Rehabilitation


Hamstrings—What about Stretching?
Rehabilitation
Written by John K. Hyland, D.C.   
Thursday, 27 April 2006 03:12

A
n interesting study has found that there is a more effective way to stretch the hamstring muscles.1 The new procedure is easy to teach to patients, and can be done anywhere and just about anytime. Unlike some forms of hamstring stretching, it does not require an assistant or any special equipment to achieve significant improvement in flexibility. The new stretch is termed a “stance phase” stretch for the hamstring, contrasting this method with all others that position the leg in the forward swing phase during the stretch period. It is also a “closed-chain” stretch, while all other hamstring stretches use an “open-chain” position. An example of an open-chain stretch is the commonly used Standing Hamstring Stretch, with the upper body bent forward over the outstretched leg.

A Better Hamstring Stretch

Hyland-HamstringsIn this new hamstring stretch, the subject starts in the standing position, and then takes a short step forward with the leg to be stretched. Both hands are placed on the forward knee, both knees are bent slightly, and the pelvis is then tilted forward while the lumbar spine extends. (The forward tilt of the pelvis places the hamstring in a “pre-stretch”.) While maintaining lumbar extension, the subject bends forward at the hip until the hamstring muscle tightens. The stretch is accentuated further by slowly extending the forward knee. The stretch is held at tension for thirty seconds, and then the leg positions are reversed. Each leg is stretched five times. One set of these stretches was done five days a week for a period of two weeks (a total of ten five-minute stretching sessions). The investigators reported that “evaluation of the data indicated that the stance phase stretch was significantly more effective at increasing hamstring flexibility than the forward swing phase stretches.”

The beauty of this method for stretching the hamstrings (besides the rapid improvement in flexibility experienced by the patient) is that the joints, muscles, and connective tissues all are bearing weight during the exercise. The foot and ankle are in the stance phase, when the hamstring will be most active. This provides a more specific active retraining of neuromotor patterns, thereby preparing all involved structures for more efficient daily activities. 

Adjustments and Muscle Balancing

Hamstring muscle imbalances often contribute to (or may be caused by) pelvic malpositions and spinal subluxations.2 And, other pre-existing muscle imbalances may contribute to chronic hamstring tightness and recurrent strains. The gluteus maximus muscle is often relatively weak, causing the hamstring to work harder to extend the hip joint. This may be found along with an iliopsoas muscle that is shortened or hypertonic on the same side. The tightness of the iliopsoas inhibits the gluteus maximus, thereby placing the hamstring at a disadvantage.3

Foot and Knee Alignment

The hamstrings are most active during the last 25% of the swing phase of gait, and the first 50% of the stance phase.4 Since this initial 50% of stance phase consists of heel strike and maximum pronation, the hamstrings help to control the alignment of the knee and ankle and help absorb some of the impact. A study of runners found a significant decrease in electromyographic activity in the hamstrings when wearing orthotics.5 In fact, these investigators found that the biceps femoris had the greatest decrease in activity of all muscles tested, which included the tibialis anterior, the medial gastrocnemius, and the medial and lateral vastus muscles. The researchers theorized that the additional support from the orthotics helped the hamstrings control the position of the calcaneus and knee, and also absorb some of the shock of heel strike. Previous studies have also demonstrated significant decreases in tibial internal rotation6 and pronation velocity7 when using orthotics, which could also relieve some of the strain on the hamstring muscles.

Conclusion

This new stance-phase, closed-chain stretch is not only more effective, but it is easier to do than most other forms of hamstring stretching. That makes it more likely that our patients will actually do the stretch we have recommended, and get positive results. Comprehensive treatment of pelvis and lower spine problems should include an evaluation of the lower extremities and the hamstrings, in particular. Stretching of tight hamstrings may be needed, along with orthotic support to stabilize rearfoot function. The electromyography investigations have shown that orthotics have a direct effect on the hamstring muscles.

John K. Hyland, D.C., M.P.H. D.A.C.B.R., D.A.B.C.O., C.S.C.S., C.H.E.S. is board-certified in two chiropractic specialties, and is also certified as a Strength and Conditioning Specialist and a Health Education Specialist. He has 20 years of clinical practice; for eight years he specialized in chiropractic rehabilitation. He is currently a Research Associate at Parker College of Chiropractic, and an Adjunct Professor of Clinical Sciences at the University of Bridgeport’s College of Chiropractic. You can contact him at This e-mail address is being protected from spambots. You need JavaScript enabled to view it .

References

1. Ross M. Effect of lower extremity position and stretching on hamstring muscle flexibility. J Strength Cond Res 1999; 13:124-9.

2. Muckle DS. Associated factors in recurrent groin and hamstring injuries. Brit J Sports Med 1982; 16:37-9.

3. Geraci MC. Rehabilitation of the hip, pelvis, and thigh. In: Kibler WB, ed. Functional rehabilitation of sports and musculoskeletal injuries. Gaithersburg: Aspen Pubs; 1998. p. 225.

4. Mack RP. AAOS Symposium on the foot and leg in running sports. St. Louis: Mosby; 1982.

5. Nawoczenski DA, Ludewig PM. Electromyographic effects of foot orthotics on selected lower extremity muscles during running. Arch Phys Med Rehabil 1999; 80:540-4.

6. Nawoczenski DA, Cook TM, Saltzman CL. The effect of foot orthotics on three-dimensional kinematics of the leg and rearfoot during running. J Orthop Sports Phys Ther 1995; 21:317-27.

7. Eng JJ, Pierrynowski MR. The effect of soft orthotics on three-dimensional lower limb kinematics during walking and running. Phys Ther 1994; 74:836-44.

 
Avoid Rehab Overload
Rehabilitation
Written by John K. Hyland, D.C.   
Monday, 27 March 2006 02:20

Most of us know that exercises are an important key to full recovery of spinal function. Unfortunately, I have found that the more knowledgeable doctors are in rehab procedures, the more likely they are to overwhelm their patients with exercises. The result is frequently a long laundry-list of exercises given to each patient. This often includes stretches for all of the tight muscles, strengthening for all of the weak muscles, and (of course) stabilizing, proprioception, and coordination exercises. In the real world, though, patients have a limited amount of time (and willingness) to exercise. One of the most important concepts in designing an effective rehab program is this: don’t overwhelm your patient with exercises.

Exercise Overload

Unfortunately, patients don’t get better from the exercise recommendations we give them. In order to get the benefits of active exercising, the patients have to actually do the exercises. If they don’t do the exercises, they just won’t get any better, even when they have been given beautifully planned programs. Exercise recommendations must be designed so patients can realistically follow them. Overload happens when a patient is advised to do six to ten (or more!) exercises once or even twice a day. The doctor or therapist strongly believes in the benefits to be gained from these various exercises, and the patient is gung-ho to get better. Problems begin by the second day, when the patient realizes that this amount of commitment is simply not compatible with real life. 

Take a Walk in the Patient’s Shoes

The best way to avoid this problem is to recognize that our patients have their own lives. We must advise and treat our patients the same way we would treat ourselves. Since we often have a hard time finding an extra hour or so each day to do the exercises we know we should be doing, we can’t expect our patients to have an easier time. Do you regularly perform the spinal strengthening and flexibility exercises that you recommend for your patients?

An informative study looked at home exercise performance in adults over 65 years of age (an age group that has previously been found to have difficulty with exercise compliance). Volunteer subjects aged 67 to 82 years were instructed in either two, or eight exercises to be done daily. When they were checked ten days later, the group who had been shown only two exercises performed significantly better than the group who had been shown eight exercises.1 While the results may seem self-evident, many doctors and therapists apparently need this evidence-based reminder.

Getting Started is First

The most effective way to begin an exercise program is small, but consistent. This means that the patient starts with the one or two exercises they really need, and they perform the exercises frequently (daily). Once-a-day exercising is the quickest and easiest way to establish a regular exercise routine. Patients are allowed to fit the exercise(s) into their daily schedules whenever it’s best for them — mornings, during lunch breaks, or evenings. Initially, we are not asking our patients to do heavy resistance, muscle tear-down exercises, so the traditional “day of rest in between” is not needed. We want to establish a new habit of regular, consistent exercising of the problem area.

The Next Step

As patients begin to respond, and a routine has been established, we can add one or two more exercises to address adjacent or more involved areas. Even so, it is vital that we continue to monitor our patients’ levels of compliance and commitment, and provide praise and recognition. We all do better and are more motivated when we have achieved some small success before we tackle larger projects. The confidence that comes from succeeding at the initial exercises makes it much easier to, then, integrate more complex or time-consuming exercise routines.

Conclusion

Patients should begin with a graduated exercise program that starts with minimal commitment, and then builds upon the exercise habit that they establish. This should be integrated into our early phases of chiropractic care, in order to gain the most advantage from the benefits of exercising problem areas. We should avoid giving exercise recommendations that overwhelm or ask too much from patients. And we really should try out the exercises ourselves for a week or so, to see how much time and effort is really required to follow our exercise programs.

John K. Hyland, D.C., M.P.H. D.A.C.B.R., D.A.B.C.O., C.S.C.S., C.H.E.S. is board-certified in two chiropractic specialties, and is also certified as a Strength and Conditioning Specialist and a Health Education Specialist. He has 20 years of clinical practice; for eight years he specialized in chiropractic rehabilitation. He is currently a Research Associate at Parker College of Chiropractic, and an Adjunct Professor of Clinical Sciences at the University of Bridgeport’s College of Chiropractic. You can contact him at This e-mail address is being protected from spambots. You need JavaScript enabled to view it .

References

1. Henry KD, Rosemond C, Eckert LB. Effect of number of home exercises on compliance and performance in adults over 65 years of age. Phys Ther 1999; 79:270-7.

 
Exercise for Healthy Aging
Rehabilitation
Written by John K. Hyland, D.C.   
Monday, 27 February 2006 01:22

There is now a wealth of data that supports the value of aerobic and resistance exercise for the geriatric population. Improvements are seen in weight and body composition, greater insulin sensitivity, decreased falls/improved balance, better psychological health, less frailty and improved function. With exercise, the resting blood pressure lowers, and there is a reduction in the risk of all-cause mortality.1 Studies have shown that the stronger the back and leg muscles are, the higher the bone density is in the region.2 These benefits are so wide-spread, that they should encourage us to recommend exercise to our older patients. But both doctors and patients often hesitate to pursue exercise for the aged, due to several concerns.

Hypertension/Artherosclerosis

Hardening and constriction of the arteries cause a decrease in blood flow, especially to the extremities. The heart responds by increasing the blood pressure, trying to force the blood through the restricted areas. When resting measurements are consistently above 140 mmHg (systolic) and/or 90 mmHg (diastolic), the person has hypertension. Some patients will need medication to control their high blood pressure, especially in the higher age ranges. While the drugs do decrease the likelihood of strokes and heart attacks, many patients are hesitant to exercise, and they become even more sedentary. There is good evidence that exercise is not contra-indicated, and is actually beneficial for patients taking blood pressure medications.3

Osteoarthrosis

Degenerative arthritis is a common musculoskeletal disorder in older adults, causing significant amounts of physical disability. Osteoarthrosis afflicts an estimated 20 million Americans, with the knee being the most commonly affected weight bearing joint.4 In addition to pain with movement, the involved joint(s) lose flexibility and strength. Contrary to what is commonly believed, moderate exercise does not increase the risk for osteoarthrosis or exacerbate it; rather, it has been found to improve function and reduce pain.5

Deconditioning/Low Muscle Mass

National surveys reveal that 70% or more of older adults do not engage in any regular exercise.6 This compounds the loss of strength and muscle mass, and increase in body fat that is normally seen in aging. In fact, this change in body composition is tied to many factors, including poor nutrition, decreased physical activity, increased disability and disuse, type II muscle fiber atrophy, and drug side effects.

ACSM/NSCA Guidelines

Two major organizations-the American College of Sports Medicine7 and the National Strength and Conditioning Association8-have published recommendations to be followed when advising older adults to exercise. Both state that aerobic and resistance exercises for older populations are generally safe and can be very effective, both for treating specific problems as well as avoiding general disability. These guidelines encourage the use of regular physical activity, along with specific exercises to improve endurance, strength, and proprioception. Current research has found that even high-intensity training of frail men and women in their 90’s is safe and leads to significant gains in muscle strength and functional mobility.9

Since isometric exercises may increase the systolic blood pressure, isotonic (or “dynamic”) exercises are considered safer for building strength.10 Elastic resistance tubing is an excellent method to provide strengthening dynamic exercise without the need for machines or heavy weights. Older adults often have difficulty figuring out complex machines and may not be able to handle exercise weights and barbells. A home-based program using elastic tubing can provide significant gains in strength and flexibility.11 These exercises can be done standing or sitting, providing an additional weight-bearing stress to the muscles and bones.

Conclusion

Selecting the best exercise approach for an older patient is not difficult, but does require some special considerations. A review of the patient’s health history is necessary, in order to identify any complicating or restricting factors. A closely monitored home exercise program allows the doctor of chiropractic to provide cost-efficient, yet very effective, exercise recommendations for patients of all ages.

John K. Hyland, D.C., M.P.H. D.A.C.B.R., D.A.B.C.O., C.S.C.S., C.H.E.S. is board-certified in two chiropractic specialties, and is also certified as a Strength and Conditioning Specialist and a Health Education Specialist. He has 20 years of clinical practice; for eight years he specialized in chiropractic rehabilitation. He is currently a Research Associate at Parker College of Chiropractic, and an Adjunct Professor of Clinical Sciences at the University of Bridgeport’s College of Chiropractic. You can contact him at This e-mail address is being protected from spambots. You need JavaScript enabled to view it .

References

1. Blair SN, et al. Influences of cardiorespiratory fitness and other precursors on cardiovascular disease and all-cause mortality in men and women. JAMA 1996; 276:205-10.

2. Sinaki M, Offord KP. Physical activity in postmenopausal women: effect on back muscle strength and bone mineral density. Arch Phys Med Rehabil 1988; 69:277-80.

3. LaFontaine T. Resistance training for patients with hypertension. Strength & Conditioning J 1997; 19:5-7.

4.Lawrence RC, et al. Estimates of the prevalence of arthritis and selected musculoskeletal disorders in the United States. Arthritis Rheum 1998; 41:778-99.

5. Casper J, Berg K. Effects of exercise on osteoarthritis: a review. J Strength Condition Res 1998; 12:120-5.

6. Clark DO. Racial and educational differences in physical activity among older adults. Gerontologist 1995; 35:472-80.

7. American College of Sports Medicine. Exercise and physical activity for older adults. Med Sci Sports Exerc 1998; 30:992-1008.

8. Pearson D, et al. The national strength and conditioning association’s basic guidelines for the resistance training of athletes. Strength & Conditioning J 2000; 22(4):14-27.

9. Fiatarone, et al. High-intensity strength training in nonagenarians: effects on skeletal muscle. JAMA 1990; 263:3029-34.

10. American College of Sports Medicine. Exercise prescription for special populations. In: Guidelines for exercise testing and prescription; 1991. p. 166.

11. Jette AM, et al. Exercise- it’s never too late: the strong-for-life program. Am J Publ Health 1999;

 
Idiopathic Scoliosis Treatment with Scoliosis Systems
Rehabilitation
Written by Marc J. Lamantia, D.C., and Gary A. Deutchman, D.C.   
Monday, 26 December 2005 23:58

Scoliosis Systems™ is a complete chiropractic technique designed to manage idiopathic scoliosis without the use of a rigid brace.  Dr. Gary Deutchman and Dr. Marc Lamantia have combined their thirty years of experience and training in the development of this system, which includes both spinal and vestibular rehabilitation procedures.  “The key to the success of spinal remodeling is the use of dynamic movement and neuro-muscular retraining actively performed by the patient,” says Dr. Lamantia.  The vestibular control of posture has been shown to be abnormal in scoliosis; but the good news is, these imbalances respond well to chiropractic care.

Scoliosis Systems™ teaches CE accredited courses co-sponsored by New York Chiropractic College in New York, Los Angeles, and Chicago.  There are three modules. Module-1, Spinal Rehabilitation, is taught by Dr. Deutchman and is designed to introduce the concepts of the “Corrective Movement Principle,” as well as mobilization and manipulation techniques, to allow soft tissue changes necessary for correction. Module-2, Vestibular Rehabilitation, is taught by Dr. Lamantia, who holds a diplomate degree in neurology.  This course teaches the doctor to identify and correct underlying vestibular deficits associated with scoliosis.

“Muscle recruitment patterns are abnormal in scoliosis and contribute to the progressive nature of the disorder. The vestibular system is an avenue for neuro-rehabilitation, and the chiropractor is the most qualified professional to evaluate and balance central nervous system dysfunction,” says Dr. Lamantia.

Scoliosis Systems™ Module-3 offers a certification in the use of the SpineCor™ brace. SpineCor™ is a flexible dynamic system of elastic straps, which allows for movement into a corrective posture.  Drs. Lamantia and Deutchman have trained with some of the top researchers in non-surgical scoliosis treatment, including the developers of the SpineCor and the Rigo Chernaeu Braces. “The concept of bracing does not always sit well with chiropractors, but it is an integral part of the non-surgical management of scoliosis.  The struggle is to find a brace that is consistent with the chiropractic paradigm of maintaining movement throughout normal growth,” says Dr. Gary Deutchman.

Case Study

This case study follows the treatment of an adolescent female patient with idiopathic scoliosis whose initial presentation was at 9 ½ years of age, and Risser 0 was with a 36º right thoracic curve.

After evaluation of the patient’s radiological, clinical and postural data, she was classified as a Right Thoracic Type 1 according to the SpineCor classification.

Each SpineCor classification has a specific corrective movement strategy for progressive curve reduction. In the case of Right Thoracic Type I, the corrective movement is counter clockwise rotation of the thorax and clockwise rotation of the shoulder girdle.

Patient C’s postural correction and Cobb angle reduction have been maintained three years post bracing.  SpineCor Brace wearing ceased 3 June 1999, after 15 months of wear.

For more information about seminar dates and locations, visit www.ScoliosisSystems.com, or call Dr. Gary Deutchman at 212-360-7760.

 
Rehab After Injury
Rehabilitation
Written by John K. Hyland, D.C.   
Wednesday, 26 October 2005 22:04

Communication skills are vital to achieving good results when dealing with patients after an injury. One of the most important components of post-injury rehabilitation is to give very clear instructions when the patients first start to exercise. This is because it is easy for patients to do too little or too much, and both will interfere with the desired outcome. It also helps to deal with the common “fear avoidance” of physical use that can develop after an injury. I find it helpful to communicate two topics specifically: I describe what the patients can expect to feel, and then also how they will know if they have pushed the exercise too far. This is important for those patients who have never exercised before, as well as for the athletes and weekend warriors, who tend to move along too quickly.

What to Expect

Patients starting to rehab do much better when they know exactly what they can expect to feel as they start doing the exercises. They appreciate the guidance and reassurance, and are more likely to follow through with my rehab recommendations. I begin with the following discussion: “As you start to exercise this area, you are likely to feel some soreness, some stiffness, perhaps even some mild irritation in the involved joints and muscles. That’s to be expected, and it means you’re working in the right area.”

This provides the needed encouragement to start exercising after an injury. It also prepares the patients for the expected soreness, so they don’t avoid using the injured area out of fear of re-injury. I then tell them it’s important to differentiate soreness and stiffness from true pain, which is an indicator that they have gone beyond their current capability.

Going Too Far

I don’t want my patients to continually aggravate the area that is healing so, when they start to do exercises after an injury, I want them to do it so it doesn’t cause pain. Some people (athletes in particular) have the idea that exercise has to be painful to be beneficial (the “no pain, no gain” concept). I tell my patients very directly that I don’t want them exercising through or beyond a painful point. My cardinal rule is “no pain for maximum gain”, and I instruct them to do their exercises in the pain-free range of motion. Unfortunately, I have found that, if I say “pain-free range,” most patients will nod their heads in understanding, but not really know what to do. The words sound familiar, but they are not really sure how to implement this in their exercising. To ensure accurate communication, I use a visual concept based on the colors of traffic lights.

Red Zone/Green Zone

I tell my patients, “As you do this exercise, some stiffness and soreness is to be expected.  However, if your body gives you a pain message during the exercise, I want you to pay attention. That pain message is your body’s warning signal, similar to a caution sign or a yellow traffic light. It doesn’t mean you have hurt yourself, but it means that, if you push the exercise beyond this point into the red zone, you risk aggravating your condition and slowing your progress. I want you to do the exercise all the way through the green zone and up to the yellow light. I do not want you to exercise into the red zone. This is not necessary, and is likely to slow your progress.”

Conclusion

Clear, specific guidelines are needed by all patients starting an exercise program; this is especially true for those who are trying to return to normal function after an injury. Rehab programs should be started early in the treatment of patients with injuries, and should take place simultaneously with the biological healing of the injured tissues. Optimal outcomes require patients to understand when to push ahead with their exercises, and when to reduce the exercise stress on the healing tissues. By clearly describing what they can expect to feel, and then providing a visually-cued description of the green zone and red zone, I find that patients are able to perform their exercises with confidence.

References

1. Swinkels-Meewisse IE, Roelofs J, Verbeek AL, et al.  Fear of movement/(re)injury, disability and participation in acute low back pain. Pain 2003; 105(1-2):371-9.
2. Klaber Moffett JA, Carr J, Howarth E. High fear-avoiders of physical activity benefit from an exercise program for patients with back pain. Spine 2004; 29(11):1167-72.

Dr. Hyland D.C., M.P.H., D.A.C.B.R., D.A.B.C.O., C.S.C.S., C.H.E.S. is board-certified in two chiropractic specialties, and is also certified as a Strength and Conditioning Specialist and a Health Education Specialist. He has 20 years of clinical practice; for eight years he specialized in chiropractic rehabilitation. He is currently a Research Associate at Parker College of Chiropractic, and an Adjunct Professor of Clinical Sciences at the University of Bridgeport’s College of Chiropractic. You can contact him at This e-mail address is being protected from spambots. You need JavaScript enabled to view it .

 
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