Rehabilitation


Rehab: Results Speak for Themselves
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Rehabilitation
Written by Jon Pettibon, DC   
Saturday, 25 May 2013 13:28
W
hat happens with your patients if you are no longer physically able to adjust them using manual manipulation on a short-term or long-term basis? After experiencing some major medical issues I found myself in just that position, asking the same question.
 
posturerehabWhen I was able to return to my office, an infection had left my lumbar spine in such bad shape that most activities were painful and impossible to perform. In addition, my colleague of many years decided to move on with his own practice, and I realized that my business was finished. I reluctantly wrote a letter thanking my patients for 34 years of support and assuring them that their records would be available and ready to be transferred to the provider of their choice. As I contemplated my future, my father, Dr. Burl Pettibon, came to me with an idea he was working on for a decompression system. The system utilizes simultaneous cervical and lumbar traction combined with whole body vibration and an exercise protocol. Although my practice was finished, I was able to temporarily interact with patients in a research capacity. I also had an opportunity to find out if subluxation configurations could not only be corrected but also be maintained without the typical high-velocity, low-amplitude spinal manipulation.
 
In late 2011, we recruited patients who were willing to follow an initial three-month program of three to four sessions per week. Many patients liked the idea of not getting their “backs cracked.” The in-office research program began with:
 
  • Therapeutic Wobble ChairTM  warm-up exercises on a Pettibon Vibration Platform for 10 minutes
  • 20 to 30 repetitions on a Repetitive Cervical TractionTM unit
  • 10-12 minutes on a Cervical and Lumbar Traction Table with vibration
  • Wobble chair exercises and tractioning repeated after the traction table
  • Pettibon Tendon Ligament Muscle Stimulator (PTLMS) utilized for the first two to four weeks, depending on individual symptomatology and administered after each session

Subluxation configurations were greatly reduced, cervical lordosis was highly improved and symptomatic changes were dramatic.

 
Body weighting was prescribed after the first week with X-ray to determine proper weight and placement. Daily homecare was also prescribed, and patients were sent home with a Portable Wobble chair, Repetitive Cervical Traction unit, cervical and low-back supports for spinal molding along with head and body weighting.
 
Post X-ray showed amazing results. Subluxation configurations were greatly reduced, cervical lordosis was highly improved and symptomatic changes were dramatic. The following patient cases include brief case histories from participants in this program. We did pre- and post X-rays for each patient. All participants experienced rapid, positive changes in symptomatology and a return to normal daily activity. Keep in mind, none of the patients received manual spinal manipulation; the improvements were solely a result of exercise, traction, traction-table therapy and the use of body weights to engage the body’s proprioception system to correct poor posture.


The Auto Body Mechanic (47-year old male)
xrayautomechanicPresenting Complaints:
  • Low-back pain
  • Left leg pain, intermittent for 10 years
  • Has current low-back and left leg pain with numbness of lower leg and foot
Treatment:
Therapeutic Wobble Chair warm-up exercises with vibration and cervical traction. Once warmed up, he used a traction table with a combination of lumbar and cervical traction, followed by PTLMS. The patient followed the treatment plan three times per week for three months with no manual manipulation.
 
Homecare Treatment:
Wobble Chair exercises, cervical traction, Pettibon head and body weighting, and spinal molding. The patient followed the regimen twice daily during the three-month study and continues to do this to maintain his correction.
 
Progress:
Patient’s pain was reduced, and he returned to work after the first week of treatment. He was pain free after the second week and relieved of numbness after the third week. His test X-rays show what is possible, with the results of head-weighting at five weeks and at one month followed by pre- and post X-rays taken three months apart.


The Welder/Iron worker (46-year old male)
xraywelderPresenting Complaints:
  • Severe low-back pain – VAS 9 (visual analog pain scale)
  • Radiating pain in left hip/buttock – VAS 7-9
  • Intermittent left leg pain (VAS 5)
  • Woke up with pain three days prior
  • Taking Flexeril and Vicodin without relief
Treatment:
Therapeutic Wobble Chair warm-up exercises with vibration and cervical traction. Once warmed up, the patient used a traction table with a combination of lumbar and cervical traction, followed by PTLMS. He followed the treatment plan three times per week for three months with no manual manipulation.
 
Homecare Treatment:
Wobble Chair exercises, cervical traction, Pettibon head and body weighting, and spinal molding. The patient followed this regimen twice daily during the three-month study and continues to do this to maintain his correction.
 
Progress:
Patient was pain free within three office sessions and returned to work. Above are his pre- and post X-rays, taken three months apart:


xrayretailclerkThe Retail Clerk (51-year old female)
Presenting Complaints:
  • Neck and upper-back pain with stiffness for many years
  • Headaches two to three times per week
  • Left hand numbness
Treatment:
Therapeutic Wobble Chair warm-up exercises with vibration and cervical traction. Once warmed up, she used a traction table with a combination of lumbar and cervical traction, followed by PTLMS. The patient followed the treatment plan three times per week for three months with no manual manipulation.
 
Homecare Treatment:
Wobble Chair exercises, cervical traction, Pettibon head and body weighting, and spinal molding. The patient followed the regimen twice daily during the three-month period and continues to do this to maintain her correction.
 
Progress:
Left hand numbness was gone after the second session. Neck and upper-back pain and stiffness were greatly improved after four sessions. Headaches were greatly diminished within two weeks. Headaches were gone after five weeks. Above are her pre- and post X-rays taken three months apart:


Jon M Pettibon, DC – graduated from Western States Chiropractic College in 1979 and was  one of the school’s Instructor of Pettibon Spinal Bio-Mechanics elective courses during 1978-1979.  He has practiced a majority of his 34 year career in Tacoma, Washington, with 1 year in Hawaii.  For 19 years Dr. Pettibon taught Pettibon Spinal Biomechanics for The Pettibon Institute.  He has been involved with numerous research projects and co-authored “Chiropractic Technician Manual”. He also had numerous years as an extension faculty member and lecturer at Palmer College of Chiropractic. Visit: www.PettibonSystem.com
 
MIX, FIX, SET™ Protocols for Posture Rehab
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Rehabilitation
Written by Dennis Woggon, BSc, DC   
Saturday, 25 May 2013 12:11
“Don’t slump, stand up straight!” How’s that working for you? Probably not very well, as I think back to how effective that was when I was a child. We talk about changing posture, but how can we permanently change it.
 
poorposturePosture is not a conscious decision but a subconscious relationship with our environment.
 
Posture can be defined as the body’s position to gravity that keeps the body in a minimal energy state as it relates to its environment via all of the joints of the body. This would include the five righting reflexes of the body as well as balance and proprioception (orientation in time and space). The five righting reflexes are:
  1. Labyrinthine righting reflexes maintain the head’s position in time and space (midbrain).
  2. Body righting reflexes that act upon the head keep the head orientated with respect to the body (midbrain).
  3. Body righting reflexes that arise from body surface receptors act on the body and orientate it in space (midbrain).
  4. Neck righting reflexes that arise in the neck keep the body orientated with the head (medulla).
  5. Optic righting reflexes keep the head in proper orientation (occipital cortex).
A righting reflex is defined as the ability to assume an optimal position when there has been a departure from it.
 
Gray’s Anatomy states, “Human’s adapt in need to their environment.” If we change the relationship of the body to its new adapted environment, we can fix the spine in that position.

Rene Calliet says, “The head is the most neglected body part in fitness programs. . . . It’s an axiom, that the body follows the head. . . . You can realign your entire body by moving your head. The position of the head is more important than the shoulders and pelvis.” Iang et al., states, “Identification of the location, extent and pathway of sensory neurologic feedback after mechanical stimulation of a lateral spinal ligament in chickens”, Spine, 22: 17-25. in scoliosis states:
 
“Stretching a single lateral ligament of the spine produces a barrage of sensory feedback from several spinal cord levels on both sides of the spinal cord. This sensory information is also transferred to higher levels of the brain, including the nucleus gracilis and cuneatus, the vestibular nuclei and the thalamus.”
 
“These sites of FOS production suggest the locations of pathways for this sensory information, which includes the dorsal columns and spinocerebellar tracts. Incorrect perception of sensory information from the ligaments may be a major contributing factor.”Change, either positively or negatively, takes retraining.
 
The CLEAR Scoliosis Institute has made amazing changes with scoliosis patients on a consistent basis for the first time in chiropractic. By utilizing these same principles, all patients can benefit. I first came up with the idea of Mix, Fix, Set™ after a workshop in my clinic years ago when we “cold adjusted” a number of DCs at a seminar. On the following Monday, two had severe low back pain and couldn’t work.
 
Just after that incident, I had broken a piece of plastic so I took it to my workshop. I used epoxy glue, which first has to be “mixed” together. I then had to “fix” the pieces into the correct position. Then I had to allow them to “set” in that position to make the process work. I found this to be the same with my patients.
 
You wouldn’t go out and drive a car in -25 °F without warming up the car first, a lesson I’ve learned living in Minnesota. This also applies to adjusting a cold spine.
 
MIX—The “mix” procedures we utilize in the clinic are Active Chair Rehab that puts the spine through a range of motions. Motion creates friction, which creates heat and changes the hydrogel properties of the discs and ligaments to hydrocele. We also utilize cervical traction, the Eckard table, core muscle stimulation, and vibrating traction.
 
FIX—Once the spine is in a receptive state, it is ready to be adjusted. We utilize specific spinal adjustments based on static and dynamic x-rays. The ArthroStim is used for cervical adjusting, as manual adjusting is contraindicated in hypermobile areas of the spine where there is ligament instability. This specific upper cervical adjusting is a critical component of correcting a neurological short leg. Posture is controlled by the upper cervical spine, especially C1, C2, C3 and C4. Chiropractic corrective care includes pre- and post-x-rays to verify reduction of the radiographic manifestation of the vertebral subluxations complex. A heel lift will not correct the upper cervical subluxations complex that is critical in postural correction.
 
SET—Once the “fix,” or adjustment, is made, we then must make sure that the correction is “set” in that position. This is the proprioceptive neuromuscular re-education phase. Guyton’s Physiology states that “humans adapt in need to their environment.” If we can change the gravitational environment with spinal weighting, then we win. This would include anterior head weighting like Halo Posture, therapy glasses, and spinal weighting on the whole-body vibrating platform (the Vibe).
 
Patented spinal weighting is most effective on a whole-body vibration platform.
 
In our clinic, we use the Vibe, as it is the only vibrating platform specifically designed for chiropractic spinal neuromuscular re-education. Its constant 30 Hz and the amplitude is the only whole-body vibration platform to be used for spinal neuromuscular re-education.
 
Cardinale and Bosco in Ex Sport Sci Rev, 2003, 31: 3-7 state, “The Physiology of whole-body Vibration Training is simple. As the muscles respond to the Vibratory Stimulus, certain Mechanical (Muscle spindle and Golgi Tendon Organs and Joint Mechanical Receptors) Adaptations, Proprioceptive and Neurological Adaptations, and Systemic Adaptations (Circulation, Metabolic, etc.) begin taking place.” Research and outcomes show us the frequencies and g-forces have a significant impact on these adaptations.
 
The other vibrating platforms are not for the chiropractic profession but for exercising. That’s okay if you want a chiropractic gymnasium. 
 
The goal of postural spinal rehab is to utilize the best tools to objectively verify the best results.
 
Dr. Dennis Woggon graduated cum laude from Palmer College of Chiropractic in 1974, with a Bachelor of Science in Biology. He founded the St. Cloud Chiropractic Clinic in St. Cloud, Minnesota that same year. He is licensed in Minnesota, Wisconsin, Florida and Hawaii. Dr. Woggon taught seminars on Spinal Biomechanics at Palmer College in Davenport for 25 years. He also taught at Northwestern Health Science University. He currently teaches the CLEAR Scoliosis Program at Parker University in Dallas, Texas. He has lectured worldwide, including two trips to Vladivostok, Russia, to work with their doctors regarding scoliosis. He has written numerous publications and books on chiropractic, spinal biomechanics and scoliosis. He was certified in video fluoroscopy by Palmer College in 1992 and utilizes digital motion x-ray in his practice. He began the CLEAR Scoliosis Institute in 2000, which has become a non-profit organization to teach the public and doctors how to help patients with scoliosis. Dr. Woggon can be reached at: This e-mail address is being protected from spambots. You need JavaScript enabled to view it or visit: www.DrWoggon.com or www.CLEAR-Institute.org.
 
Chiropractic and Elastic Therapeutic Taping: Helping a Young Athlete Finish the Game
Rehabilitation
Written by Stephen W. Boyles D.C,CKTI   
Thursday, 30 August 2012 00:32
W
e all employ a variety of techniques with our patients, and even with people we may not originally have thought of as patients. In almost 20 years as an educator and practicing DC, I have often been asked to share in unexpected areas. Kinesio Taping, or Elastic Therapeutic Taping, has been a valuable tool for me since 1999, and I now have the pleasure of helping to spread its use in my role as a Certified Kinesio Taping® Instructor (CKTI). 
 
elastictherapeutictapingSeveral years ago I was practicing in the Houston area.  My daughter attended a private school just north of Houston that had a nationally ranked basketball program. I was a pretty involved parent, and it doesn’t take long for the school to discover which parents have useful skills. I was happy to help whenever I could, to keep the school’s athletes in top form, but more importantly to help the young people get the most possible enjoyment from their high school years.
 
The head coach asked me to look at one of his best players who was having low back pain. The young man could only play half a game because his low back would tighten up and become painful by halftime. Even so, he was still scoring around 40 points a game, so it was natural for the coach to want him available for the entire game. And we all wanted the kid to feel better!
 
I adjusted him several times within a few days and applied tape to his low back to relax his muscles and relieve his low back pain. He had pretty classic lower lumber facet joint subluxation and sacroiliac inflammation. His range of motion was limited in flexion and extension. 
 
I treated him with side posture adjustments to the lower back and sacroiliac (SI) joints and then applied tape in a space correction to the lumbosacral area along with an I-O application to the lumbar paraspinal muscles. The space correction helped reduce the edema in the lumbosacral and SI region, while the I-O lumbar muscle application reduced muscle tension and edema in the lumbar paraspinal musculature. 
 
The next game he not only was able to play the  whole game without pain, but he scored 102 points. I’m not going to try and take credit for the young man’s basketball skills, but apparently my treatment helped him get to a new level!
 
There are many individual considerations in developing a treatment and therapeutic taping program for each patient’s needs. The following is a basic elastic therapeutic taping strategy for the lumbar fascia:  
 
With the patient standing in a neutral extension (with the closer arm raised) laterally flex the trunk to the opposite side. Apply the base of the tape “I” strip to the lateral 1/3 of the gluteal muscle bulk, approximately the posterior border of the gluteus medius.
 
Stabilize the base of the tape and apply downward pressure to increase the tissue tension. Apply the elastic therapeutic tape to the lateral border of the inferior angle of the scapula. Apply a second strip of tape to the other side in the same manner. 
 
With the patient again in a neutral standing position, apply an “x” tape formation to the sacrum. Tear the paper backing away from the central portion of the tape, leaving the backing on the tails. 

Holding the piece by the tails, direct the tape obliquely, pull the tape gently (mild tension) and apply the central portion of the tape to the center of the sacrum. Pull both ends of the tape with equal tension away from the central portion and apply the tape to the borders of the vertical pieces that you already applied.
 
As always, you will want to perform a thorough assessment before choosing your course of treatment for any situation, but elastic therapeutic taping is a great addition to the toolbox!
 
Dr. Stephen Boyles, DC, CKTI graduated from Parker College of Chiropractic in 1992. He was the team doctor for the Parker College of Chiropractic Olympic Team and worked there for 8 years as an associate professor in the student clinic. Since 2008 Steve has been with Southern Trace and Colony Chiropractic Center in central Florida. He is also certified as a Golf Fitness Professional by Titleist Performance Institute.  http://www.southerntracechiropractic.com/ (352) 205-8500
 
Why Every Chiropractor Should Be a DME (Durable Medical Equipment) Supplier
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Rehabilitation
Written by James C. Antos , D.C.   
Wednesday, 29 August 2012 22:00
A
fter 34 years of private chiropractic practice, I have found that some fundamental keys to practice security, financial security, and peace of mind lie in these simple facts.  
 
dmeFirst, as a chiropractor I must be able to get positive results for my patients concerning both their goals and mine.  The patients must feel that I am there “for them” and that their goals are the most important in our relationship.
 
Second, I need accurate information in order to be able to work and perform efficiently.  Accurate information allows me to achieve clinical results and to develop passion, enthusiasm, and satisfaction in excellent clinical performance.  It has been my experience that one of the side effects of this is becoming financially successful and stable.  For me this helps to achieve peace of mind in my “money” life and my chiropractic practice.
 
A number of years ago, especially after additional seminars in orthopedics, I began using lumbar braces and cervical collars.  I also remember years ago using the at-home over-the-door cervical water bag traction devices.  I would try anything reasonable to get better patient care outcomes.  All of these things helped but there was very little financial profit in using them.  
 
But today net income from such equipment is very good.  Also, at this time the financial as well as the clinical improvement in Medicare, especially in providing DME supplies, such as back braces or at home traction devices, is excellent.
 
For years I have been providing DME supplies with great patient results and satisfaction.  After sharing what I was doing with some close associates and friends, they started enjoying the benefits.  Once they found out the “secrets” of this undiscovered opportunity that is “naturally right” in delivering chiropractic care, their practices became better.
 
The most common question I get from chiropractors is, “How does Durable Medical Equipment (DME) fit into the clinical picture for a chiropractor?  Why should I even consider DME in my practice?”
 
My answer is always the same. Consider this: As a chiropractor who is certified as a supplier of Durable Medical Equipment (DME) under Medicare, you are certified to be able to be paid by Medicare at a strong net financial gain. The reimbursement levels are very good at this time.  How would an additional $5,000 in your pocket or more affect your lifestyle?  Did you know that your patients are receiving these supplies from other sources already?  Medical doctors, physical therapists, and supply stores have been in this side of the health care business for a long time. You are letting business that is sitting on the table in front of you just go to other sources.
 
Now consider that durable medical equipment includes strong clinical items that greatly help your patients live healthier lives.  Consider that you may be insufficiently treating your patients if you do not incorporate, when appropriate, durable medical supplies in your treatment plans.  
 
Utilizing durable medical equipment helps a chiropractor achieve two very important goals.  First, we achieve results in patient care and second, we capture a sound financial compensation stream for the practice.  Let’s be honest; without both why are we practicing chiropractic care anyway?
 
The next question I hear all the time is, “What are some durable medical items that I, as a chiropractor, could consider as useful in my chiropractic practice for my chiropractic patients?”
 
The most common durable medical items used by chiropractors and other physicians are lumbar braces, cervical traction devices, and tens units.  Besides these, there are many other categories and items that are considered DME supplies.  The key is to use durable medical equipment that is approved and certified by the proper Medicare agency. You must use approved items for approved uses.
 
The next most common question is, “How do I get certified as a DME Provider/supplier?” First, anyone can contact the DME department of Medicare and try to do all the forms by themselves.  This may prove to be a difficult thing to do as the forms can be very confusing.  Submitted improperly, the difficulties can be overwhelming.  Consultants, such as me, can be very helpful at this point. 
 
The next strategy is to hire a consultant to help with the process.  Be sure to use reliable people or companies and make sure that your needs are met so you can accomplish your goals with the best integrity possible. 
 
Every day I have chiropractors asking for help with their DME situations. Many got their DME Medicare certification by themselves or from other companies. Now they are confused over some issue and need help with something their previous consultant did not resolve.

For example, the chiropractor may not know how to bill, or how to document, or how to protect themselves when there is an audit from Medicare or when another agency investigates, and they may not know how to solve the many little problems that show up along the way.  Again, a consultant who has experience in this area can make the difference between success and failure as a DME provider. 
 
Being a DME provider/supplier is a wonderful addition to any chiropractic practice in this day of diminishing returns and increasing government regulations.  I do not know of any other addition to a chiropractic practice in this day and age that has the benefits and safety that being a DME provider/supplier has to offer.  Be not afraid!  Help yourself and your patients.  Become a DME provider.
 
James C. Antos D.C., DABCO, Dr. Antos has been in private chiropractic practice for 34 years. He is a a lecturer for Florida State License renewal on behalf of the Florida Chiropractic Association in the years of 2011 and 2012, teaching the the topic"DME and Lumbar Bracing". He can be reached by phone at 386-212-0007, or visit his website at www.antosdmebrace.com
 
The Importance of Good Form
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Rehabilitation
Written by Dr. Dennis Woggon & Dr. Josh Woggon   
Tuesday, 01 May 2012 17:20
What Scoliois Can Teach Us about Postural Rehab
 
M
anifestation of any health problem is not a spontaneous event; before the clinical onset, precluding factors exist.  Although these factors are unique in each patient, understanding how they contributed to the malady is the first step in reversing it.  Regardless of the specific disorder, the crux of the issue is mal-adaptation: the body is adapting to demands placed upon it. When the ability of the body to adapt is exceeded, the result is overt symptomatology, often classified into a medically-recognized disorder.
 
posturalrehabPosture is a classic example of a condition which lacks a medical label to apply to it, but nonetheless has a dramatic effect upon health. Due to the fact that “poor posture” is not recognized as a medical condition, very little standardized research can be performed upon it, and this makes it difficult to understand its etiopathogenesis and the ideal methods to combat it.  However, there are few diseases which have as strong an association with posture as scoliosis, and ongoing research on scoliosis may shed some light on the best strategies for patients suffering from imbalanced posture.
 
There can be numerous causes of poor posture – some directly identifiable, others less so. While pathological conditions (such as a congenital malformations) or external forces (unlevel shoes, for instance) can be a cause, most postural deficits can be traced to repetitive micro-traumas. Almost all healthy children around the age of 5, before beginning schooling, have no readily-identifiable postural abnormalities; at the end, almost all of them do.1 Similarly, scoliosis seldom has a direct cause, but in some populations is so prevalent as to be considered practically a normal phenomenon.2 Understanding both scoliosis and poor posture as mal-adaptations to imposed demands leads us to search for similarities between the two, and may provide helpful clues for postural rehab.
 
Axial loading of the spine: it’s all in your head!

One of the main drivers of adaptation is the innate desire of our nervous system to expend as little resources as possible on tasks such as balance, posture, and co-ordination; in essence, to operate in a “minimum-energy state.” Understanding how to use this natural tendency towards energy conservation to your advantage is a key factor in postural rehab.
 
Spinal imbalances frequently arise as a consequence of the body’s attempt to integrate the primary righting reflex - our vision – with the proprioceptive feedback from the rest of the body and maintain erect bipedalism. The unique mechanics of the fully upright human spine play a decisive role in the pathogenesis of scoliosis.3  While scoliosis can be induced in an animal model artificially, humans are the only species on Earth that spontaneously develop idiopathic, structural scoliosis. Human bipedalism induces forces into the spine which predispose the spine to rotate in a certain fashion; in non-scoliotic spines, there is a pre-existent pattern of rotation, similar to what is observed in idiopathic scoliosis, which is lessened when a quadrupedal-like (on hands-and-knees) position is adopted.4
 
Compressively loading the spine exacerbates spinal curvature.5   Renee Cailliet, MD stated that for every inch of forward head translation, ten pounds of compressive loading are applied to the spine.6   Positive sagittal imbalance predicts health-related quality of life in adult scoliosis patients,7 and forward head posture (FHP) is a common clinical finding in adolescent scoliosis patients that can lead to a flexion or “librarian”-type posture.8
 
The typical scoliosis patient exhibits right head tilt; when the visual righting reflex establishes its dominance, a right high shoulder manifests.  This chain reaction continues in the form of a left low hip and left weight-bearing foot behind the right one. Whether the righting reflex is a cause or effect of the scoliosis, the end result is that it reinforces the spinal deformity. To correct postural abnormalities, begin by examining how the righting reflex of the eyes affects them.

Self-correction of posture versus Innate Correction

postureselfcorrectionWithout proper instruction, many strategies employed by people to correct their posture actually have a detrimental effect. Research suggests verbal commands to “stand up straight!” are insufficient to retrain children’s postural habits, and may cause a worsening of the thoracic kyphosis, with little to no effect on the lumbar lordosis.9 This information is especially poignant to the parents of children with scoliosis; thoracic lordosis is a predominant component of the deformity,10,11 and this research suggests that this is aggravated when the parents instruct their children to ‘straighten up.’  
 
This phenomenon is not isolated to the sagittal plane, either; the “pathological pattern of incorrect posture” involved in scoliosis leads to alterations in body weight distribution (e.g., bilateral weight scales).12   When patients were instructed to equalize their weight distribution, the deformity worsened in subjects with scoliosis, and non-scoliosis patients developed spinal asymmetries.  An active attempt on the part of the untrained patient to “self-correct” their posture appears to lead to further sagittal and coronal imbalances.
 
The patient’s posture may be changed passively through a brace; however, the obvious detriment is that any corrective benefit is lost after a sustained period outside of the brace.  This is exemplified in scoliosis, where this loss of correction has prompted many researchers to suggest an exercising during weaning to prevent this.13   For non-scoliotic patients, there are numerous braces on the market which claim to improve posture; however, very few published studies exist regarding their effectiveness, and while they may show improvement in-brace, there is no evidence that this correction is maintained out of the brace. 
 
With immobilization, muscular atrophy and disc degeneration is accelerated.14,15   There are concerns that bracing could encourage a mild, postural scoliosis to develop into a rigid and permanent spinal deformity.  Bracing is an effective short-term solution for sprains, strains, and sports injuries; however, there is insufficient evidence that bracing creates long-term postural changes, and increasing evidence that long-term immobilization has dramatic negative effects.
 
New research, new possibilities

If telling the patient to “stand up straight” won’t work, and bracing is not an ideal long-term solution, the question remains, what is the best method of correcting posture?  Firstly, by recognizing that balance, posture, and co-ordination are regulated primarily by the cerebellum as involuntary and automatic responses.  Altering posture through active muscle contraction can actually have the opposite of the intended effect.  The improvements documented in a case series of 19 scoliosis patients has implications for non-scoliotic patients.16 Rather than focusing on active, patient-initiated exercises, or passive, external methods, there is a third option: re-active therapy. Have you ever observed someone carrying a heavy bag at an airport? Too much weight pulls them over, but with the right amount, they react and counter-balance for the uneven load, thereby affecting their spine and posture. 
 
There exists a motor-sensory feedback loop between the postural regulation systems of the cerebellum and the intrinsic spinal musculature; improper processing of vestibular signals by the CNS may lead to spinal deformity, which in turn prompts the development of new neuromuscular motor control strategies.17 In scoliosis, whether it is a defect of the CNS or a purely mechanical issue that initiates the process, once the curvature is present, both biomechanical and neuromuscular forces become involved in its progression.18   This creates a “Vicious Cycle” of scoliosis progression leading to imbalanced forces, which then encourage further progression.  Arresting this cyclical pathology demands recognition of all of the biomechanical, soft tissue, and neuromuscular adaptations involved - this does not apply only to the scoliotic population, but to all individuals with postural problems.
 
Basic principles of re-active therapy

It is imperative in re-active therapy that the patient is standing on an unstable surface, such as a foam pad or inflated disc.  By first destabilizing the patient, we increase the communication that is required between the brain and the body to maintain overall balance; perturbation initiates the process of consolidation in balance-control strategies.19   Next, a patient-specific system of weights, cantilevers, and therapy glasses are combined to achieve ideal posture, or even an over-correction.  The idea is primarily to work with the body’s natural righting reflexes; if the patient has a right head tilt, and through re- active therapy we can induce a left head tilt, as the eyes balance out to the horizon, we achieve a complete reversal of the physical stance of the body. This form of dynamic rehabilitation is not active therapy, as it does not require the patient to perform any form of conscious, self-directed motion.
 
Rather they are re-acting to the imposed demands without conscious thought. Posture should be rehabilitated in the same manner that it began to deteriorate – without conscious thought.One quick note: it is surprisingly easy to measure posture in a quantifiable manner, with the aid of inexpensive and readily available software programs. Furthermore, the accuracy of these methods has been established in the peer-reviewed literature.20  Assigning a numerical value to postural deviations greatly enhances the perceived value of care; it is one thing to tell a patient that their posture has improved, but quite another to be able to tell them that their right shoulder, which was 1.13 inches higher than their left, is now only 0.34 inches higher. These objective measurements reinforce the patient’s confidence in the effectiveness of chiropractic.  As Galileo famously stated, “Measure what is measurable, and make measurable what is not so.”
 
Chiropractors play a vital role in public health by promoting awareness of the importance of good posture. As the general public begins to recognize the numerous correlations between posture and health – including headaches,21 spinal pain,22 depression,23 impaired respiratory function,24 and increased vulnerability to injury,25,26 to name a few – it is imperative that the chiropractic profession employs effective, validated methods of measuring and improving posture objectively.  The ideal method of postural rehabilitation works with the natural reflexes of the body and simultaneously addresses all of the involved aspects – including spinal biomechanics, soft tissue deformations, and neuromuscular adaptation strategies.
 
Research & References
  1. Widhe T: Spine: posture, mobility and pain. A longitudinal study from childhood to adolescence.  Eur Spine J. 2001 Apr;10(2):118-23.
  2. Avikainen VJ, Vaherto H: A high incidence of spinal curvature: a study of 100 young female students. Acta Orthop Scand. 1983;54:267-73.
  3. Kouwenhoven JW, Castelein RM: The pathogenesis of adolescent idiopathic scoliosis: review of the literature. Spine 2008 Dec 15;33(26):2898-908.
  4. Janssen MM, Vincken KL, Kemp B, Obradov M, de Kleuver M, Viergever MA, Castelein RM, Bartels LW: Pre-existent vertebral rotation in the human spine is influenced by body position.  Eur Spine J. 2010 Oct;19(10):1728-34.
  5. Little JP, Izatt MT, Labrom RD, Askin GN, Adam CJ: Investigating the change in three dimensional deformity for idiopathic scoliosis using axially loaded MRI. Clin Biomech 2012 Jan 4 [Epub ahead of print]
  6. Caillet R: Soft Tissue Pain and Disability. Philadelphia: FA Davis Co., 1977, p. 214.
  7. Mac-Thiong JM, Transfeldt EE, Mehbod AA, Perra JH, Denis F, Garvey TA, Lonstein JE, Wu C, Dorman CW, Winter RB: Can c7 plumb line and gravity line predict health-related quality of life in adult scoliosis? Spine 2009 Jul 1;34(15):E519-27.
  8. Culbert T, Olness K: Integrative Pediatrics. Oxford University Press, 2010, p. 164.
  9. Stolinski L, Kotiwcki T: Self-correction of posture: assessment of the quality of the movement accomplished by non-instructed school children. Scoliosis 2012 Jan 27;7 Suppl 1:O66. [Epub ahead of print]
  10. Dickson RA, Lawton JO, Archer IA, Butt WP: The pathogenesis of idiopathic scoliosis. Biplanar spinal asymmetry. J Bone Joint Surg. 1984 Jan;66(1):8-15.
  11. Millner PA, Dickson RA: Idiopathic scoliosis: biomechanics and biology. Eur Spine J. 1996;5(6):362-73.
  12. Nowotny J, Brzek A, Nowotny-Czupryna O, Czupryna K, Plaszewski M: Some possibilities of correction and compensation in body posture regulation among children and youth with low degree scoliosis. Scoliosis 2012, 7(Suppl 1):O64.
  13. Zaina F, Negrini S, Atanasio S, Fusco C, Romano M, Negrini A: Specific exercises performed in the period of brace weaning can avoid loss of correction in adolescent idiopathic scoliosis (AIS) patients: Winner of SOSORT’s 2008 Award for Best Clinical Paper. Scoliosis 2009 Apr 7;4:8.
  14. Eisinger DB, Kumar R, Woodrow R: Effect of lumbar orthotics on trunk muscle strength. Am J Phys Med Rehabil. 1996;75:194-197.
  15. Stokes IA, McBride C, Aronsson DD, Roughley PJ: Intervertebral disc changes with angulation, compression, and reduced mobility simulating altered mechanical environment in scoliosis. Eur Spine J. 2011 Oct;20(10):1735-44.
  16. Morningstar MW, Woggon DA, Lawrence G: Scoliosis treatment using a combination of manipulative and rehabilitative therapy: a retrospective case series. BMC Musculoskeletal Disorders 2004 Sept 14;5:32.
  17. Burwell RG, Dangerfield PH, Freeman BJ: Etiologic theories of idiopathic scoliosis. Somatic nervous system and the NOTOM escalator concept as one component in the pathogenesis of adolescent idiopathic scoliosis. Stud Health Tech Inform. 2008;140:208-17.
  18. Veldhuizen AG, Wever DJ, Webb PJ: The aetiology of idiopathic scoliosis: biomechanical and neuromuscular factors. Eur Spine J 2000 Jun;9(3):178-84.
  19. Tjernstrom F, Fransson PA, Hafstrom A, Magnusson M: Adaptation of postural control to perturbations - a process that initiates long-term motor memory. Gait Posture 2002, 15:75-82.
  20. Brink Y, Louw Q, Grimmer-Somers K: The quality of evidence of psychometric properties of three-dimensional spinal posture-measuring instruments. BMC Musculoskeletal Disorders 2011, 12:93.
  21. Lennon J, Shealy N, Cady RK, Matta W, Cox R, Simpson WF: Postural and respiratory modulation of autonomic function, pain, and health. Am J Pain Manag. 1994;4:36-39.
  22. Mieke D, Barbara C, Pascal C, Guy V, Greet C, Roseline D, Lieven D: Sagittal standing posture and its association with spinal pain: a school-based epidemiological study of 1196 Flemish adolescents before age at peak height velocity. Spine 2011 Nov 19. [Epub ahead of print]
  23. Canales JZ, Cordas TA, Fiquer JT, Cavalcante AF, Moreno RA: Posture and body image in individuals with major depressive disorder: a controlled study. Rev Bras Psiquiatr. 2010 Dec;32(4):375-80.
  24. Huggare JA, Laine-Alava MT. Nasorespiratory function and head posture. Am J Orthod Dentofacial Orthop. 1997;112(5):507-11.
  25. Stemper BD, Yoganandan N, Pintar FA: Effects of abnormal posture on capsular ligament elongations in a computational model subjected to whiplash loading. J Biomech. 2005 Jun; 38(6) 1313-23.
  26. Oktenoğlu T, Ozer AF, Ferrara LA, Andalkar N, Sarioğlu AC, Benzel EC: Effects of cervical spine posture on axial load bearing ability: a biomechanical study.  J Neurosurg. 2001 Jan;94 (1 Suppl) 108-14.
 
 
Dr. A. Joshua Woggon, a 2010 Graduate of Parker College, is the Associate Director of the CLEAR Scoliosis Treatment and Research Clinic in Dallas, Texas. He can be contacted at This e-mail address is being protected from spambots. You need JavaScript enabled to view it , www.clear-institute.org.
 
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