Rehabilitation


Effects of Whole Body Vibration on Posture and Kinesthetic Perception
Rehabilitation
Written by Christian H. Reichardt, D.C., C.C.S.P.   
Monday, 04 June 2007 15:01

Many patients who present themselves to the chiropractic office suffer from musculo-skeletal disorders. More and more research confirms what we know to be true from our own daily anecdotal knowledge. There is hardly a modality that works better for these conditions than chiropractic. Yet there are a number of modalities that can enhance the benefits of adjustments.

One of these modalities is just finding its way into the healthcare field in America, after having been used and researched for the last four decades in Russia and Europe—Whole Body Vibration.

In a number of articles over the next few months, I will outline the scientific reasoning behind WBV and how it can be beneficial to the chiropractic practitioner’s practice.

I will start with a brief review of the neurologic control of posture. The definition given in Wikipedia –Posture, standing reads as follows: Although quiet standing appears to be static, modern instrumentation shows it to be a process of rocking from the ankle in the sagittal plane. Standing posture is often likened to an inverted pyramid.

Standing posture relies on dynamic rather than static balance. Our Center of Mass (COM) is in front of the ankle. A static pose would cause us to keel over on our face. In addition, we are constantly subjected to external perturbations such as breeze and internal perturbations from respiration. Erect posture requires adjustment and correction. Traditionally, our correction was explained by the spring action of our muscles. This is a local mechanism that takes place without the intervention of the Central Nervous System (CNS). Recent studies, however, show that spring action, by itself, is insufficient to prevent a forward fall. Also, human sway is too complicated for spring action to be the sole mechanism.

According to current theory, the CNS continually monitors our direction and velocity below our conscious awareness. Our vertical body axis alternates between forward and backwards tilts. Before each tilt reaches the tip-over point, the CNS counters with a signal to reverse direction. Sway also occurs in the hip and there is a slight winding and unwinding of the lower back.

An analogy would be a ball that is volleyed back and forth between two players and is not allowed to touch the ground. The muscle exertion required to maintain an aligned standing posture is crucial but minimal. A little goes a long way. Electromyography has detected slight activity in the muscles of the calves, hips and lower back.

Although the pendulum model is a good approximation, a time series of postural sway shows much more variation than is seen in a physical pendulum. In the past, the variation was attributed to random effects. A more recent interpretation is that sway has a fractal structure. A fractal pattern consists of a motif repeated at varying levels of magnification. The levels are related by a ratio called the fractal dimension. It is believed that the fractal pattern offers a range of fine and gross control tuning. Fractal dimension is altered in some motor dysfunctions.

This is one of the best definitions I have read and, therefore opted to re-use it in this context. WBV introduces a significant additional stimulus to the CNS in order to challenge the postural reflexes. Utilizing WBV on many of my patients over the last year, I have found a number of them are making significant gains in their spatial awareness and proprioceptive responses. This is particularly true for the geriatric patient and, in particular, those that have not exercised for years. Patients with chronic postural distortions also derived tremendous benefit and excelled in their improvement.

Doctors practicing with somatic release may be familiar with the term somato-motor amnesia. Many of these patients’ postural senses have become overwhelmed by the aberrant stimuli of faulty positioning. WBV helps patients to key in on their own bodies on a subconscious level. Integrating the stimulus of WBV into the treatment protocol increases assists the patient in becoming more aware of their position in the three dimensional room. Many experience an improved sense of balance, all of which facilitates becoming more limber and flexible.

All of these above mentioned changes are, of course, benefits of regular exercise. Moving our limbs through the three dimensional room helps to gain better control over our whole body. Yet many of our patients may not be able to go to a gym or other exercise facility for a multitude of reasons.

Having a WBV unit in the chiropractor’s office, therefore, becomes a feasible choice. Standing on a vibrating platform creates a safe and user-friendly environment to introduce a postural challenge into the above described neuromuscular control system. If the patients are assisted by a therapist and taken through a series of exercise while standing on the plate, they are performing neuromuscular re-education and the office is well justified in billing for such a service.

WBV can be a tremendous asset to the chiropractic care of our patients. It relaxes the patients, helps them to get ready for an adjustment and prepares their neurologic systems to accept the input provided by the articular manipulation. It is difficult to imagine a better preparation for the chiropractic adjustment.

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

 

 
Can Children Benefit from Rehabilitation?
Rehabilitation
Written by Dr. Kirk A. Lee, D.C., C.C.S.P.   
Monday, 04 June 2007 14:59

A common question I get in the office, as well as when I am lecturing, is what’s the earliest age you can start rehabilitation procedures for children? Unfortunately, for many of us, we forget that we are dealing with children and not just small adults. It is important to note that protocols or principles of rehabilitation are the same for everyone—youths, baby boomers, and our elderly population. They vary in that each rehabilitation program we develop must be specific to that person’s needs. This is governed totally by anatomical and physiological differences that exist within our patients’ age groups.

Since we are focusing today on the younger population we must keep in mind those differences:

  •  Muscular strength, maximal oxygen uptake, and cardiac output are all proportionately lower in children.
  •  The apophyses or area of tendon insertion may be particularly predisposed to injury, especially from both micro and macro repetitive stresses.
  •  More injuries involve the epiphysis of long bones in children, and growing bone has inherent areas of weakness.
  •  Ligaments are usually two to five times as strong as the epiphyseal plate. This can lead to damage by overloading of an immature and growing joint.
  •  Flexibility and muscle imbalances change constantly as a child grows.
  •  The younger patient may be less motivated to follow through a rehab plan.

Having identified some important factors, we must also consider the type of rehabilitation we are doing. Is this to help restore our patient to a prior level of normal activity as quickly and safely as possible? Or, is it to improve and enhance athletic participation, or activities of daily living? Following any injury, we must focus on reducing swelling and pain that may have resulted. Here, we may focus on flexibility, strength, joint function (motion), power and endurance, proprioception, coordination and agility. When our patient has returned to normal function, our focus will be more centered on specific needs. For example, if we are dealing with trying to improve our patient’s athletic performance or prevent further injuries, then additional rehabilitation programs need be specific to enhancing movement patterns that are sport or job specific. To allow success for all our rehabilitation strategies, we must be knowledgeable of the amount of "tissue loading" that will result from each movement or task we recommend.

In conjunction with the Chiropractic Manipulative Therapy (chiropractic adjustment), we may choose to use modalities or therapeutic exercises to promote normal healing and restore function while reducing the vertebral subluxation complexes. We must consider how these modalities and therapeutic exercises may affect an open epiphysis and the length of bone during its growth. Finally, we must consider the "physiological" factors of maturity, motivation, and how well our patient understands the significance of the neuromusculoskeletal condition we are treating.

When we consider the use of the most common adjuncts available to us (cold and heat), we must keep some important things in mind. If we are using cold to reduce acute inflammatory response of an injury or inflammation caused by exercise, the cold should also include the use of compression and elevation (PRICE). Contraindications for cold would include prolonged use over an area which may lead to tissue damage. This could result in a neurpraxis or axonotmesis of superficial nerves, or altered increases and decreases of blood flow. This is referred to as "Hunting Reaction." Always consider not using ice over areas of skin that my have a reduced or compressed blood flow.

The use of heat as a modality is usually used after the acute signs and symptoms have resolved. Application of heat increases blood flow of an area, which helps bring oxygen and needed nutrients, while removing toxins and debris away from the injured area. The use of heat commonly is used as a precursor on joints to help improve ranges of motion. Contraindications of heat are acute traumatic injuries. This can cause an increase of edema and hemorrhage formation. Likewise, use over areas of decreased sensitivity and ischemia may result in overheating and cause tissue damage.

We must exercise extreme caution when using any modality with adolescent or younger patients; their thermoregulatory systems may not be able to judge just how cold or hot an application may be.

When determining the type of resistance exercises to perform, rehabilitation tubing is easy and safe to use, regardless of age. These bands will come in usually three types of resistance, as identified by color: red being the lightest; yellow, medium; and black having the most resistance. To determine the amount of resistance to use, always keep in mind you want your patient to be able to perform full ranges of motion in a smooth, steady motion. Any jerky or restricted motion means the resistance is too strong and the joint is being over-loaded. The number of repetitions you recommend should be based on how well your patient can perform the exercise. We are not trying to make strength gains in the beginning. Proper mechanics for re-education is what is important here. I would recommend not performing more than three sets of no more than eight to fifteen repetitions. A very good rule of thumb here is that each repetition must be performed the same as the one before it—meaning repetition number five must be performed with the same easy, smooth motion as the first repetition. If it is not, then we are possibly over-loading that joint. I would rather see good quality in technique and full ranges of motion than a jerky pattern that is not completed through a full range of motion. Commonly, with both my younger and elderly patients, I like to have them do what is referred to as a "Reverse Pyramid"—one set of eight, a second set of six, and a third set of four; keeping in mind that the last set of four must be done as smoothly as the first eight.

In closing, a very common question I know we all are asked by parents is, "Is it safe for my child to lift weights?" The answer is yes, but it must be a properly supervised and implemented program. When this takes place, strength gains have been noted by children without risk of injury. This is well documented by such organizations as the American College of Sports Medicine, The American Academy of Pediatrics, and the National Strength and Conditioning Association.

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.

 

 
Active Therapeutic Movement (ATM) Therapy in a Chiropractic Clinic
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.

 
Evaluating the Gait Cycle as Part of Your Chiropractic Treatment Plan
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.

 
The Ear Adjustment
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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 .

 

 
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