American Chiropractic Association Rehab Council

By: Anthony C. Distano, M.S., D.C., C.S.C.S.

INTRODUCTION

Breathing is the process that moves air in and out of the lungs for the purpose of delivering oxygen to tissues in exchange for carbon dioxide. The centers for the motor engram of breathing are located in parts of the brain stem, the medulla oblongata and the pons and are under the control of the autonomic nervous system. More specifically, these centers are referred to as the pneumotaxic center, the apneaustic center, and the dorsal and ventral respiratory groups. Breathing, although essential for living, can be detrimental to the spine if the motor engram for breathing is dysfunctional. Alterations in the motor engram for breathing may occur as a result of pain, poor posture, poor nutrition, stress, or anxiety. In the presence of breathing pattern dysfunction in patients with spine pain, rehabilitation of the spine, upper or lower quadrants alone may be unsuccessful or short lived unless the breathing pattern is also normalized.

A MISSING LINK IN SPINAL REHABILITATION

Clinicians involved in spine rehabilitation are well aware of the presence of overactive and/or shortened muscles, weak or inhibited muscles, altered motor control, and decreased muscular endurance in spine pain patients. Clinicians who are thinking outside the box realize that the site of pain may not be the cause of pain and will perform a functional examination of the entire upper and lower quadrants, in addition to the spine, to uncover a weak link to be targeted in the rehabilitation program. An overlooked component of the functional examination may be the assessment of breathing patterns.

A normal breathing pattern is essential for the maintenance of spine stability. Inherently, the rehabilitation of dysfunctional breathing patterns is paramount in spine rehabilitation. Assessment of breathing patterns is quick and easy and can be achieved in a relatively short period of time, starting from the initial subjective examination of the patient. The information gained from assessing breathing patterns is invaluable and could play a major role in the rehabilitation of spine pain patients.

THE RELATIONSHIP BETWEEN BREATHING AND SPINAL STABILIZATION

The diaphragm, scalenes, transverse abdominis, pelvic floor and deep intrinsic spinal muscles are among the primary muscles of breathing. The sternocleidomastoid and upper trapezius are accessory muscles that get recruited when respiration demands are increased. The latissimus dorsi, pectoralis major and pectoralis minor are not typically thought of as accessory muscles of breathing, but may be recruited in the faulty movement pattern of paradoxical breathing (the abdomen moves in on inspiration and out on expiration).

A complex interplay exists between the diaphragm, transverse abdominis and pelvic floor during normal quiet breathing. During normal quiet inhalation the diaphragm contracts and descends towards the abdomen. This causes a decrease in intra-pleural pressure and increase in intra-abdominal pressure. The increased intra-abdominal pressure causes an outward expansion of the abdomen. The transverse abdominis and pelvic floor work synergistically with diaphragm to increase intra-abdominal pressure. As the diaphragm continues to contract and descend, its attachment to the lower ribs causes the lower ribs to begin to expand horizontally. The horizontal expansion of the ribs proceeds rostrally, providing a gentle mobilization to the spine and ribs at every level. A dysfunctional breathing pattern existed when there is decreased, asymmetrical or absent lateral rib excursion. This is indicative of an inhibited diaphragm. As a result, normal rib and spine motion is lost and spine stabilization is compromised. Recurrent or chronic thoracolumbar pain may be the end result of an inhibited diagram in this example of dysfunction.

The scalenes play a crucial role in stabilizing the rib cage during inhalation. The scalenes were once thought to be an accessory muscle of breathing. It is now understood that they are active at a low level with every breath. As intra-pleural pressure decreases, the scalenes along with the parasternal muscles contract to prevent inward movement of the upper ribs during inhalation. This creates a horizontal expansion of the upper ribs and sternum. The dysfunctional breathing pattern of chest breathing (vertical elevation of the upper ribs, sternum, or clavicles) is indicative of over activity of the upper trapezius, scalenes, and/or levator scapulae. If chronic, deep supraclavicular grooves may be observed. This dysfunctional breathing pattern may be a cause of repetitive stress and overload to pain sensitive structure of the cervical spine. Also, vertical elevation the rib cage may cause thoracolumbar pain due to repetitive hyperextension of the thoracolumbar junction that occurs as the rib cage is vertically elevated with each breath. Normal quiet exhalation is the exact opposite and involves passive elastic recoil of the ribs, lungs and abdomen. A dysfunctional breathing pattern during exhalation exists if breath holding occurs and air is not fully exhaled or paradoxical breathing occurs.

EVALUATION OF BREATHING PATTERN DYSFUNCTION

As previously stated, evaluation of breathing pattern dysfunction begins during the subjective examination of the patient. It is essential to avoid informing the patient that his or her breathing pattern is being assessed. This may alter the patient’s stereotypical motor engram for breathing and give the clinician a false positive. Simple observations such as frequent yawning, rapid or labored breathing, nasal flaring, mouth breathing, tension in the face lips or jaw, shoulder elevation on inspiration, and altered respiratory rate are indications that a dysfunctional breathing pattern may be present. In addition, the presence of deep supraclavicular grooves, gothic shoulders, upper or lower cross syndrome, thoracolumbar hypertonicity are all compensations that may occur in the presence of a dysfunctional breathing pattern. Formal assessment of the breathing pattern should be performed in the standing, seated and supine position.

The following is a list of key findings indicative of a dysfunctional breathing pattern:

1. Breathing is initiated in the chest during inhalation
2. Chest breathing predominates over abdominal breathing during inhalation. This finding is best assessed in the supine position, as the postural role of the abdominal muscles is eliminated. Chest breathing can be assessed visually or manually by the clinician placing one hand on the chest of the patient and one hand on the abdomen of the patient during normal quiet breathing. Alternatively, the clinician can ask the patient to place his or her hands on the chest and abdomen as previously described while the clinician observes the breathing pattern
3. Decreased, absence or asymmetrical lateral excursion of the lower ribs. This finding is best assessed in the seated position. The clinician stands behind the patient and places his or her hands on the lateral borders of the lower ribs of the patient during normal quite breathing.
4. Vertical elevation of the upper rib cage, sternum, and/or clavicles during inhalation
5. Paradoxical breathing

One or more of these findings may be present. In addition to assessment in the standing, seated and supine positions, it is also important to observe the patient’s breathing pattern during manual muscle testing or during a functional movement (such as the overhead squat). A patient may display a normal pattern of breathing when assessed standing, seated and supine, however, when a patient is presented with a challenge the aberrant breathing pattern may be revealed.

REHABILITATION OF BREATHING PATTERN DYSFUNCTION

Besides poor posture, stress, anxiety, or poor nutrition, breathing pattern dysfunction can result from sinister pathology. If breathing pattern dysfunction is found, the clinician must first rule out underlying pathology contributing to the etiology of the dysfunction. If an underlying pathology is suspected, a referral to the appropriate specialist must be made before beginning breathing pattern rehabilitation.

Once underlying pathology is ruled out, breathing pattern rehabilitation may begin. The following is a suggested protocol for breathing pattern rehabilitation:

1. Educate the patient on the relationship between an altered breathing pattern and repetitive stress and strain to the spine.
2. Suggest spine sparing strategies such as the Brugger relief position and McGill’s overhead reach to improve posture and facilitate normal breathing mechanics.
3. Allow the patient to experience his or her breathing dysfunction. This can be done by having the patient observe his or her breathing in a mirror and by having the patient manually palpate the dysfunctional pattern of chest breathing, aberrant lateral rib excursion, and/or vertical deviation of the upper ribs, sternum or clavicles.
4. Provide a visual demonstration of normal breathing mechanics. This can be demonstrated fairly easily and effectively with a balloon. Emphasize to the patient that as air enters the balloon, expansion of the balloon begins from the bottom and proceeds upward as the balloon expands from both front to back and side to side. Also, if possible, demonstrate the anatomy of the spine and ribs on a skeleton to re-enforce the anatomy involved in the process of breathing that was described during the balloon demonstration. This allows the patient to visualize what the lungs and rib cage should be doing during normal breathing and provides the patient with an improved and accurate cortical representation of normal breathing mechanics. Visualization is an invaluable tool in rehabilitation.
5. Retrain the dysfunctional breathing pattern. One or more of the key findings associated with a dysfunctional breathing pattern may have been identified in the assessment. Each of findings may initially require separate rehabilitation and then must be integrated together into a normal breathing pattern. Techniques can be used to help to facilitate the diaphragm and lateral rib excursion.
   • If chest breathing initiates or predominates during inhalation: place the patient in the supine position with feet flat on the table, with 45 degrees of hip flexion and 90 degrees of knee flexion. Instruct the patient to place both hands on the abdomen. As the patient inhales, instruct the patient to exert a slight pressure on the abdomen with both hands. As the patient exhales, instruct the patient to relax the pressure on the abdomen.
   • If there is a decrease, asymmetrical or absence of lateral rib excursion during inspiration: place the patient in the supine position with feet flat on the table, with 45 degrees of hip flexion and 90 degrees of knee flexion. Instruct the patient to place both hands on the lateral border of the lower ribs. As the patient inhales, instruct the patient to exert a slight pressure on the lateral border of the lower ribs with both hands. As the patient exhales, instruct the patient to relax the pressure on the lateral border of the lower ribs. This can also be accomplished by tying elastic tubing around the lateral border of the lower ribs.
   • If vertical elevation of the upper ribs, sternum, and/or clavicles is present during inhalation: place the patient in the supine position with feet flat on the table, with 45 degrees of hip flexion and 90 degrees of knee flexion. The patient is then instructed to place both hands behind the head interlocking the fingers with 90 degrees of shoulder abduction and external rotation. If in addition to vertical elevation of the upper ribs, sternum, and clavicle, chest breathing and/or altered lateral rib excursion is also present, the clinician may then manually facilitate the diaphragm and/or lateral rib excursion using the same instructions described above.
6. Once a normal pattern of breathing is established, the next step is to focus on the breathing rhythm. Initially, instruct the patient to gradually increase the length of exhalation relative to inhalation. The patient can be instructed to exhale with pursed lips (visualize blowing out of straw) to decrease exhalation time. An ideal goal is to achieve 3 seconds of inhalation followed by 6 seconds exhalation (1:2 ratio) during breathing pattern rehabilitation.
7. Practice the normal breathing pattern and rhythm in a seated, then standing position. Eventually, integrate the new breathing pattern while performing spinal stabilization exercises.
8. Prescribe home breathing exercises for the patient. Have the patient perform 2-3 breaths every hour the patient is awake and 10-20 breaths upon awakening in the morning and before bed. Instruct the patient to perform the breaths with the newly learned pattern of breathing along with the 1:2 ration of inhalation to exhalation as previously described. Instruct the patient to stop the exercises if they feel weakness, dizziness or light headedness.

CONCLUSION

The importance of rehabilitating breathing pattern dysfunction to aid in the rehabilitation and restoration of spine stability cannot be overstated. The same muscles that are weakened, inhibited or facilitated in spine pain patients can become dysfunctional if a patient’s breathing pattern is dysfunctional. Spine pain can lead to changes in the breathing pattern of the patient, conversely altered breathing patterns can cause a repetitive stress and overload to pain sensitive structure in the spine. In the presence of breathing pattern dysfunction in spine pain patients, rehabilitation of the spine, upper or lower quadrants alone may be unsuccessful or short lived unless the breathing pattern is also rehabilitated and normalized.

REFERENCES

1. Liebenson C. Rehabilitation of the Spine: A Practitioner’s Manual, (2ed). Lippincott, Williams and Wilkins, Baltimore, 2007.
2. Page P., Frank, C., Lardner, R. Assessment and Treatment of Muscle Imbalance: The Janda Approach. Human Kinetics, 2010
3. Standaert, C., Weinstein, S., Rumpeltes, J. Evidence informed management of chronic low back pain with lumbar stabilization exercise. Spine J 2008;8: 114-120
4. Muscle dysfunction in cervical spine pain: Implications for assessment and management, JOSPT 2009;29:324-333
5. De Troyer A, Estennne M. Coordination between rib cage muscles and diaphragm during quiet breathing in humans. J Appl Physiol 1984; 57:899.
6. De Troyer A, Estennne M. Functional Anatomy of the Respiratory Muscles. In: Belmen M, ed. Respiratory Muscles: Function in Health and Disease. Philadelphia: WB Saunders, 1985:175-195.
7. Hruska J. Influences of dysfunctional respiratory mechanics on orofacial pain. J. Orofacial Pain Related Dis 1997; 41:21-27.

by George K. Petruska DC, DACRB

Abstract

Often many health care providers perform orthopedic and neurological testing without functional assessment. In depth assessment of acute and chronic conditions is paramount to forming an accurate diagnosis. Complete assessment is equally important in designing an effective treatment plan. Accurate assessment and an effective treatment plan enhance the chances of a favorable outcome.

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December 17, 2011

123Rehab Schedule – Fall 2011

David D. Juehring DC, DACRB
Associate Professor, Director Palmer Chiropractic Rehabilitation and Sports Injury Department, Palmer College of Chiropractic

Palmer College of Chiropractic
1000 Brady Street
Davenport, IA 52803

Corresponding author:
David D. Juehring, DC, DACRB
Juehring_d@palmer.edu
Palmer College of Chiropractic
1000 Brady Street Davenport, IA 52803
563-884-5455
(fax) 563-884-5865

Abstract:

Introduction: A role delineation process was used to develop content, validate knowledge, and skills statements needed for competencies used by the American Chiropractic Rehabilitation Board for diplomat certification examinations.

Methods: Three phases were used in the process of completion of the role delineation. The first phase contains the initial development, evaluation of domains, tasks, knowledge, and skill statements by a 7-member role delineation expert panel. In the next phase, a representative sample of professionals (in the field of chiropractic rehabilitation) utilize Cronbach’s alpha. Finally, the third phase contains the development of test specifications based on the domains, tasks, knowledge, and skills statements.

Results: This role delineation was shown to be a valid study with all its’ reliability coefficients scores which are strong within the domains; all domains exceed the critical value of 0.7 for importance, criticality and frequency.

Conclusion: Compared to the DACRBs sample, the work of the expert panel is shown to be valid. This valid role delineation study allows a new, defensible, and content outline with testing percentages to be used by the ACRB. This is used for implementation to Rehabilitation Diplomat programs and Rehabilitation Residencies.

Keywords: role delineation, validation, domain

Introduction:

Before a content-valid examination is developed, knowledge and skills must be determined by professionals in a respective field. The process for identifying these competencies is through a role delineation, which serves as a blueprint for examination development. A role delineation is helpful in determining the content, and type of examination along with the development of a percentage breakdown in order to assess competency. Certain logically sound and legally defensible procedures for developing examinations must be followed (Standards for Educational and Psychological Testing 1999). The critical reason for conducting a role delineation study is to ensure that an examination is content-valid. Content validity is the most commonly applied and accepted validation strategy utilized in establishing certification programs (Rykiel 1996). In psychometric terms, validation is the way a test developer documents the competence inferred from a test score, which is actually measured by the examination. A content-valid examination appropriately evaluates knowledge, or skills required to function as a competent practitioner in the field. A content-valid examination contains a representative sample of items that measure the knowledge, or skills contained in the profession/group being tested. Currently, the American Chiropractic Rehabilitation Board (ACRB) is the major credentialing organization in the Chiropractic profession; they are responsible for overseeing programs and quality assurance by testing competence for the Diplomat American Chiropractic Rehabilitation Board (DACRB) credentials. The Board ensures competence, professionalism in the field of chiropractic rehabilitation, and provides assurance that the certified practitioners have met the specific criteria designed; a set standard on examinations is used to affirm their adequacy. Thus, the role delineation study is an integral part of ensuring that an examination is content-valid. In essence, the aspects of the profession covered on the examination, reflect the tasks performed in practice settings. For both broad content areas and tasks, the study identifies their importance, criticality, and frequency. These ratings play an important role in determining the content of the examination. This role delineation was performed to verify that knowledge, and skill statement (along with percentage breaks of these competencies) was content-valid for the ACRB.

Methods:

This role delineation study consisted of the following 3 phases, which are the focus of this report:

1. Initial Development and Evaluation. The 7-member role delineation panel was assembled by a project chair. Then the panel was given the assignment to identify the domains, tasks, knowledge, and skills essential for a chiropractor to perform the most effective clinical rehabilitation. A Delphi approach was used to gather data from the panel (Rowe 1999). This material was then evaluated by the group based on importance, criticality and frequency.
2. Validation Study. A representative sample of professionals in the field of chiropractic rehabilitation (attendees of the General Assembly meeting at the 2008 National Chiropractic Rehabilitation Convention) reviewed the above domains, tasks, knowledge, and skills statements; they validated the work of the panel again based on importance, criticality and frequency. Reliability was measured utilizing Cronbach’s alpha.
3. Development of Test Specifications. Based on the ratings gathered from the above mentioned representative sample, the test specifications for the certification examination were developed.

Results:

Phase One – Initial Development and Evaluation:

The initial steps in the role delineation were the identification of first, the major content areas or domains, secondly, the listing of tasks performed under each domain, and finally, the identification of the knowledge and skills associated with each task. This phase was accomplished by the work by an expert panel. An ACRB elected project chair assembled the panel based on the recommendations of chiropractic rehabilitation diplomat administrators from Southern California University of Health Sciences (SCU), the Chiropractic Rehabilitation Association (CRA), National University of Health Sciences (NUH), American Chiropractic Educational Systems (ACES) and the recommendations of the ACRB along with various major authors within chiropractic rehabilitation. The panel members represented a variety of practice settings, geographic regions and gender as well as being assembled of ACRB members, SCU and CRA instructors along with a layman familiar with rehabilitation in a chiropractic setting. The following steps were undertaken to complete Phase I:

1. The above panel was posed with the question, “What knowledge and skills does it take for a chiropractor to perform the most effective clinical rehabilitation?” ¹ The panel through numerous blinded e-mail correspondences determined that the topic area of chiropractic rehabilitation could be divided into 2 major content areas or performance domains. These performance domains were as followed:
   1. Assessment
   2. Patient Care/Management
2. Next, the panel broke down each of the domains into task statements. Thirteen tasks were developed for the Assessment domain, and 21 tasks were developed for the Patient Care/Management domain. The panel subsequently took each task statement; they broke the statements into knowledge, and skills requirements needed to perform each task. Varying numbers of knowledge and skill requirements were developed for each task statement within the respective domain.
3. Last, the panel rated each domain and task statement within the domain, on importance, criticality, and frequency. They defined Importance as the degree to which knowledge in the domain and each task is essential in the overall job performance as a chiropractor performing rehabilitation. Criticality was defined as the degree to which the inability to perform the domain and each task in each domain would be seen as causing harm to a patient, the rehabilitation DC, the public, etc. “Harm” may be physical, emotional, financial, etc. Frequency was defined as the percent of total case time within the specific domain, and task within the domain, spent performing rehabilitative duties associated with an average rehabilitative case. With all three ratings, domains were first rated relative to the other domains, and then on completion of this requirement each task was rated relative to other tasks exclusive to the specific domain².
   This phase of the role delineation was accomplished via numerous guided e-mails by the project chair. Based on this phase of the role delineation panel, the project chair developed an 18-page survey ³.

Phase Two – Validation Study:

The 18-page questionnaire was distributed to and completed by a representative sample of professionals in the field of chiropractic rehabilitation for evaluation. The questionnaire gave feedback on the role delineation expert panel’s domain, and task statements. Next, the sample group rated each aspect of the domains and tasks based on importance, criticality, and frequency. The survey was distributed to the attendees of the General Assembly meeting at the 2008 National Chiropractic Rehabilitation Convention in Las Vegas NV. The survey was distributed to 52 attendees with the requirement for a return of the survey within at least thirty days. Of the 52 questionnaires distributed, 34 (65.4%) usable responses were returned within the cut-off period. Biographical information was also solicited on the survey in order to ensure a representative response and completion by appropriately qualified individuals. The majority of respondents (29 or 85.3%) are male, with 5 (14.7%) female. The average age was 46.5 with a range of 34 to 64. The most common state represented in the survey was Pennsylvania with 13 (38.2%) respondents followed by Ohio with 4 (11.8%), Minnesota 3 (8.8%), California 3 (8.8%), Washington 2 (5.9%) and 1 (2.9%) for New Jersey, Maryland, Texas, Nevada, North Carolina, Missouri, South Dakota, Oregon and Arkansas. Note: due to rounding error the state total is 99.6%. Continuing education program sponsors for DACRB certification programs represented in the study was SCU, CRA, ACES, Palmer Chiropractic College and Canadian Memorial Chiropractic College⁴.

The reliability of the respondents’ results of the survey was assessed relative to the panel’s results in order to determine how well the tasks consistently measured the domain of question. Reliability refers to the degree to which tests or surveys are free from measurement error. Reliability was measured by internal consistency via Cronbach’s alpha (Reynaldo 1999) using the respondent’s ratings of importance, criticality, and frequency for each domain in order to draw defensible conclusions. Cronbach’s alpha can be written as a function of the number of test items, and the average inter-correlation among the items. Below, for conceptual purposes, we show the formula for the standardized Cronbach’s alpha:

Here it states that N is equal to the number of items, c-bar is the average inter-item covariance among the items, and v-bar equals the average variance. Calculations were performed on an Excel spreadsheet for all domains and tasks within the domains. Only the calculation of the Assessment Domain Frequency was shown⁵ and all other calculation results are listed in the below Reliability Table. Reliability coefficients can be low, when the pattern of respondents to a particular task in a domain is different from the pattern of respondents to the other tasks in the domain. This calculates the extent to which each task rating within each domain consistently measures what other tasks within that domain measure. Reliability coefficients range from 0 to 1 and should be above 0.7 to be judged as adequate (Reynaldo 1999). Reliability values below 0.7 indicate an unacceptable amount of measurement error (Reynaldo 1999). As shown below, the reliability statistics are strong since all domains exceed the critical value of 0.7.

RELIABILITY TABLE
Domain	Importance	Criticality	Frequency
I. Assessment	0.79	0.83	0.89
II. Patient Care/Management	0.93	0.95	0.96

Phase Three – Development of Test Specifications:

The final phase of the role delineation study was the development of test specifications. These identify the proportion of questions from each domain and task and appear on the DACRB examinations. Test specifications are developed by combining the overall evaluations of importance, criticality, frequency, and the converting of the results into percentages. These percentages are listed below; they are used to determine the number of questions related to each domain and task that should appear on examinations.

Domain	Test Blueprint % of Test
I. Assessment 19 %	II. Patient Care/Management 81 %

The results of the Test Percentage Specific Document⁶ were forward to the ACRB to ultimately be distributed to the diplomat certification programs as content guidelines for their education programs.

Conclusion:

The expert panels’ content and outline are valid compared to the sample DACRBs, including the testing breakdowns. The results of this role delineation study were determined to be valid. The new content outline and testing percentages were forwarded to the ACRB for implementation to Rehabilitation Diplomat programs and Rehabilitation Residencies. Each reliability rating for importance, criticality, and frequency were all based on Cronbach’s alpha. Therefore the domains, tasks, knowledge, and skills developed by the role delineation panel constitute an accurate definition of the work of the credentialed DACRB.

References:

1. Reynaldo J, Santos A 1999 Cronbach’s Alpha: a tool for assessing the reliability of scales. Journal of Extension 37(2)
2. Rowe G, Wright G 1999 The Delphi technique as a forecasting tool: issues and analysis. International Journal of Forecasting 15(4):353-375
3. Rykiel EJ 1996 Testing ecological models: meaning of validation. Ecological Modeling, 90:229-244
4. Standards for Educational and Psychological Testing published by the American Educational Research Association, 1999
5. 
6. 

 

Dr. Jeffrey Tucker
11600 Wilshire Blvd. 3412
Los Angeles, CA 90025
310-473-2911
DrJeffreyTucker.com

Julie is in her junior-year in high school and is a club team soccer player. She came to see me on a Monday afternoon complaining of left-sided frequent mild to moderate patellofemoral pain as well as some distal IT band pain and tightness. Her last match was on Saturday. She fell on the outside of her left knee, when she collided with another player. Her evaluation did not show any ligament laxity in her main knee ligaments (MCL, LCL, ACL, and PCL), nor did she exhibit signs of meniscus involvement. Past history included experiencing Osgood Schlatter’s condition in her left knee early in her freshman year of high school while playing soccer. She had a physical therapist provide treatment for the Osgood Schlatter during and after her freshmen soccer season.

The patient complained of plus 2-3 tenderness and soreness upon palpation of her infra-patellar tendon, and along the bony deposit (bump) on her tibial tuberosity (this was more uncomfortable to palpation than the infrapatellar tendon). She felt tenderness with palpation around the medial aspect of her patellofemoral joint.

After performing knee range of motion and standard orthopedic tests, I performed functional movement tests. Julie was unable to perform a one-legged bridge using her gluteus maximus, without overactivity of her hamstrings and loss of pelvis position.

Next, I asked Julie to perform the Thomas Test. The psoas was tight and this will inhibit the gluteus maximus. To test the strength of the psoas muscle, I had Julie sit at the edge of the examining table with both feet lightly touching the floor and control the natural lumbar arch (neutral posture) as she lifted and held her bent leg in flexion past 90 degrees (I said “just lift your knee up past 90 degrees”). She was unable to hold the leg even slightly off the floor without slumping in her low back. This indicates weakness of the psoas. One way to strengthen a weak psoas is by bringing your knee above 90 degrees. Sit with your knees bent on a low box or bench (6 to 10 inches high). Maintaining good posture and keeping your abs tight, use your hips to raise one bent knee slightly higher than your hips. If you lean forward or backward, you’re not performing the exercise correctly. I had Julie hold it for10 seconds, and return to the starting position. She was instructed to complete 3 sets of 5 repetitions per leg.

Next I watched Julie perform the hands held Overhead Squat movement assessment. Her overhead squat assessment displayed excessive torso forward lean, toes rotating outward, and slight knee valgus. Her single leg squat assessment showed knee valgus and foot flattening. During her passive ROM assessment there was significant lack of dorsiflexion in both ankles. She exhibited tibial internal rotation during passive dorsiflexion.

I suggest that as practitioners we always assess tibial alignment in three positions: 1) weight bearing static posture, noting rotation; 2) non-weight bearing passive tibial rotation when the ankle is dorsiflexed; and 3) weight bearing tibial rotation during active motion during the squat. During the overhead squat motion analysis and passive analysis, I look at the tibia and measure by the direction in which the tibial tuberosity faces relative to the patella and relative to the second toe with the foot in neutral alignment. This patient’s tibia rotated medially on passive motion. I manually tested the muscle strength of the medial versus lateral hamstrings. The semitendinosus and semimembranosus tested tight but weak. This suggests performing manual stretching and fascial release work to the semitendinosus and semimembranosus. I found the best results when I worked the tissue toward the knee. The short head of the biceps femoris was also tight and needed to be worked away from the knee. I think it is important to consider the direction of movement that you do when performing fascial therapy.

Running, cutting, and jumping were all activities that increased Julie’s knee symptoms. When I analysed Julie’s running posture on a follow-up visit she was very flexed at the hip, almost leaning over at about a 20-25 degree angle. This correlates with the weak glut max and tight/weak psoas.

Sarcevic (2008) did a study in regards to the relationship between limitations in ankle dorsiflexion and the occurence of Morbus Osgood Schlatter in children that were participating in athletic activities. He studied 45 children, all of whom were clinically diagnosed with Morbus Osgood Schlatter (MOS). Forty subjects were boys coming ages ranging from 11-14 years of age, and 5 subjects were girls, ages ranging from 10-12 years of age.

Sarcevic defines MOS as a “traction apophysitis of the tibial tubercle caused by repetitive strain, as well as a chronic avulsion of the secondary ossification center.” Many practitioners attribute the main cause of MOS to a strong, chronic pull of the quadriceps during athletic activities. The presence of inflexbility of the hamstrings and quadriceps is a common finding. Strategies for corrective exercise intervention included focusing on the thigh musculature (quads and hamstrings) and improving ankle dorsiflexion.

The results of the Sarcevic study showed that 37 of the 40 boys studied exhibited a dorsiflexion angle (DFA) of 10 ° or less, and 3 had a DFA of 10° or more. All of the 5 girls that participated in the study exhibited a DFA of 10° or less (Sarcevic, 2008). The quadriceps muscle group eccentrically decelerates the lower leg during the stance/ support phase of the running gait. Limitations in ankle dorsiflexion have been associated with pronation of the foot, internal rotation of the tibia, as well as an increase in knee flexion (Sarcevic, 2008). The lack of dorsiflexion in Julie’s ankle probably contributed to  the torso lean during the overhead squat and her running gait. The combination of these motion disturbances and the presence of limitations in ankle dorsiflexion may create an increase in shear stress on the quadriceps tendon/ patellar tendon during the act of running. Limitations in dorsiflexion can be attributed to overactivity in the gastroc /soleus complex, and movement compensations are observed during the overhead squat as well as the single leg squat assessments. The correlation that Sarcevic is making between limited dorsiflexion and the presence of MOS can lead the practitioner to identify and address overactivity in the gastroc/soleus complex (inhibit and lengthen) as a possible way to proceed in designing a corrective exercise strategy. Self Myofascial Release (foam rolling) and lengthening techniques of static stretching and PNF can be useful tools in this situation (Clark and Lucett, 2011). This reinforces the concept that conditions such as Morbus Osgood Schlatter should not only focus on a localized area , but address dysfunction affecting the entire kinetic chain.

TREATMENT

Initial treatment focused on relieving the pain around the patella, using warm laser. I did soft tissue/fascial therapy to the quads, hamstrings, gastrocsoleus, and psoas. I performed mobilization to the ankle joint to increase dorsiflexion. I had Julie perform foam rolling to the overactive calfs, and stretch the quads and hamstrings. I got her to perform one-legged bridges to increase glute max strength. I felt that she was overusing her quads as a consequence of poor hip flexion. Julie’s symptoms eased up quickly once we restored ankle dorsiflexion and she could recruit her stabilizing muscles. I encouraged her to continue her exercises for eight weeks so she could fully incorporate the muscular recruitment patterns into her soccer play.

Clark, M., and Lucett, S. NASM Essentials of Corrective Exercise. (2011) Lippincott Wiliiams and Wilkins. Baltimore, MD.

Sarcevic, Z. Limited Ankle Dorsiflexion: a predisposing factor to Morbus Osgood Schlatter? (2008) Knee Surgery, Sports Traumatology, Arthroscopy. 6: 726-728

Author, Scott Schreiber, DC, DACRB, MS, Cert. MDT, CKTP, CNS

Authored, September 8, 2009

Peer reviewed by the American Chiropractic Rehabilitation Board

 

Introduction

There have been a growing number of chiropractic physicians that have been treating patients after surgical procedures.  After reviewing the literature, there have been no studies involving Chiropractic Management of multilevel post surgical fusion.  In fact, a review of the literature was very sparse, only a handful of case studies pertaining to chiropractic management of post surgical cases.  Cases reported include wrist rehabilitation ⁽¹⁾, post surgical neck ⁽²⁾, post surgical disk herniation ⁽³⁾, Achilles tendon rupture ⁽⁴⁾, failed back surgery ⁽⁵⁾, sacroiliac syndrome ⁽⁶⁾, and calceanal exostectomy ⁽⁷⁾.

There have been many reported complications of spinal fusion surgery ⁽⁸⁾.  They include in hospital mortality, deep infection, superficial infection, deep vein thrombosis, pulmonary embolus, neural injury, donor site complications, graft extrusion, instrumentation failure and other myocardial infarction, urinary tract infections, respiratory complications, gastrointestinal, transfusion reactions, peripheral vascular complications, accidental cut or puncture during the procedure ⁽⁹⁾. Reactions to anesthesia and comorbid conditions also need to be considered ⁽⁸⁾.

There have not been any indications established for spinal fusion surgery. However, fusion has been performed in patients with spinal stenosis, degenerative disk disease, disk herniation, unstable spine (8), and significant nerve root compression ⁽¹⁰⁾. According to Bederman et. al., there exists no clear consensus on the ideal management for these patients despite overall improvement with surgical management.

The incidence of surgeries has increased ⁽¹⁰⁾, but there also has been an increase in the number of failed back surgeries ⁽¹⁰⁾.  Information regarding chiropractic management of these failed back surgeries is sparse; however, there have been several suggested reasons why surgeries fail. These include iatrogenic changes, the original diagnosis was wrong; there was little or no rehabilitative effort after the procedure ⁽⁵⁾. In addition, Chiropractic management can occur when no other surgery is warranted.  This will include physical therapy to reduce pain, remove myofascial trigger points and restore mobility and finally increase strength and aerobic capacity. It will also include work hardening and educational programs directed toward pain management and disability ⁽⁵⁾.

The role of Chiropractic manipulation is not certain as described in the literature ^{(5, 11)}. The fusion regardless of instrumentation must be solid as shown on flexion/extension radiographs.  Healing depends on the patient but usually takes three to five months ⁽¹¹⁾.

Case Report

Physical Examination

A thirty year-old African American presented with lower back pain and right sided sciatica following an L3-S1 laminotomy, foraminotomy, and decompression with instrumentation.  Before the surgery, she completed a course of Chiropractic manipulative therapy and rehabilitation, as well as interventional pain management.

Vital Signs performed included Ht, 66in, Wt 213lbs, Oral temperature 98.7°F, Blood Pressure 104/70, Pulse 75 BPM, and Respiration at 15 RPM.

The revised oswestry low back pain disability index was given and disability index was 58%. Par-Q was also given and the patient was given clearance for rehab despite initial hesitation.

Upon Physical examination, Patient presented alert and orientated to person, place, and time.  The patient stated that she was depressed, agitated and angry due to the complications after surgery. Range of motion was difficult to measure due to the degree of the patient’s pain.  Observed was a six inch surgical scar midline. Upon palpation tenderness and tightness was palpated along the lumbosacral erector spinae with joint dysfunction above and below the surgical fusion.  Straight leg testing revealed pain and tight hamstrings bilaterally at 20°.  Quadriceps tightness and lower back pain was observed bilaterally on Nicholas’ test.  Gainslens’s, Yeoman’s, and Patrick’s Test were all positive for low back pain and leg pain. Gait was antalgic and guarded.

Neurologic Examination

Cranial nerves, cerebellar function, coordination were all intact. Muscle strength testing of the right psoas, rectus femoris, quadriceps, hamstrings, gastronemius, soleus and peroneus muscles tested at grade 3 when compared to the left which tested at grade 5. Deep tendon reflexes 1+ bilaterally for patella and Achilles reflexes. Sensory testing of pain and light touch revealed increased sensation to the entire right leg when compared to the left leg, which was within normal limits.

Functional Examination

At time of initial examination, a functional examination was not able to be performed due to the patient’s acute symptoms, however, will be performed when the acute symptoms resolve.

Treatment Plan

Initial treatment consisted of posture and proper lifting instruction as well as hip hinge advice. Abdominal breathing exercises and initial core strengthening consisting abdominal bracing were done in a sitting position due to the patient’s discomfort in the prone position.  Also, proprioceptive balance training was used.  It consisted of one-legged standing in a door way with shoes off.  Additionally, the patient was given a lumbar roll and educated on maintaining a neutral spine. The patient felt relief of symptoms on the first day.  During the first week, the abdominal bracing and abdominal breathing were progressed to sitting on a physioball.  The patient was instructed to perform these exercises several times per day at home.

After the first week, the patient felt a decrease in leg pain; however, the low back pain was still present.  Her gait and activities of daily living improved. At that point, higher level core strengthening exercises including side bridges with bent legs and bridges on back. The patient was instructed to perform the exercises using the abdominal brace combined with abdominal breathing.  McKenzie examination was performed and upon repeated extension it was observed to centralize leg pain.  Prone pressups were prescribed ten repetitions every hour.  Proprioceptive treatment progressed to balance pad with eyes open.  At this point the patient still had trouble sleeping. The patient was instructed to add the new exercises to her home exercise program.

After two weeks of therapeutic exercises, Cox Flexion-distraction technique was added to address the joint dysfunction. Sleeping became easier.  Sciatic pain decreased and low back pain improved.  Activities of daily living improved.

At this point a functional examination was performed.  Testing included breathing observation, t-4 mobility test, squat, lunge, one leg standing, hip abduction, hip extension and sit to stand.  Results from the functional examination included chest breathing, improper squat and lunge mechanics, inhibited gluteus maximus and medius bilaterally and improper sit to stand mechanics. Treatment for the findings began immediately with basic gluteus medius and maximus retraining and progressing to squats and lunges.

At five weeks after the initiation of treatment, functional activities were added.  These included squats with physioball and lunges.  Balance pad proprioceptive exercises included increasing the resistance and rocker board exercises.  With McKenzie extension exercises, she was able to control her leg pain.  Low back pain was decreasing and Activities of daily living were consistently improving.

At seven weeks after initial treatment, functional training continued.  Side bridges were progressed to straight legs.  Lower back extensions on the Strive™ machine were added with the overload in a bell-shaped curve.  Cardiovascular training was added using a recumbent bicycle for ten minutes.  McKenzie extensions were now being used for prophylaxis with occasional progression of forces if needed.  Again, the patient added the new exercises to her home program.

Ten weeks included balance training on a Bosu™ ball walking lunges and core stabilization exercises. Manipulation of motion segments adjacent to the fusion was initiated.  The patient felt an immediate increase in range of motion after the manipulation was performed. Future manipulation was only considered if joint dysfunction was present.

At this point, a quantitative functional capacity examination was performed to determine functional deficits.  The patient results were below average for strength of the legs, low back extensors and side bridges.  Quadriceps femoris were still tight bilaterally.  A therapeutic exercise program consisting of side bridges, squats and lower back extension as well as quadriceps stretching was emphasized and progressed for one month upon re- evaluation.  McKenzie extension exercises were prescribed prophylactically.

Three months following initial presentation, the patient’s back pain reduced and sciatica was eliminated.  Sensation returned and the patient resumed all activities of daily living. She began exercising in a gym and was instructed to perform home exercises in addition to her strength program.  McKenzie exercises were to be done daily to prevent sciatic pain from returning.  The patient was discharged with instructions to return if her current status regressed.

Discussion

Therapeutic intervention involved a combination of rehabilitation protocols complicated by a multilevel surgical fusion. A combination of diaphragmatic breathing, abdominal bracing, proprioceptive balance exercises, and McKenzie protocol progressing to functional training were used. There was no one treatment that alone seemed to elicit symptom resolution.  The patient responded very well to treatment and was able to maintain her resolution of symptoms.

Manipulative therapy consisted of Cox Flexion-distraction and diversified manipulation but was used only PRN.  The role of high velocity–low amplitude manipulation in post surgical rehabilitation is not understood.  If a Chiropractic physician chooses to perform that modality, care should be taken and the fusion needs to be stabilized.  Mobilization or non-force technique should be used at first to determine if manipulation would be appropriate.

The outcome of this case is encouraging and the avoidance of repeated surgical intervention is also encouraging. Upon reviewing the case, the quantitative functional capacity exam should be performed sooner in the course of treatment. If radicular symptoms returned an MRI and a flexion/extension radiograph would have been ordered to determine stability of the lumbar spine and any adjacent disk degeneration.

Conclusion

This case provides supporting evidence determining the role of Chiropractic physicians in a multidisciplinary setting, particularly in the post surgical spinal fusion arena.  More research needs to be conducted to determine the role of the chiropractic physician in the care of post surgical fusion patient.

References

1)McDermott A. A Chiropractic Case Study in Post-Surgical Wrist Rehabilitation. J Can Chiropr Assoc. 2003:40(10):32-4.

2)Polkinghorn BS, Colloca CJ. Chiropractic Treatment of Postsurgical Neck Syndrome with Mechanical Force, Manually Assisted Short-Lever Spinal Adjustments. J Manipulative Physiol Ther. 2001:24(9):589-95.

3)Estadt GM. Chiropractic/Rehabilitative Management of Post-Surgical Disc Herniation: A Retrospective Case Report. J Chiropr Med. 2004:3(3):108-15.

4)Ramelli FD. Diagnosis, Management and Post-surgical Rehabilitation of an Achilles Tendon Rupture: A Case Report. J Can Chiropr Assoc 2003:47(4):261-8.

5)Walker BF. Failed Back Surgery Syndrome.Cosmig Rev.1992: 1(1):3-6.

6)Diakow PR, Cassidy JD, DeKorompay VL. Post-surgical Sacroiliac Syndrome. J Can Chiropr Assoc. 1983:27(1):19-21.

7)Kobsar B,Alcantra J.Poat-surgical Care of a Professional Ballet Dancer Following Calceanal Exostectomy and Debribement with Re-Attachment of the Left Achilles Tendon. J Can Chiropr Assoc.2009:53(1):17-22.

8)Turner JA et. al. Patient Outcomes After Spinal Fusions. J Am Med Assoc. 1992:268(7):907-11.

9)Deyo RD et. al. Morbidity and Mortality in Association with Operations on the Lumbar Spine. J Bone and Joint Surg. 1992:74-A(4):536-543.

10)Bederman et.al. The Who, What and When od Surgery for the Degeneative Lumbar Spine: A Population-Based Study of Surgeon Factors, Surgical Procedures, Recent Trends and Reopration Rates. Can J Surg.2009:52(4):283-90.

11)Triano JJ, McGregor M, Skogsburg DR. Use of Chiropractic Manipulation in Lumbar Rehabilitation. J Rehab Research and Development. 1997:34(4):394-404.

Author’s contact information:

Scott Schreiber, DC, DACRB, MS, Cert. MDT, CKTP, CNS
Delaware Back Pain & Sports Rehabilitation Centers

2600 Glasgow Ave, Suite 210
Newark, DE 19702

Robert M. Smith, D.C., DACRB

Key Learning Points:

• Compliance with home exercises is poor
• Knowledge of the patient’s exercise history is important
• The patient’s lifestyle and prognosis should guide prescription
• Doctor-Patient relationship can improve compliance
• Number, type and format of exercises influences motivation

ABSTRACT

Objectives: The vast majority of Doctors of Chiropractic (D.C.) use both in-office and at-home rehabilitation programs with their patients. The hypothesis is that many doctors have difficulty getting some patients to comply with their prescribed exercise programs. There is very little chiropractic literature regarding exercise compliance. The purpose of this study was to summarize current research on motivational strategies for improving patient compliance with prescribed exercise plans.

Methods: Searches were performed of online journal databases which did not require a subscription using keywords such as “exercise (compliance)”, “(non-)compliance”, “adherence”, “behavioral interventions”, “exercise (non)adherence”, “exercise motivation”, “home exercise program (compliance)”, “drop-out (research)” and “improving exercise compliance”. Articles were grouped according to type of strategy used (intrinsic or extrinsic), patient characteristics or condition, patient relationships and exercise prescription format.

Results: Only one article addressing this topic was found in the chiropractic literature, and this was used as a platform on which to add additional findings. No articles were found which summarized the variety of strategies addressed in the literature. A wide range of sources addressed this topic in limited ways, and these sources were organized in hopes of providing a basis for future study. A checklist was developed to summarize the best strategies.

Conclusions: A provider who gathers appropriate information regarding the patient’s exercise history and lifestyle, develops an exercise plan with the patient to improve symptoms, limitations or prognosis, and prescribes an appropriate amount and difficulty level of exercise with adequate descriptions and follow up, will improve the chances of success.

KEYWORDS

Key Indexing Terms: Physical Exercise, Patient Compliance, Rehabilitation, Motivation

INTRODUCTION

This article will focus on a basic question that Doctors of Chiropractic deal with on a daily basis: How can I motivate my patients to comply with their exercise plan? Chiropractors, especially those specializing in rehabilitation, confront a common scenario with patients: Time is spent during the initial visits analyzing a new patient’s weaknesses, asymmetries, deficiencies and tendencies as they relate to the presenting problem. An exercise or series of exercises is developed to address these deficiencies, and the chiropractor spends time demonstrating and reviewing these exercises with the patient. On proceeding visits, the patient is questioned as to how the exercises are going at home, how often they are being performed, and if any problems were encountered. Typical responses indicate that the patient has been too busy to practice, has forgotten, or simply didn’t do the exercises. During review of the exercises, the patient makes gross errors or is unable to recall exactly how to do them. The chiropractor gets frustrated as this interaction is repeated over several visits and precious time with other patients is lost. Eventually, doctor and patient may give up: the patient may discontinue care and seek other avenues of treatment, or the doctor may release the patient, refer the patient elsewhere for care, or simply continue satisfying the patient’s desire for passive care.

For the Doctor of Chiropractic, years of learned and applied knowledge and expertise in rehabilitation procedures are useless if the patient does not comply. However, there is a paucity of chiropractic literature on the subject of improving compliance. There is one article in the chiropractic literature which specifically addresses this topic; almost all noted references are found in the physical therapy literature. Even the Chiropractic Rehabilitation Diplomate program does not provide formal training in the area of compliance, although Leibenson’s second edition text does include a chapter on “Active Self-Care”, which incorporates a section on “Motivation Issues”¹. The purpose of this literature review is to consolidate and categorize documented motivational strategies that can be used by the busy clinician to improve compliance.

Between 96 and 98% of chiropractors provide exercise advice or instruction to their patients^2-3. However, studies estimating and defining compliance vary greatly, but generally show that long-term patient compliance with home exercises is poor, ranging from approximately 25-75%^4-10. This impacts the effectiveness of care by extending the duration of symptoms or slowing the rate of healing and progress. It is well-known and even assumed by the practitioner that compliance is poor, but many chiropractors lack the knowledge of how to improve compliance.

Most often, exercise instruction is in a format that can be performed at home, instead of in-office rehab^2-3. It is not economically feasible for most chiropractors to implement a full in-office rehab program due to limitations of time, insurance reimbursement, space or staffing. Most chiropractic offices are not set up to handle high volumes of rehab patients, because time is dedicated to other procedures such as evaluations, modalities or manipulation. Supervising therapeutic exercise is also a very time-intensive procedure and sometimes does not provide adequate reimbursement under many insurance plans. Rehab requires additional space, especially for high volumes, and most chiropractors have a majority of their office space dedicated to exam, treatment and administrative tasks. If a chiropractor does have adequate time and space to handle high volumes of rehabilitation patients, extra staff will be required to assist in patient flow and supervision.  These obstacles make supervised home exercise programs a valid compromise solution. It is noted that “…supervision of exercising is also a very time-intensive and expensive form of treatment. In these days of cost-awareness and health price competition chiropractors need to do everything possible to minimize the costs of such supervision, while still making sure that the time spent in designing an active program is not wasted. This balance of supervision and cost-effectiveness can be best achieved by regular monitoring of home exercise programs.”¹¹ For patients with ankle sprains, these results have been confirmed in a small randomized controlled trial.¹²

METHODS

Compliance Strategies

Compliance strategies can be divided into two basic groups: Intrinsic motivators and extrinsic motivators¹³. Intrinsic motivators are characteristics within the patient that would inhibit or enhance the patient’s desire to exercise. Based on a review of the literature on exercise compliance, sub-groups were created: patient characteristics and patient condition. (See Table 1) Intrinsic motivators can include patient characteristics such as attitude toward exercise, feelings of self-efficacy, chronological age, home life, and willingness to incorporate exercise into daily life. Other intrinsic motivators focus on the type of condition the patient suffers from, its severity and prognosis, and the level of disability and limitation it places on everyday life.
Extrinsic motivators are conditions existing outside of the patient which influence his or her desire to exercise. Extrinsic motivators include the basic groupings of Doctor-Patient relationship, social relationships, and presentation format. (See Table 1) The Doctor-Patient relationship can influence the patient’s loyalty to the doctor, his perception of barriers to improvement and his desire for feedback. The patient’s other social relationships can modify his enjoyment of home exercise and perception of social supports in the process of getting better. Finally, the way exercises are presented to the patient can have a large impact on his continuing level of motivation. Instructions can be given in any number of formats and follow-up strategies can be targeted to provide the proper balance of independence and doctor-driven motivation.

Table 1

Intrinsic Motivators	Extrinsic Motivators
Patient Characteristics • Exercise History • Self-Efficacy & Exercise Beliefs • Age and Lifestyle • Accommodating Exercise & Value of Treatment	Relationships • Doctor-Patient Relationship • Social Relationships
Patient Condition • Severity and Prognosis • Symptom Alleviation • Functional Limitations	Prescription Format • Goal-Setting • Number of Exercises & Visits • Presentation/Education • Follow-up

INTRINSIC MOTIVATORS: PATIENT CHARACTERISTICS

Exercise History

Patient characteristics should be taken into account when designing a rehab plan, which may lead to improved compliance. Although beyond the scope of this paper, it may be possible in the future to prescreen patients and identify characteristics that will improve compliance to rehabilitation programs. Two pilot studies have investigated the use of a short intake questionnaire or “exercise motivation index” to prescreen potential exercise compliance levels.^14-15 During the initial visits with the new patient, it is important to gain insight into the patient’s history of exercise involvement and rehabilitation from prior injuries, and how the patient felt about those experiences. The uniqueness of each patient will affect their ability and willingness to comply. In general, patients who have more positive exercise experiences and a belief in the benefits of exercise will have better compliance^{14, 16-17}. Reinforcement of the idea that exercise is critical to improvement should occur on each visit.

Self-Efficacy & Exercise Beliefs

Patients who have a sense of self-efficacy, a positive attitude and belief in the benefits of exercise will more likely comply with rehab assignments.^{14; 17-18} There are several practical ways to determine a patient’s level of self-efficacy in a busy office setting. The use of a “yellow flags” form filled out by the patient, or a yellow flags checklist evaluated by the doctor¹⁹, can provide advance warning to the practitioner of potential compliance problems. In addition, being alert to any comments a patient makes regarding “Fear Avoidance Beliefs”²⁰ can help the doctor focus on reinforcing the importance of rehabilitation and consistently providing motivation before non-compliance becomes a hindrance to care.

Age and Lifestyle

In developing a supervised home exercise plan for our patients, chiropractors should take into account their age and home life. In general, research indicates that patients who are younger will have lower levels of compliance.^21-22 Younger patients may tend to place a lower priority on exercise as a means of healing, or may simply be engaged in too many other activities (education, social activities, career advancement, childcare) to be able to accommodate exercise. Similarly, patients who have children at home will have more difficulty adhering to a home exercise plan.²¹ In taking a history of the patient and inquiring about their lifestyle and ADLs, it is common for patients to relate how busy they are or how they lack sufficient time to accomplish their daily tasks. In one study, among patients who are non-compliant with exercise, 80% cited “lack of time” or “too busy” as key reasons.²³ “It is suggested that particularly for middle-aged individuals, insistence on medically supervised exercise prescription and programming offers an unnecessary barrier to exercise adoption and compliance.”²⁴ Accounting for the patient’s commute, job demands and family & home responsibilities should be a key component in developing their supervised home exercise plans.

Accommodating Exercise and Treatment Value

Having knowledge of the patient’s outlook regarding treatment is also important. Again, referencing “Yellow Flags”, does the patient tend to have a “passive” mindset regarding treatment? Does she seem willing to accommodate exercise into her ADLs? Patients who place a priority on having a set schedule of exercise will have a better level of compliance than those who have no routine.16 Patients who continue to comply with exercises have a greater willingness and ability to accommodate exercises within everyday life.²⁵ A study of patient compliance with individualized rehabilitation programs revealed that those who exercised once a week or less often valued the significance of healthcare treatment less.²² It is important in developing a rehab plan with a patient to consider the priority they are placing on treatment and specifically, exercise.

INTRINSIC MOTIVATORS: PATIENT CONDITION

Severity and Prognosis

When designing a rehab program for a new patient, it is critically important for the practitioner to understand the severity of the condition, as well as understand the patient’s perception of their own condition and its severity. A number of intake forms are widely available and allow the chiropractor to understand the patient’s perceived severity of symptoms, which will influence the patient’s reasoning for continued compliance.²⁵ The use of an Oswestry Disability Index, Neck Disability index or Quadruple Visual Analog scale allows comparison between the practitioner’s and patient’s perception of the condition. A study of adults diagnosed with arthritis found that severity of disease differentiated exercisers from non-exercisers.¹⁷ Another research article summarized it best, “Results also showed that those who exercised once a week or less often valued the significance of healthcare treatment less, perceived higher pain intensity, presented a higher Oswestry score, worse general health (and) more pain locations”.²²

In addition to the severity of the condition, the prognosis is also a determining factor for exercise compliance. Simply put, “a bad prognosis is negatively related to compliance”.²⁶ This may be because the patient feels a degree of helplessness in the face of a chronic disease, or feels distressed about the lack of an available cure. When presenting the diagnosis and prognosis to the patient, it is important to focus the patient on the importance of rehabilitation as a means of ongoing management. The chiropractor can provide support by encouraging exercise to prevent relapses or exacerbations.

Symptom Alleviation

Rehabilitative exercises can help not only in the prevention of relapses, but can also provide short-term symptom relief. For example, chiropractic patients with radiculopathies can quickly learn the value of Mackenzie-based exercises in alleviating extremity pain. This ability to quickly relieve pain becomes a motivator in and of itself. Research with elderly patients experiencing chronic lower back pain found that “the most frequently stated reasons for nonadherence was that exercise did not help or aggravated pain”.²⁷ Conversely, 80% of these patients who continued regular exercise cited the health benefits they received. Yet another experimental trial found similar results: 75% of those who continued exercise referenced “symptom relief” or “feel better” as reasons.²³ A necessary precondition for continued compliance includes the patient’s perception that the exercise ameliorates unpleasant symptoms.²⁵ When designing the home exercise plan it is wise to include, whenever possible, exercises that will relieve the patient’s symptoms. This will increase the likelihood of compliance with the plan.

Functional Limitations

A final intrinsic motivator related to the patient’s condition is the impact it has on their ADLs. Patients who are very limited in daily functioning will have a harder time complying with exercise instructions. Activity limitations function as a barrier to self-care, so it is important for the chiropractic rehabilitation specialist to account for these limitations when giving instructions.^{18, 26, 28} The home exercise plan must strike a delicate balance between working within the patient’s limitations, while at the same time improving that limitation. Take, for example, a patient who has increased lower back pain with lumbar flexion but also has abdominal weakness. Starting the patient with hook-lying pelvic tilt exercises or prone half-planks would be preferable to starting them on abdominal crunches. Compliance should improve by working within the patient’s limitations.

Summary

Getting to know the patient is a key to developing an appropriate home exercise plan. From intake through reevaluation, the chiropractor must gain insight into the patient’s exercise beliefs, exercise history, lifestyle and the value they place on exercise and treatment. Taking into account her diagnosis, the severity of her condition, what makes it better or worse and how badly it limits ADLs will provide a higher likelihood of compliance. The chiropractic rehabilitation specialist who develops this knowledge will have a better understanding of how to specifically provide motivation to the patient.

EXTRINSIC MOTIVATORS: RELATIONSHIPS

Doctor-Patient Relationship

Just as accurate understanding of the patient improves compliance, so the Doctor-Patient relationship can also influence compliance. Setting goals together, establishing a bond of trust and loyalty, and providing positive feedback will set the tone for your continued work together. Meshing patient and doctor goals shows promise as a means of improving compliance.²⁹ A study of the effect of treatment goals on compliance lead to the conclusion that “collaboratively set goals appear to lead to a higher level of treatment compliance than physiotherapist-mandated goals.³⁰ Loyalty to the practitioner initially produces higher compliance, emphasizing that establishing a close relationship helps.²⁵ Does the treatment plan include praise for success in achieving the goals you set together? An important factor related to noncompliance was a lack of positive feedback.²⁶ The doctor-patient relationship is so important that it can drive a patient to the opposite of compliance. A study of compliance with medication dosages among elderly Japanese found that intentional noncompliance was the strongest predictor for poor compliance, which was influenced by the relationship between the patient and the physician.³¹ It is critical for the chiropractor to earn the patient’s respect and trust, set goals together with the patient, and praise progress when it occurs.

Social Relationships

Patients who receive support at home will also improve their chances of complying with home exercise plans. A review of three studies in the psychology field found that it is possible to predict an individual’s intention to exercise by the “extent to which individuals perceive that significant others encourage choice and participation in decision-making, provide a meaningful rationale, minimize pressure, and acknowledge the individual’s feelings and perspectives.”³² Another study of exercise among elderly knee osteoarthritis patients found that among those who exercised regularly, social support was important for companionship, making friends and exercising with others who had similar problems.¹⁶ The doctor should be aware of social supports at home and encourage the patient to make their family and close friends aware of their condition and the expectations of exercise. This will provide the patient with encouragement and accountability.

EXTRINSIC MOTIVATORS: EXERCISE FORMAT

On a more practical level, the format in which the exercise prescription is given can influence the patient’s level of compliance. This is the area in which the chiropractor has perhaps the greatest amount of control. The way in which goals are set, the number of exercises given, the types of materials used to explain them, and the type of follow up can all be controlled to provide a better chance of patient follow through, and thus a better potential outcome.

Goal-Setting

Goal-setting is an often overlooked element in the exercise prescription. The patient and doctor need to agree on what is to be expected and this needs to be clearly outlined. This provides the patient with a target to aim for, as well as a means for the doctor to track progress and improvement. A discussion on the importance of collaborative goal-setting has already been included.³⁰ This area holds promise as a means of improving physical activity behavior.²⁹

Goal-setting works particularly well when the patient is in pain1, which is when patients are most open to any avenue of relief and are willing to do what it takes to reduce their own suffering. This is likely why short-term compliance is typically higher than long-term compliance. The addition of some motivational strategies during this “window of opportunity” may be helpful. A double-blind prospective randomized controlled trial comparing an exercise program with a combined exercise and motivation program (using five compliance-enhancing interventions) found that “the combined exercise and motivation program increased the rate of attendance at scheduled physical therapy sessions, i.e., short-term compliance, and reduced disability and pain levels by the 12-month follow-up. However, there was no difference between the motivation and control groups with regard to long-term exercise compliance.³³ Thus, motivation strategies used by the doctor during the initial visits can prove helpful in supplementing treatment with home exercise.

Number of Exercises & Visits

When selecting exercises, the chiropractic rehabilitation specialist should focus only on the most important deficiencies or movements they want to accomplish with the patient. Giving too many exercises, too soon, may discourage or confuse the patient. This is an obvious but important reminder. Among elderly subjects, those who were prescribed 2 exercises performed better than subjects who were prescribed 8 exercises. ³⁴ As the chiropractor sees the patient achieve mastery of the home plan and the patient finds the exercises helpful, additional exercises can be added or the current exercises can be made incrementally more difficult. “It is important to keep the less fearful patient sufficiently challenged to avoid boring the patient while at the same time being sure they are performing exercises with the necessary control to isolate the ‘deep’ stabilizer muscles.”1 Once the provider and patient are satisfied that the patient is ready to progress, new exercises and challenges can be added to the home program.

To reinforce performance of the exercises, they should be reviewed periodically. “The high rates of relapse that tend to occur after short-term behavioral interventions indicate the need for maintenance programs that promote long-term adherence to new behavior patterns”.³⁵ A trial of older adult in-patients showed that they did not remember physiotherapy exercises effectively after a single teaching session.³⁶ Although it is not necessary to see the patient multiple times a week to review, it is helpful to add a small number of additional visits to review and supervise the exercises.³⁷ It is also helpful to the patient to periodically review the home exercise plan in order to emphasize its importance, provide accountability and ensure that the exercises remain challenging. A number of other studies reinforce this point; several reinforce the conclusion that the “supplementation of a home-based exercise program with a class-based exercise program led to clinically significant superior improvement”³⁸, and was “more effective than home exercise alone”³⁹, also ⁴⁰. These improvements were still evident at 12-month review.

Presentation/Education

What is the best way to present the exercises to the patient? There are multiple learning styles, so the best approach will most likely utilize a variety of measures. Obviously, once the doctor has described the exercise and why it is being prescribed, the patient should perform the exercise with direct supervision. Is it helpful to send the patient home with instructions? A study comparing patients who received verbal and written instruction with patients who received only verbal instruction concluded, “Patients receiving additional written and illustrated instruction had a significantly higher mean compliance (77.4%) compared to the group who received verbal instruction alone (38.1%).⁴¹ This is a significant difference and reinforces the importance of sending the patient home with written instructions. Brochures, when combined with verbal instruction, can be as effective as audio or video instructions to enhance correct performance of exercises.⁴² There are a number of vendors or rehabilitation software programs available to accomplish this.

However, the doctor should not depend entirely on an exercise handout or brochure to achieve compliance. Continued follow up and review is important. Elderly in-patients were not found to remember exercises effectively after a single teaching session and an exercise handout did not significantly improve their memory.³⁶ Additional visits to review the home exercise plan are helpful and can provide greater symptomatic relief.³⁷ And when exercises are difficult for the patient to perform, “audiotapes and videotapes may provide additional cues to maintain correctness of performance.”⁴²

Internet & Telephone Interventions

In addition to in-office follow-up, doctors can try making use of other means of intervention. Research is beginning into “innovative and time-efficient alternatives to face to face contact with healthcare providers”.³⁵ Can chiropractors utilize their administrative staff or the internet to follow up with patients in an effective manner, freeing up time to focus on care in the office? One systematic review of the literature indicates that this is possible, finding that in 69% of physical activity studies, positive outcomes were reported using the telephone as the primary intervention method43. Follow-up for 6 to 12 months and 12 or more calls produced the most favorable outcome. In another study, 511 women were mailed six sets of computer-tailored health messages and received two computer-tailored telephone counseling sessions. Intervention participants were more likely to move forward into more advanced stages of physical activity change than the control group.³⁵ In practice, this could be accomplished by having one’s chiropractic assistant call patients briefly every month to provide accountability or review exercises verbally.

More recent research is delving into the use of internet-based physical activity interventions. This has been defined as an exchange of information via the internet between a health care provider and a patient, or the use of email for communication between a health care professional and a patient.⁴⁴ There is significant evidence that website-delivered or internet-based physical activity interventions are superior to a print-based intervention, waiting list strategy or other non-Web-based intervention.^44-46 A 2007 review of the literature found that better outcomes resulted when email or website interventions had more than five contacts with participants and when the time to follow-up was short (less than three months).⁴⁵ Many chiropractors already utilize e-newsletters to communicate health messages to patients, making this an easy strategy to incorporate into practice. Early studies are promising but are limited by small sample sizes and unclear identification of internet strategies that improve compliance.

Conclusion

This article has provided a review of successful motivational strategies to improve patient compliance with home exercise plans. Almost all chiropractors utilize exercise advice or instruction in the care of their patients. This is most easily done in the form of a supervised home exercise program. Because accountability and contact with the patient are limited, compliance with this instruction is generally poor and limits the effectiveness of treatment. However, knowledge of effective motivational strategies can improve the patient’s compliance and the outcomes of care. Patients can be motivated internally or externally, and research has outlined many strategies that the practicing chiropractic rehabilitation specialist can use to tap this drive. It would be helpful to use a checklist (see Table 2) to ensure that these strategies are being used.

Table 2: Rehab Checklist

___ 1. Does the patient have a history of successful rehabilitation of a prior injury?
___ 2. Has the patient regularly exercised at some point in the past?
___ 3. What is the patient’s belief regarding the necessity or usefulness of exercise in
their treatment?
___ 4. Is the patient’s lifestyle conducive to incorporating exercise?
___ 5. Will my exercise plan alleviate symptoms or help the patient overcome ADL limitations?
___ 6. Will my exercise plan improve the patient’s prognosis?
___ 7. Have I established a relationship of trust and collaboration with the patient?
___ 8. Does the patient have a support network to encourage home exercise?
___ 9. Did exercise goals include patient input?
___ 10. Is the number of exercises given appropriate and challenging for the patient?
___ 11. Have I given the patient materials describing the exercises and do I plan on following
up to review them with the patient?

During new patient intake, the chiropractor can use knowledge of the patient’s exercise history, exercise beliefs, age, lifestyle and value the patient places on treatment to formulate a plan for home exercises. Once the diagnosis is made and treatment is initiated, taking into account the severity of the condition, how it limits the patient’s ADLs, the prognosis and what alleviates the symptoms will lay the groundwork for a successful treatment regimen.

When introducing the exercise plan to the patient, the chiropractor should ensure that he is collaborating effectively with a trusting patient by setting goals together. The patient can consider bringing a workout partner or family member along to a visit to provide support and accountability. The initial rehabilitation plan should be limited in scope to avoid overwhelming the patient or aggravating the patient’s condition, but regularly reviewed and updated to challenge the patient and foster progress. The chiropractor should provide printed take-home materials for the patient to use as a reminder, and can consider using his website as a platform for the patient to review or update exercises. It may also be feasible to use email as a means of communication regarding the home exercise plan.

There is much research to be done in the area of chiropractic exercise compliance. The chiropractic rehabilitation diplomate program fits in well with the overall trend in healthcare toward patient-centered care. This paper attempts to move the research base forward by summarizing current research and categorizing known motivational strategies. The ability to further motivate patients using proven and innovative strategies will enhance our standing in the healthcare community and improve our patient’s lives.

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16. Hendry, M, Williams, NH, Markland, D, Wilkinson, C and Maddison, P. Why should we exercise when our knees hurt? A qualitative study of primary care patients with osteoarthritis of the knee. Family Practice 2006 23(5):558-567.
17. Gecht MR, Connell KJ, Sinacore JM, Prohaska TR. A survey of exercise beliefs and exercise habits among people with arthritis. Arthritis Care Res. 1996 (Apr), 9(2): 82-8.
18. Der Ananian C, Wilcox S, Watkins K, Saunders R, Evans AE. Factors associated with exercise participation in adults with arthritis. J Aging Phys Act. 2008 (Apr), 16(2): 125-43.
19. Liebenson C. Assessment of Psychosocial Risk Factors of Chronicity-“Yellow Flags”. In: Liebenson C. Rehabilitation of the Spine: A Practitioner’s Manual, Second Edition. Baltimore: Williams and Willkins 2007, 183-202.
20. Waddell G, Newton M, Henderson I, Somerville D, Main CJ. A fear-avoidance beliefs questionnaire (FABQ) and the role of fear-avoidance beliefs in chronic low back pain and disability. Pain 1993 (Feb), 52(2): 157-68.
21. Näslund, GK, Fredrikson, M, Hellénius, M and de Faire, U. Determinants of compliance in men enrolled in a diet and exercise intervention trial: a randomized, controlled study Patient Education and Counseling, 1996 (Dec), 29(3): 247-256.
22. Engström, LO. Patient adherence in an individualized rehabilitation programme: A clinical follow-up. Scandinavian Journal of Public Health 2005, 33(1): 11-18.
23. Lazo, MG, Filipinas, SG and Valdez Jr., JR. Poster 139: Compliance with home exercise programs: a preliminary report. Archives of Physical Medicine and Rehabilitation 2003 (September), 84(9): E29.
24. Kirkcaldy, B, Furnham, A and Shephard, R. Attitudes towards health and illness among exercisers and non-exercisers. Stress Medicine 1994, 10(1): 21 – 26.
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26. Sluijs, EM, Kok,GJ and van der Zee, J. Correlates of exercise compliance in physical therapy Phys Ther. 1993 (Nov), 73(11):771-782.
27. Mailloux J, Finno M and Rainville J. Long-term exercise adherence in the elderly with chronic low back pain. Am J Phys Med Rehabil. 2006 (Feb), 85(2): 120-6.
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29. Shilts MK, Horowitz M and Townsend MS. Goal setting as a strategy for dietary and physical activity behavior change: a review of the literature. Am J Health Promot. 2004 (Nov-Dec), 19(2):81-93.
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31. Okuno J, Yanagi H, Tomura S. Is cognitive impairment a risk factor for poor compliance among Japanese elderly in the community? Eur J Clin Pharmacol. 2001 (Oct), 57(8): 589-94.
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33. Friedrich, M, Gittler, G, Halberstadt, Y, Cermak, T and Heiller, I. Combined exercise and motivation program: Effect on the compliance and level of disability of patients with chronic low back pain: A randomized controlled trial. Archives of Physical Medicine and Rehabilitation 1998 (May), 79(5): 475-487.
34. Henry, KD, Rosemond, C and Eckert, LB. Effect of number of home exercises on compliance and performance in adults over 65 years of age. Phys Ther. 1999 (March), 79(3): 270-277.
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38. McCarthy, CJ, Mills, PM, Pullen, R, Roberts, C, Silman, A and Oldham, JA. Supplementing a home exercise programme with a class-based exercise programme is more effective than home exercise alone in the treatment of knee osteoarthritis. Rheumatology 2004 (July), 43(7): 880-886.
39. Thomas, KS, Muir, KR, Doherty, M, Jones, AC, O’Reilly, SC and Bassey, EJ.
Home based exercise programme for knee pain and knee osteoarthritis: randomised controlled trial. BMJ 2002 (5 October),325: 752.
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41. Schneiders, AG, Zusman, M and Singer, KP. Exercise therapy compliance in acute low back pain patients. Manual Therapy 1998 (August), 3(3): 147-152.
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Not Used:
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Author Information:
Robert M. Smith, D.C., DACRB
Private Practice of Chiropractic, Easton, PA, USA
DocSmith@DrRobertSmith.com, cwh@rcn.com
3413 Sullivan Trail
Easton, PA 18040
Ph: 610.438.2015
Fax: 610.438.2016

Craig Liebenson, DC With Special Guest Charlie Weingroff, PT

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January 15,16 2011 Santa Monica, CA

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Location: AFPerformance, 1653 10th Street Santa Monica, CA 90404

About Dr. Liebenson:

• Author, Rehabilitation of the Spine
• Authorofover100 articles & 4 books
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• Focused on modern soft tissue & training updates on – The Functional Pathology of the Motor System – which I have learned from Dr Karel Lewit & Pr Vladimir Janda
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• How to perform movement assessment & convert Cook 2’s into 3’s

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Title
Neuromuscular Dysphagia as a variant of sternocleidomastoid syndrome

A Case Report

Running Header
Dysphagia from SCM Dysfunction

Author
Randall C. McLeod DC, FCCRS(c), DACRB
Private practice, IHCrehab, 52401 Range Rd 13, Stony Plain, AB T7Z 1Y4

Keywords
MeSH -Chiropractic, manipulation, dysphagia. Non MeSH – sternocleidomastoid, trigger point

ABSTRACT

Introduction
This patient was a 10 year old female who was suffering from a progressive dysphagia. Her condition was highly responsive to chiropractic spinal manipulative therapy coupled with trigger point therapy and proprioceptive neuromuscular facilitation.

Case Presentation
This patient presented complaining of a progressive dysphagia of 11 months duration and apparently insidious onset, which, by this point, was causing severe difficulty in swallowing. Her condition further resulted in a mounting anxiety regarding her ability to ingest food and provoked a severe weight loss. My examinations revealed mechanical cervical dysfunctions, autonomic and postural functional anomalies as well as mediation of her symptoms through trigger point and articular stimulation.

Outcome
This patient responded exceptionally well to chiropractic spinal manipulative therapy coupled with neuromuscular rehabilitative techniques. She showed a very good early response and ultimately complete resolution of her signs and symptoms.

Conclusion
Dysphagia can be the primary presenting symptom of a cervical neuromusculoskeletal dysfunction such as sternocleidomastoid syndrome.

FULL TEXT

Introduction
Dysphagia (difficulty swallowing) is a relatively uncommon primary symptom in a chiropractic office. When experienced however, it can be extremely disconcerting for the patient in that the process of ingesting foods and fluids is a biological necessity for sustaining life. As well it can create a concern for the practitioner regarding differential diagnosis.

According to the online Merck Manual (1) the majority of cases of dysphagia are the result of some type of severe central nervous system pathology. Of particular interest to the chiropractor would be the possibility that a presentation of dysphagia could be a symptom of an evolving stroke, as outlined in the diagnostic protocol represented by the “5D’s And 3 N’s” (table 1). There are a small but intriguing number of papers which refer to a multitude of symptoms, including dysphagia, arising from “sternocleidomastoid syndrome” (That being the result of a functional disturbance of the sternocleidomastoid (SCM) muscle(s) and it’s attendant innervations). Missaghi (2) gives an excellent overview of this syndrome as well as a detailed description of the anatomy and usual symptoms associated with SCM syndrome. Dr Donald Murphy DC, DACAN (clinical faculty at Brown Medical Univ), in his summary notes the potential for swallowing disorders associated with this syndrome. His position is supported by Dr Burl Pettibon DC, FABCS, FRCCM, PhD.(Hon) in his text on chiropractic rehabilitation (3) and Travell and Simons (4) note the shared neurology of these tissues. Further, Braune et al (5) cites a case where dysphagia was apparently caused by a fasciculation of the SCM muscle.

My particular interest in this case was piqued by having seen two prior occasions of dysphagia which responded to chiropractic care. The first was in me. I had spent an entire day renovating a ceiling with my head and neck in extension. Late in the afternoon I suddenly found I had great difficulty swallowing, my throat simply would not work. A prompt visit to my chiropractor relieved the problem; however I can clearly recall the sense of near panic that I felt when I realized that I was unable to swallow. The second incidence was in an adolescent female who was suffering from a diffuse juvenile myositis and hospitalized for the same. Her mother advised me she was having difficulty swallowing and her physicians were proposing surgery in an attempt to alleviate her symptoms. A trial of spinal manipulative therapy (SMT) resulted in her also responding very rapidly and subsequently demonstrating a complete resolution. With these cases in mind, when I was presented with a third case, I felt it should be documented somewhat more carefully for further consideration or study.

Case Presentation
In this case a 10 year old female presented with an11 month history of progressive dysphagia of apparently insidious onset. For the first 9.5 months her condition progressed slowly (Sept to mid June). Approximately mid June her symptoms began to progress much more rapidly resulting in such difficulty swallowing that she suffered a weight loss of 26 lbs during the next 6 weeks. This was not only a red flag denoting the advancing severity of her condition, but also resulted in a substantial amount of anxiety on the part of the patient due to her inability to ingest food or drink normally. The patient had been examined by her physicians including a referral for endoscopic evaluation, all of which were unremarkable.

Closer inquiry revealed that she was able to recall that she had experienced 3 memorable traumas the previous summer, including an injury from rough play with her siblings, a trampoline injury and a boat/tubing injury. (In general, it is my experience that when a patient remembers an injury 12 months later it was usually significant.)

My evaluation revealed:

• Mechanical dysfunction of the cervical spine;
  • Rt lat bend 33deg, Lt lat Bend 50deg,(norm 49)
  • Flexion 58deg (norm 67) , Extension 70deg, (norm 86)
  • Rt Rot 70deg, Lt Rot 80deg, (norm 76)
    
    (norms are age weighted and from CROM charts)
• Specific site fixation was noted at C5 on Rt. lat. Bending (motion palpation)
• She had notable weakness of the deep cervical neck flexors (poor resistance to forced extension)
• Her symptoms were aggravated by;
  • Lateral pressure on C5
  • C5-6 facet pressure on the right
  • Full Cervical extension
  • Trigger point pressure at Rt. Medial sub occipital area, Rt SCMs and Rt Levator scapulae musc. (figure 1)

Her symptoms were diminished by;

• Cervical flexion
• Trigger points at Lt. SCMs and Lt. Levator scapulae.musc.

An ad hoc “Borg”(6) type of severity scale was created where 0 meant no difficulty or normal swallowing and 10 meant complete inability to swallow. She reported a difficulty of 8

Her thermography showed a strong unilateral bias as well a severe asymmetries in her cervical spine

A postural sEMG study showed only mild to moderated increases, predominately in the lower thoracic spine and a moderate spike at C1.

I arrived at a working diagnosis of dysphagia of somato-visceral origin as a result of referred symptoms from post traumatic subluxation of the mid cervical spine, co-morbid with symptom referral from the cervical musculature, ie. an atypical sternocleidomastoid syndrome.

Management and Outcomes
Due to the severity of her symptoms and the relatively short chronicity of her condition, I advised an intensive but declining treatment schedule beginning at 5X the first week, 3X the second week, 2X the third week followed by 1X weekly support until she was satisfactorily resolved.. This would parallel a program I would use for acute pain levels of 8 or more. Her treatment would involve chiropractic spinal manipulative therapy (SMT), proprioceptive neuromuscular facilitative (PNF) techniques (predominately post isometric relaxation/stretching) and active home care as required.

More specifically she was treated with SMT at C6 (right posterior), C5 (left posterior) occasionally C7 (inferior or extended) with mild 5 + 6 rib on the left and some lumbar adjustments at L2 and L3 which were not likely directly related. Her PNF care consisted of post isometric relaxation (contract-relax-stretch) at both heads of the SCMs, sub occipital musculature and the pectoralis muscles (roughly the same PNF care as would be used for an upper crossed syndrome of Janda). Her home care was predominately for strengthening the deep cervical neck flexors and involved neck retractions against resistance (supine with mid cervical pressure into a cervical roll under C5) as well as seated neck retractions with no resistance.

Her progress was excellent. By the end of her first week of care she still demonstrated some apprehension regarding food but her difficulty in swallowing was down to a 2 of 10 (a 75% reduction). Most soft foods had been re-introduced. By the end of the second week hard foods were being introduced and her swallowing difficulty was down to a 1. By the end of her third week of care her swallowing difficulty was at 0.

At re-evaluation (after ten visits) she showed:

• Mild tendency to recurrence
• Aggravation at full cervical extension
• Mild mechanical dysfunction of the cervical spine;
  • Rt lat bend 50deg, Lt lat Bend 52deg, (norm 49)
  • Flexion 60deg (norm 67), Extension 92deg, (norm 86)
  • Rt Rot 80deg, Lt Rot 80deg, (norm 76)
    (norms are age weighted and from CROM charts)

Her care continued at 1X per week for 4 more weeks and at that time she self discharged as satisfied. At 2.5 years she has had no recurrence of her condition

From: Myofascial Pain and Dysfunction, The Trigger Point Manual, Vol. 1, Upper Half of the Body, Simons DG, Travell JG, Simons LS, Lippencott Williams and Wilkins © 1999, used with permission

Discussion
It appears that this case could well represent an atypical presentation of a sternocleidomastoid syndrome.

With this case, I felt a high degree of confidence regarding a probable positive outcome due to the combination of the negative outcomes of her conventional diagnostic studies, the presence of a probable mechanism(s) of injury, relatively short duration of chronicity and the combined positive and negative responses of her symptoms during provocative testing. With neuromusculoskeletal conditions, we tend to find that if we can provoke the symptom, we can effectively treat it. This was clearly the case with this patient. We had a body of data which was encouraging, positive physical findings and negative histopathological findings.

As we continue to progress and expand our body of knowledge, we are finding that not only pain conditions, but also a great many other disorders are, or can be, facilitated by abnormal neurological / neuromusculoskeletal function. Anatomical advances teach us that there are many delicate tissues and fibers supplying (or attaching to) sites which used to be seen to be unrelated but which we now find are, in fact, related or connected (such as T4 syndrome where fibers from the upper thoracics have now been found to contribute to the brachial plexus). It seems quite possible that these relationships may account for many of the uncommon results we see in practice.

It is important to remember that our evidence base begins with clinical experience, which then leads to the studies that eventually provide “good” evidence. But it all begins with sharing our clinical experiences. If we all wait until there is good evidence before we move ahead, we never move ahead. Hippocrates told us to; “Look well to the spine, for it is the requisite of many diseases”. My hope is that sharing this clinical experience may stimulate other practitioners to pursue, or at the very least, consider the possibility of, neuromusculoskeletal involvement in more that just pain cases. I refer not only to dysphagia, but also the many other atypical presentations we see as well. In particular we should be mindful of those patients who seem to have no clear etiology and/or who demonstrate those perplexingly normative histopathological diagnostics. These patients may well be, and indeed often seem to be, suffering from a functional disturbance of the neuromusculoskeletal system which is cascading out to other areas.

Post Script
Since I began this article I have seen 4 more similar cases. One, a juvenile female whose condition showed a duration of approx 1 month, responded with 100% resolution with only one or two visits and currently remains symptom free several months later. The others, all adults, (one male two female) have responded positively and are all progressing well.

Acknowledgements
I would like to thank Dr. Brain Budgell for his encouragement and assistance in getting me to step outside my comfort zone.

References
1. Merk Manuals, online Medical Library- www.merck.com
2. Missaghi B. Journal of the Canadian Chiropractic Association, 2004: Sept:48(3):201-205
3. Dr Burl Pettibon DC, FABCS, FRCCM, Phd (Hon), The Pettibon System, Chiropractic and Rehabilitation Procedures Re-Invented to Correct the Spine and Posture, © 2006, Ch – Initiating Event Displacement Complex pp4
4. Travell, Simons, Thoraco Fascial Pain and Dysfunction, the trigger Point manual, Vol 1 2nd edition
5. Braun et al Involvement of the Esophagus in the Cramp Fasiculation Syndrome, Muscle and Nerve, 1998 June:21(6): 802-4
6. Borg Pain Scale; Leibenson C, Rehabilitation of the Spine, pp 61

TABLE 1
Explanation of the 5D’s And 3N’s

Diplopia	Double vision or other vision problems
Dizziness	Vertigo, light-headedness
Drop Attacks	Sudden numbness/weakness of face/arm/leg
Disarthria	Difficulty speaking
Dysphagia	Difficulty swallowing
Ataxia of Gait	Difficulty walking
Nausea	Vomiting or queasiness
Numbness	Loss of sensation on one side
Nystagmus	Involuntary rapid eye movements

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.

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.(70) 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
It has been questioned whether a patient could achieve proper stabilization and recovery through physical rehabilitation after receiving radiofrequency neurolysis, considering the important role the multifidus muscle plays in stabilization.

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

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

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

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

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

REFERENCES:

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.

What’s New in Cervical Spine Rehab

My personal in-office experience of patients that present with pain after a motor vehicle injury is consistent with a 2010 study by Hincapié CA, et al. I find most patients report pain in multiple body areas and that isolated neck pain is extremely rare.

Hincapié CA, et al report 86% of 6481 Saskatchewan residents that responded reported posterior neck pain, 72% indicated head pain, and 60% noted lumbar back pain. Ninety-five percent of claimants reported some pain within the posterior trunk region, comprising the posterior neck, shoulder, mid-back, lumbar, and buttock areas.

Regarding cervical rehab for these patients, in the past I’ve used everything from bodyweight isometrics and elastic Thera-Bands to strengthen the neck; dumbbells and kettlebells to strengthen the upper body; low load exercises for strength and motor control concepts performing 10 repetitions of deep neck flexor activation against an inflatable blood pressure cuff and a whole lot more. All of these are effective at reducing acute and chronic neck pain. Oh, I can’t forget teaching patients all the foam rolling, stretching, warm-ups and cool downs I can get them to do. I can probably do an entire seminar on rehab compliance at this point.

My treatment choice has always depended on the individual patient, weather they are young or old, active or inactive, conditioned or de-conditioned. Truthfully I don’t see a significant difference between the different treatments modalities. Most patients obtain clinically important improvements at 6 weeks after the beginning of treatment and exercise programs. I think that is in line with what most practitioners were taught to expect. However, I still see that 10% (plus or minus) or so of clients take a lot longer than 6 weeks to resolve and have on-going residual complaints and problems. On the other hand, I love treating chronic pain patients that come into my office that were not originally treated by me – those who had previous chiropractic care, acupuncture, medical care or physical therapy without active rehab (they just received passive modalities). With some new tweeks on rehab, I expect good results with these individuals.

My hands-on treatment over the past few years seems to include more cervical mobilization (stair-stepping technique), lower cervical manipulation (rather than upper cervical manipulation), thoracic manipulation, and I continue to do a lot of specialized deep soft tissue therapy for pain reduction. The deep tissue work is especially valuable to the upper cervical region. Over the last few years, I’ve added warm laser, but it is so unpredictable who will benefit and change and who doesn’t, I’m losing interest in the whole “laser” thing for the cervical region.

One of the most helpful things I’ve learned in the last five to six years is Dr. Kim Christensen’s Neuromobilization technique. If you have a patient with radiculitis, this technique can produce some clinically important reduction of pain immediately post-treatment. The biggest changes in my cervical treatment come in my rehab. Helpful strategies in the past several years include using the NASM protocol for the ‘overhead squat’ as a diagnostic tool and treatment guide, and using the Functional Movement Screen (FMS) as a predictor of risk for injury.

My latest rehab management strategies for MVA & cervical spine patients:

• Manual therapy: I am spending a lot of personal thought and patient time figuring out exercises to influence the fascia – that thin fibrous layer consisting of longitudinal and transverse connective tissue fibers. Restrictions seem to show up everywhere. Along the sacrotuberous ligament, the thoracolumbar fascia, the latissimus dorsi muscle, the spinous processes of all of the thoracic vertebrae, the angles of ribs, the serratus muscle, the splenius capitis muscles and the deep fascia of the neck.
• Balancing (sensorimotor training) exercises: I begin sensorimotor training as early as possible. I start patients standing with a narrow stance, progressing to tandem stance and single leg stance. The progression includes the use of foam under each foot to augment postural instability. Manipulate visual inputs (focusing on a point 2 meters away on the wall at eye level and under, with eyes open (EO) plus eyes closed (EC) conditions. I use 30 second bouts.
• Stretching exercises: Mobility needs to be taught before stability. We have to reduce neck/shoulder stiffness and enhance neck range of motion. The levator scapulae, suboccipitals, SCM, pectoralis minor, and scalenes continue to be at the top of the list. I am enjoying using the stretch strap from Theraband.
• Strengthening exercises: I still go after the deep neck flexors (DNF). Sometimes I begin with the head positioned against gravity to enhance isometric strength of the neck extensor muscles. I still do typical strengthening exercises for the paraspinal muscles and shoulder girdle muscles (upper and middle trapezius, rhombo-serratus). These exercises help increase the sustained isometric effort tolerance of the neck muscles. Progression includes unstable surface and escalating resistance and movement pattern improvement. I progress my corrective exercise strategy starting with bodyweight, progress to Therabands resistance, then progress to free weights and kettlebells.
• Oculomotor and head/eye exercises: In the upright, sitting and supine positions I teach patients eye tracking while moving the head. This involves coordination exercises and re-establishing proper movement patterns. The progression includes increasing neck rotation amplitude, instability on a stability ball and augmenting neck muscle activity with the head in a weight-dependent position.

For the past few years I’ve been using the overhead squat for cervical evaluation. Dr. Christensen and I wrote a chapter on the cervical spine in Mike Clark’s new book. In the past we used the overhead squat as a movement pattern to evaluate the ankles, knees, and lumbopelvic-hip complex. Now we use it to evaluate the cervical spine as well. Just think of it as closely related to the supine cervical flexion movement pattern. Have the patient perform the overhead squat. Observe them from the front and side. The normal pattern would be for them to lead with the posterosuperiour aspect of head. If the SCM’s & subocciptals are dominating, they will lead with their chin. This is a faulty pattern. Remember these muscle actions:

• Anatomical action of longus capitus and colli (cranio-cervical flexion) nods the chin.
• Sternocleidomastoid (SCM) extends the cranio-cervical region and flexes the neck.
• Scalenes are neck flexors.

During the overhead squat I seem to find a lot of overactive SCM, anterior scalene, and suboccipital muscles.

Here are a couple of corrective exercises:

Hyoid Stretch
Scalenes & hyoids can be short, limiting cervical extension.
Hyoid stretch: teeth touching – extend the neck – open mouth & your head extends further. The stretch is close the mouth = fascial stretch of hyoids.
To find out if it‘s articular, perform the chin tuck & extend the cervical spine over the upper thoracic region.

4 Point Kneeling
The head & neck are passively positioned in neutral alignment, then the patient actively moves (turning side to side, looking up & down) & attempts to return to neutral position. Perform this procedure twice. Notice if they can come back to the neutral position.
Score:
Good= the patient accurately & confidently returns to the neutral position both times without making adjustments.
Average=the patient returns to neutral position with reasonable accuracy but lacks confidence – may need to make several adjusting movements or is “not quite sure”.
Poor= the patient cannot return to the neutral position and is often very unsure of the correct position as evidenced by the vacant facial expression that frequently is associated with performing this test.

I’m sure there are dozens of specific treatments, exercises, and natural remedies out there for our patients. I’d be interested to know about them, but if you’re following the rehab model in all its facets – manipulation/mobilization, modalities, diet, activity, exercise, leisure, sleep, stress prevention – I think you’ll find we do so much good!

I look forward to seeing you in Orlando 2011. I have new material to share with you.

Sincerely,

Jeff

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

1. J Occup Environ Med. 2010 Mar 30. Whiplash Injury is More Than Neck Pain: A Population-Based Study of Pain Localization After Traffic Injury. Hincapié CA, Cassidy JD, Côté P, Carroll LJ, Guzmán J.

2. Comerford lecture notes 2009.

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

Schedule

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

Hotel

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

COURSE OBJECTIVES

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

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

OPTIONAL EXAMINATION

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

Testimonials

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

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

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

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

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

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

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

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

Craig Liebenson

Introduction

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

The dangers of the sit-up

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

Isolation vs Integration

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

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

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

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

How Should Functionl Core Training Occur?

Proper Breathing

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

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

The Exhalation Position of the Rib Cage

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

Figure 1

Figure 2

Bracing the Core

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

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

Neutral Spine Posture

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

Training the Core

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

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

Figure 3

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

Conclusion

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

References:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Figure Legend:

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

Leanne N. Cupon, DC, DACRB, DABFP

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

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

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

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

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

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

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

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

Dr. Jeffrey Tucker, DC

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Reprinted from an article published in  the CCA Journal Feb 2010

About the Author:

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

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

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

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

Functional Action, Inc.
Presents

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

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

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

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

Workshop Timetable

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

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

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

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

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

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

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

Hotel Accommodations

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

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

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

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

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

Workshop Timetable

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

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

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

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

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

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

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

Hotel Accommodations

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

Functional Action, Inc.
Presents

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

Course attendees will have a clear understanding of:

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

Course attendees will possess:

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

Course Description

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

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 Instructors

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

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

Workshop Timetable

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

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

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

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

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

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

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

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

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

Functional Action, Inc.
Presents

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

Course attendees will have a clear understanding of:

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

Course attendees will possess:

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

Course Description

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.

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 Instructors

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

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

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

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

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

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

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

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

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

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

View Flyer

Functional Action, Inc.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Duke Integrative Medicine

SUMMARY

How to integrate mindfulness into your Chiropractic practice:

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

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

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

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

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

There are many ways to practice mindfulness:

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

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

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

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

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

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

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

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

Bibliography — Peer Reviewed Papers

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

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

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

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

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

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

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

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

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

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

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

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

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

Abstracts and Poster Sessions

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Other Researchers

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

CONCLUSION

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

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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.

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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.

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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.