Rehabilitation


To Rehab or Not to Rehab?
Rehabilitation
Written by Dwight Whynot, D.C.   
Monday, 06 August 2007 11:44

If you are not performing rehabilitation in your clinic right now, you should consider doing rehab in the near future because it is these types of CPT® codes that are getting doctors paid better by the insurance companies. The insurance companies pay better because the patients not only get better faster, but the patients stay better longer.

 

 

Table 1Case Management Strategy

 

Initial Visit-

Questionnaire(s), Examination, X-rays, Therapeutic Modalities, Algometry (PPT testing)

Second Visit-

cROM Testing, CMT, Therapeutic Modalities

Third Visit-

cMT, CMT, Therapeutic Modalities

Fourth Visit-

PPT testing, CMT, Therapeutic Modalities

Fifth Visit-

CMT, Therapeutic Modalities

Sixth Visit-

CMT, Therapeutic Modalities

Seventh Visit-

CMT, Therapeutic Modalities

Eighth Visit-

CMT, Therapeutic Modalities

Ninth Visit-

CMT, Therapeutic Modalities

Tenth Visit-

CMT, Therapeutic Modalities

Eleventh Visit-

CMT, Therapeutic Modalities

Twelfth Visit-

Re-Exam,Therapeutic Procedures

Thirteenth Visit-

cROM Testing, CMT, Therapeutic Procedures

Fourteenth Visit-

cMT, CMT, Therapeutic Procedures

Fifteenth Visit-

PPT testing, CMT, Therapeutic Procedures

Sixteenth Visit-

CMT, Therapeutic Procedures

 

Most modern chiropractic offices have a physical therapy/rehab department/room that is dedicated to performing the therapeutic modalities or therapeutic procedures (see Table 1). There are three reasons doctors of chiropractic should be performing therapeutic procedures:  

1) business reasons—the reimbursement rate is very good for these codes

2) clinical reasons—the patients get well faster and stay well longer.1, 2

3) insurance reasons—insurance companies readily acknowledge doctors who are using these procedures The CPT® 2007 codebook defines therapeutic modalities and therapeutic procedures as:

Therapeutic Modalities—Any physical agent applied to produce therapeutic changes to biological tissue, including, but not limited to, thermal, acoustic, light, mechanical or electrical energy—essentially, the modalities such as Mechanical Traction, Ultrasound, Stim and Heat (MUSH). I call it MUSH because that it is what the insurance companies pay for these modalities—MUSH. There are two types of modalities: Supervised Modalities and Constant Attendance Modalities.

Supervised Modalities—the application of a modality that DOES NOT REQUIRE direct (one on one) patient contact by the provider.

97010 Hot or Cold Packs

97012 Traction, Mechanical

97014 Electrical Stimulation, unattended 97018 Paraffin Bath

97022 Whirlpool

97024 Diathermy

97026 Infared

97028 Ultraviolet

Constant Attendance Modalities—the application of a modality that REQUIRES direct, one on one, patient contact by the provider.

97032 Electrical Stimulation

97033 Iontophoresis

97034 Contrast Baths

97035 Ultrasound

97036 Hubbard Tanks

Therapeutic Procedures—a manner of effecting changes through the application of clinical skills and/or services that attempt to improve FUNCTION.

       97110 Therapeutic Exercises

       97112 Neuromuscular Re-education

       97113 Aquatic Therapy

       97116 Gait Training

       97124 Massage

       97140 Manual Therapy

       97530 Therapeutic Activities

       97535 ADL (home)

       97537 ADL (work)

The insurance industry is moving toward a more active model of healthcare where the policy holder/patient is becoming more responsible for his/her own healthcare, meaning the doctor should place a patient in a treatment plan that allows a patient to move from a passive care model to an active care model. In this way, the patient takes ownership of his/her health, which allows the patient to do most of the work rather than the doctor (see Table 1).

The case management strategy in Table 1 is not set in stone. You still must think as a doctor. If the patient is ahead of the set schedule and you believe that the patient can tolerate some of the therapeutic procedures, stop the modalities and start the procedures.

An important tool in determining medical necessity of the therapeutic procedures and determining whether or not the patient can tolerate the therapeutic procedures revolves around functional diagnostic tests, such as computerized ROM testing, computerized muscle testing, and pain pressure threshold testing (algometry). Theses functional diagnostic tests can be found in Table 1 as well. The patient should be re-examined using these diagnostic tests to check whether or not the patient is getting better, staying the same, or getting worse.

Again, you still must think as a doctor and decide if what you are performing on the patient is getting adequate results. The patients, in most cases, will be able to tell you either verbally or non-verbally, in the form of their body movements, as to whether or not they are able to begin the therapeutic procedures.

If you want to modernize your clinic and/or provide more services, consider the higher paying therapeutic procedure codes. The increased income from these codes is well worth the effort. The only price it costs you is in terms of documenting the medical necessity; but that can be taken care of with the use of functional diagnostic tests that are payable by the insurance companies as well.

I urge you to take a look at getting your practice ahead of the curve so that you can stay in line with the changes in the healthcare reimbursement world.


1. Jan Lucas Hoving, PT, PhD; Bart W. Koes, PhD; Henrica C.W. de Vet, PhD; Danielle A. W.M. van der Windt, PhD; Willem J.J. Assendelft, MD, PhD; Henk van Mameren, MD, PhD; Walter L.J.M. Deville, MD, PhD; Jan J.M. Pool, PT; Rob J.P.M Scholten, MD, PhD; and Lex M. Bouiter, PhD. Manual Therapy, Physical Therapy, or Continued Care by a General Practiioner for Patients with neck Pain A Randomized, Controlled Trial. Annals of Internal Medicine, Vol.136 No. 10, Pgs 713-722 May 21, 2002.

2. Ongeborg BC Korthals-de Bos, Jan L Hoving, Maurits W van Tulder, Maureen PMH Rutten-van Mölken, Hermann J Adèr, Henrica CW de Vet, Bart W Koes, Hindrik Vondeling, Lex M Bouter. Cost Effectiveness of Physiotherapy, manual therapy, and General Practitioner Care for Neck Pain: Economic Evaluation Alongside a Randomised Controlled Trial. British Medical Journal; 326:911; April 26, 2003.


 

Dr. Dwight Whynot is a successful full-time private practitioner in Johnson City, Tennessee and a graduate of Logan College with a bachelor’s degree from Dalhousie University, Nova Scotia, Canada. Dr. Whynot gives license-renewal lectures on Evidence-Based Chiropractic Practices which are promoted by the EBC Seminars and sponsored by Myo-Logic and Spinal Logic Diagnostics. Dr. Whynot also gives license-renewal lectures to the medical community in Tennessee. For questions regarding evidence-based practice procedures, email This e-mail address is being protected from spambots. You need JavaScript enabled to view it . For 6 and 12 hours CCE license renewal lecture dates and locations call Karl Parker Seminars at 1-888-437-5275 or visit www.EBCSeminars.com.

 
Muscle Spasms: How to Overcome the Chiropractic Nemesis
Rehabilitation
Written by M. Kirk Meier, D.C.   
Monday, 06 August 2007 11:39

It’s happened to all of us many times. a patient comes into our office barely able to move and in excruciating pain. They have difficulty lying on the table, let alone moving through any range of motion and we want to get them into a side posture position. RIGHT!!!!!

So, in lieu of any type of chiropractic manipulative therapy, we apply a hot pack, maybe some ultra sound or motor nerve stimulation in order to reduce the muscle spasms.

That has been the traditional approach and, eventually, it has the desired result—or at least some level of the desired result. BUT….

What if we could use the body’s own neurologic and physiologic mechanisms to reduce those muscle spasms instead of using outside interventions? After all, isn’t that what we continually profess; use the body’s own healing powers? Yet, when it comes to muscle spasms, we ignore the physiologic processes that could reduce those muscle spasms. The question that comes to mind is: Why? Perhaps the answer lies in that we clinicians, to date, have not found any type of technique or equipment that could assist with these same neurological and physiological mechanisms—not until the Active Therapeutic Movements (ATM Concept) came along. But more on this unique treatment concept a little later.

Let’s look at the purpose of a muscle spasm. First of all, we know it is a protective mechanism, often elicited by the muscle spindle fibers as the stretch reflex. The stretch reflex protects the muscles and tendons against either too much of a stretch or too quick of a stretch. So, therefore, the stretch reflex is sensitive to the amount or speed of a muscle stretch. Located in the musculotendonis junction, the muscle spindle fibers protect this most vulnerable area of the muscle, the weak link of the chain, so to speak. If this area is protected, then the rest of the muscle will surely be. Unfortunately, the muscle spindle fiber is subjected to the same environmental factors as the rest of the muscles, the worst of which is inactivity.

As we have learned, when a muscle stays in a shortened state for any prolonged period of time, it becomes shorter. The same fate is assured for the muscle spindle fiber. If the muscle spindle fiber becomes shorter, then it will also become more active. This will elicit the stretch reflex when there is no need. The result is an increase in the excitation potential of a muscle, often resulting in muscles firing before they are supposed to or even when they are not supposed to fire. Because this is a protective mechanism, it often takes priority over other factors like, for example, reciprocal inhibition.

Reciprocal inhibition is the signal of relaxation that the antagonistic muscle receives when the agonist muscle contracts. This is necessary in order to allow movement to occur. This signal of reciprocal inhibition not only tells the antagonist muscle to relax, it tells it to relax at the same speed and intensity that the agonist is contracting, which helps to keep a smooth, fluid movement that can be controlled through the entire range of motion.

If these two mechanisms are functioning properly, we should get a smooth, controlled movement, as well as the protection the muscle needs if it is lengthened too far or too fast. When the muscle is injured or in a chronic shortened state, the muscle spindle fiber is in a hyper-reactive state and, thus, will activate, causing the muscle to contract or even spasm when almost any movement occurs. Again, since the stretch reflex of the muscle spindle fiber is a protective mechanism, it takes priority. So, even when the muscle is receiving the reciprocal inhibition telling it to relax, the stretch reflex overrides it. This causes the antagonistic muscle to contract when it should be relaxing. (See Figure 1) Consider, then, what happens to the path of motion of the joint when this is happening. Not Good!!!!

 Figure1. is a graph of muscle activity with a symptomatic patient experiencing low back pain. These graphs were developed using sEMG technology whereby patients were asked to perform rotations showing left and right side back muscle contractions and documeting muscle spasm.

What if we could eliminate or at least dampen the stretch reflex? Only for a limited period of time of course, while the body’s own healing processes were underway, but what if we could actually do that? Medications could relax the muscles, obviously; but we are chiropractors, so we resort to the aforementioned modalities that mainly help to increase the blood supply to the muscle, which is certainly not a bad thing; but it still doesn’t address the neurological factors of the stretch reflex and the hyperactive muscle spindle fibers.

If we could just use the reciprocal inhibition to relax the muscle but somehow prevent the tight or spasmodic muscle from moving, we could get our patient’s own body to tell those muscles to relax. But, to do this, we would have to use an isometric contraction of the muscles that are opposing the tight or spasmodic muscles. By contracting these opposing muscles without movement, we could avoid activating the hyperactive muscle spindle fibers and receive the full benefit of the reciprocal inhibition, resulting in the body’s own mechanisms giving us the results that we want instead of using medications. This is a perfect example and illustration of how the ATM Concept works and works so wonderfully within this same interesting, dynamic and very complex neurological mechanism.

The ATM2 system is a vertical treatment table that can immobilize, support and stabilize the patient all at the same time. The ATM2 uses a series of adjustable stabilization straps against a positional pad to create a safe and stabilized environment for the patient, who can then perform isometric contractions in the opposite direction of the muscle spasms. The straps allow a forceful contraction, giving a strong message of reciprocal inhibition and, since there is no movement, it overrides the stretch reflex and helps the muscle to relax. (See Figure 2) Furthermore, the straps can be tightened in any configuration to isolate almost any of the spinal stabilizer muscles, to reduce muscle spasms. It can be used for movements in the frontal, sagital, or horizontal planes or any combination thereof, making it infinitely versatile for any movement pattern that you could imagine.

  Figure 2. shows the muscle activity after 1 treatment on the ATM2 system. Notice the distinct left side and right side muscle contractions showing their increased strength and their distinct muscle separations. This is reciprocal inhibition. Notice muscles, even in the neutralor resting position and after one 6-minute treatment intervention. Notice these same muscles contracting in a much lower intensity and in unison and at rest.

The question then becomes, how do we know the process is having the desired effect?

Actually, a very simple protocol of tightening the straps to make the patient feel safe, supported and comfortable lets you know you are isolating the proper areas. A series of short, yet forceful contractions (Active Therapeutic Movements or isometric exercises) that the patient is now able to perform, yet without discomfort or pain, also tells you that you are on the right track. The patient will be very surprised to be able to perform isometric exercises (a very conservative number of ten isometric repetitions is always recommended on the first visit) with that much force without feeling any pain. Then, after performing the contractions and being unstrapped, the patient will be amazed at the increased, pain free range of motion. (See Figure 3) You, also, will be amazed at how quickly they are able to move pain free, easily perform isometric exercises, and the increased flexibility, ROM and significant decrease in pain they exhibit on that first visit.

 Figure 3. This patient is being treated for lumbar flexion movement impairments. We see the patient doing the Active Therapeutic Movements or Isometric flexion exercises.

Just like most other conditions that we face as chiropractors, the cause of the muscle spasm will most likely not disappear after the first treatment. Although, I have heard and read instances of patients that, on their very first visit, using the ATM2 system, the muscle spasm condition was changed or rectified completely. It can obviously vary from patient to patient. I also know that many of these spasm problems are deep rooted and so, just like the manufacturer recommends, continuing along the treatment path with further ATM’s can provide the correct stimulus to change these deep rooted muscle spasm conditions. The environmental factors that cause the tight or spasmodic muscle are probably still present, whether it is from an injury or from prolonged positioning and/or poor posture. Thus, these factors also need to be addressed and can easily be identified and corrected when the right assessment and treatment protocol is in place.

Most of us, as chiropractors, now deal with patients who are very inactive, both at their jobs and at home. This has created an epidemic of spinal instability. We see more and more patients everyday that possess low back injuries as a result of some ridiculously simple task or movement.

As a developer and instructor of the personal training program for the largest fitness chain in the country, I believe I have found an easy to implement a Core Stabilization program for chiropractors that can overcome these factors and restore spinal strength and stability to our patients who suffer from the effects of prolonged sitting and poor posture. The ATM2 can greatly enhance this Core Stabilization protocol and help us, as chiropractors, completely overcome the common muscle spasm, an all too familiar nemesis in our practices—thus, making us more effective as health care providers in obtaining faster, longer lasting results for our patients.

For more information on Dr. Meier’s Core Stabilization program, visit www.drkirkmdc.com or call 1-510- 713-7117. For more information on the ATM Concept, visit www.BackProject.com or call 1- 888-470-8100.

 

 
High School Athletes and Structural Management®
Rehabilitation
Written by Tim Maggs, D.C.   
Monday, 06 August 2007 11:25

Did you know...? 

• All high school athletes in this country must undergo a physical exam prior to participating in their sport. That exam, however, is a medical exam (eyes, ears, nose and throat). (See Fig. 1)

 

Eyes______________________________ Skin (Non- communicable)_________________ 
Ears (Otoscope) ___________________ Epilepsy __________________________________
Lymph Nodes _____________________ Nervous System ___________________________ 
Thyroid __________________________ Speech ___________________________________
Nose _____________________________  Nutrition __________________________________ 
Tonsils ___________________________  Height ______________ Weight ______________ 
Teeth ____________________________  Vision ____________________________________ 
Heart _____________________________  Hearing __________________________________ 
Blood Pressure ____________________  Orthopedic _______________________________ 
Lungs ____________________________                  Feet ___________________________ 
Hernia ___________________________                 Posture ________________________ 
Genito-Urinary ____________________                  Structural ______________________
   

Figure 1. Medical exam high school athletes must undergo prior to participating in their sport of choice.

• In virtually every high school in the country, young athletes are allowed to participate in a strength program merely by being on the team, not by passing any required evaluation to determine if they are structurally ready.

• When I worked with the New York Giants and consulted with the Chicago Bulls, they made every new player pass the six tests (at the base of the pyramid) to begin their conditioning program (Fig. 2), before they could enter the weight room.

Furthermore, we live in a world where the cost of arthritic conditions runs this country $86 billion per year, and the anticipated growth of this industry is 40 percent over the next twenty-three years. And chiropractors are begging for new patients? The simple answer is this: as a profession, if we can unify our message, provide good biomechanical exams to high school athletes whether they have symptoms or not, tell the parents and athletes what you found and how they can fix it, several great things would happen.

1) Our high school athletes would have fewer injuries during their high school years.

2) Our high school athletes would learn structural management at a younger age, which would include the need for chiropractic adjustments over the course of their lifetime.

3) This group of people would grow up knowing the value of chiropractic, and would both use it and encourage others, including their children.

4) This would greatly impact the predicted 40 percent increase in arthritic costs, as chiropractic adjustments mobilize joints, and that’s the number one solution to preventing premature breakdown or degeneration of joints.

5) The world would begin to understand that "paying later" is never a better option.

In upstate New York, our practice is made up of many high school athletes, and you’d be amazed at the biomechanical imbalances with which this age group suffers. In many cases, symptoms have not yet begun. But, as a profession, we have to teach the public that symptoms should never be the initiator of action. This age group should take action long before symptoms occur and, once you start doing the appropriate exam on them (The Structural Fingerprint® Exam), you, too, will see there is much work to be done with this age group.

In addition, this age group is replenished each and every year. There is a built-in support mechanism. All parents want the best for their kids and, if you can show evidence to the parent of "biomechanical issues" that will impact that child’s future, most parents will pay for and take action to help resolve that potential issue.

Case History #1

This young man came into our office in acute pain. He had severe left posterior knee pain with an associated left Achilles tendonitis. Upon our physical exam, it was obvious where much of the problem originated. In Fig. 3, you can see the gross imbalances in both the arches of the feet (severe pronation of the left foot) and an increased Q-angle of the left knee.

 Figure 3.

This is a classic case of biomechanical need, as this young man would have been the victim of anti-inflammatories, physical therapy and staying out of running for some prolonged period of time, just to let the injury heal. However, as soon as his demanding training resumed, clearly, the injuries would come right back.

Our treatment for his acute injuries consisted of cold laser therapy and extremity adjusting and, within two weeks, we had him symptom free. However, at that point in time, we did a thorough structural exam on him to determine the other biomechanical contributing factors. The first correction we made was to put him in custom orthotics, so as to balance the foundation. The outcome was incredible (Fig. 4). Note the difference in his undershorts in Fig. 3 and Fig. 4. This imbalance can certainly reflect his pelvis, showing significant imbalance. This imbalance was greatly corrected with only the insertion of custom orthotics.

 Figure 4.

Case History #2

This young runner, 18 years old, presented with severe shin splints. Shin splints are quite common in high school athletes. However, if the biomechanics above the knees are not addressed, oftentimes you’ll miss the underlying cause of this injury. Treating only the sight of injury makes us equivalent to the medical model providers out there, and chiropractors know too much biomechanically not to use all information available for the benefit of each athlete’s future.

With this athlete, we again treated him for an acute injury of the shins, with cold laser therapy, custom orthotics, ice treatments at home and proteolytic enzymes for nutritional support; but our Structural Fingerprint™ Exam uncovered the real cause for this condition. As seen in Fig. 5, there is a 49-degree sacral base angle and a severely anterior Ferguson’s Gravity Line. Try leaning forward and feel the increased demand on your forefoot as well as your shin muscles. Until this young man makes pelvic and lumbo-sacral changes, he will never get away from this injury. And, here’s where it all comes together. There is no other profession equipped to deal with these biomechanical issues. Chiropractic is head and shoulders above everyone, yet, as a profession, we’ve not unified our talents to let the world know what we do.

Figure 5. There is a 49° sacral base angle and a severely anterior Ferguson's Gravity Line. Until this young man makes pelvic and lumbosacral changes, he will never get away from this injury.

Another test we perform on all athletes is a center of gravity scan. We look at the athlete’s center of gravity from front to back and left to right. This proprioceptive scan gives a wealth of information, and provides visual evidence to the patient as to the need for a corrective program.

Figure 6. 

Figure 7.                  

In this particular case, the center of gravity was virtually off the chart as compared to a more normal scan and clearly shows the neurological effect of his foot imbalances, as well as his abnormal low back biomedichamics that are seen in Fig. 5. (The arrow notes the only part of the graph that can be seen.)

Gaining Access to High School Athletes

This is the most difficult task for any chiropractor to achieve. We all want to deliver our services to this group, but can’t figure out how to make contact with them. Here are several ways to make this happen;

1) Contact your local Athletic Director and ask to speak at the "Meet the Coaches Night." In many cases, this is mandatory for parents of high school athletes to attend, so you’ll have a captured audience to address. If a good power point presentation is given, the chances are great that you’ll gain many new patients from this one talk.

2) Ask your local high school about any opportunities to speak with parent groups, as parents are more interested than anyone else about their high school children.

3) Advertise to high school athletes and refer to common injuries they suffer with, like shin splints, knee pains, hip and ITB problems, etc. This will begin the process of letting them know you work with high school athletes.

4) Contact individual coaches to ask if you can meet with either the teams, or with parents of team members, to explain why your "product" is so much more valuable than what is currently available. 

Stand Out from the Competition

You have to show why you are better than everyone else. As a chiropractor, you have so many more effective tools to make this claim. Here are reasons why you should be "the best:"

1) You don’t want the athletes to wait until they’re broken. You can perform a biomechanical exam on them today and give them corrective information.

2) You read your X-rays from a biomechanical perspective, not just a pathology perspective. These findings become the starting point for each patient, and re-X-rays should be considered at anytime after the first six months of care.

3) We, as a profession, have the best tool available, the chiropractic adjustment. When this tool is used to restore mobility to joints, and used enough over time to help get postural changes, that’s how a young athlete will have an improved life. If we only use the adjustment to eliminate symptoms, we’re shortchanging many patients from potential benefits that can occur.

4) As a chiropractor, we understand the role of rehabilitation, in combination with chiropractic adjustments, and this package is much more than any other professional has to offer the athletic community.

5) Custom orthotics make this package a "Gold Level Package," and these must be recommended to stabilize from the ground up. Without custom orthotics, the structure will have a reduced potential of benefit.

Conclusion

The orthodontists painstakingly educated the public years ago and, today, they are enjoying the fruits of their labor. When we remind patients of what orthodontists do, and then tell them we do that with the structure, it makes perfect sense. Then, when we remind them a child wears braces for three to four years (and it’s not based on symptoms), suggesting a one year program for their child also makes perfect sense. Can you imagine how great your results would be if you had one year of unlimited care to provide to a growing athlete? Well, that could be the future of chiropractic—if we can band together with this message of structural management.

For more information on The Structural Management® Program, contact Dr. Maggs at 1-518-393-6566 or email him at This e-mail address is being protected from spambots. You need JavaScript enabled to view it .

 
“Can Trigger Points Be Turned Off, in Seconds, Using Neurological Reflexes?”
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Rehabilitation
Written by Dr. Stephen Kaufman, D.C.   
Monday, 06 August 2007 11:14

One day, as i was working out with weights, i lifted a dumbbell over my head. The weight was heavier than I could handle. As I extended my arm, my triceps completely gave out; the weight plummeted toward the table. By using too heavy a weight, I had triggered the clasp knife reflex1,4 on my triceps. I had turned the muscle completely off, and the weight dropped like…well, like a steel weight! I thought, if I could figure out a way to turn muscles off like this at will, I might be able to turn off muscular trigger points as well.

Trigger Points Are Often Overlooked Causes of Musculoskeletal Pain

Trigger points are areas of ischemia in muscles, giving rise to pain on palpatory pressure.5,6,7,8,11,13,14 They often cause or exacerbate many types of myofascial pain syndromes,11,12,13,14 including neck pain, low back pain, headache5, migraine5, TMJ, frozen shoulder, sciatica,6,7 ileotibial band syndrome,14 post surgical and non pathological abdominal pain,3 etc. Even the pain of cervical and lumbar disc syndromes is often caused or aggravated by myofascial trigger points.6,7,10 Spinal manipulation may be therapeutic by indirectly causing an improvement in trigger point activity.14

When my arm gave out while lifting the weight, I reasoned that I had accidentally initiated a clasp knife (a.k.a. a Golgi Tendon) reflex in my triceps. This is a defensive mechanism so that, if you pick up too heavy a weight, it doesn’t tear your arm muscle. If I could do that intentionally on a muscle that had a trigger point in it, that point might resolve.

Trigger Points Should Not Be Treated Over and Over, but Turned Off by Using Specific Neurological Reflexes

I felt that, if I could apply a specific stimulation, vector, and pressure by hand to a muscle with a trigger point in it, the intentional activation of the GTO reflex would cause a tender trigger point to immediately lose its tenderness when pressed. This, in turn, might help to resolve chronic symptoms that were caused by that trigger point. I eventually found the first of a series of reflexes that consistently turns off palpatory pain.

 If the reflex is correct for the involved point, it will not be tender within a few seconds; it will be gone.

A trigger point will be painful when first pressed; the reflex is then initiated by appropriate stimulation to the muscle. If it’s the correct reflex for that trigger point, within seconds the point will no longer be painful when pressed! Very often, the patient’s symptom associated with that trigger point will clear up as well. Sometimes the symptom will improve immediately; sometimes it will resolve after several treatments. Just as it’s normal for the knee to jerk when the patellar tendon is tapped, it’s normal for a T.P. to resolve immediately when the proper reflex is stimulated.

Pain Neutralization Technique (P.N.T.) is not similar to any previous technique for treating trigger points, e.g. ischemic compression or strain counterstrain. The aim here is not to treat a trigger point but to erase it. If the reflex is correct for the involved point, it will not be tender within a few seconds; it will be gone. This treatment is not painful; it eliminates the pain.

As I applied this procedure to many patients with pain, I was surprised to find the majority of trigger points would relax and disappear within seconds of correctly applying this or one of the other Pain Neutralization Techniques. If the direction or pressure of application wasn’t right, there might only be a 50 percent improvement; when I changed the application, the improvement would often get to be 100 percent.

The treatment is effective in the large majority of cases for instantly reducing or eliminating trigger points; but, in some cases, the patient’s symptom does not resolve. Of course, not all pain is due to trigger points; eliminating the T.P. often, but not always, affects the symptom. Sometimes the trigger point will continue to recur; it keeps coming back after each treatment. However, the majority of trigger points will improve after each treatment and be undetectable after three to five visits. Many patients do things that perpetuate their symptoms, such as snapping their own necks or holding a cell phone between their ear and their shoulder. These activities need to be stopped.

In 1989, I set out to find a reflex that would instantly inactivate trigger points. It took me fifteen years to find the reflex. I discovered several dozen more in the following year.

M.D.’s Astonished as D.C. Demonstrates Pain Neutralization Technique and Eliminates Chronic Pain in Seconds on One Doctor after Another

In March 2006, I gave a presentation to a group of skeptical M.D’s. Robert Rowen, M.D., editor of Second Opinion newsletter, was there, and wrote: "Here’s a miracle I wouldn’t have believed if I wasn’t there to witness it. A previously unknown chiropractor spoke about his pain neutralization technique for instantly relieving painful trigger points. What medical doctor would believe such claims from a chiropractor? I listened with curiosity and healthy skepticism. Then he performed his technique on many of my esteemed colleagues, including some very famous ones. The majority got immediate relief, even with very long term chronic problems. It was absolutely incredible!"

I’ve now demonstrated Pain Neutralization Techniques to many hundreds of D.C.’s and M.D.’s. Many of these doctors have had instant improvement and elimination of chronic symptoms, including long standing cervical and lumbar disc problems, frozen shoulders, severe TMJ dysfunction, migraines, abdominal pain, etc.

Stephen Kaufman, D.C. graduated L.A.C.C. in 1978, and practices in Denver, CO. He’s studied and practiced dozens of chiropractic techniques. Pain Neutralization Technique and Manual Spinal Nerve Blocks represent a rapid new approach to pain. His friendly and informative website is www.painneutralization.com; he can be reached at 1-303 756-9567 or 1-800-774-5078.

References

1. Best and Taylor's Physiological Basis of Medical Practice. (1979) Edited by John Brobeck. Pp. 9-80

2. Chalmers G. Do Golgi tendon organs really inhibit muscle activity at high force levels to save muscles from injury, and adapt with strength training? Sports Biomech. 2002 Jul;1(2):239-49.

3. Cimen A, Celik M, Erdine S. Myofascial pain syndrome in the differential diagnosis of chronic abdominal pain. Agri. 2004 Jul;16(3):45-7.

4. Cleland CL, Rymer WZ. Functional properties of spinal interneurons activated by muscular free nerve endings and their potential contributions to the clasp-knife reflex.  J Neurophysiol. 1993 Apr;69(4):1181-91.

5. Couppe C, Torelli P, Fuglsang-Frederiksen A, Andersen KV, Jensen R. Myofascial trigger points are very prevalent in patients with chronic tension-type headache: a double-blinded controlled study. Clin J Pain. 2007 Jan;23(1):23-7.

6. Facco E, Ceccherelli F. Myofascial pain mimicking radicular syndromes. Acta Neurochir Suppl. 2005;92:147-50.

7. Flax HJ. Myofascial pain syndromes--the great mimicker. Bol Asoc Med P R. 1995 Oct-Dec;87(10-12):167-70.

8. Gerwin RD. Neurobiology of the myofascial trigger point. Baillieres Clin Rheumatol. 1994 Nov;8(4):747-62. Review.

9. Johnson EW. Editorial: The myth of skeletal muscle spasm. Am J Phys Med 1989; 68: 1.

10. Lauder TD. Musculoskeletal disorders that frequently mimic radiculopathy. Phys Med Rehabil Clin N Am. 2002 Aug;13(3):469-85.

11. McPartland JM. Travell trigger points--molecular and osteopathic perspectives. J Am Osteopath Assoc. 2004 Jun;104(6):244-9. Review.

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14. 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.

 
Vibrational Therapy
Rehabilitation
Written by Christian H. Reichardt, D.C., C.C.S.P.   
Friday, 06 July 2007 10:38

In the last issue of The American Chiropractor, I focused primarily on the issue of intergrating Whole Body Vibration (WBV) into your daily office procedures. When we, as Doctors of Chiropractic, are recommending a particular therapy to our patients, we want to be certain to understand the physiologic effects of the particular modality and the medical reasoning for using it. We need to be able to explain to our patients why we are recommending the routines we are prescribing and why it is important for them to follow our instructions and recommendations. In this article, I will focus on the neuro-physiology behind the WBV technology. This will explain very clearly why Whole Body Vibration is such a perfect adjunct to the chiropractic practice!

For the sake of the space available for this article, I will keep it simple and in layman’s terms.

As we have all learned in college, an active contraction of a muscle is initiated via efferent nerve fibers. For the sake of dealing with circumstances and situations where a rapid succession of contractions is necessary, nature has equipped us humans with a rather ingenious design. This design helps to prevent rapid fatigue in a muscle, When consciously contracting a muscle, only approximately 40 percent of the muscle fibers in any given skeletal muscle are being utilized at any given time. When these fibers fatigue, the brain shifts the contractions to another 40 percent of musle fibers within the same muscle. This pattern repeats itself throughout the muscle, as long as needed, thus delaying rapid fatigue.

Enter WBV: When a muscle is being isometrically loaded, approximately 40 percent of the fibers are being contracted. If, in addition to this contraction, the muscle is being subjected to a vibrational load within a specific Hertz range, the Tonic Vibration Reflex is being triggered. This reflex causes a sustained contraction of the whole muscle subjected to vibration. This Tonic Vibration Reflex is evoked by placing a vibrator—in the case of WBV, it is typically a platform set in motion by an electrical motor with an eccentric load on its shaft—in line with the isometrically loaded muscles and, therefore, activates the muscle’s tendon and muscle spindles. In order to activate receptors of the skin, tendons and, most importantly, muscle spindles, vibrations in the range of 20-100 Hz are needed. Muscle spindle excitation and subsequent discharges of afferent fibers are then sent to the spinal cord through the afferent nerve fiber’s tracts, where they activate monosynaptic and polysynaptic reflex arcs, causing the corresponding muscle to contract. Thus, the residual 60 percent of the muscle is being contracted, resulting in much more rapid fatigue of the subjected muscle! This may be due to either "central fatigue" of the neural drive or even "peripheral fatigue," which is described as an insufficient energy supply within the muscle for the increased workload and demand. This explanation founds the very basis for the effectiveness of WBV for the purpose of exercise and rehabilitation.

Since WBV activates muscles in a static, isometric position without necessitating joint ROM, it allows the chiropractic doctor to initiate exercise protocols much earlier in the treatment cycle. An injured joint and the surrounding musculature can be exercised quite early in the treatment cycle. This enhances local circulation and lymphatic drainage and accelerates tissue repair. I have found that our patients progress significantly faster through the acute phase of injuries once the WBV protocols are implemented. In the acute phase, we have the patient start by stabilizing their position by holding on to the WBV unit. Once the patient has shown improvement, we slowly progress them to doing their exercises without holding on to the unit. This necessitates them to utilize all the collateral musculature of the originally injured joint and further engages proprioceptive response and integration.

Thus, WBV offers a fast, easy, simple, yet safe, way to shift the patient from passive to active care, gets them feeling better and motivates them to participate in their own recovery.

We usually have the patient start by using the equipment three times a week and see rapid improvement. Once the patient has demonstrated improvement in their re-evaluation, they are then progressed from pain relief care to rehabilitation care. This is accompanied by the patient doing joint ROM under load while on the WBV unit. Starting with small ROM, they are ultimately progressed to doing their full ROM rehabilitation protocols while being subjected to WBV on the units.

The final stage of rehabilitation can be called the neurologic integration phase. Here, our patients perform full ROM exercises, with the added challenge of performing these exercises while doing balance positions. Based on the findings of several Russian researchers, performing full ROM exercises while experiencing WBV enhances postural automatisms and muscle memory. Also, reviewing the research done by Prof. Dr. Vladamir Janda, it is of utmost importance not to conclude the rehabilitation phase for any injury right after subsiding of the acute pain phase, but to finish the rehabilitation with neural integration techniques. As seen above, WBV can be a phenomenal tool for this purpose.

As a value-added benefit, when using WBV for injury treatment, many of our patients also encounter improved hand/eye coordination in their sports. In my humble opinion, this can only be explained through the repeated challenge to the vestibular system by the WBV while firing the afferent and efferent nerves necessary to perform a particular motion.

The utilization of WBV during training by virtually all professional teams in football, baseball, basketball and hockey promises great hope for our patients. If it works for training those athletes and helps them get better faster, I believe it ought to be good enough for our patients! Every chiropractor involved with treating patients with musculo-skeletal issues should consider implementing this modality in their office!


Dr. Christian H. Reichardt is a 1983 graduate of National College of Chiropractic. He may be reached at 1-310-829-0453, 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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