Active Treatment Strategies
Improve Patient Outcome & Clinic Profits

Building a profitable practice takes the right equipment, skills and a commitment to excellence.  Certainly central to that is a clear, results-oriented treatment strategy.  Spinal adjusting and passive modalities are ubiquitous in chiropractic. Decompression/traction is also becoming a staple of passive care.  However, exercise and specific movement therapy is fast becoming a major player in many forward thinking clinics…as the emphasis shifts to an active model of care.

Active treatment methods should, ideally, be integrated with passive care. A substantial result over a wide range of conditions is no longer an option but a necessity.  Competition and managed care necessitates it. We all are faced with the daunting task of getting our patients better faster…and certainly faster than the doctor (or therapist) down the street!  The mind-set of today’s forward thinking clinicians is to develop patient wellness strategies that are active, functional and leading to a patient self care plan. We can no longer wait weeks to get them actively engaged in functional activities—our personal and collective reputations are at stake as well as our bottom lines!

We are all faced with trying to stay ahead of changing healthcare trends.  My practice has evolved to provide treatments that compliment the philosophy you-grow-or-you-die!  I use a new and very effective device called an ATM2 (Active Therapeutic Movement). This type of treatment enlarges the scope of my practice and is an ideal transition treatment method from passive to active care. An Active Rehabilitation Suite with the ATM2 affords dramatic outcome and profit opportunities. The ATM2 creates an ideal dovetail for active relief and transition to real, substantial exercise. It is unique in the world of physical medicine. 

A highly researched concept in physical medicine suggests, IF a painful range-of-motion (a movement impairment) can be made painless (through positional fixation, compression and/or support), the central nervous system (CNS) can, and normally will, improve or optimize muscle activation patterns, i.e., the pattern or sequence of contraction it uses to create vertebral motion. (If the activation is less than optimal, untenable compression or tension on innervated tissues results in pain.) The Active Therapeutic Movement technique and ATM2 system that I use is actually a vertical treatment table with three sets of belts. Using these specialized external stabilization belts, I can safely position patients and comfortably compress and fixate specific body areas. In a matter of minutes, painful movements (impairments) become completely pain-free.  Once the movement is pain-free, a near isometric (safe-range) resistance exercise is incorporated.  This substantial exercise into the once painful direction ultimately provides substantial rehabilitation of the motion impairment. Theoretically, the resistance exercise forces the CNS to memorize a more idealized (and pain-free) muscle activation sequence.  The ATM2 treatments are done in the upright, full weight bearing position, fostering lasting changes both anatomically and neurologically. Within minutes, patients are moving pain-free. It is quite extraordinary and I have yet to find any treatment which replicates its results.

This Active treatment method and the impressive results it provides have changed my practice for the better.  Many of us use active rehab in our practices. However, most simply use a therapy ball and resistance-bands—things that require substantial pain relief before they are tolerated. In my mind, if we are to compete with the “therapist down the street,” we must offer our patients more.  And, realistically, we must offer therapies and treatment methods that are substantial, functional and provide immediate positive feedback to the patient. 

This active treatment rehabilitation involves surprisingly little time (most patients, five to eight minutes) but creates consistent and immediate pain relief in many instances. And, unlike previous PT methods demanding sometimes years of study (and two or more assistants bracing and compressing the patient into position), the ATM2 technique affords a clinician the opportunity to simply, safely (and with virtually no learning curve) attain these results without an assistant.  If you have staff, as I do, this method can be taught quickly and easily. (There is further training on-line and via DVD as well).

At our clinics, the patient is qualified for the therapy, safely positioned and participating in these pain-free therapeutic motions within minutes, gaining substantial relief and substantial therapeutic benefit unavailable anywhere else.  An additional clinician benefit is the strain reduction on your own back.  Less bending over, lifting and rotating—lengthening your own career!  Not to mention the ease of treating those very large or very de-conditioned patients who have not exercised for many years. ATM2 affords many patients the opportunity to start beneficial therapeutic movements on the very first visit, in both chronic and acute conditions.

I have developed a specific patient protocol for combining Active Therapeutic Movement with Decompression therapy (a favorite treatment of mine). Combining modalities and adjusting is also very practical.  And keep in mind that the ATM2 is an excellent and very reliable self-prognosticator.  If a patient CANNOT be set up completely pain-free, they are not, at that time, an ATM2 patient. This is extremely powerful in reducing the potential of negative or less than desirable outcomes and in reducing your liability, as well as channeling a patient to the best intervention at that time. And, since the response to a treatment is immediate, athletes and fitness enthusiasts are continually captivated by the active relief of an ATM2 treatment.  They often will comment that they feel lighter or taller.  This would seem congruent to muscle activation or muscle selection patterns being improved by the CNS, thereby re-organizing the most specific or appropriate muscles, optimally selected to do the majority of the workload.

I hope you will take the time to investigate for yourself the distinct and powerful clinical advantages of using active treatment strategies that are possible with Active Therapeutic Movements and the ATM2.  I believe it will improve your marketability as you provide a more eclectic treatment offering, including an active treatment component, and have a dramatic effect on your patient outcomes, your clinical confidence and your bottom line profits.

Dr. Jay Kennedy is a Palmer Graduate and has been in both a private & MD/DC practice in Berlin PA. for 18 years. He lectures throughout the United States on decompression and rehabilitation procedures and has successfully utilized the ATM2 treatment in his clinics for several years, creating a classification system which utilizes patient-specific conditions and as that relates to treatments with traction/modalities/adjusting & the ATM2.  He is also a clinical consultant and product designer for a major physical medicine manufacturer.

The Core

If you were to ask which muscle group you could focus on to provide your patients with the greatest benefits in the shortest amount of time, it would be the core. What is the core? The core consists of all the muscles in the abdominal and lower back areas. This includes the abdominal muscles: rectus abdominus, internal and external obliques; the transverse abdominus and the intercostals. It also includes the muscles associated with the spine: the erector spinae group and the hip flexors (iliacus and psoas, collectively known as the iliopsoas). The basis of core training is to increase the recruitment efficiency of the smaller, deeper stabilizing muscles around the hip and pelvis. The aim of core training is to recruit the trunk musculature and then learn to control the position of the lumbar spine during dynamic movements.

Why Is the Core So Important?

Weak core muscles contribute to all kinds of problems in the body, the most prevalent of which is lower back pain. Strengthening the muscles that help support the spine and improve posture dramatically decreases the symptoms of lower back pain. Picture the spine as a column of cans stacked one on top of the other. If you wanted to keep that column standing up under stress, what do you think would work better: a “tenser” bandage, as is used for wrapping injured ankles, or Scotch tape? The tape would keep the cans together, but the cans wouldn’t receive a whole lot of support, would they? When you strengthen the muscles of the core, you are, in effect, turning that Scotch tape into a nice, tight “tenser” bandage, increasing the amount of support that the spine receives.

Four Mechanisms of Active Support

The lumbar spine area is inherently unstable and relies upon support from four mechanisms that actively support the area for sufficient stability. These four mechanisms include tension from the thoracolumbar fascia; the intra-abdominal pressure mechanism; the paraspinal muscles; and the deep lumbar extensors. The thoracolumbar fascia provides a tensile support to the lumbar spine via deep-trunk muscle activity. The intra-abdominal pressure mechanism can provide a supportive effect to the whole lumbar area. The paraspinal and deep lumbar muscles act with a static contraction to resist lumbar extension and rotational forces.

The deep-trunk muscles, transversus abdominus, multifidus, internal oblique, paraspinal, and pelvic floor are key to the active support of the lumbar spine. It is not just the recruitment of these deep-trunk muscles, but how they are recruited that is important. The co-contraction of the transversus abdominus and multifidus muscles occurs prior to any movement of the limbs. These muscles anticipate dynamic forces, which may act on the lumbar spine and stabilize the area prior to any movement. The timing of coordination of these muscles is very significant. Back injury patients are unable to recruit their transversus abdominus and multifidus muscles early enough to stabilize the spine prior to movement. The onset of the contraction before any force can act on the lumbar spine is essential for these muscles to act as stabilizers.

Specificity of Training

Having identified the key muscles and how they act, the next step is to establish how best to train these muscles. As with any type of strength and conditioning training, the training protocol for improving the function of the deep-trunk muscles must be specific to the task required. The deep-trunk muscles act as stabilizers and are not involved in producing movement but, instead, involve static, or isometric, contractions. They must act as stabilizers continuously throughout everyday activities as well as fitness training, and require very good endurance of low-level forces. The deep-trunk muscles do not need to be very strong, but they must be correctly coordinated and capable of working continuously. These stabilizer muscles must hold the lumbar spine in the neutral position, which is the correct alignment of the pelvis that allows for the natural S-curve of the spine.

Warm-ups

Begin core training with a three- to four-minute cardio-vascular warm-up, such as walking on a treadmill. “Scouring the Joints” is an excellent warm-up that stimulates nutrition in the joint capsule. This warm-up is performed with the patient in the standing position. Instruct the patient to actively rotate his or her pelvis clockwise three times and then counter-clockwise three times. The patient should feel a “scouring” sensation in the acetabulae.  Follow this lower body warm-up with a warm-up of the shoulder joints. Instruct the patient to lower the shoulder blade on one side and then to move the humeral head through the hours of the clock three times in one direction, then three times in the opposite direction and, finally, to repeat the warm-up with the opposite shoulder.

The Basics: Co-contraction

Core-stability training begins with learning to co-contract the transversus abdominus and multifidus muscles effectively as the key to the lumbar-support mechanism. To perform this co-contraction requires mastering the abdominal hollowing technique with the spine in the neutral position. Begin by instructing the patient to lie on his or her back with knees bent. The lumbar spine should be neither arched up nor flattened against the floor, but aligned normally with a small gap between the floor and the back. This is the neutral lumbar position the patient must learn to achieve. Instruct the patient to breathe in deeply and to relax all the stomach muscles. Ask the patient to breathe out and, as he or she does, to draw the lower abdomen inward, as if the belly button were going back toward the floor. Pilates teachers describe this movement as “zipping up,” as if you were fastening up a tight pair of jeans. Instruct the patient to hold the contraction for ten seconds, while breathing in and out and holding the tension in the lower stomach area. This exercise should be repeated five to ten times.

Important Coaching Points

It is vital for patients to master the performance of the abdominal hollowing exercise correctly, otherwise they will not learn to recruit their transversus abdominus and multifidus effectively. Don’t allow patients to let the whole stomach tense up or upper abdominals bulge outward, as this means they are using the large rectus abdominus muscle instead of transversus abdominus. Coach patients not to brace their transversus abdominus muscles too much. A gentle contraction is enough. Be sure that patients do not tilt the pelvis or flatten the back while performing abdominal hollowing, as this means they have lost the neutral position they are learning to stabilize. Patients should breathe normally while maintaining the co-contraction of transversus abdominus and multifidus. Breath holding means the patient is not relaxed. Once a patient has mastered abdominal hollowing while lying in the supine position, it’s time to practice it while lying prone, in a four-point kneeling position, sitting and standing. Be sure that the patient resumes a neutral lumbar spine position in each posture before performing the hollowing movement.

Functional Stability

Once a patient has learned to recruit the transversus abdominus and multifidus muscles correctly in various positions, it is time to increase the challenge. Core stability is not defined by the ability to recruit deep stabilizing muscles in isolation. Instead, it is defined by the ability of the core muscles to work in an efficient and coordinated fashion to maintain correct alignment of the spine and pelvis while the limbs are moving. It is important that, once patients have achieved proficiency of the simple abdominal hollowing exercises, they progress to achieving stability during more functional movements. You can achieve this by adding limb movements, such as leg raises, while the patient performs abdominal hollowing in the lying, kneeling, sitting and standing positions. Use your imagination to think of ways to improve your patients’ dynamic stability. The approach only works, however, if the patient focuses 100% on posture and alignment. The aim is always to develop the correct and efficient core muscle recruitment patterns.

Dr. Mark Sanna is the CEO of Breakthrough Coaching. For more information on core training or to attend a Core Workout Training Seminar, contact Breakthrough Coaching at 1-800-723-8423 or visit
www.mybreakthrough.com.