Rehabilitation


“Can Frozen or Painful Shoulders Really Be Unlocked in Minutes, Even after Years or Decades of Pain and Immobility?”
Rehabilitation
Written by Dr. Stephen Kaufman, D.C.   
Saturday, 08 December 2007 17:10

On 2002, at a seminar in Denver, a doctor in his 30’s stated he had had only 90° shoulder abduction for ten years. After applying this technique, his arm immediately rose to almost full abduction of 160°. In Oregon, a doctor had had severe pain and limitation of motion for over thirty years. In front of 150 DC’s, his ROM increased from 30° to 130° and almost all the pain was eliminated within minutes. This improvement maintained itself the next day, which he demonstrated by waving his arm over his head!

I’ve now treated over 35 DC’s and MD’s at seminars with frozen shoulders of many years duration; over 85 percent of them have had immediate restoration of full movement; generally this improvement is permanent after just one or a few treatments.

Painful or frozen shoulder is one of the most frustrating symptoms many DC’s are confronted with. This condition occurs in up to 2 percent of the United States’ population.1,2 Painful and limited shoulder movement of any kind is much more common than true frozen shoulder (adhesive capsulitis). The treatment discussed in this article is extremely effective for all kinds of shoulder pain, if there is pain on movement, and has been successful in well over 85 percent of cases in restoring almost full range of abduction and other movement in minutes.

 

Non pathologic joint dysfunction responds best, but even severe arthritic degeneration may greatly improve.

 

Obviously, a true adhesive capsulitis with adhesions or severely arthritic joint will have a worse prognosis than a joint with no pathology that just has pain on motion.1,2,4,7,9 Nevertheless, I saw a sixty-eight-year-old patient with severe crepitus and degeneration of the shoulder joint. His abduction was restricted to 50°, and he had severe pain in the shoulder. I cautioned him that our expectations were limited. However, by the end of the first treatment, he was able to abduct easily to 135°, with no pain! After several sessions, he regained almost full movement to 150° or so, with no pain.

 

Frozen shoulder can last for years or decades.

 

Most surgeons agree that this condition is "unresponsive to treatment, including physical therapy, injections and medication"16 and generally self- limiting, usually lasting up to a year. I’ve seen many patients who’ve been frozen for years or decades. Three patients come to mind who had the problem for thirty years; they all responded within minutes with full restoration of pain free movement.

 

Here’s how to unlock a shoulder that is painful on motion.

 

These procedures are highly effective at eliminating pain on movement. If there is no pain, but the restricted ROM is due to adhesions or muscle spasm, it’s much more difficult to improve. Sometimes the pain will immediately improve but the motion will stay restricted.

The following procedure is non manipulative, with no thrusting. It aims to realign the soft tissues and retrain them to take the humerus through a normal range of motion as it rides on the glenoid cavity, in shoulder abduction. There are advanced procedures for other planes of movement, but this simple technique is often effective at immediately reducing pain on motion and allowing increased ROM on abduction.

1. Have the patient straighten their arm and actively abduct the arm away toward the ceiling.

2. Note where pain begins.

3. Search the insertion and origins of the deltoid tendons for tender areas; if you find them, apply firm pressure on each area for ten seconds. The deltoid is the prime mover for shoulder abduction; this procedure will facilitate full functioning.

4. Stabilize the patient’s scapula with the palm of your hand pressing anteriorly, and gently pull the humerus posteriorly. Maintaining this pull, have him again abduct the shoulder. He may immediately have less pain when it moves. If so, have him continue to slowly abduct and lower his arm five to ten times. Remember, no thrusting!

5. Note: this procedure will not affect palpatory pain (trigger points) or the subjective pain the patient feels; it is only for pain on movement. The subjective pain will usually improve as the ROM increases. (Other procedures that instantly inhibit trigger points are described in The American Chiropractor, Aug. 2007, "Can Trigger Points Be Turned Off in Seconds, Using Neurological Reflexes?".)

Of course, in your office, you may need to continue treatment for several weeks for an injury of this duration. There are other techniques to restore shoulder internal and external rotation, flexion, adduction, etc., as well as different procedures for instantly neutralizing trigger points in the shoulder. Many shoulder problems are complicated by local trigger points and it may be necessary to eliminate these using Pain Neutralization Technique (P.N.T.), as described in a previous issue of The American Chiropractor.8

Stephen Kaufman, DC, graduated from Los Angeles Chiropractic College in 1978, and practices in Denver, CO. After studying dozens of techniques and being dissatisfied with the lack of consistent results, he finally developed P.N.T. to relieve pain in seconds. For more information, visit www.painneutralization.com. He can be reached at 1-800-774-5078 or 1-303-756-9567.

References

1. Amir-Us-Saqlain H, Zubairi A, Taufiq I. Functional outcome of frozen shoulder after manipulation under anaesthesia. J Pak Med Assoc. 2007 Apr;57(4):181-5

2. Andrews JR. Diagnosis and treatment of chronic painful shoulder: review of nonsurgical interventions. Arthroscopy. 2005 Mar;21(3):333-47. Comment in: Arthroscopy. 2006 Jan;22(1):117-8; author reply 118-9.

3. Bunker TD, Anthony PP. The pathology of frozen shoulder. A Dupuytren-like disease. J Bone Joint Surg Br. 1995 Sep;77(5):677-83.

4. Cutts S, Clarke D. The patient with frozen shoulder. Practitioner. 2002 Nov;246(1640):730, 734-6, 738-9.

5. Dias R, Cutts S, Massoud S. Frozen shoulder. BMJ. 2005 Dec 17;331(7530):1453-6.

6. Dinnes J, Loveman E, McIntyre L, Waugh N. The effectiveness of diagnostic tests for the assessment of shoulder pain due to soft tissue disorders: a systematic review. Health Technol Assess. 2003;7(29):iii, 1-166.

7. Hand GC, Athanasou NA, Matthews T, Carr AJ. The pathology of frozen shoulder. J Bone Joint Surg Br. 2007 Jul;89(7):928-32

8. Kaufman, Stephen. Can Trigger Points Be Turned Off in Seconds Using Neurological Reflexes? The American Chiropractor, Aug. 2007. p. 40-42.

9. Malhi AM, Khan R. Correlation between clinical diagnosis and arthroscopic findings of the shoulder. Postgrad Med J. 2005 Oct;81(960):657-9.

10. Need patients be stuck with frozen shoulder? Drug Ther Bull. 2000 Nov;38(11):86-8 [No authors listed]

11. Nitz AJ. Physical therapy management of the shoulder. Phys Ther. 1986 Dec;66(12):1912-9.

12. Noël E, Thomas T, Schaeverbeke T, Thomas P, Bonjean M, Revel M. Frozen shoulder. Joint Bone Spine. 2000;67(5):393-400

13. Polkinghorn BS. Chiropractic treatment of frozen shoulder syndrome (adhesive capsulitis) utilizing mechanical force, manually assisted short lever adjusting procedures. J Manipulative Physiol Ther. 1995 Feb;18(2):105-15

14. Wadsworth CT. Frozen shoulder. Phys Ther. 1986 Dec;66(12):1878-83

15. Warner, JJ. Frozen Shoulder: Diagnosis and Management. J. Am. Acad. Ortho. Surg., May 1997; 5: 130 - 140.

16. Frozen shoulder. www.mayoclinic.com.

 
Getting the Most Support from Assisted Devices
Rehabilitation
Written by Dr. Kirk A. Lee, D.C., C.C.S.P.   
Saturday, 08 December 2007 17:00

An elderly patient enters your office with complaints of low back pain. She is using an assisted device (e.g., cane, walker, crutches). As you watch her walk, you think to yourself, "She looks like Yoda from Star Wars, and I would hurt also if I were walking like that."

Or your patient asks, "Dr. Bones, am I using my cane correctly?" or "Dr. Bones, do you think my walker is at the right height for me?"

Can you answer any of these questions with certainty? After reading this article, you should be able to give your patients an educated answer.

Traditionally, as Doctors of Chiropractic, we do not prescribe or recommend the use of canes, crutches, or walkers. The patient usually has them from a previous condition such as stroke, fractures, and other neuromusculoskeletal conditions. Sometimes they just purchased or rented them to allow them to get to our offices.

We will address some of the most common recommendations for the use of canes, crutches and walkers. Today these devices are referred to as "assisted devices." First, we will talk about how to properly determine the correct height of our patients’ devices and then discuss their proper use.

Our basic goal for the use of an "assisted device" is to help the patient with ambulation. But, even more, it is to have the patient walk as normally as possible without sacrificing safety. As chiropractors, we understand the importance of a normal gait pattern. We have discussed this phenomenon in previous articles. Commonly, our elderly patients present a forward-flexed posture with the head carried in an anterior translation, while the thoracic spine follows with an opposite kyphosis. These postural changes are the results of poor posture, ankylosing, muscle imbalances and degenerative changes. If our patients are using their assisted devices incorrectly, they will develop other compensatory complications throughout the entire musculoskeletal system.

 

Cane

 

The patient should stand in an upright, straight posture, shoulders relaxed, with one hand on the cane. Make sure she is holding the cane in a good weightbearing position. Place the cane approximately six inches ahead and to the outside of the patient’s foot. The hand holding the top of the cane should rest so the elbow is about 160 degrees in extension or about even with the greater trochanter on that side.

 

Walker

 

With patient standing, place the walker in front of her, so that it is also partially around her on the sides. The patient should stand in an upright, straight posture with shoulders relaxed. Elbows should be almost straight. Once the patient feels comfortable, see if she can apply a push and pull on the walker without having to bend over.

 

Crutches

 

The patient should position the crutches with the tips touching the floor about six inches from each foot and out to the sides, in a comfortable, weightbearing position. The patient again needs to assume an upright, straight posture with shoulders relaxed. The axillary pads (top of the crutch) should lie against the ribs about three to four finger widths from the axila (armpit). The handles of the crutches should be positioned so the elbows are about 160 degrees extended or about even with the greater trochanter. This positioning is the same as the cane. Instruct your patient not to press down on the axillary pads. Weight bearing needs to be on the hands and not the axillary (armpit) areas. Axillary pads should be placing pressure into the body.

 

Walking with a Cane

 

The patient must understand that she is forming a "triangle foundation" with her feet and the cane. This is for stability. The cane should always be used in the hand opposite the involved leg. The function of the cane is to assist with lateral stability.

Move the cane forward and out to the side. Have patient put her weight onto the cane, shifting the weight off the involved leg. Have her move her involved leg up even with the cane. Make sure patient keeps a good center of gravity for balance. This can be assisted by having her assume a little wider stance, then press on the cane with as much weight as possible on the involved leg. Have her step past the cane with her non-involved leg. Continue this sequence.

With consideration to the different types of canes that are available, the best cane for a patient to use for general ambulatory needs is the basic "straight cane." Other canes, such as the quad cane or hemi cane, are designed for specific patients with specific gait deficiencies. They are designed for patients with limited weightbearing abilities (due to conditions such as stroke, cerebral palsy, fractures), where partial- to non-weightbearing is necessary. What commonly happens for a patient who uses a quad cane for normal ambulation, when they place the cane down, it is usually placed on one or two of the supporting legs, which now creates a rock mechanism as the weight is shifted forward onto the other legs of the cane. This is unlike a straight cane that has only one contact point to allow easy pivoting for better ambulation.


Using the Walker

 

Instruct the patient to pick the walker up and place it forward a little. Step into the walker, first with the involved leg and then with the other. Have the patient put the involved foot or leg forward and place it on the floor. For non-weightbearing gait or partial weight bearing, the patient now needs to push on her hands and, lifting her weight, step forward with involved leg, then uninvolved leg, placing it next to the involved leg. Repeat this sequence with each step. Place only weight bearing on the involved leg.

Keep reminding the patient of the importance of maintaining as normal of a heel-to-toe gait as possible and avoid limping.


Using the Crutches

 

The patient must keep in mind the proper positioning of the crutches. A triangle position of the feet and crutches makes her more stabile. When walking, maintain weight bearing on one leg and put both crutches forward. Place all pressure on the hands, and step past the crutches with her opposite foot landing on the heel first (heel strike) for balance.

Now the patient’s position should present as a backward triangle. If patient can put weight on the involved foot, we would have her try to place the crutches forward and then step forward with the involved foot up to the crutches, followed by having her step past the crutches with her uninvolved foot, placing her uninvolved foot on the ground with a heel-first landing. This maneuver is commonly used for weak legs and restricted weight bearing.

When your patient is able to bear considerable weight on the involved leg and foot, the gait pattern will resemble the pattern used for cane walking. Move one crutch, or one foot at a time (4 point) or move one crutch and one foot together (2 point).

Ultimately, the important issue with our patients and walking devices is that they are comfortable with both their use of the device and are maintaining as upright and stable posture as possible. This includes walking with as close to a normal gait pattern as possible so we do not elicit compensatory stresses throughout the musculoskeletal chain, thus allowing our patients to maintain their chiropractic adjustments for better patient outcomes.

I would like to thank my wonderful wife Terri for her advice and assistance in writing this article.

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. He is very active with the Michigan Chiropractic Society serving on the legal and government affairs committees.

 
Occupational Health and Chiropractic
Rehabilitation
Written by Iain G. Smith, D.C.   
Saturday, 08 September 2007 09:12

A few years ago I met Patsy Mckenna, an Occupational Health Regional Manager for a large national gas pipeline company here in the UK. Patsy invited me to give a presentation to some of her colleagues at their head office in Birmingham, and although it was over 50 miles from my practice I agreed to do it. After all, I felt it could only enhance chiropractic awareness both within the industrial care arena, and for the community in general.

The presentation was received enthusiastically and I went back to my clinic and gave it little thought. A few weeks later Patsy informed me that she was changing companies and moving closer to home. She was now to take on the role of Occupational Health Advisor for Heinz Foodservice in Telford, Shropshire - a factory with around 200 employees less than ten miles away (she was later to take on an advisory role for Heinz Europe regarding Occupational Health).

At that time my chiropractic clinic, unlike the mainstream medical providers Heinz was utilizing, was not covered by their particular health insurance provider. Patsy, to her credit, was not to be deterred. Understanding the benefi ts of a proactive approach, and wanting to introduce chiropractic care as part of her industrial care strategy, she managed to secure a small budget from Heinz that would allow her to send particular cases to me for a consultation and a subsequent six follow up visits with a re-exam.

Any chiropractor in clinical practice will recognize that healing is a process rather than an event. The challenge here would be to show signifi cant results within a limited timeframe. Thankfully this was achieved, and well documented, so when the time came for the next budget Heinz extended their commitment to an initial twelve visits for their staff. This again was outside their insurance coverage at that time and so they were paying directly out of their Occupational Health budget. (We were later to be covered by their providers in 2005).


 

So why would a company like Heinz—under strict budget controls, as all big companies are - be so interested in providing chiropractic services for their staff? If we take a look at the graph below it becomes clear and apparent. Put simply, it just made good business sense.

This graph pertains to the fi rst 13 month period that Patsy McKenna was gathering data at Heinz Foodservice in Telford and as such represents the fi rst 13 month introduction of chiropractic into their industrial care strategy. It is important to note that access to standard medical services was still covered by insurance and therefore did not change during this time period. The main variable was a good working relationship between Occupational Health Advisor and Chiropractic Provider.

An understanding that Chiropractic is based on the reintegration of normal nerve function, and therefore can have positive influences on the body as a whole, was refl ected by the type of referrals that Patsy sent to this clinic.

The typical neuro-musculo-skeletal disorders associated with factory and offi ce workers made up the primary reason for refer- ral. However, patients with pregnancy related conditions, GI disturbances, respiratory complaints, and generally poor immune function also attended for care with good results. (N.B. No patients were referred directly for mental health problems).

These figures demonstrate that Heinz Foodservice Telford, with a staffi ng level of around 200 employees, reported a statistically signifi cant reduction in workdays lost over the 13 month period that these records refl ect.

This suggests that many companies could achieve signifi cant cost savings with regard to employee attendance simply by incorporating chiropractic services into their industrial care strategies. Newport Chiropractic and Heinz Foodservice Telford continue to have a positive working relationship.

- My thanks go to Patsy McKenna for her work in promoting chiropractic within the occupational health fi eld and for keeping these statistics, and also to Nigel Disney, Health and Safety Manager Heinz Foodservice Telford, for agreeing to allow us to use them.

- Please note that we did not embark with the intention of creating a designed research study. This data merely refl ects a record of what happened.

- Newport Chiropractic utilizes SOT and SOT Cranial protocols as its primary systems of care.


Dr. Iain Smith is a graduate of Palmer College of Chiropractic (USA) and a member of the BCA, ICA and SOTO Europe. He can be reached at This e-mail address is being protected from spambots. You need JavaScript enabled to view it .

 
Traveling with a Wellness Lifestyle
Rehabilitation
Written by Dr. Kirk A. Lee, D.C., C.C.S.P.   
Monday, 06 August 2007 12:19

travelerWith the treatment of any new patient following initial consultation, evaluation and management we must make some decisions; or to meet our E&M requirements we have some "medical decision making" to do. How many Chiropractic Manipulative Therapies (CMT), do we schedule before our next progress exam or re-evaluation? Are we scheduling any type of conjunctive therapy like muscle stimulation, ultrasound, hot or cold packs, mechanical traction to help promote healing? Maybe we will include some soft tissue work like active release, Nimmo, Graston technique to assist in stabilizing the components of the vertebral subluxation complex. Finally, we may determine that rehabilitative exercises or neuromuscular reeducation is necessary to help further the patient’s progress and ultimate outcome.

All these procedures may or may not make up your patient’s chiropractic office visit; but when the patient is not in your office, what instructions have we provided to further allow them to develop the "chiropractic lifestyle" or "wellness lifestyle?" Have you discussed activities of daily living do’s and don’ts? Have we considered home use of hot or cold application and home instructions of rehabilitative exercises or just general fitness options? What about our patient, who is a salesperson or is leaving on vacation, are we addressing their rehabilitation and physical fitness needs?

Rehab-to-go

Let us take a look at this patient who may use the excuse that they are on vacation or have a busy daily schedule and are traveling for business all the time.

As our patients travel, whether it has to do with vacation or business, we want them to maintain the types of "wellness lifestyle" that we have incorporated as part of their care plan. If we have placed our patients on a home rehabilitation program, it is essential that they follow your recommendations—regardless of whether they have to go on vacation or a business meeting. Today hotels have developed state-of-the-art fitness centers to attract guests; some may even have a complete spa facility. But, what if our patients are on tight schedules, long days in the car, sitting in long meetings or standing while giving a presentation? When they finally get something to eat and go back to their rooms, going to the fitness room is probably the last thing on their minds. Maybe they did not bring any clothes for a work out?

Patients who are assigned at-home resistance exercise programs need to continue performing their exercises when they are traveling. Keep in mind that most types of resistance tubing come in a variety of strengths, This is usually demonstrated by color sequences, with red being the lightest, yellow or green mid-range and black being the most resistant. The main objective is to move a joint through a complete range of motion or specific movement, while stimulating the muscle or muscle groups by acting to the resistance—all for the purpose of reeducation, toning, or strengthening a muscle or muscle group. If you provide only one type of tubing strength for your patient (yellow), show them how to vary the length of the tubing to either decrease or increase the strength of resistance.

Make sure you have your patients loosen up their muscles a little before starting the resistance exercises. Have them do some general stretches or perform a couple of the recommended exercises without the tubing or resistance. It is very important that our patients perform the tubing exercises properly. Full ranges of motion and being able to pull the band through the complete movement pattern to end-point is essential. If end-point is not achievable then we are having them use too much resistance which can lead to "overloading the joint" and possibly creating an aggravation or re-aggravating a previously stable condition. Proper instruction on correct breathing patterns must also be included, such as exhaling during the resistance movement pattern and inhaling during the return to starting point.

Many of your larger hotel chains like Hilton, Westin, Marriott provide in-room resistance tubing kits upon request. Some even have in-house TV channels that allow you to follow along. During your wellness lectures is another great time to introduce the importance of maintaining some form of exercise program.

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. He is very active with the Michigan Chiropractic Society serving on the legal and government affairs committees.

 

 
Vibrational Therapy and the Aging Baby Boomers
Rehabilitation
Written by Christian H. Reichardt, D.C., C.C.S.P.   
Monday, 06 August 2007 12:16

Looking at recent statistics, the boomer population is going to increase by almost 70 percent over the next fifteen years. This is the fastest growing population segment of our society! The three most common musculo-skeletal ailments afflicting this group are osteoporosis, lack of flexibility and strength, as well as balance. In this article, I will show that Whole Body Vibration (WBV) therapy in the chiropractic office setting can serve the purpose of attracting and helping many patients from this demographic.

Statistically, the most common reason for which elderly patients are checking into assisted living facilities is not disease or illness, it is immobility: All those individuals have lost the ability to move freely around their homes, and therefore, experience significant difficulties in taking care of themselves.

Baby boomers

Many of them consider themselves part of the LOHAS (Life Style of Health and Sustainability) community. They are the people who are interested in the wellness lifestyle and want to be involved with their own process of well-being. Yet often they end up with some dis-abilities that interfere with the activities of daily living (ADL).

Here are a number of facts about this population group:

• Many know they should be exercising, but have not done so.

• Many do not know where to start or where to go to. They often look for easy, safe and uncomplicated exercise choices that will not take a tremendous amount of time to learn and do.

• Virtually all of them are willing to invest the time, effort and have the money to not only live longer, but live better.

• Many are already chiropractic patients or at least have friends that have tried our type of health care!

Our profession is in the perfect position to assist this market segment in their quest. There is no doubt that it is the market to be in.

Over the years, probably the largest percentage of research about WBV was done about its effectiveness in the treatment of osteoporosis. Early studies in Russia were dealing with cosmonauts being subjected to weightlessness in outer space for prolonged periods of time. The lack of gravity had a profoundly diminishing effect on bone density as well as muscular strength. One of the therapies implemented was WBV. The results were very favorable. Since then, dozens of researchers in as many countries have spent years researching the effects of WBV as a form of osteoporosis treatment. The general consensus is that utilization of WBV in addition to weight-bearing exercise represents the best non-pharmaceutical treatment of that disorder!1, 2, 3, 4

Similar results were achieved when evaluating the effectiveness of WBV on loss of strength and flexibility. Dozens of research projects showed that the "Acceleration/Deceleration" effect of WBV has a direct impact on muscular activity and strength, primarily via the tonic vibration reflex as described in last month’s article. Numerous articles have been published on this issue and some researchers have shown as much as 24.4 percent improvement of muscular strength development over a twenty four week time period. This represents far better results than the control groups who were using traditional weight training(16 percent).5

It further shows that WBV, and the reflexive muscle contraction it provokes, can induce strength gain in previously untrained participants to the same extent as weight training!6

Thus WBV offers a fast, simple, easy-to-learn and safe alternative to going to the gym for the above mentioned Baby Boomers. The chiropractor’s office is the perfect location to introduce and implement WBV. With its small space requirements, the units can be placed easily into a doctor’s office. Look for units that supply informational as well as instructional DVD’s and materials that will make the training of the staff and patients easy and hassle free.

If the usage of WBV on the European continent is any indication, it is clear that WBV is here to stay and will become more and more a treatment modality of choice for many musculo-skeletal problems. Over the next years, more research will be done about WBV in the healthcare arena and lead to better protocols and guidelines. In the meantime, many doctors in the healthcare field are already using the beneficial effects of WBV to assist their patients and getting them to feel better faster.

Dr. Christian H. Reichardt is a 1983 graduate of National College of Chiropractic. He may be reached at 1-310-829-0453, by email at This e-mail address is being protected from spambots. You need JavaScript enabled to view it or visit www.Golf-Health.com.

 
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