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Rehabilitation


Spinal Exercises in Rehab
Rehabilitation
Written by Roger R. Coleman, DC and Stephan J. Troyanovich, DC   
Friday, 26 August 2005 19:58

Spinal exercise is an important part of any spinal rehabilitation program. The timing of the prescription of spinal exercises is very important, so as not to cause more trouble for the injured patient.

Recommendations on Exercise

The use of active methods of care, such as exercise, have been discussed in some detail in published articles and books on the subject.1,2,3 Guidelines have been established that suggest that, in the first week of an acute episode of spinal pain, active strengthening exercises should be avoided, because they tend to aggravate acute conditions.

After a brief period of rest (usually three days or less), reactivation to usual activities of daily living is to be encouraged. Within the first week of an acute injury, endurance exercise programs that minimally stress the spine, such as walking or swimming, are found to be beneficial.2,3

Typically, we have our acutely injured patients begin a walking regimen in the first week of care, consisting of walking 10-15 minutes per hour throughout their waking hours. A protocol for spinal rehabilitation authored by Troyanovich, et al.,4 also suggests the use of applications of deep cooling procedures in the acute phase of treatment to control pain and inflammation. The application of ice packs in thirty-minute intervals, in combination with the initial walking regimen of 10-15 minutes per hour, is an adequate first step in patient management.

The next types of exercises that are advocated are range of motion exercises in the non-painful directions.  We typically employ extension, lateral bending, and axial rotation movements, as long as they can be performed without pain.

A word of caution is necessary here. Spinal exercises should not provoke a patient’s acute pain. The patients should always be warned that the movements should not cause any acute increase of their pain and should not cause any radiation of pain into their extremities. If such an occurrence of pain is provoked, the patient can still be instructed to perform the range of motion exercises; however, the patient is instructed to perform the movements at a slower pace, through a smaller range of motion that is not painful, or to discontinue the exercise and simply continue with their walking regimen.

Resistance Exercises

Christiansen5 has described a specific protocol for using isometric and isotonic exercises. He recommends that such exercise programs begin with isometric exercise, since they are best suited for use early in rehabilitation programs because, ideally, no active movement occurs during the performance of isometric exercise. What this means, in a practical sense, is that, since no movement of the joints occurs, the likelihood of further injuring the articular tissues is very low. Consequently, for patients ready to move to the next step in their rehabilitation programs, submaximal isometric exercises are an ideal procedure to follow their initial walking regimen and range of motion exercises.

For simplicity of discussion, we advocate isometric exercises in the same planes of motion as described above, including extension, lateral bending and axial rotation.  For greatest benefit, Christiansen5 recommends using the “rule of 10’s”.  That is to say, the patient is instructed to perform 10 repetitions per set and up to 10 sets per day (i.e., up to 100 reps per day). The total of 100 repetitions per day is considered a long-term goal and the patient is cautioned to begin with three to five sets of 10 reps per day and gradually add one additional set of 10 reps per day, until the full number can be accomplished without aggravation of symptoms and without causing radiation of symptoms into the extremities.

Isotonic Exercises

After completing approximately one to two weeks of isometric exercise, most patients are ready to begin isotonic (resistance) exercises. Recent guidelines, based upon reviews of the scientific literature on resistance exercise, suggest that acute patients should avoid beginning resistance exercise programs until two weeks have passed since the onset of symptoms.2,3  Sub acute and chronic patients may begin resistance exercise programs as early as the first week of treatment.2,3

Low-cost resistance exercise can be accomplished in the practitioner’s office with the use of a small number of simple devices. Several companies produce differing gauges of surgical tubing that can be used to provide resistance while performing spinal exercises. The advantage to these devices is that they are relatively inexpensive and require little or no special hardware to mount in the home or office setting. In addition, there is no scientific evidence that suggests that expensive resistance exercise equipment is any more effective in spinal rehabilitation than these simple devices.2

Heyward6 has described protocols for isotonic exercise designed to increase strength, endurance, and for toning of muscles. Based upon her data, endurance training of trunk muscles requires a protocol of three sets of 15-20 repetitions per set, performed at least three times per week for six weeks or more. This is the frequency and duration we advocate.

Additionally, the speed of the muscular contraction is important. The patient should take approximately one to two seconds to move into concentric position against the resistance of the exerciser (contraction phase) and another one to two seconds as they move back to the neutral position (eccentric contraction phase).

Patients are started on isotonic exercise at approximately the beginning of the second or third week of their rehabilitation programs (after completing one to two weeks of isometric exercise).  The rubber tubing type exercisers are used initially, performing three sets of 15-20 repetitions. Between each set of exercises, the patient is asked to rest for one to two minutes before proceeding to the next set. After one to two weeks of using relatively low resistance tubing, the patient then advances to higher resistance tubing.

At first, isotonic exercises are performed under the supervision of the doctor or an assistant. When the patients can perform the exercises competently, they are allowed to exercise independently in the office. This practice allows patients to enter the office and begin their exercises without having to wait for the doctor or assistant and facilitates a shorter duration of time in the office for each patient visit.

The isotonic resistance exercises are performed for the duration of the patient’s in-office rehab program.  Patients can, then, be sent home with the device to continue spinal strengthening programs upon their discharge from care.

Note: This information in not intended as healthcare advice. The determination of the risk and usability of information rests entirely with the attending doctor of chiropractic.

Dr. Roger R. Coleman is a 1974 graduate of Palmer College of Chiropractic, practicing in Othello, WA.  He is a member of the Adjunct Research Faculty at Life Chiropractic College West, and on the postgraduate faculty of National University of Health Sciences.

Dr. Stephan J. Troyanovich is a 1987 graduate of Palmer College of Chiropractic, practicing in Normal, IL, and a member of the Adjunct Research Faculty, Dept. of Research, at Life Chiropractic College West.  He may be reached at 309-454-5556.

References

1. Spitzer O, et al. Scientific monograph of the Quebec task force on whiplash-associated disorders: redefining “whiplash” and its management. Spine 1995;20(8S):2-73.
2. Bigos S, Bowyer O, Braen G, et al. Acute low back problems in adults. Clinical practice guideline no. 14. AHCPR Publication No. 95-0624. Rockville, MD: Agency for Health Policy and research, Public Health Service, U.S. Department of Health and Human Services. December 1994.
3. Abenhaim L, Rossignol M, Valat JP, et al. The role of activity in the therapeutic management of back pain. Spine 2000;25:1S-33S.
4. Troyanovich SJ, Harrison DE, Harrison DD.  Structural rehabilitation of the spine and posture: rationale for treatment beyond the resolution of symptoms. J Manipulative Physiol Ther 1998;21:37-50.
5. Christiansen K. Chiropractic rehabilitation volume I: protocols. Ridgefield, WA: Chiropractic Rehabilitation Association 1991.
6. Heyward V. Advanced fitness assessment & exercise prescription. Champaign, IL. Human Kinetics 1998.

 
Returning the Injured Athlete to Optimum Performance
Rehabilitation
Written by James W. Gudgel, D.C.   
Tuesday, 26 July 2005 18:17

hurtathleteLow back pain affects almost everyone during their lifetime, and this includes well-conditioned athletes. The very nature of athletics is that the athlete is performing an activity that requires a high level of skill, strength, power and/or coordination. Most athletic activities impart very high short-duration repetitive forces into various parts of the body, while other areas are subjected to less force, but for prolonged periods. The former leads to macrotrauma, while the latter leads to microtrauma. In either case, when tissue tolerance is exceeded, tissue failure and breakdown occurs leading to injury.1

In tennis, for example, the shoulder is required to move through extreme ranges while the shoulder muscles are generating tremendous torque, i.e., the overhead serve. Meanwhile, some of the shoulder muscles function to maintain the head of the humerus in a very specific location against the glenoid, while the trunk/spinal muscles stabilize the trunk/spine to provide a stable base of support to the shoulder complex. Most often, shoulder pain results from the repetitiveness of the motions rather than one single event (repetitive microtrauma). The prime movers of the shoulder adapt and become stronger, while the stabilizers (most often the infraspinatus) are eventually over-powered and fail in their attempt to maintain optimum joint position, referred to as movement in the neutral zone. Research has linked excessive neutral zone motion to pain production.2

The tissue damage that occurs from tissue failure produces an immediate neurological reflex inhibition to the muscles acting across the injured joint.3,4 This leads to muscle weakness and atrophy, which predisposes the joint to further injury.5

This inhibition and muscle weakening can occur across any joint in the body that sustains an injury, including the lower back joints. Current research has shown that the small stabilization muscles of the lower lumbar spine atrophy and weaken following tissue failure in the area.6 This, then, reduces the stability of the segment affected by the specific muscle weakness leading to instability. Panjabi defines clinical instability as occurring when the stabilizing system cannot maintain the intervertebral neutral zone in physiological limits.7

In an attempt to compensate for the weakened tissues of the injured lumbar segment, the body will resort to activating the large global muscles of the back. This has the effect of “stiffening” the spine and reduces movement in the whole lumbar spine.7,8 Every chiropractor has, at one time or another, witnessed the patient with debilitating lumbar muscle spasm and extremely reduced motion.

Highly conditioned athletes often incur forces into their lower back that lead to tissue failure and this cycle of inhibition, weakness and instability. Roy found local muscle dysfunction in elite athletes despite rigorous general training regimens.9

“Injury to a joint or its associated passive structures will have direct effects upon muscle function and control and needs to be understood, if rehabilitation programs are to be efficient and effective.”10 Rehabilitation of the athlete with low back pain must address the motion (vertebral movement and position) and motor (muscle) changes that take place when there has been tissue damage, whatever the tissue might be.11 The chiropractic physician trained in spinal manipulative therapy and rehabilitation procedures can usually help athletes recover from their injuries without the need for medication, injections, or surgery and their potential adverse side-affects.

Research demonstrated an immediate increase in muscle strength following spinal manipulative therapy performed via mechanical force, i.e, manually assisted instrument adjusting, following the Activator Methods protocol.12 I have no doubt that similar strength increases occur with other methods of spinal adjusting. This appears to be the result of reducing the inhibition to the inhibited muscles by altering the proprioceptive input from the tissues in the area of the injury.

Spinal adjusting to correct the motion problem and specific rehabilitation procedures to correct the motor changes are vital for the return of the athlete to optimum performance.

References

1. McGill, S. Low Back Disorders, 2002, Human Kinetics

2. Panjabi M 1992 The stabilizing system of the spine. Part 1. Function, dysfunction, adaption, and enhancement. Journal of Spinal Disorders 5:383-389.

3. Morrissey M 1989 Relfex inhibition of thigh muscles in knee injury: causes and treatment. Sports Medicine 7:263-276

4. Hurley M, Newham D 1993 The influence of arthrogenous muscle inhibition on quadriceps inhibition with quadriceps rehabilitation of patients with early unilateral osteoarthritic knees. British Journal of Rheumatology 32:127131

5. Stokes M, Young A 1984a The contribution of reflex inhibition to arthrogenous muscle weakness. Clinical Science 67:7-14

6. Hides J, et al., 1994 Evidence of lumbar multifidus muscle wasting ipsilateral to symptoms in patients with acute/subacute low back pain. Spine 19:165-172

7. Panjabi M 1992a The stabilizing system of the spine. Part 1. Function, dysfunction, adaption, and enhancement. Journal of Spinal Disorders 5:383-389

8. Cholewicki J, et al, 1997 Stabilizing function of trunk flexor-extensor muscles around a neutral spine posture. Spine:22:2207-2212

9. Roy S, et al., 1990 Fatigue, recovery and low back pain in varsity rowers. Medicine and Science in Sports and Exercise. 22:463-469

10. Richardson C, et al., 2004  Therapeutic Exercise for Lumbopelvic Stabilization, Churchill Livingstone

11. McGill S, 2004 Ultimate Back Fitness and Performance, pg 10. Wabuno Publishers

12. Keller T, Colloca C 2000 Mechanical manipulation increases trunk muscle strength assessed by electromyography: a controlled clinical trial. 27th Annual Meeting of the International Society for the Lumbar Spine, Adelaide, Australia, April 9-13.

Dr. Gudgel has been a practicing chiropractor and physical therapist for 30 years and recently joined the Activator Health Center in Phoenix, Arizona, as Director of Rehabilitation Services. He was a contributing editor to the Activator Methods Chiropractic Technique textbook. He has been an Activator Methods instructor for more than 22 years.

 
Rapid Rehabilitation of a Hamstring Strain: A Case Study
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Rehabilitation
Written by David Rick, D.C. and Alan Oolo Austin, D.C.   
Tuesday, 26 July 2005 18:07

hamstringinjuryHamstring Strain Discussion

Hamstring strains are an extremely common occurrence in the sport of soccer. The hamstrings span two joints and are, therefore, subject to stretching at more than one point. Therapies for this type of injury have traditionally involved different forms of physiotherapy and soft tissue techniques.

Dorman2 reported on 140 hamstring injuries and found that they usually occurred either quite early or in the latter stages of practices or matches, and concluded that improper warm-up and fatigue are risk factors for injury.

What appears clear from the literature is the tendency for hamstring injuries to recur. Ekstrand and Gillquist3 prospectively studied male Swedish soccer players and found hamstrings to be the muscle group most often injured. Perhaps more important, they noted that minor injuries doubled the risk of having a more severe injury within two months. Others4 have noted a recurrence rate of 25 percent for hamstring injuries in intercollegiate football players. Despite such observations, it is not well understood why these injuries tend to recur so frequently.

Hamstring Strain: A Case Study Using Trigenics® as the Primary Treatment

A 15-year-old mid-field soccer player presented, complaining of chronic right hamstring pain. He had injured it approximately four weeks earlier and it had progressively worsened with time. He had not noticed any swelling; however, pain was experienced even with simple walking. He had stopped practicing/playing games for approximately two weeks and tried unsuccessfully to return to practice three days prior to departure to Florida.

Physical Examination

On examination, there was no swelling or bruising.  Upon palpation, a large, muscular “nodule” was evident on the lateral aspect of the semimembranosus/semitendinosus belly, approximately half way up the posterior thigh.  When mild pressure was applied to the nodule, a sharp pain radiated superiorly toward the right gluteal fold. There was extreme hypertonicity and tenderness throughout the hamstrings.  Neurokinetic assessment showed that active and passive hip flexion was quite restricted and painful, as well as knee extension. Resisted hip flexion and knee extension was pain free; however, resisted knee flexion and hip extension reproduced the pain and broke with muscle strength testing.  The patient’s gait was assessed and he walked with a mild limp, not being able to completely extend the right knee, or push-off with any power with the right leg.

Diagnosis

Chronic strain of the right hamstrings (specifically the semimembranosus/semitendinosus) with aberrant sensorimotor function.

Treatment

Treatment involved specific applications of Trigenics neurological strengthening and Trigenics neurological lengthening procedures administered to the hamstrings group and other neurokinetically related muscles.  The patient was also instructed on the proper, post-procedural use of icing applications and was initially given gentle stretching exercises, which progressed to more aggressive stretches.  He was also advised to minimize the amount of training and game playing, until the pain subsided.  He was continually monitored throughout each day’s training session.

Team Ontario was in Florida for 10 days, training two times per day for six out of those 10 days, and playing the American Olympic Developmental Program teams for five out of the 10 days.  Needless to say, it was a rather intense period for the team.  As is standard with Trigenics protocols for injured athletes, the patient was treated consistently two times per day, before and after a training session/game, and his hamstrings were iced several times throughout the day.  Realizing that this injury had been chronic, it was amazing at how quickly the patient had recovered.  Immediately after the first day of treatment, he reported that his leg felt considerably stronger and more mobile and that he could finally walk without pain.  After the third day of treatment, the patient was running pain free, with powerful and explosive bursts.  By the fourth day of training, the patient reported feeling better than he had felt in months.  Normally, with any other treatment, such a chronic condition could sideline a soccer player anywhere from four to six weeks.1 

Summary

We have continually kept up to date with current soft tissue treatments; however, after observing the benefits of the Trigenics sensorimotor treatment system, we are convinced that this is most definitely a significant breakthrough in the field of rehabilitation and performance enhancement. The multimodal approach used in Trigenics to treat causative aberrant neurology is, in our opinion, quite truly the “missing element” of care.

References

1. Burkett LN: Causative factors of hamstring strains. Med Sci Sports Exerc 1970;2(1):39-42

2. Dorman P: A report of 140 hamstring injuries. Aust J Sports Med 1971;4:30-36

3. Ekstrand J, Gillquist J: Soccer injuries and their mechanisms: a prospective study. Med Sci Sports Exerc 1983;15(3):267-270

4. Heiser TM, Weber J, Sullivan G, et al: Prophylaxis and management of hamstring muscle injuries in intercollegiate football players. Am J Sports Med 1984;12(5):368-370

Dr. David Rick is a resident in the College of Chiropractic Sports Sciences of Canada and has a keen interest in the treatment and performance enhancement of athletes.

Canadian-Estonian chiropractor, Dr. Allan Gary Oolo Austin is the originator of Trigenics. Dr Austin began developing Trigenics in the early 1980’s.  In 1994, Dr. Austin began to write the current procedural and theory manuals and commenced forming the Trigenics Institute of Myoneural Medicine. Doctors and therapists throughout North America, Australia, and Europe have taken the Trigenics RTP program. For more information, visit www.trigenicsinstitute.com or call 888-514-9355, Ext. 1

 
All Tendinitis is Basically the Same No Matter the Location
Rehabilitation
Written by Edward G. Holtman, D.C.   
Tuesday, 26 July 2005 18:01

Even though all health professionals realize that the most common cause of tendinitis is muscle over-use and/or abuse, few have concentrated sufficient and proper rehabilitative effort on the involved muscles. Also, the treatment of tendinitis in all areas of the body is fundamentally the same. Yes, the exercises vary, but the basic treatment principal is the same!

Unfortunately, there is no one single pill, potion, lotion or procedure that will cure tendinitis.  Little has changed in the past 20 years regarding the treatment of tendonitis. Medical treatment is essentially the same: pain killers and anti-inflammatory drugs; although, the FDA has recently approved an instrument that delivers shock waves to the tendons. This causes microscopic damage to the tendon, which is supposed to form new blood vessels and, as a result, new cells supposedly form healthy tissue.

Current Therapies

Physical therapy remains about the same. The “no pain, no gain” motto still seems to be very much in vogue; “encouraging” the patient to do muscle work exercises (the activity that initiated the tendinitis in the beginning) is still being done. Application of heat to the tendons (a definite no-no), even if alternating with cold, is still popular with physical therapists. Acupuncturists are still trying but, for the most part, not succeeding.

Chiropractic is very successful in about 10-20 percent of those tendonitis cases seen. Nevertheless, these are marvelous results when compared to other health professions. And, when all else fails—operate!  (We don’t recommend surgery unless the tendon is ruptured, or noticeably torn.)
If there is no single pill, potion, lotion, or procedure that cures tendinitis, WHAT DOES? Unlocking the answer to tendinitis is like unlocking a combination lock.  You need all the correct numbers dialed correctly before the lock opens.  Similarly, we need all of the elements that help tendinitis combined into a treatment program that will deliver lasting results to almost all cases.

Procedures to Follow

Step 1—Place a small (1" x 3") freezable gel pack directly on the involved tendon twice each day for 10 minutes. Re-freeze. Keep cold away from the muscles.

Step 2—Apply heat on belly of involved muscle, once each day for 20-25 minutes.  Keep heat away from tendons! 

Do not use heat and cold at the same exact time.  This sends conflicting messages to the brain.

Step 3—Take “Tendon E’s” (a supplement that contains several natural anti-inflammatories and one natural muscle relaxant).

Step 4—Perform recommended stretching exercises twice each day.  Do what is possible, without forcing, although some “pulling” should be felt.  Over time, always work toward more stretch. 

Following is a demonstration of two of eight stretching exercises that are effective for the shoulder and elbow areas.

Patient Supine

Imagine the patient’s head at 12 o’clock with the feet at 6 o’clock.  With the arm down at the patient’s side, slowly move the arm “around the clock” four times clock-wise, then four times counter clock-wise. Additionally, the patient again starts with the arm down at the side and begins to twist the entire arm briskly clock-wise then counter clock-wise while, at the same time, moving the arm slowly “around the clock” four times in each direction, as before.

The end result of stretching is relaxation of the muscles and tendons. It also restores some elasticity to the muscles and tendons. This, in time, leads to great relief of the symptoms of tendinitis.

Continue stretching exercises after the patient is well.  This facilitates continued tendon health.

Step 5—Perform opposing muscle-work exercises when possible.  Contraction of opposing muscles facilitates relaxation of the involved muscles, with a very desirable effect.

Step 6—Apply a large vibrator (4" x 9" applicator pad) on the tendon and involved muscles for 5-10 minutes once each day.  I don’t believe this can be over-done, but 15 minutes should be the maximum.

Step 7—Perform transverse friction massage twice each week (rub hard across tendon).

Step 8—Rest the tendons for one to two weeks, if possible.

Two Very Important Points

1. The health professional must make sure the patients perform all of the proper procedures to attain optimum results.  If they compromise the program, they will compromise the results.  Therefore, the health professional must check to make sure, at the three-week level, that the patient is performing everything properly.

2. Bear in mind during the treatment period that the true root of the tendinitis problem is in the muscles.  The tendons are actually innocent victims of muscle over-use or abuse.

Why would a chiropractor bother?  Because there are at least 400,000 cases of tendinitis being seen each month by all health professionals nationally.  Notice, I said, “being seen,” not “being cured.” As a result, many patients are desperate for help. Between my method as well as what you can do chiropractically, you can achieve nearly 100 percent great and lasting results with tendinitis. No one else in the world can do that.  You can accomplish, in your office, the same great results.

Edward Holtman, D.C., practiced chiropractic for 48 years in Hartford, WI. He has written many published tendonitis articles, among them, “It’s Time to Help Your Patients Say Goodbye to Tendinitis, because No One Else Is”; “Why Let Tendinitis Stop You?”; and “Do Something Good for the Muscles and You Will Be Doing Something Good for the Tendons”.

He may be reached by mail at 315 E. Sumner St., Harford, WI  53027; by phone at 800-673-5650; or email at This e-mail address is being protected from spambots. You need JavaScript enabled to view it . Web site www.tendonrelief.com.

 
Reducing the Need for Narcotic Medications: A Retrospective Case Report
Rehabilitation
Written by Mark S. Matvey, D.C.   
Tuesday, 26 July 2005 17:58

fdadrugsIntroduction

The purpose of this case report is to display the dynamics of a complete tear on an anterior cruciate ligament that required surgical intervention with a graph (cadaver) insertion via arthroscopy surgery and the chiropractic care and rehabilitation technique/procedures used to benefit and expedite the recovery process. In addition, the need for the routine narcotic medications prescribed for this type of surgery by the orthopedic surgeon was reduced.

Mechanism

A typical mechanism of an ACL injury is a non-contact twisting movement, usually due to abrupt deceleration and change of direction.  Sidestepping (cutting), pivoting and landing from a jump are examples of events that may cause an ACL tear. An audible pop or crack, pain and the knee giving way are typical initial signs, followed by almost immediate swelling, due to bleeding inside the joint.  When an ACL injury occurs, the knee becomes less stable.  The ACL injury is a problem because this instability can make sudden, pivoting movements difficult, and may make the knee more prone to developing arthritis and cartilage tears.  Epidemiological and frequency studies have demonstrated that the vast majority of acute ACL tears occur without any contact or direct trauma to the athlete’s knee. Landing at foot strike with the knee extended or a slight flexion (less than 20 degrees) and internally rotating the tibial in relation to the femur is by far the most commonly described incident which results in injury of the ACL.

Case Report

A 31-year-old male presents with knee pain, discomfort and limited range of motion due to swelling that began the previous night.  Since that time, the swelling has become worse with extreme difficulty in walking.  His pain is located at the medial and lateral aspect of the left knee and deep to the patella. He has no significant left knee history, with no known congenital conditions or symptoms.

Examinations

Plain film X-rays were taken of AP and Lateral views of the left knee with right knee comparisons.  Initial analysis revealed no evidence of fracture or dislocation of the patella, distal femur and proximal tibia tuberosity and fibula.  He consumed 600 mg. of ibuprofen the night after the incident and again in the early A.M. Physical examination included a thorough physical, orthopedic and neurological examination, which did clinically indicate an anterior cruciate ligament compromise. The palpatory exam revealed significant gross swelling at the lateral, medial and inferior patella.

Following the MRI, and due to the confirmed tear, an initial consult was made with an orthopedic surgeon. The patient chose to have surgery with a graft insertion, due to the severity of the ACL, which revealed a complete rupture. It was four weeks before the surgery was performed.  Therefore, it was imperative to provide proper acute techniques to promote the injury healing process and reduce the potential deconditioning syndrome of the patient. Special attention was geared to reducing swelling and pain. 

Treatment pre-surgery

Immobilization and protection of the injured tissue area during the first one to three weeks was initiated.  In the early phase of healing, immobilization allows undisturbed fibroblast invasion of the injured area that leads to unrestricted cell proliferation and collage fiber production.  Protection (such as with a cast or brace) prevents secondary injuries and early distention and lengthening of injured collagen structures, such as a torn ACL.  The patient was provided an immobilization brace to wear until surgery.  He was also fitted at the orthopedic surgeon’s office for a custom fit brace for post-operative activities, to prevent adduction and abduction of the left knee.  He was seen at the chiropractic office three times per week for four weeks up until the day before the surgery.  Treatment provided consisted of acute settings (advanced to subacute settings) on the ultrasound, ice, electrical muscle stimulation, activator adjustment to the left knee and diversified spinal adjustments to the bilateral lumbar spine and pre-surgery rehabilitation.  The pre-surgery rehabilitation consisted of isometric exercises to strengthen the muscles of the quadriceps and biceps femoris muscles.  In addition, strengthening and stretching exercises were also performed and instructed for the gastrocnemius, soleus and tibialis anterior muscles to support and maintain any muscles which could potentially affect the gait. 

Treatment post-surgery

Following the surgery, he was at home and on bed-rest for two days, until he returned back to the chiropractic rehabilitation office and started post-surgical rehabilitation. The patient returned on crutches non-weight bearing. He was instructed to be non-weight bearing on crutches for two weeks or until further notice following the first post-operative office visit. The frequency for this was four times per week for the first two weeks, then three times per week for the next six weeks.

Following surgery, one week post-operatively, an in-office rehabilitation program was continued with positive response.  He was eventually released to continued home therapy and supported care continued with extremity adjustments, nutritional advice, and monitoring exacerbations and functional performance. This patient was also able to take less than the prescribed and recommended pain medication of Oxycontin and Percocet.

Conclusion

No firm conclusion can be made from a single retrospective case study to ascertain that chiropractic manipulation and rehabilitation can reduce the average post-operative narcotic regimen following ACL surgery. However, this case does suggest and brings attention to the fact that the patient did fully recover, return to work and require very little of the controlled substances of Oxycontin and Percocet. Chiropractic intervention with manipulation of the involved extremity and lower spine along with pre- and post-surgical rehabilitation should be considered.

Mark S. Matvey, D.C., D.A.C.R.B., practicing chiropractor for 11 years, has been in private practice near the north side of Columbus, Ohio since graduating Cleveland Chiropractic College, Summa Cum Laude (Kansas City, MO) in 1994. He was originally a registered nurse, prior to becoming a chiropractor, and worked in orthopedics, neurological and medical surgical units, while at Research Medical Center, Kansas City, MO. He recently earned Diplomate status for the American Chiropractic Rehabilitation Board. Contact Dr. Matvey at This e-mail address is being protected from spambots. You need JavaScript enabled to view it , or Dimensions Health Plus, 2615 East Dublin-Granville Road, Columbus, OH, 43231; phone 614-899-9933.

 
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