|
Rehabilitation
|
|
Rehabilitation
|
|
Written by Jay Kennedy, D.C.
|
|
Friday, 04 May 2007 13:57 |
|
For the past five years I have been a consultant for one of the largest rehab medical companies in the USA in charge of co-developing their flagship decompression table. Being in this position, I was also called upon by them to evaluate other company products. As such, a few years ago I was introduced to a new and dynamic rehabilitation concept called the Active Therapeutic Movement (ATM) Concept. Once I became aware of the simple and down to earth logic behind the technique, I began to implement its utilitarian protocols.
The most compelling aspect of the ATM treatment is the fact that the painful motion is used to determine the therapy parameters, and the elimination of this painful motion is its specific outcome. We don’t need to appeal to complex analysis systems, opinions, beliefs or diagnostic tests, per se. The patient’s pain and movement impairment, and the rectification of that pain, is all we need. In this article, I’ll detail the functional examination, basic patient selection classification and theoretical basis of the ATM therapy.
The ATM concept is a treatment that revolves around several key elements. (1) Joint repositioning, (2) External Stabilization, (3) Upright, weight bearing, functional positioning of the patient. The simultaneous combination of these elements will transition almost any painful movement to become 100 percent pain-free in the full range-of-motion. When a painful movement transitions to become pain-free, that is our indicator that the patient’s central nervous system (CNS) has transitioned from a pathological muscle activation pattern to a normal pattern. Doing isometric exercises, while in this stabilized, pain-free position, affords the body and the CNS the ability to re-negotiate an improved, pain-free range-of-motion.
Creating a pain-free ROM is key. Research has proven that lack of motion is often as detrimental as too much motion, especially in the long term. But to impart more motion into a painful range-of-motion will typically increase pain. However, painful motion (or worse, pain inducing therapy) is universally rejected by most clinicians and certainly most patients. And, since pain is the body’s prime defense against further injury, it is enormously short sighted for a clinician to say, "Damn the pain; full steam ahead." The secret, if you will, is to somehow be able to impart meaningful motion without pain or the risk of increasing damage to the surrounding tissues. Restoring motion enhances not only local tissue healing but also neurological influences and proprioception.
I have used the ATM method in my clinic now for more than two years, treating athletes, farmers, children and the elderly. Excellent responses are noted in most cases. Just yesterday, a 44-year-old male entered our clinic in severe pain (8/10) and left antalgia. He had pain at the initiation of flexion but the pain didn’t radiate. The pain intensity precluded prone positioning and the thought of a lumbar roll made me uncomfortable. I chose an upright ATM flexion technique. By repositioning his pelvis, we were able to afford him complete flexion relief through ten resisted isometric movements. Post the treatment, the pain was reported as a 2/10 and the antalgia was rectified. One additional treatment was all that was needed to zero the pain rating.
Any treatment which rectifies movement pain quickly, without trauma and in a large percent of patients, is worthy of inclusion in a spine-care practice. I place the ATM in a unique and necessary category at this point in my professional career. Functional, weight-bearing procedures simply make more biomechanical sense. Immediate relief and the prognostic value of the ATM methods make business sense.
The ATM therapy has distinct value in well over 50 percent of initial patient presentations and up to 85percent of secondary presentations (e.g., compression patients with an underlying movement impairment disorder). These disorders can be hidden behind nerve tension or disc compression signs often contributing to difficulties in decompression/traction tolerance or the application of a spinal adjustment. Movement disorders are probably present in ALL of our patients to some degree. They are often haphazardly or inconsistently addressed with some of our other treatment methods. Keep in mind, virtually all body areas are amenable. With the ATM procedures, we now have a direct and highly effective method to treat these problems painlessly, safely and with a remarkable level of effectiveness.
Dr. Jay Kennedy is a Palmer graduate and has been in both private and MD/DC practices in Berlin, PA, for twenty years. In addition to authoring various decompression therapy protocol manuals, he has lectured to thousands of chiropractors throughout the United States on decompression therapy and ATM2 treatments. He is the developer of the Kennedy Decompression Technique™,which utilizes a specific classification system, protocols and rehabilitation strategies that empower chiropractors to achieve the highest outcomes with decompression devices.
Contact Dr. Kennedy at www.KennedyTechnique.com.
|
|
|
Rehabilitation
|
|
Written by Dr. Kirk A. Lee, D.C., C.C.S.P.
|
|
Wednesday, 04 April 2007 12:27 |
|
As a doctor of chiropractic, how you perform your initial evaluation and management on a patient may vary greatly from your peers. Many doctors’ examinations include numerous neurological and orthopedic procedures. Do you rely heavily on visual and palpatory findings, range of motion studies, or maybe totally on radiographic findings? For most of us, it is probably a combination of all of the above, with our final goal being the location of the vertebral subluxation complexes we feel may be creating the patient’s symptomatology, or restricted range of motion or alterations in their gait cycle. Does the patient present with an acute antalgic gait, neurological gait or is it a postural gait that has developed over time, either through poor posture or compensation due to pain?
What about adolescent patients whose primary complaint is a parent’s concern over the turning in or turning out of a foot or leg while he or she is standing, walking or running? We evaluate the patient for some type of subluxation complex that may be causing the foot or leg to turn out or in. Once we have located our subluxation complexes, we begin our treatment plan of Chiropractic Manipulative Therapy (CMT) to help reduce and stabilize the subluxation complexes.
Our treatment plan may also include nutrition, rehabilitative exercise, and an assessment for Spinal Pelvic Stabilizers. Our rehab may include providing patients with instructions on exercises using a rehab band, Thera-Ciser™, or doing isometrics against a wall. We may even teach parents how to do isometric and resistance exercise to counteract the internal or external rotation. We may recommend the use of Spinal Pelvic Stabilizers to stabilize early stages of hyperpronation that result in a common finding of foot flare.
But is that enough? One of the main issues we must address is the patient’s gait cycle. Visually watching a patient via video tape, or just visual observation as he/she walks down your hallway may give you clues to biomechanical alterations and muscle imbalances. To many of us, analyzing and gait retraining may not be considered a form of rehabilitation, but it should. We even have CPT coding for billing purposes. Gait Training 97116: training of the manner or style of walking, including rhythm and speed—each 15-minute intervals. Neuromuscular reeducation 97112: reeducation of movement, balance and/or proprioception for sitting and standing activities.
We must introduce neuromuscular re-education. If the patient does all the exercises we provide, but then goes outside and walks and runs, she will immediately slip back into the pattern that her body has become accustomed to. One way we address this phase of our treatment plan is by providing a regime of gait pattern exercises she can do at home. All that is needed is a hallway, mirror and string.
Ask your patient to use a long hallway or a walkway that is approximately twenty to thirty feet in length. At one end, ask your patient to stand in a normal posture and mark the floor with a piece of tape or sticker to indicate the width of her foot or feet. Make sure you have reviewed this with your patient in your office, in case you feel the clinical need to widen or narrow her stance. Then place two strings from those marked locations to maintain the same width the length of the hallway.
Finally, place a mirror at the end of the hallway. This is for the purpose of visual feedback to make sure she is walking in the desired pattern you have recommended. This may be establishing memory of a correct heel strike, midstance, and exaggerated toe-off. It could be as simple as just making sure the foot is placed directly straight on the line without any internal or external rotation. Again the purpose of the mirror is to allow that patient to walk in as normal an upright posture while looking forward at the mirror to check foot placement. If she looks down at her feet as she does the exercise, then we are introducing an abnormal pattern.
As a point of consideration, once your patient comes to the end of the strings, have her walk backwards, while still maintaining proper foot placement on the strings. Backward walking is an excellent addition to help with balance and unsteadiness. It also helps re-educate the musculature in a reversed pattern.
I recommend three sets of fifteen repetitions (a repetition being down and back as one) twice per day. The speed at which you have the patient go originally is a slow natural walking pattern. The focus here is not how quickly she can do the activity but making sure the feet come down in a heel strike position on the line followed by correct placement of mid-stance, and toe-off of the line in a straight pattern.
Earlier we mentioned gait retraining as a concern for why the patient entered your office in the first place with respect to her child. To help assure compliance with the adolescent, try developing a contract between you and the patient—the ultimate goal being ice cream. We have children sign a contract stating they will do their exercises daily for fourteen days. It has two columns with lines for a parent’s signature as well as the child’s signature. Once the contract is completed, that child is able to bring the signed contract back to the office to receive a coupon for a free small hot fudge sundae or milkshake. It’s a very cheap, yet fun way to help with compliance from your patient. (If you would like a copy of our contract we will be glad to fax it to you. Just fax your request to 517- 629-3805, asking for the "Child rehab contract.")
Often, with our chronic patients, some type of reaggravating condition is usually an underlying factor. This may be from an old, worn-out mattress, poor sitting posture, wearing improperly fitting shoes, or just a poor adaptation to lifestyle. After you have introduced your treatment plan of chiropractic adjustments, rehabilitation, nutrition or any other adjuncts you use, do not forget to evaluate the patient’s gait cycle. It could be the difference between your patient’s being able to return to and enjoy a normal healthy 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. He is very active with the Michigan Chiropractic Society serving on the legal and government affairs committees.
|
|
Rehabilitation
|
|
Written by George LeBeau, D.C.
|
|
Sunday, 04 March 2007 10:56 |
|
Mrs. "H" and her husband had been coming in for their "maintenance" adjustments for quite a while and, during one particular visit, she brought her fifteen-month-old daughter, who was in a seriously poor mood. When asked, Mom said the little girl, Amy, had an ear infection "again" and was going to have the tubes put into her ears "again."
I asked how many times this had been done and she said this would be the third time.
I told her chiropractic works well with ear infections and related how I had been able to help my own daughter with a similar problem.
She said, "Why not; nothing else seems to help".
I did a very gentle Atlas adjustment on Amy then adjusted her ears.
I saw the Mom again several weeks later and she told me this story. One day Amy wakes up crying, pulling her ears and whining, "Boat, boat."
Mom asks, "What, dear? What are you trying to say?"
All day this went on, "Boat, boat."
When the husband came home he had no more luck than his wife trying to interpret what Amy was saying. This went on for days. Finally, Mom comes in for her regular treatment and has Amy with her. As soon as I walk into the room, Amy jumps up, points her finger at me and shouts out, "BOAT!" She didn’t know how to say Dr. Le Beau; the closest thing in her vocabulary was "boat."
Mom says, "Oh, my God, that’s what she’s been driving us crazy with! She wants to see you!"
Even now, after so many years, I still get goose bumps relating this story. Here is this very young child who knew she needed a chiropractic adjustment. She needed, "The Boat!" She didn’t watch videos on the history of chiropractic, nor was she educated in chiropractic philosophy. All she did was experience a chiropractic adjustment and it changed her life. This young child experienced the power of chiropractic firsthand and innately knew she needed more. All this and she never once asked to see the evidence based research on this technique.
Mom taught her to say, "Dr. Le Beau," in case of further episodes. Oh, by the way, she never did have the surgery again.
Dr. Jim Lee from Twin Cities, Minnesota, taught the "Ear Adjustment" to me in 1973. When performed properly, this adjustment can help with numerous conditions involving the ears and head. A partial list is, of course, ear infections, earaches, tinnitus, sinus problems, vertigo, headaches, difficulty swallowing and numerous syndromes involving the head and ears, including Minnere’s Syndrome.
The technique is simple, but must be done very carefully. There is a potential for injury if you pull too hard or contact the wrong area. In the photo, please note the contact. I use my thumb and the first interphalangeal joint of my index finger to contact the deep portion of the lower ear. Please Do NOT contact the ear lobe. This is a very sensitive and weak area and a forceful pull on this structure can easily pull the ear lobe off or seriously injure the lower ear (please take note; this is a BAD thing).
Once you have the correct contact, the line of adjustment is up with an outward pull. Quite often there is a loud audible that many doctors tell me is the Eustachian tube breaking the vacuum causing the problem in the first place. Whatever causes the audible noise, this can be very dramatic and, in the case of small children, can be quite frightening. It is best with young children to make an adventure of the adjustment and tell them to listen for the "pop."
Also with small children and, yes, even babies, I change my contact slightly. I use the tips of my thumb and index finger and pull up and out, very lightly. Even in babies, the audible is quite noticeable. I have had numerous times when the mom will call me the next day and tell me the child’s pillow was covered with a thick green mucus resulting from the ear draining. I tell you this so you can reassure the parents that this is to be expected when the ear "opens up."
When I demonstrate this technique at my seminars, I always seem to have literally dozens of doctors come up and want to experience the feeling of the "Ear Adjustment." When you first start doing this treatment on your patients, please go easy until you get familiar with the technique. Have fun and, as always, if you need help or have questions,t please feel free to contact me any time at my e-mail.
Dr. Le Beau practices at Chiropractic Industrial and Sports Center; 1365 West Vista Way, Suite 100; Vista, CA 92083. Send your questions to Dr. Le Beau, send them to him at
This e-mail address is being protected from spambots. You need JavaScript enabled to view it
.
|
|
|
Rehabilitation
|
|
Written by Dr. John Danchik, D.C., C.C.S.P., F.I.C.C.
|
|
Sunday, 04 March 2007 10:53 |
|
History and Presenting Symptoms
A 25-year-old female presents with a combination of recurring pain in the lower back region and pain and tightness in the front of her right hip. She is very frustrated by her condition, since she has already had six weeks of physical therapy for her hip pain (with only a little relief), and she received four months of chiropractic care (with moderate relief of her back pain). Her prior treatments included adjustments and diathermy heat for her back and stretches and mobilization for her hip. She has had no specific injuries to these regions, and she can’t identify any precipitating activities. On a 100mm Visual Analog Scale, she rates the pain in her lower back as varying from 20mm to 40mm, and her right hip pain as varying wildly from 0mm to 65mm. She is on her feet a lot in her occupation as a dance instructor for young girls.
Exam Findings
Vitals. This active young woman weighs 142 lbs, which at 5’9’’, results in a BMI of 21; she is definitely not overweight or obese. She is a vegan, a non-smoker, and drinks alcohol only rarely. Her blood pressure and pulse rate are at the lower end of the normal ranges.
Posture and gait. Standing postural evaluation finds a lower iliac crest on the right, and a low right greater trochanter. She also demonstrates a mild bilateral knee valgus and static pronation of the right foot (calcaneal eversion with low medial arch). The left foot and ankle show a normal, non-pronated alignment. Gait screening is negative for limp or noticeable asymmetry.
Chiropractic evaluation. Motion palpation identifies functional limitations at the L2/L3 and L4/L5 levels, with moderate tenderness and loss of endrange mobility. Hip ranges of motion are full and pain-free on both sides. The Thomas test finds a painful tightness of the right iliopsoas muscle. She finds it difficult to lie comfortably on her back while her legs are extended.
Imaging
Because of her persistent, non-responsive low back and hip pain, AP and lateral lumbopelvic X-rays in the upright standing position are obtained. A discrepancy in femur head heights is seen, with a measured difference of 5mm (right side lower). A moderate right convex lumbar curvature (6°) is noted, and both the sacral base and the iliac crest are lower on the right side. The sacral base angle is a somewhat elevated, but the lumbar lordosis is within normal limits.
Clinical Impression
Moderate functional leg length discrepancy (right short leg), with associated pelvic tilt and lumbar curvature. There is a chronic shortening of the right iliopsoas muscle, and a significant history of recurrent mechanical low back pain and occasional right hip pain.
Treatment Plan
Adjustments. Specific, corrective adjustments for the lumbar spinal region were provided as needed, with good response. Additional manual therapy included contract/relax stretches for the iliopsoas muscle.
Stabilization. Custom-made, flexible stabilizing orthotics were supplied, with a varus pronation wedge under the medial aspect of the right calcaneus. She had no difficulty in adapting to the orthotics.
Rehabilitation. She stretched her right iliopsoas muscle at least four times each day, after a brief brisk walking warm-up. She also strengthened her hip extensor muscles in the upright position using elastic exercise tubing.
Response to Care
This patient responded rapidly to her spinal adjustments and active resistance stretches. She immediately began wearing her orthotics in all of her shoes, and especially at work. After six weeks of adjustments (10 visits) and daily home exercises, she was released to a self-directed maintenance program.
Discussion
A relatively slight functional short leg can produce chronic symptoms in people who experience a lot of weightbearing biomechanical stress. This situation will often be identified in long-distance runners, dancers, and in occupations such as drill press operators and warehouse stockers. A moderate amount of asymmetrical pronation, when exposed to repetitive or constant loading strain, can develop into chronic muscle tension, with shortening tightness. Spinal adjustments and very specific stretching and strengthening exercises provided relief, but the underlying functional leg length inequality had to be addressed with stabilizing orthotics for long-lasting results.
Dr. John J. Danchik is the seventh inductee to the American Chiropractic Association Sports Hall of Fame. He is the current chairperson of the United States Olympic Committee’s Chiropractic Selection Program and lectures extensively in the United States and abroad on current trends in sports chiropractic and rehabilitation. Dr. Danchik is an associate editor of the Journal of the Neuromusculoskeletal System. He can be reached by e-mail at
This e-mail address is being protected from spambots. You need JavaScript enabled to view it
.
|
|
Rehabilitation
|
|
Written by Dr. Kirk A. Lee, D.C., C.C.S.P.
|
|
Thursday, 01 February 2007 16:41 |
|
The use of rehabilitation procedures is becoming more of a mainstay within chiropractic health care. Core spinal musculature stabilizing exercises, proprioceptive training, as well as activities designed to enhance flexibility are currently being used to help support the chiropractic adjustment. Each of these methods has become a major point of interest to help a patient enhance his/her overall health and wellness. This has subsequently helped patients to be more involved in their health care by physically participating.
There are a few things that we do well, and other things we do not do so well when creating a treatment plan. Are your rehabilitation programs designed to address postural deviations, improve strength, balance, sport specific or prevent injuries?
Depending on the scopes of practice in the state you practice, the amount and types of rehabilitation the Doctor of Chiropractic is allowed to do will vary. For many doctors, the use of rehabilitative exercise, neuromuscular reeducation and therapeutic activities are of most importance. Others choose to use physical modalities to help increase healing time by improving circulation and decreasing edema. The choices you make are more than likely based on your state statute and, possibly, the chiropractic college you graduated from.
The profession’s approach to therapy maybe demonstrated as recently as 1935. When B. J. Palmer established the Rehabilitation Laboratory at the B. J. Palmer Chiropractic Clinic, all the equipment was patient driven. The only electrical piece of equipment used then was a mechanical horse. One of the rules at the clinic included, “At no time, in no way, do we use any therapeutic apparatus on any case.”
A common mistake many Doctors of Chiropractic make when developing a rehabilitation program for their patients is that they overload a joint before it has healed or full ranges of pain-free motion have been reestablished. This usually occurs by using a weight that is too heavy or of too high resistance. The difference between neuromuscular reeducation and strength training should be reviewed by many of us so that we are accurately performing therapy. Neuromuscular reeducation should be established prior to initiating strengthening protocols, especially if the patient is someone who appears to be physically fit and/or has a history of working out.
The mistake of muscle strengthening before neuromuscular reeducation usually results in the patients’ complaining that the exercise or activity you initiated aggravated their present condition or exacerbated an improving condition. Whether pain is present, either constantly or during an activity, it will prevent the body from performing normal moving patterns. To ensure this will not happen, the Doctor of Chiropractic must have a good understanding of the patient’s present-time muscle strength and his physical endurance. This must be established through initial and interim chiropractic evaluations and management.
Gait Cycle:
Another commonly overlooked patient presentation is gait cycle. Evaluation of the patient’s gait cycle can show muscle imbalances. These imbalances can occur from differences between antagonist and protagonist strength, flexibility, and the subluxation complex. One of the most frequent gait alterations that may be seen is the Trendelenburg gait. Clinically, this presents as a dropping of the hip on the unsupported leg during each step of the gait cycle. This usually results from a weakness of the gluteal musculature. Often this problem can be addressed and stabilized by reducing the subluxation complexes and initiating normal motor pattern movements, followed by strengthening exercises.
Base of Support:
Another area to observe would be the patient’s base of support: Is it too narrow or too wide? Are the abnormalities within the gait due to neurological inducement, altered biomechanical dysfunction, or antalgic due to pain? Is the patient’s posture in good alignment from head to toe? Keep in mind, postural defects and movement distortions in one area can affect seemingly unrelated distant areas, causing dysfunction and pain. Does the patient show an anterior translation of the head, rounding of the shoulders with thoracic extension, anterior pelvis translation, functional leg length inequality, and asymmetrical bilateral pronation?
One of the most frequently missed patient presentations is how a patient raises and lowers himself from a seated position. How often has a patient said to you he is having difficulty raising and lowering himself from the toilet, difficulty maneuvering stairs and getting out of bed? Quite often, this is the result of weakened musculature and altered spinal biomechanics. Are the assistive devices (walkers, canes, crutches) being used properly, or are they a contributing factor?
As the Doctor of Chiropractic, you routinely develop a plan for how you will provide the chiropractic adjustment. You do this from a correlation of your examination findings, which may include X-ray and other additional testing. It is important to have and implement a plan that may compliment the chiropractic adjustment with thorough rehabilitative techniques. Please remember, this is much more than merely handing your patients a bunch of exercises and expecting them to do them on their own.
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.
|
|
|
|
|
|
|
Page 13 of 21 |
|
|
|
