and position of the body”. (5) Specialized nerve endings are present throughout the soft tissues of the musculoskeletal system which interact with the central nervous system and coordinate our body movements, our postural alignment, and our balance. Athletic activities, in particular, rely on this delicately controlled and finely-tuned system of receptors and feedback loops, as well as the validity of the information which is sent into the spinal cord. This coordination normally allows for appropriate motor responses — and in some special cases, artistic physical performances.

Proprioceptive sensory organs are found in two distinct groups which are located in either muscles and tendons, or within the connective tissues (ligaments and capsules) of joints (Table 1). These specialized nerve fibers provide information regarding the status and function of the musculoskeletal system with a constant flow of information to the spinal cord, the cerebellum, and the brain.

When there is a communications breakdown, or when improper information is supplied by one or more of these sensors, efficiency of movement decreases. This is harmful and possibly injurious to the muscles and joints, and results in problems with postural coordination and/or joint alignment. Beyond being just an annoyance, faulty coordination or misalignments can also be the source of chronic, unresolving pain.

Location of Nerve Endings

The most important sensory nerve endings for controlling the muscular system are the muscle spindle fibers and the Golgi tendon organs. Muscle spindle fibers are found interspersed within the contractile fibers of all skeletal muscles, with the highest concentration in the central portion (belly) of each muscle. Muscle spindles respond to changes in the length of muscles. A complex circuitry of these nerve endings, with interconnections in the dorsal horn of the spinal cord, maintains muscle tone and, most importantly, the appropriate tension in the muscles on opposite sides of each joint. Without this basic “wiring”, proper joint alignment can’t be maintained, and relaxed, upright posture is almost impossible.

Golgi tendon organs are located in the junctions of muscles and their tendons. These protective nerve endings exert a powerful inhibitory effect on contraction of the muscle fibers. They are stimulated by strong stretching of the muscle/tendon junction (as when the muscle fibers are contracting too strongly). Golgi tendon organs transmit their information to the spinal cord and cerebellum through large, rapidly conducting nerve fibers, and they can rapidly inhibit a muscle contraction in order to protect the tendon.

Joint Mechanoreceptors

Surrounding and protecting all joints are tough, fibrous tissues which contain a variety of sensory nerve endings. The input from these specialized sensors keeps the nervous system informed as to the location of the joint, and also the degree of stretch, compression, tension, acceleration, and rotation. (6) These joint mechanoreceptors are classified by their anatomy and their neurological function. (7) Type I mechanoreceptors are found in higher densities in the proximal joints. They sense the position of a joint by signaling the joint angle through normal ranges of motion. These help determine postural (tonic) muscle contractions. Type II nerve endings adapt to changes in position, and are most active at onset and termination of movement. These are more densely distributed though the distal joints, and affect phasic muscle actions. Type III mechanoreceptors are high threshold, which means they require considerable joint stress at end ranges before firing. These receptors serve a protective function similar to the Golgi tendon organs. Type IV receptors are free nerve endings located in the ligaments, joint capsules, and articular fat pads which respond to pain stimulus. They can generate intense, non-adapting motor responses in all muscles related to a joint, resulting in the protective muscle contractions that restrict joint movement.

Foot Involvement

These six specialized nerve sensors are found throughout the musculoskeletal system, in all skeletal muscles and in every ligament, joint capsule, and articular connective tissue. With many small joints, lots of connective and articular tissues, and both intrinsic and extrinsic muscles, the feet are particularly well-supplied with proprioceptive nerve endings. Mechanoreceptors in the joints along with the muscle spindles of the foot muscles are responsible for the positive support reflexes and a variety of automatic reflexive reactions. (8) These include the flexor/extensor reflex, which converts the lower limb into a firm, yet compliant pillar. Weightbearing compresses the joints and muscles, evoking reflexive activity in the extensors and inhibition of the flexor muscles. (9)

The first research to demonstrate how altered proprioceptive input predisposes to recurring injuries was performed on patients with chronically sprained ankles. (10) Freeman et al. called this phenomenon “articular de-afferentiation” to recognize the importance of inappropriate afferent signals from injured ankle and foot proprioceptors. They pointed out that, “Since articular nerve fibers lie in ligaments and capsules, and since these fibers have a lower tensile strength than collagen fibers, it seems inevitable that a traction injury to a ligament or capsule will lead to the rupture of nerve fibers as well as collagen fibers”. (11)

Conclusion

Except for the spine, the foot is the anatomical region which contains the most proprioceptive sensory receptors, and the foot has very distinctive nerve circuits which must be considered. Because of the magnitude of sensory input, the feet are frequently involved in clinical conditions which will respond to specific treatment approaches that include the proprioceptors — such as custom orthotics. Structural support and shock absorption for the musculoskeletal system is provided by the corrective orthotics, thereby reducing physical stressors on the muscles and joints of the feet, legs, and pelvis.

Greater understanding of the proprioceptive system of sensory receptors in the muscles and joints has enabled us to more accurately assess and treat many complex musculoskeletal problems. When custom-fitted orthotics are included, treatments can be more effective and responses will be more comprehensive and longer-lasting.

Table 1.

SENSORY ORGANS FOR PROPRIOCEPTION
Muscles and Tendons	Muscle spindle fibers Golgi tendon organs
Joint Ligaments and Capsules (Mechanoreceptors)	Type I – low threshold, slow-adapting Type II – low threshold, fast-adapting Type III – high threshold, slow-adapting Type IV – nociceptive (pain endings)

SENSORY ORGANS FOR PROPRIOCEPTION

Muscles and Tendons

Muscle spindle fibers

Golgi tendon organs

Joint Ligaments and Capsules

(Mechanoreceptors)

Type I – low threshold, slow-adapting

Type II – low threshold, fast-adapting

Type III – high threshold, slow-adapting

Type IV – nociceptive (pain endings)

References

1. Kuhn DR, Shibley NJ, Austin WM, Yochum TR. Radiographic evaluation of weight bearing orthotics and their effect on flexible pes planus. J Manip Physiol Ther 1999; 22(4):221-226.

2. Stude DE, Brink DK. Effects of nine holes of simulated golf and orthotic intervention on balance and proprioception in experienced golfers. J Manip Physiol Ther 1997; 20:590-601.

3. Stude D, Gullickson J. Effects of orthotic intervention and nine holes of simulated golf on gait in experienced golfers. J Manip Physiol Ther 2001; 24(4):279-287.

4. Stude D, Gullickson J. Effects of orthotic intervention and nine holes of simulated golf on club-head velocity in experienced golfers. J Manip Physiol Ther 2000; 23(3):168-174.

5. Gatterman MI, ed. Chiropractic Management of Spine-Related Disorders. Baltimore: Williams & Wilkins, 1990:413.

6. Slosberg M. Effects of altered afferent articular input on sensation, proprioception, muscle tone and sympathetic reflex responses. J Manip Physiol Ther 1988; 11:400-408.

7. Wyke BD. The neurology of joints. Ann R Coll Surg Engl 1967; 41:25.

8. Freeman MAR, Wyke BD. Articular contributions to limb muscle reflexes. J Physiol 1964; 171:20.

9. Panzer DM, Fechtel SG, Gatterman MI. Postural complex. In: Gatterman MI, ed. Chiropractic Management of Spine-Related Disorders. Baltimore: Williams & Wilkins, 1990:263.

10. Bosien WR, Staples OS, Russell SW. Residual disability following acute ankle sprains. J Bone Joint Surg Am 1955; 37:1237.

11. Freeman MAR, Dean MRE, Hanham IWF. The etiology and prevention of functional instability of the foot. J Bone Joint Surg Br 1965; 47:678-685.

Hyperpronation: Treating Secondary Conditions

July 22nd, 2003

by K.D. Christensen DC, CCSP, DACRB

Patients seldom present with the complaint of “hyperpronation” or “excessive pronation.” It is usually left to the doctor to realize that the reported problem is due to pronation. Unfortunately, too many times the patient undergoes unnecessary or excessive examinations and treatment procedures, when the underlying problem is actually a hyperpronated foot (or feet).

What follows is a listing of commonly seen patient complaints that are frequently caused by (secondary to) excessive pronation, and which indicate the need for custom-fitted foot orthotics. Patients with an obvious need should be fitted with orthotics early in their chiropractic care. This will produce a good response to spinal and extremity adjustments, and will prevent frustration in both doctor and patient.

In the History

Back problems are worse with standing, walking, running. When a patient reports a history of upright locomotor activities and spinal symptoms, a close evaluation of the feet will often identify excessive and/or asymmetrical pronation. A brief gait evaluation should look for abnormalities such as foot flare or poor toe-off. This clearly calls for orthotics to minimize the stress being transmitted from the lower extremities to the spine.

Recurrent ankle sprains. A history of previous sprain injuries to one or both ankles indicates biomechanical instability and probable permanent ligament damage. The important ligaments that support the arches of the foot are often injured during an ankle sprain, and arch collapse and/or unilateral hyperpronation can result. Orthotics will provide the proprioceptive stimulus and mechanical advantage needed to prevent re-injury.

Family history of foot problems or surgery. Since we inherit many health tendencies, a patient who has family members with foot problems and/or surgery has a much higher probability of the same. Excessive calcaneal mobility, hallux valgus, plantar fascitis, and poor arch development are all associated with hyperpronation and appear to have a familial tendency. Fitting for orthotics may prevent these problems from developing, and could avoid surgery.

Strenuous athletic activities. Those who regularly engage in weight-bearing sports need both shock absorption and foot/ankle stability. Patients who present with athletic injuries associated with their sport activities often demonstrate excessive pronation as a complicating and inhibiting factor. (1) Orthotic support can increase performance and prevent injuries in a long list of individual and team sports — such as running, tennis, skiing, skating, soccer, baseball, football, and basketball.

History of lower extremity stress fractures, tendinitis, shin splints, hamstring strains. Whenever an athlete, whether recreational or competitive, reports symptoms of overuse injury (microtrauma) in the lower extremities, excessive pronation must be considered. These conditions have been closely correlated with biomechanical asymmetries (such as hyperpronation) and require better support and shock absorption. (2)

Chronic knee pain, patellofemoral arthralgia, ACL injury. The knee joint is a sensitive indicator of abnormal biomechanical stress, and many knee problems have been found to indicate the need for orthotics. Controlling pronation decreases the rotational forces, which improves patellar tracking and protects the anterior cruciate ligament. (3)

During the Exam

Postural imbalances (pelvic tilt, scoliosis, forward head). When a standing structural evaluation discloses a pelvic tilt (whether forward, backward, or low on one side), a lower extremity asymmetry due to unilateral or bilateral hyperpronation is likely. Both functional and idiopathic types of spinal curvatures can be associated with pronation, and will benefit from the foot stabilization and neurological stimulus provided by orthotics. Many postural complexes (forward head is one of the most common) are secondary to excessive pronation, with poor standing balance and proprioception from the feet.

Gait asymmetry, calcaneal eversion, foot flare. Watching a patient walk, and looking for indicators of biomechanical asymmetry, will often demonstrate the need for orthotics. Whenever there is excessive pronation, the foot and ankle complex does not function correctly during the stance phase of gait, and this stress is transmitted to the pelvis and spine with every step.

Foot calluses, bunions, hallux valgus. A careful examination of foot problems will often show evidence of hyperpronation and arch collapse. Heavy callusing, bunion development, and abnormal alignment all indicate the need for improved biomechanics and orthotics. (4)

Lack of an arch (especially unilateral). This is easily seen during the weight-bearing portion of the exam, when a foot collapses under the weight of the body. An even better method is the Navicular Drop Test, which measures the change in height of the medial longitudinal arch at the navicular prominence from sitting to standing. (5) A foot without an arch will pronate excessively, and needs orthotic support. (6)

Knee instability, high Q-angle, poor patellar tracking. When the knee does not align properly or track correctly, degenerative wear-and-tear and chronic symptoms will follow. Orthotic alignment is required to reduce the abnormal pronation forces on this complex joint, which must be able to sustain frequent high forces during walking and running. (7)

On the X-rays

Scoliosis (functional or idiopathic), widespread disc degeneration. The spine responds to poor support from one of the lower extremities by developing a lateral curvature. Some studies indicate that gait disturbances (during the stance phase, in particular) may be one of the causative factors for idiopathic scoliosis. (8) Significant intervertebral disc degeneration is made worse when the foot pronates, and transmits heel strike shock upwards into the spine. In this case, orthotics with viscoelastic properties will often reduce chronic symptoms dramatically.

Unlevel sacral base, sacroiliac joint degeneration. The pelvis shows evidence of inadequate support by the appearance of a tilted sacral base when standing. This is often due to a functional short leg secondary to hyperpronation, which requires orthotic support. (9) Sacroiliac degeneration may be due to chronic SI joint dysfunction, which may be secondary to hyperpronation.

Low femur head, coxafemoral DJD. These conditions are due to either an anatomical or a functional short leg, which are often associated with asymmetrical and/or excessive pronation. Degenerative changes in the hip joint have been correlated with the stress of a longer leg. Both will benefit from the improved balance and support provided by orthotics.

Heel spurs, DJD in knees, metatarsals. X-rays of the feet and knees may reveal evidence of long-standing regional stress, such as degenerative changes in weight-bearing joints, and connective tissue calcification. Calcium deposited in the calcaneal attachment of the plantar fascia specifically indicates the need for support of the arches of the foot.

Response to Care

Recurrent subluxations, symptom flare-ups. Making the same adjustment to a patient’s spine again and again suggests poor structural support for the region. Excessive pronation is often the underlying lack of proper support. Orthotics have been used for decades by chiropractors who don’t want to continue adjusting the same area, and want to see the adjustment “hold” better.

Conclusion

Chiropractic care is based on the concept of the treating the cause, and not just decreasing the symptoms. Our goal is to achieve long-term health, and not just short-term relief of pain. As can be seen by the above list, excessive foot pronation can be the source of many of our patients presenting symptoms. In fact, the feet are seldom painful in most of the conditions that are clear indicators of the need for orthotics. All doctors of chiropractic must be alert for signs of lower extremity involvement in spinal conditions and musculoskeletal problems.

References

1. Freychat P et al. Relationship between rearfoot and forefoot orientation and ground reaction forces during running. Med Sci Sports Exerc 1996; 28:225-232.

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

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

4. Eustace S et al. Hallux valgus, first metatarsal pronation and collapse of the medial longitudinal arch — a radiological correlation. Skeletal Radiol 1994; 23:191-194.

5. McPoil TG, Cornwall MW. The relationship between static lower extremity measurements and rearfoot motion during walking. J Orthop Sports Phys Ther 1996; 24:309-314.

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

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

8. Giakas G et al. Comparison of gait patterns between healthy and scoliotic patients using time and frequency domain analysis of ground reaction forces. Spine 1996; 19:2235-2242.

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

Flexibility Training and Rehabilitation

July 22nd, 2003

by K.D. Christensen DC, CCSP, DACRB

Flexibility exercises are used to facilitate rehabilitation, prevent injury or reinjury, and provide a warm-up regimen. In rehabilitation regimens, flexibility or range-of-motion (ROM) exercises are used to establish a functional range of motion before proceeding to resistive exercises. Prescribed motions are emphasized with ROM exercises for certain conditions, e.g., calcific tendinitis and bursitis. The patient must execute the correct protocol in a consistent manner to avoid problems.

Is PNF Superior to Static Stretching?

A flexibility program is designed to improve the range of motion at a given joint by altering the extensibility of the musculotendinous units. Static stretching, once recommended, is now considered by many out of favor. 1, 2, 3 Proprioceptive neuromuscular facilitation (PNF) techniques by others are preferred. Both methods are based on alteration of the myotatic stretch reflex. Prentice 4 compared static stretching with PNF stretching by the slow-reversal-hold method for improving the range of hip joint motions in 46 subjects of both sexes, aged 18-34 years, who participated in a 10-week general fitness program emphasizing flexibility and cardiovascular endurance. Flexibility measures were applied three days a week under direct supervision. Only the right hamstrings were stretched, and goniometric measurements were repeated after the 10-week training period. The slow-reversal-hold PNF technique was superior to static stretching. The slight gain in range of motion in the control extremity suggested that some training effect took place to improve flexibility.

The efficacy of various stretching methods in improving flexibility may be explained by autogenic inhibition, based on inhibition that is mediated by afferent fibers and that acts on the alpha motor neurons supplying a muscle, and also by reciprocal inhibition. The PNF approach denotes any method in which input from peripheral receptors is used for either facilitation or inhibition. Static stretching relies on autogenic inhibition, as does the slow-reversal-hold technique. In the latter method, the sustained isotonic contraction by the antagonist muscle increases tension in the muscle, again exciting the inhibitory Golgi tendon organs. The isometric contraction of the agonist is based on reciprocal inhibition. The PNF method is superior to static stretching in improving in general range of motion of most subjects.

Adequate flexibility is necessary for rehabilitation from injury as well as for prevention of injuries and superior performance. Sady et al. 5 compared the effects of static and PNF stretching techniques for shoulder, trunk, and hamstring muscles on the flexibility of 65 male college students. Forty-eight subjects (three groups of 16) used the techniques; 17 served as controls. Results were available in 43 subjects. A Leighton flexometer was used to measure the range of motion at the joints traversed by the tested muscle groups. Exercises were performed three days a week for six consecutive weeks.

Only the PNF group had an increase in flexibility greater than the control group (10.6 vs. 3.4 degrees). The hamstrings improved by 9.4 degrees and the trunk by 5.2 degrees. Reliability generally was higher for post-training scores. Variability between test days was lower for post-training scores of the shoulder and hamstrings. Significant between-day changes in flexibility were observed before training.

These findings again indicate that PNF is a preferred method of improving flexibility. Flexibility training appears to result in more consistent flexibility scores. PNF techniques can be integrated into any rehabilitation setting and provide increased flexibility relatively rapidly. Further studies are needed to learn which combination of repetitions, sets, duration, and frequency will result in maximal gains in flexibility.

The proprioceptive neuromuscular facilitation mobilization techniques of contract-relax (C-R) and hold-relax (H-R) are commonly applied at the point of limitation of motion and require active, resisted contractions of the range-limiting antagonistic pattern. Range of motion may increase contralaterally when these methods are used on an uninvolved extremity. Markos 6 compared the effectiveness of H-R and C-R in increasing range of hip flexion bilaterally during straight-leg raising. Studies were done in 30 normal women with a mean age of 22 years.

Maneuvers were applied to the right leg in two diagonal patterns while electrical activity was monitored in the contralateral rectus femoris, vastus medialis, semimembranosus and biceps femoris. The increase in range of motion of the right leg in subjects in the C-R group was significantly greater than that in the H-R and control groups. For the unexercised limb, the increase in motion in the C-R group was significantly greater than that in the control group. All but one of the 30 subjects exhibited electrical activity in the contralateral limb when the right leg contracted against resistance.

Both H-R and resistance toward the non-painful range deserve consideration when a treatment program is being planned. Contract-relax appears to be of most benefit in increasing the range of motion of tight musculature in both the involved and uninvolved limb.

Cryostretch

Many musculoskeletal injuries cause some degree of muscle spasm or tightness. Cryostretch therapy 7 combines ice application with the hold-relax technique of proprioceptive neuromuscular facilitation, involving static and isometric stretching of the affected muscle. A brief neuromuscular training session is conducted before the first exercise session to help the patient so that the joint moves through as great a range of motion as possible without resistance. The motion is repeated two or three times.

Each exercise bout consists of a 65-second set of static stretches and isometric contractions, a 20 second rest, and another set of exercises. Three bouts are performed during each treatment session, with two or three sessions each day. The muscle is numbed with a large cold pack or by massage with an ice cone. Initially the extremity or body part is moved until tightness or pain is felt. After holding the part in a pain-free position for 20 seconds, the patient is told to contract the muscle and try to perform the practiced motion while the therapist resists. Rapid contraction is avoided; contraction should last about five seconds and be as strong as possible. After this, the part is again moved to the point of pain for 10 seconds. The sequence is repeated, ending with a 10 second stretch, and the 65-second set of exercises is repeated after the limb has rested in the anatomical position for 20 seconds.

Combined cryokinetic and cryostretch therapy is instituted when the spasm is partially relieved, often within two-three days. Cryokinetic exercises begin with manually resisted muscle contraction through a functional range of motion, and should proceed through graded activity exercises. Full activity must be resumed gradually to avoid reinjury.

In order to assess the effectiveness of a PNF treatment plan, both objective and subjective data on patient results on outcomes must be collected and documented. The data typically focus upon the physical changes noted at the time of consultation and in subsequent visits (eg, range of motion). Ongoing outcome assessment data with comparative graphs over treatment time (available at www.outcomesassessment.org) documents the longterm results and effectiveness of the technique.

References

1. Pope RP, Herbert RD, et al. A randomized trial of preexercise stretching for prevention of lower-limb injury. Med Sci Sports Exerc 2000; 32(2):271-277.

2. Johansson PH, Lindstrom L et al. The effects of preexercise stretching on muscular soreness, tenderness and force loss following heavy eccentric exercise. Scand J Med Sci Sports 1999; 9(4):219-225.

3. Shrier I. Stretching before exercise does not reduce the risk of local muscle injury: a critical review of the clinical and basic science literature. Clin J Sport Med 1999; 9(4):221-227.

4. Prentice WE. Athletic Training 1983; 18(Spring):56-59.

5. Sady SP, Wortman M, Blanke D. Flexibility training: ballistic, static or proprioceptive neuromuscular facilitation? Arch Phys Med Rehabil 1982; 63(6):261-263.

6. Markos PD. Ipsilateral and contralateral effects of proprioceptive neuromuscular facilitation techniques on hip motion and electromyographic activity. Phys Ther 1979; 59(11):1366-1373.

7. Knight KL. Physician Sportsmed 1980; 8(Apr):129.

Adjunctive Therapies to the Adjustment Flat Feet in Adults

July 22nd, 2003

by K.D. Christensen DC, CCSP, DACRB

Flatfoot is defined as a lack of the medial longitudinal arch of the foot. Adults with flat feet demonstrate several biomechanical inefficiencies in the foot and ankle, as well as a variety of gait abnormalities. The development of clinical problems is dependent on the levels of activity and the amount of repetitive stress the feet must endure. The average person spends four hours each day on their feet, and takes between 8,000 and 10,000 steps every day. In some jobs and many sports, these amounts are more than doubled. During an average day, the feet support a combined force equivalent to several hundred tons. In addition to carrying the weight of the body, each foot acts as a shock absorber and a lever to propel the leg and body forward, and it serves to balance and adjust the body to uneven surfaces. The various problems associated with flatfoot can interfere significantly with normal daily activities, as well as limiting participation in recreational and competitive sports. Flat feet are due to either a loss of the normal arch due to breakdown of the supportive collagen structures, or a lack of development of a normal arch in the first place.

Congenital Flatfoot

Until about the age of 2 years, infants have flat feet, due to the presence of a large medial fat pad, and incomplete development of the foot structures. (1) As children begin to walk and spend more time on their feet, this fat pad slowly decreases, resulting in a noticeable medial longitudinal arch. (2) A study of the developing arch in children has confirmed that 28 to 35% of school children have an apparent flatfoot deformity, but 80% of those are classified as “mild.” (3) Follow-up evaluations have determined that 90% of these children will have normal arches by the age of 10 years. (4) The remainder never develop an arch, and are considered to have a “congenital flatfoot.”

Acquired Flatfoot

As adults, some of those who did develop a normal arch gradually lose it. This occurs secondary to a breakdown of the normally strong and dense connective tissues of the foot. It is the ligaments and connective tissues that support the medial longitudinal arch, (5) and not muscular strength. (6) In fact, normal alignment depends on a complex arrangement of dense collagenous fibers, and no single structure provides all of the support. (7) Problems with this arch will develop when these supportive tissues are put under excessive stress. This can be either from high loads for sudden, brief periods, or from more moderate, but repetitive stresses over longer periods, resulting in an “acquired flatfoot.”

Rigid Flatfoot

The overwhelming majority of flat feet are considered “flexible,” and will respond well to external support. In some cases, however, the arch never develops due to a bony abnormality (most commonly a tarsal coalition). This results in a “rigid” flatfoot, which will can be greatly aggravated by attempts to provide external support with inserts and orthotics. Differentiation is important, but can be easily done during the examination. If an arch is present when the patient is sitting with the foot dangling, or when standing up on the toes (toe-raise test), then the flatfoot is “supple and is correctable with an arch support.” (8) If the foot remains flat and rigid during this test, any attempt to lift up or support the arch can be painful, and corrective orthotics generally are avoided. Evaluation by a foot specialist is usually necessary to determine the underlying cause of a rigid flatfoot. Treatment may consist of accommodative orthotics and/or surgery.

Associated Terminology

Two descriptive terms are often used interchangeably with flatfoot, and can contribute to confusion. Pes planus is the more technical term that represents a flattening of the longitudinal arch; the arch is lower than established normal parameters when standing, especially on radiographic evaluation. (9) Hyperpronation (or excessive pronation) refers to excessive medial deviation of the talus during gait, primarily during the stance phase of gait. (10) Both of these problems are found in patients with flexible flatfoot, and will interfere with lower extremity biomechanics. An extensive list of the varied symptom complexes and health problems caused by flexible flatfeet has been compiled by Dr. Yale (Table 1). (11)

Energy Cost / Athletic Performance

An interesting study assessed the effects of arch supports on oxygen consumption in 20 subjects with flat feet who complained of fatigue and “weariness.” (12) The participants were between 18 and 38 years old, and had no specific foot symptoms. Their heart rates, blood pressures, and walking oxygen consumption were measured on a treadmill – first without, and then with arch-supporting orthotics. The results demonstrated that use of the orthotics significantly improved their gait efficiency, and decreased their oxygen consumption during normal walking. These responses can be extrapolated to athletic performance. In fact, it has long been observed that a flat foot, and hyperpronation, in particular, can interfere with performance in a number of sports. (13)

Support From Orthotics

In order to improve the biomechanics of the foot and provide permanent support for the medial longitudinal arch, most patients will need custom-fitted orthotics. Active patients generally benefit from flexible orthotics which are most beneficial for athletes and workers who must be on their feet for many hours each day. A recently published study found that custom-made flexible orthotics cast in a weight-bearing position significantly improved the alignment of the foot and increased the medial longitudinal arch when standing. (14) The materials and fit of an orthotic are critical, since support is needed for all three arches of the foot, along with cushioning and shock absorption in a comfortable insert. Additional padding under the forefoot is a recent addition that appears to be very helpful.

Conclusion

Flatfoot in adults may be congenital (the medial arch never developed), or acquired (the connective tissues no longer can support the medial arch). A rigid flatfoot is due to an osseous deformity, such as a tarsal coalition. As long as a flat foot is flexible, orthotic support for the medial arch can improve foot and ankle biomechanics, decreasing hyperpronation and enhancing performance in daily activities and during sports.

References

1. Magee DJ. Orthopedic Physical Assessment. Philadelphia: WB Saunders; 1987, 329.

2. Kemp HC. Current Pediatric Diagnosis and Treatment. Norwalk: Appleton and Lange; 1984, 614.

3. Notari MA. A study of the incidence of pedal pathology in children. J Am Podiatr Med Assn 1988; 78:518-521.

4. Wetton EA. The Harris and Beath footprint: interpretation and clinical value. Foot & Ankle 1992; 13:462-468.

5. Huang CK, et al. Biomechanical evaluation of longitudinal arch stability. Foot & Ankle 1993; 14:353-357.

6. Basmajian JV, Stecko G. The role of muscles in arch support of the foot. J Bone Joint Surg 1963; 45A:1184-1190.

7. Kitaoka HB, et al. Stability of the arch of the foot. Foot & Ankle 1997; 18:644-648.

8. Hoppenfeld S. Physical Examination of the Spine and Extremities. New York: Appleton-Century-Crofts; 1976, 232.

9. Forrester D, Kerr R, Kricun ME. Imaging of the Foot and Ankle. Gaithersburg: Aspen Pubs; 1988.

10. Gould N. Evaluation of hyperpronation and pes planus in adults. Clin Orthop Rel Res 1983; 181:37-45.

11. Yale JF. The conservative treatment of adult flexible flatfoot. Clin Pod Med and Surg 1989; 6:555-660.

12. Otman S, et al. Energy cost of walking with flat feet. Prosthets and Orthots Intl 1988; 12:73-76.

13. Subotnick SI. Sports Medicine of the Lower Extremity. New York: Churchill Livingstone; 1989, 159.

14. Kuhn DR, et al. Radiographic evaluation of weight-bearing orthotics and their effect on flexible pes planus. J Manip Physiol Ther 1999; 22:221-226.

Table 1. Flexible Flatfoot Associated Pathology (11)

Medial longitudinal arch strain with pain in the spring ligament
Abductor hallucis strain, pain, and spasm
Plantar fascial inflammation
“Jamming” at the first metatarsophalangeal joint with resultant traumatic arthritic changes
Plantar fascial insertional strain and inflammation, with or without calcaneal exostosis (heel spur)
Periarticular fibrocystis of the second metatarsophalangeal joint (Morton’s syndrome)
“Pinching” of the calcaneofibular ligament
Secondary fifth toe contraction deformities
Shearing hyperkeratotic lesions beneath the metatarsal heads
Second or third intermetatarsal space neuritis or neuroma
Sinus tarsi syndrome
Achilles tendinitis
Anterior or posterior Achilles bursitis
Peroneus longus spasm
Tibialis posterior overuse (posterior shin splints)
Tibialis anterior overuse (anterior shin splints)
Patellar tendinitis
Medial collateral knee ligamentous strain
Patellofemoral syndrome
Synovial plica syndrome
Popliteus muscle syndrome
Iliotibial band syndrome at knee or hip level
Hip adductor tendinitis
Greater trochanteric bursitis
Hamstring muscle strain and spasms (usually at night)
Lumbosacral muscle spasms
Sciatic neuritis
L4, L5, S1 disc narrowing symptoms
Cervical muscle spasm
Temporomandibular joint syndrome

How to Improve Exercise Compliance

July 22nd, 2003

by K.D. Christensen DC, CCSP, DACRB

Here’s a frustrating fact: a large percentage of patients don’t do the home-based rehabilitative exercises that are recommended to them. [1] Even though you spend precious time deciding which exercises will be helpful and explaining them to the patient, your experience has probably been the same as most Chiropractors: too many patients just can’t seem to do their exercises. And yet, you know that if they would just do the exercises, they would get better faster. Patient cooperation and satisfaction with at-home exercise programs are important for successful outcomes. [2]

In my opinion, each patient has several barriers or “hurdles” to get over in order to reach the goal of exercising. The more hurdles we can lower or even eliminate, the more likely it is that the exercises will get done. Here are some ways to lower the hurdles and help your patients get to the “finish line.”

Start Small

Lower the first big hurdle by initially recommending only one (or at most two) exercises initially. This minimizes the start-up effort and decreases the amount of time required. Once a patient has been doing one or two exercises regularly for a couple of weeks, additional or more complex exercises can be more easily implemented.

Schedule for Consistency

Consistency helps to ensure success in many areas. When a new habit needs to be learned, frequent and regular repetition helps. [3] Trying to schedule exercises into a busy schedule is difficult, especially when your patient has to decide which days to exercise and which days to rest. Since rehabilitative exercises do not tear down muscles, daily exercising is safe, and the scheduling hurdle can be eliminated. Initially, instruct your patients to “do the exercises every day.”

Explain and Motivate

Make sure your patient knows why the exercise needs to be done, and what benefits to expect. Motivation improves compliance with exercise. [4] Motivation is much better when a purpose is understood and a mutual goal has been established. Explain that doing the exercise will help your patient better perform the activities he or she enjoys.

Keep It Simple

Keep instructions to patients clear and simple. This is particularly important when discussing the numbers of repetitions and “sets” (groups of repetitions). Many doctors recommend six repetitions of the exercise, followed by a brief (up to one minute) rest, done three times. This “three sets of six” concept is quick to perform and easy to understand. Recent research has shown that only one set of 10 to 12 repetitions can be just as effective. This is particularly true when patients are just starting to exercise, and especially when they are exercising daily. Use either approach, but keep the instructions clear.

No Set Schedule

Any time of day is the right time to exercise — what’s most important is getting the exercises done. Even though some professionals feel that athletic activities are somewhat safer in the afternoon (when muscles and joints are warmer), encourage your patients to exercise whenever it works for their schedule (and once a day is plenty).

Recruit Allies

A spouse or family member should accompany the patient when exercises are taught, so they can help ensure correct and regular performance of the exercise. A second person who wants your patient to get better can be a tremendous ally, [1] one who will provide encouragement and reminders.

Stress Functional Position

Exercising in a comfortable weight-bearing position is generally easier for patients. In addition to being more focused and practical, upright exercising trains and strengthens the spine to perform better in everyday activities. Patients like the idea of doing an exercise that clearly prepares them for better function during normal activities of daily life.

Guide the Performance

Demonstrate, then watch and correct your patients’ performance of the exercise. When patients need an exercise, they usually can’t do the exercise correctly. Diagrams, pictures, even videos can’t ensure that patients will be able to figure out the suggested exercise. When you spend the time to show them the exercise, and then you guide them through it, they realize that you believe this is an important part of their treatment. Patients are then much more likely to do the exercise. [1]

Make It Easy to Do

Well-designed, easy-to-use home rehab equipment helps to ensure compliance. [5] Home equipment should be easy to figure out and set up, and should help guide your patients through the necessary exercises.

Monitor Regularly

As an integral part of their rehab while under your care, all patients must record their exercising in some form of exercise log. This allows them to “give themselves a pat on the back” each time they do the exercise. And remind them to bring the exercise log with them to every adjustment, so you can see how the exercises are going. Make sure to give them praise and recognition for the exercises they perform.

Review the Exercise

At least once a week, have the patient perform their exercise in front of you. This allows you to confirm that it’s being done properly, and you can correct any faults that creep in. A regular review also reinforces in the patient’s mind the importance of the exercising and encourages them to continue.

Customize the Exercise

There is nothing more motivating than the feeling that the most important exercises are being done. Make sure that the exercise(s) you are recommending will produce a rapid response, so the patient starts to feel the benefits of the exercising immediately. Don’t give all patients the same six exercises; instead, try to start the patient on the most important exercise for his or her condition. [1]

Conclusion

If you implement these rehab tips, your patients will be more likely to do their exercises faithfully. Once they have established the habit of doing one or two exercises, you can use the rehab review to add other exercises. With this method, a patient can gradually develop a good general fitness and spinal health exercise program while under your care.

Word will soon get around your community that you care enough about your patients to help them establish a regular spinal health and exercise program. This will build your practice, and also improve the reputation of Chiropractic for years to come.

References

1. Kamiya A, Ohsawa I et al. A clinical survey on the compliance of exercise therapy for diabetic outpatients. Diabetes Res Clin Pract 1995; 27(2):141-145.

2. Chen CY, Neufeld PS et al. Factors influencing compliance with home exercise programs among patients with upper-extremity impairment. Am J Occup Ther 1999; 53(2):171-180.

3. Rejeski WJ, Brawley LR et al. Compliance to exercise therapy in older participants with knee osteoarthritis: implications for treating disability. Med Sci Sports Exerc 1997; 29(8):977-985.

4. Friedrich M, Gittler G et al. Combined exercise and motivation program: effect on the compliance and level of disability of patients with chronic low back pain: a randomized controlled trial. Arch Phys Med Rehabil 1998; 79(5):475-487.

5. Stenstrom CH, Arge B, Sundbom A. Home exercise and compliance in inflammatory rheumatic diseases: a prospective clinical trial. J Rheumatol 1997; 24(3):4700-476.

Cross Education Exercise and Injury Recovery

July 22nd, 2003

by K.D. Christensen DC, CCSP, DACRB

Research supports the premise that exercising soon after an injury can actually speed up the healing process. In a 1995 study by Gregory et al. (1) using laboratory rats, the rats all received a contusion injury to a hamstring muscle, and were then sorted into five different groups. One group (the control) was not exercised. Two groups were returned to their cages to rest for 72 hours, and then started exercising (one group began swimming daily; the other began running every day). The final two groups began their swimming or running exercises within an hour of being injured.

Results by Group

The four rat groups which exercised all showed earlier resolution of their injuries than did the control (no exercise) group. The immediate (same day) exercisers showed more rapid healing response than those who rested for three days. Surprisingly, the data indicated that the injuries in the running group were resolving much more quickly than those of the swimmers. In fact, the study concluded that “Running with immediate onset is the regimen of choice. Any of the given exercises is preferable to no exercise, immediate onset of exercise is preferable to delayed onset, and running is preferable to swimming.” (1)

Clinical Impact

The Gregory et al. study results may impact on the methods of rehabilitative exercise therapy we perform in our clinics. However, keep two important facts in mind: First, many of our acute injury patients are trying to repair a sprain/strain type of injury, not a contusion. Strains and sprains involve tissue tears, while contusions produce a crushing of tissues. When tissues are torn, some period of decreased or restricted activity is needed, in order to allow for early repair of the tear by fibroblasts. The injuries sustained by the rats in the above study may be quite different from most injuries many chiropractors deal with, especially those found in the spine.

Secondly, the time the lab rats spent swimming or running was 15 minutes every day in all exercise groups. It’s possible that longer periods of exercise may have worsened the damage and delayed healing, rather than speeding the process. More research is needed to clarify these concerns.

Cross Education Exercise

An excellent way to stimulate an injured area, while avoiding excessive irritation, is to employ what is known as “cross education.” This neurological curiosity has been known for years, but it is apparently rarely employed by health care professionals treating acute injuries. Cross education is a procedure which has been found to be particularly useful in the treatment of shoulder and ankle injuries, and also provides benefits in most other types of injuries.

When a muscle performs resistance exercise, a neurological stimulus crosses the spinal cord and is received in the corresponding muscle group on the other side of the body. The technical description of this phenomenon is “neural integration of interlimb coordination.” (2) This concept can be used to help patients recover rapidly from an acute injury.

Cross Education and Your Patients

To use cross education in your practice, you must first identify the exercises your patient needs to perform for an injured area. Prior to starting, have the patient perform the desired exercises on the uninjured side. In a case involving a major acute injury (or during post-surgery), the exercise of the opposite uninjured muscle group should continue for between several days to numerous weeks, depending on the extent and severity of the damage. The cross educational exercises should specifically be done any time an injury is immobilized (casted or pinned), or when the area directly injured is too painful to consider direct exercise.

As healing progresses, your patient should begin exercising the injured region. Even at this stage, however, the patient could begin and end each session by exercising the uninjured side. Cross education will permit early, aggressive exercising without directly irritating or further damaging the injured area. This, in turn, should lead to a more rapid recovery.

An Example of Cross Education

A common example of cross educational exercise would involve an acute right shoulder injury which prevents abduction. Immediately start the patient doing abduction exercises with the uninjured left arm. When the patient is ready to start limited exercising of the injured right shoulder, the patient should first perform a similar pattern of left shoulder abduction against resistance.

Cross Educational Research

A 1997 study investigated the various parameters of cross education on human volunteers. (3) Both quadriceps muscles of the subjects were tested for strength, and then progressive resistance exercising was performed with the left leg only. Twelve weeks after the inception of the study, significant strength gains were measured in the unexercised legs. Researchers found the most significant improvement and the greatest gains in strength in the group that used lengthening (eccentric) exercises.

Conclusion

Arrange for your acute injury patients to begin an exercise program immediately after an injury; however, have them avoid direct exercise of the injured area initially. Recommend cross educational exercises to supply the stimulus necessary to take advantage of the early exercise phenomenon, while avoiding the potential for re-injury of the damaged area. Show the patient which exercises to do, but start the exercises on the opposite side of the body for the first several days.

Consider that patients focus on the lengthening (eccentric) part of the exercise movement, in order to make rapid progress. As they progress, and the injury begins to heal, the symptomatic region can be safely exercised and remember the uninjured side is exercised at the beginning and end of each session.

References

1. Gregory TM, Heckman RA, Francis RS. The effect of exercise on the presence of leukocytes, erythrocytes, and collagen fibers in skeletal muscle after contusion. J Manip Physiol Ther 1995; 18:72-78.

2. Howard JD, Enoka RM. Maximum bilateral contractions are modified by neurally mediated interlimb effects. J Appl Physiol 1991; 70:306-316.

3. Hortobagyi T, Lambert NJ, Hill JP. Greater cross education following training with muscle lengthening than shortening. Med Sci Sports Exerc 1997; 29:107-112.

Adjunctive Therapies to the Adjustment Children and Scoliosis

July 22nd, 2003

by K.D. Christensen DC, CCSP, DACRB

Scoliosis is defined as “any lateral deviation of the spine from the mid-sagittal plane.” (1) While there are many causes for scoliosis, children and adolescents with a scoliosis who present to chiropractors usually fall into one of three categories. Successful treatment is very dependent upon differentiating the underlying cause of the spinal curvature. In most children, the scoliotic spine is not symptomatic. The spinal curvature is first noticed either by a parent who becomes concerned about a child’s posture, or during a screening examination, usually at school. The importance of a good evaluation and early treatment is to prevent progression and worsening of the curvature. Children with all three major causes of scoliosis should have a careful evaluation of the lower extremities as part of their spinal examination to determine associated or contributing components to the spinal deviation.

Structural vs. Nonstructural Scoliosis

A structural scoliosis is defined as a spinal curvature that does not correct during recumbent, lateral flexion radiographs. The two most common causes of a structural scoliosis are congenital and idiopathic. A nonstructural scoliosis can be reduced when lying down, and will correct with recumbent lateral flexion. This type of spinal curvature is sometimes called a “functional curve,” and is often secondary to a leg length discrepancy.

Congenital Scoliosis. Of the three major etiologies of scoliosis, this is the least common. Congenital scoliosis develops secondary to a bony anomaly of the sacrum, vertebrae, or ribs. These are often defects of formation or segmentation, resulting in wedged, blocked, or hemi-vertebrae. In some cases, the abnormality will require corrective surgery. In many children, a heel lift or shoe build-up can provide sufficient structural support, and help to maintain a balanced spine.

When a congenital spinal anomaly is discovered, it’s important to remember that there are usually multiple affected areas. For instance, it is more common to have multiple bony abnormalities than just a single level. Non-osseous and extraspinal deformities are also often present. These may include the cartilaginous and connective tissues, and even genitourinary or cardiovascular abnormalities. Clubfoot, a congenitally dislocated hip, or an anatomically short leg often will contribute to the spinal imbalance.

Idiopathic Scoliosis. Idiopathic scoliosis can be progressive, worsening significantly during periods of rapid growth. In the more severe cases bracing, or possibly surgery, may be necessary to prevent substantial deformity. (2) After skeletal maturity, most curvatures progress only slowly, if at all. Recent scientific research has focused on hormonal and neurological causes for idiopathic scoliosis, with some promising early results, but no definitive conclusions.

Hormonal Influences

The pineal gland appears to have some influence on the development of a balanced spine, at least in chickens and rats. Surgical removal of the pineal gland in young chickens (3) and more recently in bipedal rats (4) produced spinal curvatures that are very similar to human idiopathic scoliosis, including vertebral rotation and rib humps. In the recent study on rats, the investigators found that providing a source of melatonin prevented the development of scoliosis in pinealectomized rats. They theorize that “melatonin may facilitate the fine neuromuscular coordination needed to maintain the 24 stacked vertebrae in balance.” While some studies have found that human patients with progressive scoliosis do have lower levels of melatonin, other investigations have not been able to establish a direct correlation. Injections of 5-hydroxytryptophan (a precursor to serotonin) into pinealectomized chickens prevented the development of scoliosis in most of them. (5) These researchers report that “…normal spine growth requires a precise and delicate balance of equilibrium and postural tone. The results of our current study and those we have reported previously imply that both melatonin and serotonin, and appropriately balanced use of both, are required for normal spine growth…” Does imply that nutritional support may be an answer?

Coordination and Gait

Numerous studies over the years have shown that humans with scoliosis have various defects in muscle coordination and standing balance. The source of these difficulties with fine motor control is unknown, and many theories have been developed and then discarded. The gait of children with scoliosis has been found to be somewhat abnormal, but there is controversy about whether this causes a curvature to develop or is simply a result of walking with a curved spine.

A recent study using sophisticated measuring devices and advanced computer analysis found a significant difference in gait between normal subjects and those with scoliosis. (6) This was most noticeable in the medial-lateral component of gait, indicating problems with pronation and supination control. They observed that the “…differences between the scoliosis and the control group, together with previously reported abnormalities of torsion in the tibia and femur and the hypothesis of pelvic rotation, suggests these are primary mechanisms of the cause of idiopathic scoliosis.”

These researchers believe that gait asymmetry could very well be the underlying cause of the balance and coordination problems that result in a curved spine. In fact, they conclude that “Patients with scoliosis exhibit balance problems during the stance phase of gait and have significant asymmetry in the frequency characteristics. These findings could be a primary effect that contributes to the medial-lateral deformity of the spine and its initiation and progression.”

Nonstructural Scoliosis

When a child’s lateral spinal curvature reduces significantly during recumbency, and side-bending is relatively symmetrical, a biomechanical imbalance must be considered. The causes include postural habits, muscle imbalances, pelvic and spinal misalignments and subluxations, and leg length discrepancies. These are all very responsive to conservative care, as long as the underlying source of the imbalance has been identified.

Pelvic and Spinal Imbalances

Muscular imbalances and recurrent subluxations may develop secondary to a child’s postural habits. Asymmetrical development of musculature used frequently in a sport can also be the source of a nonstructural scoliosis. These curves are usually mild, and will correct rapidly with education, corrective exercises, and chiropractic treatment.

Leg Length Difference

A discrepancy in the lengths of the legs during growth will cause a tilted sacral base, with a lumbar curvature. Once again, the scoliosis is usually mild, but the underlying cause should be identified and corrected in order to allow balanced spinal growth. If there is an anatomical difference in the length of the legs, a heel lift (or sole lift, in some cases) should be supplied. A functional short leg is due to an asymmetry in alignment, most commonly excessive pronation and/or lack of development of an arch of one foot. It is very important to recognize the functional short leg, since providing a heel lift instead of an orthotic is likely to perpetuate any associated sacroiliac subluxations. (7) There is little reliable information on the radiographs to differentiate these conditions. A pelvic tilt, a lower sacral base, and a femur head discrepancy seen on an x-ray of a child with a lumbar scoliosis indicate a lower extremity source, but not whether it is an anatomical or a functional short leg. A good clinical postural exam with lower extremity screening (including shoe wear patterns) is a way to make this determination.

Orthotic Support

All three major causes of scoliosis in children have been related to lower extremity asymmetries. Placing a child with a lateral curvature in custom-made orthotics provides an appropriate chance for developing a balanced spine, supports the chiropractic adjustments, and contributes to structural balance. If a heel lift is considered, an preferred method is to provide orthotics with an adjustable lift. This allows for increases or decreases that may be needed due to bone growth and lengthening. Of course, the orthotics themselves will need to be replaced as the child’s feet grow.

Conclusion

A child with a scoliosis must receive a careful spinal examination to determine the cause of the lateral curvature. In all cases, an assessment of the alignments and lengths of the lower extremities must be included. Accurate, standing x-ray films are also necessary, first to measure the amount of lateral deviation, rotation, and angulation of vertebrae, second to determine the spinal maturity (and risk of progression), and finally to rule out any leg length inequality. In many cases, custom-fitted orthotics (sometimes with added heel lifts) are needed for long-term results.

When conservative treatment of idiopathic scoliosis is indicated, nutritional support for the pineal gland should be considered. Perhaps most importantly, the neurological system needs to be checked thoroughly, and any interferences and sources of incoordination eliminated. Exercises to develop fine control of balance and posture, as well as gait training may be helpful. Custom-fitted orthotics should be provided early in treatment of all patients with scoliosis, to improve bilateral balance and gait symmetry.

References

1. Yochum TR, Rowe LJ. Essentials of Skeletal Radiology, 2nd ed. Baltimore: Williams & Wilkins; 1996. 307.

2. Rowe DE, et al. A meta-analysis of the efficacy of non-operative treatments for idiopathic scoliosis. J Bone Joint Surg 1997; 79A:664-674.

3. Dubousset J, Queneau P, Thillard MJ. Experimental scoliosis induced by pineal and diencephalic lesions in young chickens: its relation with clinical findings. Orthop Trans 1983; 7:7.

4. Machida M, et al. Pathogenesis of idiopathic scoliosis: experimental study in rats. Spine 1999; 24:1985-1989.

5. Machida M, et al. Role of serotonin for scoliotic deformity in pinealectomized chicken. Spine 1997; 22:1297-1301.

6. Giakas G, et al. Comparison of gait patterns between healthy and scoliotic patients using time and frequency domain analysis of ground reaction forces. Spine 1996; 21:2235-2242.

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

Children and Rehabilitation

July 22nd, 2003

by K.D. Christensen DC, CCSP, DACRB

As with adults, children often need to do some exercises as part of their Chiropractic treatment. A common question asked by physicians is whether children can safely perform exercise with resistance? How much weight is appropriate for a growing body? Which exercises are most effective? Doctors of Chiropractic may hesitate to recommend exercises for their younger patients because of these and similar questions. Since this is such an important topic, here is a reasoned and experienced response, along with useful consensus information.

Prepubescence is the phase of childhood prior to the onset of secondary sex characteristics. Rapid, but variable growth occurs during this period, with open physes and changing muscle and ligament lengths. Adolescence begins with the onset of secondary sex characteristics and continues until physical and skeletal maturity. Selecting the best exercise approach for each child’s situation is important, since needs may vary during growth. [1] However, all children should be encouraged to engage in frequent and regular fitness activities.

Benefits of Exercise

The benefits of youth physical activity include fitness, weight control, and the development of habits having the potential to span a lifetime. One study systematically determined the amount of moderate to vigorous physical activity students obtain during elementary and middle-school physical education classes (time spent performing moderate to vigorous physical activity/total class time). The researchers concluded that the amount of physical activity observed (elementary schools, 8.6%; middle schools, 16.1%) was significantly less than the estimated national average of 27% and far below the national recommendation of a minimum of 50%. [2] A review of current youth fitness data indicates that children in the United States are fatter, slower, and weaker than children in other developed nations. Also, children in the United States appear to be developing a sedentary lifestyle at earlier ages. A low level of exercise is a contributing factor for childhood obesity and hypertension, and predisposes the individual to premature death from coronary heart disease. [3] Fortunately, through intervention in children and adolescents in the form of education and motivation, exercise levels may be increased to the recommended minimum of 30 minutes on most days. [4]

Resistance Exercise Safety

High-intensity resistance training appears to be effective in increasing strength in preadolescents. Children make similar relative, but smaller absolute strength gains when compared with adolescents and young adults. Resistance training appears to have little if any hypertrophic effect, rather being associated with increased levels of neuromuscular activation. Researchers have found that the risk of injury from prudently prescribed and closely supervised resistance training appears to be low during preadolescence. [5] In 1993, Mazur reviewed the types and causes of injuries to preadolescents and adolescents resulting from weight lifting/training. [6] The researchers concluded that “prepubescent and older athletes who are well-trained and supervised appear to have low injury rates in strength training programs.”

A risk that must be considered in the immature skeleton is the susceptibility of the growth cartilage of the epiphyseal plates (physes). Weight training in a submaximal controlled, supervised situation is beneficial to bone deposition. Strength training can be a valuable and safe mode of exercise provided 1) instructors are properly educated; 2) participants are properly instructed; and 3) the absolute necessity of avoiding maximal lifts is reinforced. [7] The most important factors in avoiding injury in children who are doing resistance exercises are: proper performance of the exercise; avoiding overload by focusing on repetitions, not weight; enforcing rest periods during exercise; and resistance training only twice a week. Exercise tubing is an excellent tool for strength training of children, since the risks of injury are minimized, and a spotter or expensive equipment is not needed (Fig. 1).

Training Coordination and Balance

For many children, it is more important to learn the fine neurological control necessary for accurate spinal and full body performance than to simply build strength. Better coordination and balance will often result in improved physical function, both in daily and in sports activities. This may entail performing exercises while standing on one leg, with the eyes closed, while standing on a mini-tramp, or using a rocker board. The advantage of these balance exercises is seen when children engage in sports activities and perform at advanced levels for their age group.

Exercises are effective when done in an upright, weight-bearing position, since the entire body is in a closed chain position during the training. The stabilizing muscles, the co-contractors, and the antagonist muscles all learn to coordinate with the major movers during movements that are performed during closed chain exercising. This makes these types of exercises very valuable in the long run, particularly for children who are interested in becoming competitive athletes.

Corrective Spinal Exercises

Children’s spinal problems are often associated with poor postural support. A spinal asymmetry such as scoliosis and kyphosis is invariably accompanied by neuromuscular imbalance. This may be compounded by poor postural habits and tendencies to “slump.” One important factor in Chiropractic treatment is the correction of any loss of the normal upright alignment of the pelvis and spine. In addition to general strengthening and coordination exercises, patients (including children) should be shown corrective exercises that are specific for the postural imbalances they have developed. For instance, when the pelvis is carried flexed forward, a patient of any age will need to retrain with resisted pelvic extension exercises. Likewise, when there is a forward head, posterior translation exercises for the cervical region are very important (Fig. 2).

Whenever a child shows evidence of abnormal gait or begins to develop lower extremity complaints, a careful evaluation for the need for shoe inserts is warranted. Custom-fitted orthotics can improve performance and spinal alignment by ensuring proper lower extremity alignment and reduce overuse injuries by providing additional shock absorption.

Conclusion

A well-designed exercise program for children who need to strengthen, develop better coordination, and improve postural support will allow the doctor of Chiropractic to provide cost-efficient pediatric spinal care. Exercises performed with the spine upright (standing or sitting) can specifically train and condition all the involved structures to work together smoothly. In some children, orthotic support is necessary to help ensure correct alignment from the lower extremities. The end result is a more effective rehab component and young patients who will make a rapid response to their Chiropractic care. With a few common-sense cautions and careful supervision, children are capable of performing rehabilitative exercises very safely.

References

1. American College of Sports Medicine. Guidelines for Exercise Testing and Prescription, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2000.

2. Simons-Morton BG, Taylor WC. Observed levels of elementary and middle school children’s physical activity during physical education classes. Prevent Med 1994; 23:437-441.

3. Cunnane SC. Childhood origins of lifestyle-related risk factors for coronary heart disease in adulthood. Nutr Health 1993; 9:107-115.

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

5. Blimke CJ. Resistance training during preadolescence: issues and controversies. Sports Med 1993; 15:389-407.

6. Mazur LJ, Etman RJ, Risser WL. Weight-training injuries: common injuries and preventative methods. Sports Med 1993; 16:57-63.

7. Schafer J. Prepubescent and adolescent weight training: is it safe? Is it beneficial? Natl Strength Conditioning Assoc J 1991; 13:39-45.

About the Author

Kim D. Christensen, DC, CCSP, DACRB, is co-director of the SportsMedicine & Rehab Clinics of Washington. He is a popular speaker at numerous conventions and participates as a team physician and consultant to high school and university athletic programs, as well as being a Chiropractic faculty member. He is currently a postgraduate faculty member of numerous Chiropractic colleges and is the current president of the American Chiropractic Association (ACA) Rehab Council. He recently received the “Founding Father” award at the annual ACA meeting from the American Chiropractic Rehabilitation Board. He has participated in college sports, and has served as a trainer, coach, and team doctor. Dr. Christensen is the author of numerous publications and texts encompassing musculoskeletal rehabilitation and nutrition. He has recently been appointed as a Board Member of the Commission on Accreditation of Rehabilitation Facilities (CARF). Dr. Christensen has also recently been appointed to the HCFA Therapy Review Program (the only Chiropractor in the United States on this government panel). He can be reached at Chiropractic Rehabilitation Associates, 18604 NW 64th Avenue, Ridgefield, WA 98642.

[captions for illustrations]

Fig. 1. Resistance exercise with a rubber tubing system (light resistance for children)

Fig. 2. Posterior translation exercise for the cervical region

ACA Rehab Council: Your #1 source for the latest in neuromuscular rehabilitation and state of the art doctors

Kent C. Long, D.C.

ABSTRACT

KEYWORDS

INTRODUCTION

CASE REPORT

DISCUSSION

CONCLUSION

REFERENCES:

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

COURSE OBJECTIVES

Testimonials

George K. Petruska DC, DACRB presents

2009-2010 Chiropractic Rehab Diplomate Series

Pennsburg – Pennsylvania

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

COURSE BEGINS OCTOBER 17, 2009

Outline

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

Course Goals

Course Description

Course Instructors

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

Course Description

Course Instructors

by K.D. Christensen DC, CCSP, DACRB

Selection Criteria

Specific Adaptation to Imposed Demands

Kinetic Chain Exercises

Functional Position Exercise

How to Spot a “Sham” Exercise

The Value of Balance Exercises

Functional Alignment

Conclusion

References

by K.D. Christensen DC, CCSP, DACRB

Signs, Causes, Complications

Improving Quality of Life

Foot Concerns

Orthotic Support

References

by K.D. Christensen DC, CCSP, DACRB

Post-exercise Stiffness

Exercise-Induced Soreness

Exercise-Delayed Soreness

Sleep and Exercise

References

by K.D. Christensen DC, CCSP, DACRB

Shoulder Function

Mechanics of Shoulder Injury

Rehabilitation of Shoulder Strain Injuries

Outcome Management

Shoulder Injury Self-Assessment of Function Questionnaire

Shoulder pain and Disability Index (SPADI)

Conclusion

References

by K.D. Christensen DC, CCSP, DACRB

Hip and Thigh Injuries

Knee Injuries

Lower Leg Injuries

Foot and Ankle Injuries

Conclusion

References

by K.D. Christensen DC, CCSP, DACRB

Benefits of Exercise to Bone

Exercise Types

Spinal Osteoporosis

Corrective Spinal Exercises

Conclusion

References

by K.D. Christensen DC, CCSP, DACRB

Rehab Concerns in the Elderly

Benefits of Elder Exercise

Solutions

ACSM/NSCA Guidelines

Conclusion

References

by K.D. Christensen DC, CCSP, DACRB

Types of Warm-Up

Static Stretching Exercise