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Rehabilitation
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Rehabilitation
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Written by Dr. Benjamin Griffes, M.A., D.C.
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Friday, 21 August 2009 14:05 |
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Rehabilitation of the patient with a herniated disc consists of improving their strength and flexibility while, at the same time, addressing their posture and habits. You must reorient yourself to think about low back problems in a functional way rather than a pathoanatomical way.1 The focus should be on restoring correct posture and normal productivity, achieved by teaching your patients the proper way to engage in their normal activities, while acknowledging the origins of herniations. McGill, in Low Back Disorders, makes four general conclusions from his research that most herniations come from extreme deviated posture, repeated loading of the spine over thousands of times, and the sitting posture in sedentary occupations.2
In order to prevent further herniation and low back dysfunction, the patient must relearn how to sit and stand properly, strengthen weak muscles and lengthen restrictive muscles and fascia. Specifically with disc herniations, you do not want to increase the compression forces on the discs with unnecessary loading, so it’s preferable not to prescribe sit-ups or exercises which put the spine in extreme flexion, or with extreme extension, like "reverse sit-ups" and the "Superman." Instead, you want to teach your patients to do the "Bird Dog" (Fig. 1) and Side Bridges (Fig. 2). Both exercises are two of the safest and most effective core stabilization exercises anyone can do.
Functionally, it is strongly recommended not to do any flexing of the spine immediately upon rising in the morning or after long periods of driving. A patient of mine complained that he was getting back pain every morning after he got up, lasting about 45 minutes. We figured out that he bent over the sink and brushed his teeth every morning, then took a shower. I had him change his habit and shower first, then brush the teeth. Within the week, his low back pain disappeared. One reason you feel stiffer in the morning is because, while lying horizontal for 6 to 8 hours, the extracellular fluid in the body pools in the joints, and movement redistributes it.
There is also the variable of "internal friction" within the joints caused by prolonged static posture, seen in truck drivers and athletes who sit on the bench for long periods.3 Because a high percentage of chronic low back pain is due to a sedentary lifestyle, it is imperative that you teach your patients to sit properly and to take frequent breaks. I have always taught my patients to establish a "neutral posture" while sitting (and standing); but there is also the philosophy that there is no ideal sitting posture and it is better to employ a "variable" posture which reduces the risk of tissue overload.4 It is repetitive immobility, replicated on a daily basis that leads to chronic postural overload and adaptive shortening of the muscles and fascia. Kendall, in Posture and Pain, notes that "normal joint range for adults should provide an effective balance between motion and stability. A joint which is either too limited in range or not sufficiently limited is vulnerable to strain."5
This promotes the need for both a trunk stabilization program and a daily stretching program. Stretching should become a habit, like brushing your teeth. Without any stretching, you and your patients continue to promote a pattern of restricted movement and muscle fatigue. Guyton points out in Medical Physiology that muscle fatigue comes from prolonged and strong contraction of a muscle. This causes the interruption of blood flow, which leads to muscle fatigue due to a loss of the nutrient supply and lack of oxygen.6
I recommend four basic back stretches that should be done daily. They are the Cat/Camel (Fig.3), lateral side bends, and back rotation. These stretches minimize the compressive load on the spine and move the spine through all ranges of motion. The fourth stretch is The Lunge, which stretches the psoas muscle, a major hip flexor and postural muscle. It has a tendency to tighten and shorten with prolonged sitting, leading to weakness, and the Lunge stretch helps to keep it lengthened and balanced. Consider, then, that a key element of your care is the education of your patients. This means that you must address their posture, habits, strength and flexibility, and to make sure they do not engage in any activity which will increase the compressive forces on the spine, be it active or passive.
 Benjamin Griffes, M.A., D.C., shares his time between Tarzana and Thousand Oaks, CA, offices when he’s not lecturing or writing on health, fitness, stretching and proper posture. A 1990 graduate of Cleveland Chiropractic College, he also has a Master's Degree in Physical Education/Sportsmedicine from California State University Northridge. He is the author and producer of Stretching for Life products ( www.Stretching4Life.com ) and recently joined Your Best Form ( www.YourBestForm.com ) as Chief Health Advisor.
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Rehabilitation
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Written by Dr. Mark R. Payne, D.C.
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Wednesday, 24 September 2008 17:10 |
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Feeling frustrated with the long time frames required for corrective care programs?
Maybe you should try a little C.R.A.C. No…I’m not recommending you seek solace in some vicious street drug. Instead, you might want to try combining a well accepted muscle stretching technique with extension traction to speed up the corrective process. Here’s how it works.
The acronym C.R.A.C. (Contract-Relax-Antagonist Contract) normally refers to an effective method of assisted stretching. The method has a simple three-step sequence in which the patient is instructed to;
- Contract the shortened muscle (the agonist) for 8-10 seconds.
- Relax
- Contract the antagonist of the shortened muscle, followed by the therapist’s applying stretch force to the agonist.
When used in conjunction with extension traction, the stretching efforts of the therapist are replaced by the applied force of the extension traction unit.
Here’s how I have used the C.R.A.C. method in combination with the Dakota Traction. The patient is first positioned properly on the fulcrum with the head free-hanging and the headband in place over the forehead. Tip: I prefer patients to have already been using the Dakota Traction for a week or two, just to make sure they can tolerate the extension traction process without undue discomfort.
During the first few minutes of each traction session, patients are instructed to perform the following movements to initiate the C.R.A.C. sequence.
I typically instruct patients to repeat the entire sequence six to eight times and then simply relax for their full traction session of 20-30 minutes (or according to their tolerance).
The method works by virtue of Sherrington’s Law of reciprocal inhibition, in which the taut/contracted flexors are "tricked" into relaxing by contracting the extensors. C.R.A.C. stretching has been around for a long time and appears to be a very effective way to lengthen taut or shortened musculature. Years ago, I began experimenting with combining the C.R.A.C. method of inducing muscular relaxation with various types of cervical extension traction. My idea was that, if the patient’s loss of cervical lordosis was primarily due to contracted musculature on the anterior neck, it might be possible to speed up the process of correcting the lordosis by incorporating more efficient ways of addressing the taut musculature. My results were very encouraging. I found that some (not all) patients were achieving dramatic corrections, with just five-minute applications that would have normally taken months to accomplish.
Those poor souls who have followed my columns so far may recall that I am always emphasizing the importance of applying sustained corrective forces for 20-30 minutes daily over a period of three or four months in order to correct the lordosis. Yet here were some patients getting phenomenal corrections in a fraction of the time. As it turns out, the sustained periods of loading, so vital to stretch non contractile tissues, aren’t necessarily the quickest way to stretch contracted musculature. C.R.A.C. traction can offer a practical way to speed up the process when you suspect muscle to be the primary tissue perpetuating your patient’s poor posture. My results were very encouraging. Although there is no published research on this particular combination, both methods are safe and effective. Using them in tandem is safe, logical and, best of all, won’t cost you a penny extra to try.
My personal experience with the method is that about 25-30 percent of patients will show VERY rapid corrections with C.R.A.C. traction. Those patients who are responding well will often exhibit dramatic changes in their forward head posture within just a week or two as opposed to the normal 10-12 weeks we would anticipate in most cases. In my experience, these changes in forward head posture always correlated well with improvement of the lordosis upon re-X-ray. It seems intuitive that these rapid responders must have a fairly significant muscular component as a perpetuating factor of their abnormal head postures.
And what about those who don’t respond? They just continue to progress in the slow and steady manner we have come to expect when applying corrective traction. Most likely, these non responders are those patients with a greater degree of non contractile tissue adaptation and will respond as usual to the long term application of sustained traction force. No doubt, many patients actually have postural adaptation of both muscular and non contractile tissues to varying degrees. With this in mind, and because there is really no downside to the method, I often incorporate the C.R.A.C. sequence with my extension traction methods to help remove any muscular resistance as quickly as possible. If you’ve been frustrated with long corrective care programs, I suggest you just try a little C.R.A.C. You’ll be feeling better in a week or two.
Dr. Mark Payne is the president of Matlin Mfg., a manufacturer and distributor of postural rehab products since 1988. To request more information on postural chiropractic methods, call 1-334-448-1210 or link to www.MatlinMfg.com.
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Rehabilitation
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Written by Dr. Kirk A. Lee, D.C., C.C.S.P.
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Wednesday, 24 September 2008 17:06 |
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With the approach of summer, more of our patients are turning their attention to getting outdoors and exercising. Activities can range from walking to the mailbox to running local 5K races. Regardless of our patients’ activity levels, an important factor in keeping them out of pain is addressing the shoes they are wearing.
Different Activities, Different Needs
Commonly, someone who begins a walking or running program may not take into consideration the equipment necessary to embark on their journey. They wear the same shoes that they wear to mow the lawn or take the garbage out. For someone who is only going to walk or jog a couple blocks, this may be alright; but, for anyone who is going to consider ramping up the mileage, the correct shoe types are essential.
The Three Types of Feet
Normally, we believe that people can have one of two types of feet; those that are flat and those that are not. Technically, this is incorrect; we actually have three types of feet. The first type is a supinated foot, which is usually associated with the higher arch and weight distribution that is a bit more lateral. This foot also demonstrates a footprint of a "C" shape. The second type is referred to as a neutral foot, which has a slight or semi-curve to it, and still maintains an arch upon sight inspection. This foot will have weight distribution that usually transitions through the midline of the foot. The third foot type is the flat foot or hyperpronated foot. This imprint is usually wider and straighter in appearance.
Keeping these points in mind, running shoes are designed the same way. Once you know your foot type, you should make sure your running shoes match accordingly. The supinated shoe is usually narrower and has a curved last. The neutral shoe will have a semi-curve to its last, while the hyper-pronated shoe is usually straight. In literature, you will see this shoe referred to as the "motion-control" shoe. This terminology comes from the shoes being designed to support the foot and prevent excessive hyperpronation.
What Type Are You?
How do we determine which foot types we are? You could always wet your feet and step onto a piece of dark construction paper or a brown grocery bag. The best clinical way is to use a digital scanner. By scanning your patients’ feet, this will not only show you the foot types they possess, but may also show weight bearing imbalances that affect the normal movement pattern of the foot. These imbalances are a result of a breakdown of the anterior, lateral, or medial arches. One or all three of the arches can become involved. Visually, a patient may appear to have some form of an arch; but, on scanning, it actually shows a breakdown. This can be more visual after the foot has been weight bearing and has not been supported properly. This results in what is referred to as plastic deformation, where the aponeurosa of the plantar fascia can no longer maintain its normal length due to being overstretched from repetitive microtrauma.
Now, what?
Once we have determined our foot type, we need to determine whether or not there is a need for custom-made flexible orthotics based on the scanner results. Keep in mind the importance of making sure the orthotics fit properly into the patient’s running shoes. We want to make sure the patient first takes out the store insole. This allows orthotics to fit more securely within the shoe. It is also very important, in future purchases of shoes, that our patients make sure they take their orthotics with them to place them into any new shoes they may purchase.
Another important component of the shoe structure is the shock absorbency and rigidity of the shoe. A shoe designed for a supinator is usually designed with more shock absorbency. This is due to the supinated foot’s being a very rigid foot which will absorb a lot of stress. The neutral foot and the hyperpronated foot disburse a lot of the stress they receive due to their being more flexible.
Often I am asked, will the motion control shoe be enough to support the foot when it hyperpronates? The answer is no, the reason being that, even though the shoe is designed to control the hyperpronation or medial rolling of the midfoot, it still is not designed to support all the arches as a custom-made flexible orthotic would. A great custom-made flexible orthotic and a great shoe are a perfect combination to help our runners and walkers get the best benefits to allow them to participate in a pain-free, active lifestyle.
A 1980 graduate of Palmer College of Chiropractic, Dr. Kirk Lee is a member of the Palmer College of Chiropractic Post Graduate Faculty and Parker College of Chiropractic Post Graduate Faculty. He has lectured nationwide on sports injuries and the adolescent athlete, and currently practices in Albion, Michigan. Dr. Lee can be reached at
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Rehabilitation
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Written by Dr. Stephen Kaufman, D.C.
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Wednesday, 24 September 2008 16:42 |
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Before I became a chiro-practor, I read many books about chiropractic. My limited understanding (a fantasy, really) was that chiropractors put some kind of secret pressure on spinal nerves that turned off pain instantly. After going to dozens of chiropractors and practicing for many years, I realized that this was, indeed, a hopeless fantasy. I never saw anything that consistently turned off pain by utilizing spinal nerves.
The Manual Spinal Nerve Block
One day, as I was doing research on the Internet, I came across an old Japanese chart demonstrating various neurological pathways. For some reason, the style and content of the chart triggered that ancient fantasy in my brain and an idea popped into my head. Suppose I applied a very specific form of pressure to spinal nerve roots utilizing known neurological pathways to try block pain with just manual pressure. The beauty of this theory was that it required no drugs or instruments—I could experiment using just my hands and a patient’s pain. Since the only thing involved was a type of light pressure on various nerves, it would be completely safe and pain free. (The specific pathways I was interested in were the spinothalamic tract and the tract of Lissauer.)
It’s important to note that the manual spinal nerve block procedure does not involve any type of thrusting or manipulation. Although various schools of chiropractic discuss the relationship between spinal nerves and various organs, to my knowledge, no other technique has demonstrated instant elimination of pain by stimulation of spinal nerves.
 Working with this hypothesis, I eventually found that I could instantly turn off much muscular tenderness in areas that were sore to touch. These are often called "trigger points," but our definition of trigger points is very broad—it’s any area that’s more tender to pressure than the surrounding tissues or the same area on the opposite side of the body. Often, the exquisitely tender area would become normal (not tender to pressure) instantly with the application of the correct type of pressure to a spinal nerve root, even if that spinal nerve were a foot or more away from the sore spot. This worked consistently, even if the trigger point had been sore for many years, or there was acute pathology including fractures.
In many cases, chronic pain syndromes, such as cervical and lumbar disc pain, shoulder pain, TMJ pain, sciatica, and severe low back pain, responded rapidly to this procedure. Trigger points or areas of tenderness are well known to every chiropractor. Palpating the paraspinal area from the atlas down to L5 usually reveals multiple areas of extreme tenderness; even after adjustment, these areas often remain tender. Applying one of the manual spinal nerve blocks, in most cases, will cause an immediate reduction in tenderness of these points. In chronic cases, several treatments using this procedure will usually eliminate the trigger point on a long term basis.
Numbness and Radicular Syndromes Often Respond as Well as Pain
Many doctors are afraid that numbness may be a more serious sign than pain. I have gotten many calls about patients with paraesthesias. In my experience, numbness often is due to altered circulation in muscles secondary to areas of constriction. Carefully examining the muscle that the related nerve travels through almost always reveals very painful areas (trigger points). Relieving these trigger points with manual spinal nerve blocks very often normalizes circulation rapidly. I used to tell my patients that numbness might take longer to respond than pain, but I’ve now seen many instances of it disappearing in seconds after the proper manual spinal nerve block has been performed.
Numbness and radicular symptoms in the arms and hands often is caused by trigger points in the upper trapezius muscle. Other contributors may originate in the SCM, neck extensor or scalene muscles. Numbness in the lower extremity is often caused by areas of constriction in the piriformis, gluteal, or quadratus muscles.
Utilizing different nerve pathways, there are actually ten manual spinal nerve blocks discovered so far. One near the atlas often has a wide ranging effect throughout the body. The stellate ganglion block seems to down regulate excessive sympathetic nervous activity and may profoundly reduce stress and the physical symptoms associated with it. One M.D. who specializes in Lyme’s disease has been using one of the parasympathetic techniques with dramatic effect on her patients with Lyme-related arthropathies (joint pains.)
Difficult Extremity Cases, Abdominal Pain and Even the Pain from Kidney Stones Respond.
Extremities respond well, too. I saw two cases of Osgood Schlatter’s disease with severe knee pain that both cleared rapidly when the appropriate manual spinal nerve blocks were applied. A two-year follow up showed no recurrence.
The manual spinal nerve blocks are the treatment of choice in chronic abdominal pain of many kinds. I’ve seen instant results in turning off pain in Crohn’s disease and ulcerative colitis. Post surgical pain following hernia surgery, hysterectomies, bowel surgery, etc., even if it’s been there for years, has disappeared in one or two treatments. One physician said, "This would revolutionize the way we do hernia surgery."
Even two patients with kidney stones got immediate relief; the stones passed quickly without further problem. By stimulating the related nerve roots and eliminating the palpatory pain over the kidney area, the patients’ pain disappeared. Relaxation of the musculature of the back then allowed the stones to pass through quickly.
Stephen Kaufman, D.C., graduated from Los Angeles Chiropractic College in 1978, and practices in Denver, CO. His techniques, Pain Neutralization Technique and Manual Spinal Nerve Blocks, represent a rapid new, lasting approach to pain. For further information, visit www.painneutralization.com or www.manualspinal.com, or call Dr. Kaufman at 1-800-774-5078 or 1-303-756-9567.
References:
1. Baldry, Peter. M.D. Acupuncture, Trigger Points and Musculoskeletal Pain, Churchill Livingstone; 3 edition (2005)
- Best and Taylor’s Physiological Basis of Medical Practice. (1979) Edited by John Brobeck. Pp. 9-80
- Graff-Radford SB. Myofascial pain: diagnosis and management. Curr Pain Headache Rep. 2004 Dec;8(6):463-7.
- Kaufman, Stephen, D.C. “Can Pain Be Turned Off Instantly By Using Neuromuscular Reflexes?” Townsend Letter for Doctors, 11/2007.
- Kaufman, Stephen, D.C. “Even Most Doctors Have Chronic Pain–Who Knew?“ Townsend Letter for Doctors, 05/08.
- Kaufman, Stephen. “Can Trigger Points Be Turned Off in Seconds Using Neurological Reflexes?” The American Chiropractor, Aug. 2007. p. 40-42.
- Matthews, Gary G. Neurobiology: Molecules, Cells and Systems. 2001. Blackwell Publishing.
- Rowen, Robert. M.D. “Permanently Eliminate Pain in Minutes.” Second Opinion Newsletter, July, 2006
- Rowen, Robert. M.D. “Chronic Pain Relief in Just 20 Seconds.” Second Opinion Newsletter, June, 2008.
- Schmidt, R. F. ed. Fundamental of Neurophysiology (1975). pp 102-114; 144-160
- Shah JP, Danoff JV, Desai MJ, Parikh S, Nakamura LY, Phillips TM, Gerber LH. Biochemicals Associated With Pain and Inflammation are Elevated in Sites Near to and Remote From Active Myofascial Trigger Points. Arch Phys Med Rehabil. 2008 Jan .
- Simons DG. New views of myofascial trigger points: etiology and diagnosis. Arch Phys Med Rehabil. 2008 Jan;89(1):157-9.
- Tanner, George A. Rhoades, Rodney A. PhD., Medical Physiology, Lippincott Williams & Wilkins; 2 edition, 2003.
- Travell J, Rinzler, S The myofascial genesis of pain. Postgrad Med. 1952 May;11(5):425-34.
- Travell, J. and Simons, D.G. Myofascial Pain and Dysfunction: the Trigger Point Manual. Vol. 1 and 2. Second edition, 1999. Liponcott, Williams and Wilkins.
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Rehabilitation
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Written by Dr. Mark R. Payne, D.C.
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Sunday, 27 July 2008 11:37 |
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So far, we’ve discussed a couple of different variations on extension traction methods for restoring the cervical lordosis. Before we move on, let me just say a few words regarding patient safety and extension traction procedures.
CAUTION: Extension traction procedures aren’t for everyone.
There I said it. Of course, I’ve been saying it constantly for the past twenty years or so. Nevertheless, I continue to run into doctors who have never screened a single patient before starting extension traction treatment. The purpose of this article is to get you, the doctor, focused on patient safety and to communicate what I know about the potential risks associated with extension traction procedures. Essentially, every therapeutic procedure carries with it some attendant risk and extension traction is no different. It is our duty to weigh potential risks against potential benefits. To minimize risks, it is important we do everything in our power to detect potentially "high risk" patients BEFORE they undergo any procedure which might carry with it an unacceptable level of danger.
I strongly believe we can minimize the risks associated with extension traction procedures by using simple, common sense screening procedures on every single patient before beginning treatment. That being said, there may still be some percentage of high risk patients who will slip through our safety net, for the simple reason that no screening procedure is likely to be 100 percent effective. I understand this whenever I consider using extension traction or any other type of therapy. You need to understand it, too. It is our duty to act according to the current state of knowledge; but, unfortunately, extension traction is still a relatively new procedure. The following information is the best I can offer you at this time. It is up to you, as the practitioner, to determine whether these methods are appropriate for each individual under your care.
As a general rule of thumb, you should not consider applying extension traction to any patient for whom spinal adjustment/manipulation would be contraindicated. By definition, extension traction procedures involve extension (backward bending) of the head and neck. Much has been written in the chiropractic literature about the possible dangers associated with extension of the head and neck, particularly when combined with cervical rotation. Although extension traction DOES NOT involve any rotation of the neck, it is still prudent to screen for any individuals who might be considered as "high risk" for physical treatment of the cervical spine.
During the patient history, you should screen for any conditions which might contribute to increased risk of injury/complications during extension traction and/or cervical spine manipulation. Such conditions might include: family history or predisposition to stroke; patient history of high blood pressure, hypertension, diabetes, atherosclerosis, arteriosclerosis, posterior osteophytic spurring, disc protrusion/prolapse, smoking, oral contraceptives, prolonged use of corticosteroids, Down’s Syndrome, or spinal stenosis. This list is not necessarily all inclusive; however, extreme caution is recommended if any of the above is present.
Contraindications
Factors which CONTRAINDICATE the use of extension traction include, but are not necessarily limited to: patient history of stroke or other cerebrovascular disease, a history of "drop attacks," black outs, loss of consciousness, disturbances of vision and/or dizziness or vertigo associated with head positioning, history of transient ischemic attacks, spinal fracture or instability, spinal malignancy, infection or disease of the cord or column including advanced osteoporosis, and hemophilia or other blood clotting disorders including anticoagulant therapy. All are factors of sufficient seriousness and should be considered ABSOLUTE contraindications to any attempts at extension traction. In the case of lumbar extension traction, I believe that pregnancy and/or the presence of aortic aneurysm also present unacceptable risk factors.
Provided none of the above items is present, the patient is put through a simple five-step screening procedure which includes the entire George’s Test procedure (bilateral BP, radial pulse, carotid artery auscultation, and vertebrobasilar maneuver) as well as a trial period of extension traction. If any significant pain/discomfort or, more notably, any neurological symptom is noted at any point during the screening, the doctor should discontinue all further attempts at extension traction until the cause can be determined.
Extension traction has been widely used for well over twenty years now and has a remarkable record of safety. We can help keep this safety record intact by thoroughly screening every patient for possible risk factors or contraindications prior to starting any program of extension traction. The responsibility to "do no harm" rests with each of us.
For a more complete discussion of Patient Safety: Screening Procedures and Suggested Treatment Protocols for Extension Traction, call Dr. Payne at 1-334-448-1210 for his free report on Patient Safety. Dr. Mark R. Payne is the president of Matlin Mfg., a manufacturer and distributor of postural rehab products since 1988. To download a full and unabridged version of this article, link to www.MatlinMfg.com.
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