Rehabilitation


World's Best Traction
Rehabilitation
Written by Dr. Mark R. Payne, D.C.   
Tuesday, 25 May 2010 00:00

There are basically two types of chiropractors: those concerned with correcting spines and those who aren't. Truthfully, the latter group probably won't even bother reading this article. Since you're here, I'll assume you have at least some genuine interest in trying to deliver real and lasting structural corrections to your patients. As you've probably found out, it's kind of hard to do, isn't it?

http://www.theamericanchiropractor.com/images/iStock_000012115820Small.jpgAlmost every chiropractor has experienced the frustration of adjusting patients and seeing the symptoms improve, only to see the spine stubbornly stay the same. Many docs will switch to a new technique only to have the same result. I get calls every week from doctors having problems correcting spines. The call usually starts with the doctor explaining, somewhat apologetically, which technique he/she uses. I hear statements like, "I’ve been meaning to take some ABC seminars, but just haven’t done it yet," or "I used to do XYZ technique, but I’ve kind of gotten away from it." And, of course, what that indicates is a tendency to view their poor structural outcomes as being due to some shortcoming in their adjusting technique. Well, I'm here to tell you, it’s not true.

I used to hear in chiropractic college that "all techniques work." And that's true...depending on how you define "work". The beneficial effects of all manner of chiropractic adjustments have been studied relative to a wide range of human ailments. And the jury is in. Spinal adjusting, using just about every technique has been shown beneficial for just about everything from simple back pain to infantile colic to webbed feet. Seriously, there's lots of evidence that spinal adjusting is pretty good stuff for any number of symptoms and complaints. So pretty much all techniques do "work" in terms of making folks feel and function better. We should all feel good about that. But when we start studying how well our adjustments perform in terms of actually correcting spines, we start to have a real problem.

There've been a few research papers indicating that adjustments alone are somewhat effective at producing small, intersegmental improvements in vertebral position. Unfortunately, posture is a completely different thing entirely. Posture is the "big picture." And, essentially, every method of adjusting studied has fallen short in terms of making significant changes to overall spinal alignment. Certainly there are some studies which tout the benefits of a particular technique system to correct global spinal posture. But they tend to all have one big problem. In almost every case, the researchers only looked at the effect of their unique brand of spinal adjustments combined with other therapies such as traction, exercise, stretching, vibration, head weighting, etc. And, of course, the problem when you combine different therapies into the treatment groups is that you never really know which treatment is actually producing the results.

When you read way too many research papers, like I do, you might start to get an uncomfortable feeling about how some projects are designed. For instance, if you were a technique guru, out there promoting the beneficial effects of your particular methods, wouldn't you want to prove just how effective your adjustments were? Boy, I sure would! The very first thing I would do is draw up a project where one of the treatment groups got ADJUSTMENTS ONLY using my brand new, ultra whiz-bang methods. (All properly patented and trademarked, of course.) Then, when I had proven, once and for all, that my technique was the best thing since shirt pockets, the world would literally beat a path to my seminars. (Somebody call the Nobel Prize committee please!)

Only thing is, the various gods of the technique universe never do that. Instead, they combine all manner of treatments into their studies and, not coincidentally, some mixture of adjusting, rehab, traction, postural reeducation or whatever tends to be effective. You might almost get the idea that they were avoiding the subject a bit. Call me cynical, but I've got a sneaking suspicion that it will be a long time before most technique gurus are willing to test the efficacy of their adjusting methods in isolation. A few famous techniques have done this in the past and the results were a bit embarrassing!

So, before anyone fires off a hateful letter defending their favorite guru, I'll lighten up just a bit. Most of these guys are smart, innovative doctors. Their constant desire for better results drives progress in the profession. It's generally a good thing. Just realize that most of their great corrections are typically the result of a potent combination of rehab methods, not just their unique brand of adjusting. Truthfully, very few of us totally isolate patients to only one treatment method when they are in our offices anyway. Instead, we generally throw everything but the kitchen sink at the problem. It's certainly true in my office. Adjustments, ice, traction, exercise, trigger points, stretching...the list goes on.

The point of all this is that, the "world's best technique" doesn't really exist. There's not one whit of evidence to suggest your tried and true adjustments should take a back seat to the newest and hottest technique of the decade. It's just easy for us as a profession to look at our technique whenever we experience difficulties correcting spines. After all, we've got a hundred year heritage of visualizing subluxation as a bone out of place, pressing on a soft nerve. And sometimes old thought habits die hard.

Certainly, every modern chiropractor understands that vertebral subluxation is almost always more involved than a single segment in need of being pounded back into alignment. And, yet, the old paradigm continues to lurk somewhere in the back of the chiropractic mind. Why else would our perception of the importance of "technique" be so strongly engrained in us? It's this attitude which leads many of us to incorrectly conclude that our clinical failure(s) could have been avoided, if only the proper adjustment had been given.

Well, Doctor, you can relax, because it just ain't so. Save your seminar money. Spend the weekend at home with your family. And, if you really want to understand how the best doctors in the country are making great corrections, then pay attention to the ancillary procedures they are using to address postural alignment. Consider implementing active care procedures which focus on correcting postural alignment, like reverse posture exercise, extension traction methods, spinal remodeling. Yes, those conveniently happen to be related to items that my company sells. But you might also want to take a look at other tools and methods my company doesn't manufacture, like head and shoulder weighting, wobble chairs, rocker boards, or vibration therapy. There are lots of tools out there for doctors who are genuinely interested in correcting spines...just don't get caught in the trap of thinking you need to change adjusting technique. According to the best evidence I can find, one technique is just about as good as another. You can rest easy knowing that whatever you are already doing is tied for first place as the "World's Best Technique."

 

 

Dr. Mark Payne is president of Matlin Mfg., a manufacturer and distributor of postural rehab products since 1988. Doctors interested in learning more may call 334-448-1210 or go to www.posturalrehab.com for a FREE SUBSCRIPTION to our newsletter Postural Rehab where we discuss a wide range of subjects relevant to structural rehabilitation.

 
McKenzie Spinal Rehab Methods in the Chiropractic Office
Rehabilitation
Written by Randy Reed, D.C., F.I.C.C., F.A.C.C.   
Friday, 25 December 2009 00:00

The doctors that have protocols which include movements or forces that decrease disc displacement which, in turn, cause pain to decrease, disappear, or centralize with a rapid increase of lumbar ROM, see their patients get better. These types of movements should be pursued with decompression, exercises, mobilizations, and manipulations. Doctors, who fail to recognize that their protocol’s movements or forces, which increase the disc displacement and cause pain to increase, appear or peripheralize with a rapid decrease of lumbar ROM, will observe that their patients get worse or plateau. These movements should be avoided, and that can involve decompression, exercises, mobilizations, and manipulation.2

Loss of coordinative control/co-contraction and endurance of the core musculature; the Transverse Abdominis, Lumbar Multifidus, and Internal Obliques, according to research by Richardson and McGill, et al.,3 is an underlying source of low back pain and creates susceptibility to disc injury. Therefore, any exercise pattern which promotes co-contraction of the core musculature, and increases lumbar range of motion, while observing centralization, should be pursued. In our office, we do this in two ways. First is a series of seven types of exercises that strengthen and give endurance to the core muscles. While doing these exercises, we are observing the centralization phenomenon, developing core endurance, and trying to increase active lumbar range of motion. We affectionately call the seven types of exercises the "Seven from Heaven." The seven types of exercises that we use in the office are:

• Curl Ups (Core Abs) for the Rectus Abdominis

• Side Ups (Core Abs) for the Obliques

• Bird Dogs (Spinal Extensors)

• Short Arc Extensions (Spinal Extensors)

• Squats (Gluts and Quads)

• Lunges (Gluts and Quads)

• Bridges (Gluts and Quads)

There are various ways that all of these exercises can be performed. They can be performed on the floor, exercise mat, or using a physio-ball. Just remember that, when using these exercises, we are trying to observe three things: First, centralization of pain; second, increased active lumbar range of motion; and, finally, core stabilization.

To increase centralization, lumbar range of motion (actively and passively), muscle endurance and flexibility and to increase core strength and mobility, we have added a form of flexion/extension passive motion to our lumbar disc syndrome decompression protocols. Look for a table that increases range of motion, and centralizes pain at the same time. Appropriate protocols will consider the patient’s directional movement preference, and provide measurable and positive outcomes, particularly in the management of acute and chronic, severe low back and leg pain (without a neurological deficit) patients. Directional movement preference theory uses the rule of "centralization" to evaluate and proceed into rehab using activities that "centralize" the patient’s pain and, again, restores lumbar ROM. Recently published scientific research articles have established that the presence of "Centralization" can be a strong indicator of discogenic pathology and is a highly accurate and reliable predictor of treatment outcome. Movement, activities and postures that cause the symptoms to "centralize" indicate the "preferred direction(s)" for the Doctor/Therapist to use in developing both an in-office and self-treatment strategy for each patient. Simultaneously, the Doctor/Therapist must teach the patient how to avoid those positions, activities, and movements that cause the symptoms to move "peripherally." Many patients suffering from low back or neck pain, with or without referred pain, will unmistakably exhibit a "direction preference" when repeated movements and/or static positioning are applied to the spine. This means there will be a particular movement or position which will cause the symptoms to shift to a more central (proximal) location. Frequently, there will be other movements or positions which will cause the symptoms to shift to a more peripheral (distal) location. An example of this is the patient who, when asked to go into an extension movement (restoring normal lordosis) which, in turn, reduces the pain. This is the directional movement we want to begin exercise movements that will start their rehab.

Each smart clinician will observe the centralization phenomenon, but will also pay attention to the directional preference exercises that increases the lumbar range of motion and, subsequently, increases the lordosis of the lumbar spine. This missing link is where I see most clinicians fail in their decompression protocols. They're very good at assessing the patient's needs on the decompression table, but neglect to establish a clear-cut protocol to reestablish lumbar range of motion and lordosis. Their core stabilization programs are usually weak, and their patients often drop out, or plateau in their progress. Use the missing link to your advantage, and you will have more success in treating lumbar disc syndromes. Because of billing and coding issues that differ in each state, it's best to search out an expert to assist you in collections for your services, and to keep you legal.

(For a free 15-page report on billing and coding go to www.flexionextension.com)

Randy Reed, D.C., F.I.C.C., F.A.C.C.

 Dr. Randy Reed has 22 years of clinical experience as director of Reed Chiropractic Clinic in Solon, Ohio. His expertise Is; treating scoliosis, sports injuries, Intervertebral Disc Syndromes through Axial Vertebral Decompression and enhancing athletic performance through plyometric training and manipulation under anesthesia. You can contact him at 1-888-330-3627 or visit www.betterdoctorseminars.net


References

1.    The Lumbar Spine: Mechanical Diagnosis and Therapy,  R.A. McKenzie, F.N.Z.S.P., D.I.P., M.T., Spinal Publications 1981.
2   .M. Schneider, D.C. “Rehabilitation in a Nutshell: The Lumbar Spine Seminar (2006).
3.  Richardson C, Jull G., et al: Therapeutic exercises for spinal segmental stabilization in low back pain. Churchill Livingstone NY, 1999.

 
“Reverse Posture" Adjusting Made Ridiculously Easy
Rehabilitation
Written by Dr. Mark R. Payne D.C.   
Wednesday, 25 November 2009 00:00

Used to spend a lot of time and effort on postural adjusting. These days...not so much! It's not by chance that my columns are always centered around postural rehab with rarely a word about postural adjusting methods. That's because I find rehab methods to be much more effective at actually producing spinal corrections than any form of posture based adjusting that I'm aware of.

My early exposure to postural chiropractic centered around a popular technique system which placed great emphasis on various methods of adjusting the spine back toward a more normal posture. Much of the seminar content I learned and, consequently, helped teach others revolved around adjusting the patient in "reverse posture" position to help correct the spine. For years, I pretty much did everything "by the book" just as I had been taught.

Later, as more research on various extension traction methods came to light, it became apparent that most, if not all, of the correction achieved was a result of the various traction methods employed, as opposed to the rather laborious methods of reverse posture adjusting. The research was starting to bear out what I, and other experienced posture docs, were beginning to suspect. Namely, that, at least in the realm of the sagittal curves, it's postural rehab procedures that are doing the lion's share of the work, not the adjusting methods.

One exception may be when dealing with postural distortions in the frontal plane. In my personal observation, reverse posture adjusting seems to work somewhat better in the frontal plane than in the sagittal view. With that in mind, I thought I'd just give you the quick and dirty version of how reverse posture adjusting is done. Practice the method as described below until you become comfortable with it. See what your experience is. Who knows, maybe this one article will save you a bundle on seminar fees!

Let's take each step in turn. In five minutes, you'll have a clear mental picture of exactly what postural adjusting is all about.

Step One: Posture Analysis.

 

First, we'll analyze the patient's posture in three dimensions. In the frontal plane, we will confine our observations to just three simple types of misalignment: A. Horizontal Translations, B. Axial Rotations, and C. Lateral Tilt. NOTE: I have deliberately exaggerated a thoracic posture (right horizontal translation) here for demonstration purposes. In real life, we would observe for posture distortions of the head and pelvis as well.

Step Two: Reversing the Posture.

 

Next, the patient is placed in the opposite or "reverse" posture in either the standing or side laying position on the adjusting table. This is typically made possible by inserting foam blocks or wedges beneath the patient so as to assist the body in achieving the reverse posture position. In Fig. 2 the patient is positioned standing against the wall with a large block alongside the pelvis so as to allow her thorax to translate LEFT toward the wall.

Step Three: Where to Adjust

 

Finally, all that is left is to administer the thrust. Postural adjusting can be done equally well on a drop table, or with any of the popular hand adjusting instruments available. Multiple high velocity/low amplitude thrusts are generally administered over joint surfaces, which tend to be heavily laden with mechanoreceptors. The upper cervical and iliofemoral joints (See Fig. 3) are both highly mobile joints and, consequently, tend to be mechanoreceptor rich. Thrusts over such areas appear to send large bursts of neurological input upward, causing the brain the "reconsider" the body's positioning in space. At least, that's the theory.

Unlike, traditional adjusting methods, which actually seek to mobilize a given joint in a particular vector or even to actually help misalign a subluxated segment, postural adjusting uses the mechanical thrust to stimulate the proprioceptive system while the patient is in a new and radically different posture. There is absolutely no need to cavitate the joints and, in fact, such phenomena are very rare with this procedure. Although as yet untested in any peer reviewed research of which I am aware, it would appear that such methods may have some utility in breaking up habitual patterns of stance and posture...particularly in the frontal plane. If you want to try your hand at it, just remember to stick with the three simple steps I've outlined here.

1. Analyze the standing posture.

2. Place patient in reverse or opposite position.

3. Use multiple LIGHT, rapid thrusts over the upper cervical

and femur heads.

In truth, postural adjusting really is ridiculously easy. The only tricky part here is acquiring the ability to visually analyze posture in three dimensions and then mentally visualize how to place the patient into the reverse or opposite position. To make it easier, I've prepared a free report, Visual Posture Analysis, which summarizes a simple, accurate, method of visualizing and recording three dimensional posture. Interested doctors may call our office at 1-334-448-1210 to receive their free report.


Dr. Mark Payne is the president of Matlin Mfg., a manufacturer and distributor of posturavl rehab products since 1988. For more information on postural chiropractic methods, call 1-334 448 1210 or go to www.matlinmfg.

 
McKenzie Spinal Rehab Methods in the Chiropractic Office Active Therapeutic Procedures Insurance Companies Pay For Part I
Rehabilitation
Written by Randy Reed, D.C., F.I.C.C., F.A.C.C.   
Sunday, 25 October 2009 00:00

We all want success in treating our patients. We all want to be the "Hero," and provide that special treatment to our patient which sets us apart from the other doctors in our area. That may be what drives us, but what does it take for us to be that "Special Doctor" we all strive to be?

The answer to that question is, of course, complicated; but let me talk to you about one simple thought and action that could help you tremendously in your practice. First, it is important for you to realize that you must become a "Black Belt" in any technique or treatment you use. You must go beyond the casual knowledge of the treatment philosophy and techniques used to provide the anticipated results. Having said that, this article does not provide you with the depth of knowledge that you will need to have to be proficient in this technique that I am suggesting. Be sure to seek out more information, both through the written word, and at seminars.

The thought and action step I am recommending for you to consider is using the "McKenzie Protocols" for Cervical and Lumbar spinal conditions as an adjunct treatment system to your established treatment protocols.

The challenges of treating lumbar disc syndromes are many. The lumbar disc represents the toughest challenge a clinician has in his musculoskeletal practice. As I travel the country speaking to doctors in seminars about the treatment of these syndromes with axial decompression, flexion distraction, or standard manipulation, I am constantly pulled aside by attending doctors and asked one consistent query: "What is the #1 reason why a treatment plan fails to provide the results that I desire with the disc patient? What am I missing?"

The thing I see clinicians ignore, and the thing that causes patient’s treatment plans to fail most often, is a failure by the clinician to observe the "Centralization Phenomenon" in their patient’s progress, and the lack of establishing a treatment protocol that promotes centralization. Robin McKenzie first talked of this phenomenon in the early 1980’s and suggested that, by following this principle, his success rate improved dramatically with lumbar disc patients. I have found that to be true in my office as well. McKenzie defines this phenomenon as the situation in which pain that is arising from the spine and felt laterally from the midline or distally is reduced and transferred to a more central or near midline position when certain movements are performed.1 In summary, that means any movement that reduces the pain distally and centralizes the pain should be pursued. Today, because of the advancement of biotechnology, we can now use tools such as axial decompression to lower the intradiscal pressure of the lumbar disc and facilitate restoration of the disc; but it is still the failure to observe the centralization principle in each patient that most clinician’s ignore, or fail to follow, that causes the unsatisfactory results that their treatment protocols produce.

Puzzel
 

But there is one "Missing Link" in the centralization protocols that doctors seem to omit. They forget the second part of the centralization phenomenon, which is centralizing the pain but gaining an increase in their patient’s active range of motion. They use a protocol which helps the disc repair, such as axial decompression; but they fail to use a rehab and core stabilization program to restore core stability and maintain a lordotic curve in the lumbar spine. It is my experience in teaching and talking with doctors from all over the country that use any kind of decompression as a therapy tool, that they often get bogged down with only pain reduction and centralization of that pain. The successful doctors that pay attention to the missing link, which is centralization with a restoration of normal range of motion, are the doctors who have higher success rates. This is what active rehab in your office is all about. On the business side, these are the procedures that insurance companies are looking for you to use that will increase your ratio of successful outcomes. These are the active therapeutic activities that insurance companies are willing to pay for. For more information on billing and coding, go to www.flexionextension.com for a free 15-page report produced by billing and coding experts on the content of this article.
Look for Part II in the December issue.


Randy-Reed-DCDr. Reed has 22 years of clinical experience as director of Reed Chiropractic Clinic in Solon, Ohio. Randy B. Reed, D.C. is a former member of the Cleveland Orthopedic and Spine Hospital at Lutheran Hospital, where he specialized in chiropractic rehabilitation. He has also developed and presents the clinical and scientifically based "Better Doctor Seminar Series." You can contact him at 1-888-330-3627 or visit www.betterdoctorseminars.net.

 
Lumbar Lordosis
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Rehabilitation
Written by Dr. Mark R. Payne D.C.   
Sunday, 25 October 2009 00:00

I've spent a lot of time and ink over the past year, writing about the importance of, and how to rehabilitate, the normal cervical lordosis. This month, I want to spend a bit more time on the lumbar lordosis.

Recall that, in the cervical spine, the normal lordosis should be a simple arc of a circle. Unfortunately, for us, the healthy configuration of the lumbar spine is just a bit more complex. Ideally, the lumbar lordosis should be an ellipse with more curve in the lower segments than in the upper ones. ( Fig. 1. ) shows a healthy (not perfect) lumbar ellipse. I have traced George's line in yellow to help visualize the accentuated curve in the lower segments.

Healthy-Lumbar-Ellipse

 

The procedure for measuring the amount of lordosis on the lateral lumbar radiograph is similar to the cervical spine with just a few differences. We can obtain an accurate, quantitative value for the lumbar lordosis by using Jackson's angle, just as we did for the cervical spine in an earlier article. We can construct Jackson's angle using three simple steps.

Step One: Place dots on: a) the posterior-INFERIOR and b) posterior-SUPERIOR, corners of the vertebral bodies of L-1 and L-5. (See Fig. 2.) When complete, you should have drawn a total of four dots (shown here in red) on the film. 

Line-L1-L5
  

Step Two: Construct lines for both L-1 and L-5 by connecting the dots with a ruler. Be sure to Step Three - Using a protractor, measure Jackson's angle to determine the amount of lordosis. Simply lay the base line of your protractor along the L-5 tangent line, center the protractor at the point where the lines intersect, and measure the acute (smaller) side of the angle formed between the L-1 and L-5 tangents. See Fig. 3. to see which side of the angle to measure.  

Line-L-1-and-L-5
 

What this tells us. So, what's normal?

As measured here, Jackson's angle gives us two very important pieces of information. First, it tells us the overall amount of lordosis which is present with a simple, accurate, and proven measurement. Second, it tells us where the apex of the lumbar lordosis is located. All of which sounds good, but we still need some kind of normal value to compare it to. After all, it does us little good to know how much lordosis is present if we don't know what constitutes normal.

The best paper I've read to date was published in 1997 by Troyanovich, et al., in the Journal of Spinal Disorders. The paper, entitled Radiographich mensurations charactersistics of the sagittal lumbar spine from a normal population with a method to synthesize prior studies of lordosis, studied 552 asymptomatic subjects, in a wide range of age groups. The results lead the authors to conclude that there seems to be "an ideal sagittal lumbar curvature that may tend to protect holders of the geometric configuration against nociceptive tendencies. In other words, patients who fall within a certain range of lordotic values are less likely to experience back pain.

Here's the short version. The normal value for Jackson's angle as measured from L-1 to L-5 is from 35 to 47 degrees of lordosis. In pain free subjects, approximately 65% of the lumbar lordosis occurs between L4/5 and L5/S1 with the remainder (35%) of the lordosis occurring above L-4. Patients with acute low back pain, tended to be HYPERlordotic while patients with chronic LBP tended to be HYPOlordotic.

Now take a moment to refer back to Fig. 3. This patient presented with a Jackson's angle of approximately 46 degrees (at the very upper range of "normal") and complaining of mild lower back pain of short duration. This patient was treated successfully with a brief round of adjustments followed by a home treatment program consisting primarily of low back stretches and abdominal strengthening exercise to help reduce the lordosis back toward the middle range of normal.  

Measure-Angle
 

Of course, every case isn't so clean cut. There will always be some folks who fall within the "normal" values and yet are still symptomatic. Wouldn't it be great, if everything in chiropractic was so picture perfect! Nevertheless, using simple radiographic analysis to accurately determine the postural status of your patient can be a great tool in determining how to best approach management of the case. Once you start analyzing your films in this manner, I think you will be surprised at the accuracy of Troyanovich's conclusions. If you are interested in learning more about how to accurately analyze the lateral lumbar radiograph, I have prepared a FREE REPORT entitled, Measurement of the Lateral Radiographs, which explains the process in much more detail. Interested doctors may call our office for a free copy.


Dr.-Mark-R-PayneDr. Mark Payne is the president of Matlin Mfg., a manufacturer and distributor of postural rehab products since 1988. For a free, unabridged copy of Measurement of the Lateral Radiographs as well.

 
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