Rehabilitation


Lack of Spinal Movement
Rehabilitation
Written by Roger R. Coleman, DC and Stephan J. Troyanovich, DC   
Tuesday, 26 July 2005 17:56

For every doctor of chiropractic, a factor for consideration in patient care is spinal motion.  Abnormal movement is one of the most frequent findings, whether in the form of, “Doc, I just can’t bend,” or  “There is a lack of normal motion on examination.” Or perhaps, “There is a fixation of C4.”  But, in whatever form it occurs, abnormal motion can be measured.  The question is, how?

First, we need to break the discussion into parts: the assessment of motion between two adjacent vertebral segments (intersegmental motion) and movement of an entire area of the spine (global motion). Both of these areas are interesting; but, today, we are going to confine ourselves to the global motion in the spine.  We’ll look at four easy methods to use for assessing these motions and, just like most things in life, each has its good and bad points.  For the sake of ease of explanation, we’re going to use the cervical area for all our examples.

#1 Visual Examination

The simplest method is to observe the patient as he or she moves the neck through the various planes of motion and, then, record the results, including a special note of any abnormal movement, such as motions that were less than normal.  This method is easy and quick, but it doesn’t give us quantification. In other words, you can’t say that the patient has 25 degrees of cervical extension. Well, unless your eyes are calibrated a little differently than ours.

#2 Hardware Store Method

You take a trip to your local hardware store and buy a couple of circular levels.  Then follow the directions in the Guides to the Evaluation of Permanent Impairment, Fifth Edition.  You can use these devices to measure the amount of motion in a particular plane and also to determine the amount it varies from the normal range of motion for that area and movement. The good part is that these levels are inexpensive and durable, but they do take more time than the first method, and you may have to keep tapping these levels to keep the internal part of the levels swinging freely.

#3 Fluid Filled Inclinometers

You’ll probably have to order these.  You use them the same way as the hardware store variety, but they tend to move smoothly, and you shouldn’t have to keep tapping them to get an accurate reading.  Nice method, but more costly than the hardware variety.

#4 Wireless, Electronic Inclinometer

This one is at the top of the food chain in terms of uses.  Many can give you quick readings, record those readings and put them into a form for use in reports.  The good part is they’re quick and easy to use and the results can be integrated into the company’s computer program.  The bad part is that they are the most costly of this group, and you need a computer to use them.

So, there you have four methods to determine global range of motion.  A purist would insist that we include electronic inclinometers that do not interact with your computer.  These would fall between numbers 3 and 4, and some of you might like them; so take a look.  But, this will give you a place to start. Remember, no matter what methods you use, range of motion is a concern in spinal problems.  So, give it some thought and see how it fits into your office.

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.

Roger R. Coleman, DC, is a 1974 graduate of Palmer College of Chiropractic, member of the Adjunct Research Faculty of Life Chiropractic College West, charter member of Washington State Chiropractic Association and author/co-author of eight scientific journal articles. He is heard on Coleman and Fairbanks Talk Science on the radio and is the author of the book Coleman’s Fables. A lecturer and inventor of several rehabilitation devices, he can be reached at 509-488-9679.

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.

 
Sport-Specific Rehab
Rehabilitation
Written by John K. Hyland, D.C.   
Tuesday, 26 July 2005 17:50

athleteinjuryrehabThe rehabilitation process for injured athletes is often divided into three distinct phases: acute, recovery and functional.1 A comprehensive rehabilitation plan will include different types of exercises tailored for each of the three healing phases. Each phase is important for a successful return to sports activity, but the last one may be the most critical, and is the one that is frequently overlooked in the rush to get back into the game.

Acute Phase

Immediately after an injury, there will be variable amounts of pain, swelling, weakness, muscles fatigue, limited range of motion, joint locking or instability, and decreased sports performance. Pain and swelling are indicators of inflammation due to tissue damage, and require immediate attention. Frequent cooling of the damaged tissue will limit bleeding and swelling and help to control pain. Protection of injured areas with taping or a brace may be necessary for a short period of time, in order to minimize additional tissue damage.

Carefully controlled active exercising should be initiated once the inflammation has begun to subside and the pain levels begin to drop. Since isometric exercises produce strength gains mainly at the joint angle used,2 dynamic training in a pain-free range should be initiated as soon as it can be tolerated. Electrical stimulation with high volt electrotherapy can maximize motor unit recruitment in this stage, while helping control excessive pain.3 Initially, only a light external load (such as exercise tubing with some slack) should be used, but this can be gradually progressed based on the tolerance and pain levels of the athlete.

Recovery Phase

Returning to sport activities prior to regaining full range of motion is risky, so joint mobility and flexibility exercises are crucial in the early recovery stage. To be effective, stretching exercises should be done two or three times a day, with a minimum of three repetitions of approximately 30 to 60 seconds for each muscle group. Stretches should be performed on tissues that have been heated above resting body temperature, using either an active warm-up or external heating, such as a hot tub or heating pad.

Daily dynamic resistance exercises to increase strength should be started as soon as they can be tolerated, in order to avoid atrophy and ensure a rapid return to sport activities. Both the concentric and eccentric muscle actions should be worked with gradually increasing resistance and range of motion.4 Elastic exercise tubing has been found to be a safe and effective method of providing progressive resistance exercises with an aerobic component.5

Functional Phase

This is the rehab phase that prepares an injured athlete to return to regular training sessions and competition. Exercises now must become more functionally oriented and are designed to simulate the demands of the patient’s sport. This “sport-specific training” incorporates movements and activities that train and coordinate specific muscle actions and reactions that are needed for the athlete’s sports performance. Obviously, an accurate evaluation of the metabolic and neuromuscular demands of the sport is helpful, so that specific muscle activation patterns can be trained.6 The functional phase focuses on the rehabilitation and conditioning of the entire kinetic chain, and may need to progress into specialized training for explosive strength, such as plyometric exercises.  

Conclusion

Current rehabilitation concepts now emphasize functional activities and re-training of normal loading and movement patterns. Appropriate and progressive rehab programs should be started early in the treatment of all patients with sports or exercise injuries and should be planned to take place simultaneously with the biological healing of the injured tissues. A large body of literature shows the advantage of early, progressive rehabilitation exercise for all types of sports injuries. These benefits include restoration of range of motion, decreased pain, decreased neural inhibition, quicker return of muscle function, and improved performance in both sports and normal daily activities. Elastic tubing strength retraining programs, comprised of simple, isotonic resistance techniques, are readily available, none of which require expensive equipment or great time commitments. This allows the doctor of chiropractic to provide cost-efficient, yet very effective and sport-specific rehabilitation care.

References

1. Frontera WR. Exercise and musculoskeletal rehabilitation; restoring optimal form and function. Phys SportsMed 2003; 31:39-46.

2. Lindh M. Increase of muscle strength from isometric quadriceps exercises at different knee angles. Scand J Rehabil Med 1979; 11:33-6.

3. Snyder-Mackler L, Delitto A, Bailey SL, et al. Strength of the quadriceps femoris muscle and functional recovery after reconstruction of the anterior cruciate ligament: a prospective, randomized clinical trial of electrical stimulation. J Bone Joint Surg Am 1995; 1166-73.

4. Dudley GA, Tesch PA, Miller BJ, et al. Importance of eccentric actions in performance adaptations to resistance training. Aviat Space Environ Med 1991; 62:543-50.

5. Roy S, Irvin R. Sports medicine: prevention, evaluation, management, and rehabilitation. Englewood Cliffs: Prentice-Hall; 1983.  p.195.

6. Kibler WB, Chandler TJ. Sport-specific conditioning. Am J Sports Med 1994; 22:424-32.

Dr. Hyland 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 .

 
Case Report: Lumbar Disc Lesion with Altered Lordosis
Rehabilitation
Written by Roger R. Coleman, DC and Stephan J. Troyanovich, DC   
Wednesday, 22 June 2005 17:00

Introduction

In our last article, we presented the history of lumbar traction for normalization of the lumbar lordosis in chiropractic.  In this article, we will present a case report of a patient with a herniated lumbar intervertebral disc, who had been referred to us by a medical neurologist.

Case report

Figure 1A demonstrates the pre-treatment lateral lumbar radiograph of a 28-year-old female travel agent with low back pain and radiating right lower extremity pain secondary to a herniated disc at L4-L5. A line has been drawn across the posterior vertebral body margins of L1 through S1. A solid curved line representing the normal average lordosis derived from measurements taken from an ideal normal population without back pain or spinal pathology1-3 has been superimposed on the radiograph. These markings clearly indicate that, as compared to the normal average lumbar lordosis, this patient is hypolordotic with concurrent loss of disc space height at L4-L5.

Upon examination, the patient’s lumbar range of motion was mildly to moderately reduced in all directions. She had tenderness to digital pressure in the lumbosacral region, reported pain upon bilateral leg lowering in the supine position, and also experienced pain upon sitting up from a supine position. Straight leg raising was positive for the right lower extremity in both the supine and seated positions. All other orthopedic tests were negative, and her neurologic examination was unremarkable.

A program of structural based rehabilitation was initiated including lumbar extension exercises performed at a frequency of 10 repetitions per set and up to 10 sets per day.  Standing lumbar extension traction (Figure 3), as described in our last article, was performed on each office visit for up to 20 minutes per session. In addition, spinal adjustments for pain reduction and increased mobility were also performed at each office visit. The frequency of office visits was 5 times per week for the first 2 weeks, and 3 times per week for the remaining 6 weeks of care.  The patient reported 80-90 percent improvement in pain upon completion of the second week of treatment.

The rehabilitation program continued for the 6 additional weeks, whereupon a post-treatment radiograph of her lumbar spine was obtained. The normal average lordosis has once again been superimposed on the post-treatment radiograph as the solid curved line extending from the posterior-inferior vertebral body margin of S1. Comparison of the alignment of the posterior vertebral body margins of L1 through S1 to this normal average curve demonstrates a significant improvement. Functionally, her pain resolved, her range of motion normalized, and she was able to resume normal activities without restrictions.

Conclusion

Structural rehabilitation aimed at restoring more normal spinal alignment was demonstrated in this brief case report.  In addition to helping this patient achieve better spinal and postural alignment, she also achieved improved function in the form of pain reduction, enhanced range of motion, and improvement in her ability to perform her activities of daily living.  Upon discharge, she was given instructions to continue her lumbar extension exercises as a means of maintaining her improved structure and function.  This was achieved through the combination of spinal adjustments, active exercise, and lumbar extension traction.

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.

References

1. Troyanovich SJ, Cailliet R, Janik TJ, Harrison DD, Harrison DE. Radiographic mensuration characteristics of the sagittal lumbar spine from a normal population with a method to synthesize prior studies of lordosis. J Spinal Disord 1997;10:380-386.
2. Harrison DD, Cailliet R, Janik TJ, Troyanovich SJ, Harrison DE, Holland B. Elliptical modeling of the sagittal lumbar lordosis and segmental rotation angles as a method to discriminate between normal and low back pain subjects. J Spinal Disord 1998;11;430-439.
3. Janik TJ, Harrison DD, Cailliet R, Troyanovich SJ, Harrison DE.  Can the sagittal lumbar curvature be closely approximated by an ellipse?  J Orthop Res 1998;16:766-770.

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.

 
A Brief History of Lumbar Traction in Chiropractic Rehabilitation
Rehabilitation
Written by Roger R. Coleman, DC and Stephan J. Troyanovich, DC   
Sunday, 22 May 2005 15:50

From its birth to the present, the chiropractic profession has been interested in methods to restore normal alignment (structure) to the spinal column, with the ultimate purpose of restoring normal function to the spine and nervous components housed inside.  Interestingly, mechanical traction has been used by chiropractors to reduce spinal misalignments, in spite of the fact that chiropractic is a profession founded on the principle of “by hands only” interventions.  In this brief treatise, the use of mechanical traction as a means to reduce subluxations of the lumbar lordotic curve is traced from the profession’s origin to the modern era.

Lumbar Extension Traction

The use of traction for subluxation correction can be traced to chiropractic’s original “mixer” practitioner, Solon Massey Langworthy, D.C., a 1901 graduate of D. D. Palmer’s chiropractic school.  Langworthy, one of Palmer’s original twelve chiropractic disciples, established a thriving practice and chiropractic school (American School of Chiropractic and Nature Cure) in Cedar Rapids, Iowa, in the early 1900s.  In a recent article published in the journal Chiropractic History, Troyanovich and Gibbons1 recount the important contributions made by this colorful chiropractic pioneer.

One of Langworthy’s inventions was known as the “Amplia Thrill” traction table.  He received a patent for the device in October of 19082. The device was quite versatile and had the capability of performing both cervical extension traction and lumbar extension traction.

More recently, Steve Foster, D.C., of Greeley, Colorado, has created a device to induce lumbar extension traction in an erect kneeling position, in a method he describes as 5-point traction. His invention was created circa 19953. Our own Roger Coleman, D.C. (yeah, it’s a little self-serving—sorry) created a method whereby extension traction of the lumbar spine can be induced in a patient who is standing.4  The Coleman device and method further allow the patient to perform active extension exercises while in the device, which may add to the clinical effectiveness of the method.

Lumbar extension traction has been used from the time of the earliest chiropractic pioneers until the present as a means of restoring normal alignment to the lordotic curve of the lumbar spine.  Although founded on the principle that chiropractic is a “hands only” method of care, chiropractic innovators have devised multiple mechanical devices to assist in the reduction of the chiropractic lesion.

In our next column, we’ll present a case that demonstrates how some of these devices may be used to reduce pain, restore spinal alignment, and restore spinal function.

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. Troyanovich SJ, Gibbons RW.  Finding Langworthy:  the last years of a chiropractic pioneer.  Chiro History 2003;23:9-17.
2. United States Patent Office letter of acceptance to Solon Massey Langworthy for Patent #901,628, 20 October 1908.
3. United States Patent Office letter of acceptance to Steven K. Foster for Patent #5,575,765.
4. Coleman R.  Lumbar traction:  a non-science article.  Am J Clin Chiro 1999;9:7.

 
How to Measure Successful Curve Restoration
Rehabilitation
Written by Roger R. Coleman, DC and Stephan J. Troyanovich, DC   
Friday, 22 April 2005 13:45

One of the things that we have been discussing in past issues is the cervical lordosis.  There are probably few clinicians who have not drawn an association between the loss of cervical lordosis and headache.  This clinical observation is also supported in the scientific literature.1,2  But, of course, we’d like a quick, easy, accurate and inexpensive method to measure the cervical lordosis. Fortunately, we have something that just fits the bill.

That brings us to Ruth Jackson, BA, MD, FACS, and her book, The Cervical Syndrome, the first edition of which was published in 1956. Dr. Jackson had many impressive positions during her career, including that of Associate Clinical Professor of Orthopedic Surgery at the Southwestern Medical School of The University of Texas in Dallas. But, for our purposes, Ruth was able to draw two straight lines.

Dr. Jackson drew these lines down the back of the second cervical vertebra (axis) and up the back of the seventh cervical vertebra. She taught that the level at which they crossed was the area of the greatest stress and strain in the neck.

Now, both of us, as were thousands of other doctors of chiropractic, were introduced to these lines by B. R. Pettibon, DC.  Dr. Pettibon was using these lines to determine the magnitude of the cervical lordosis on the neutral lateral cervical X-ray.

Doctors like Pettibon, and the much earlier Dr. Solon Langworthy, the father of corrective spinal traction,3 were both innovators in the field of restoring the cervical lordosis and, unfortunately, their contributions have often been pushed aside for a new crop of gurus. A mature profession recognizes its history for, without them, there would be no us. So we think it only right that we note that whatever is done in this field is built upon the shoulders of chiropractors such as these two distinguished gentlemen.

To measure the magnitude of the cervical lordosis, Ruth Jackson’s stress lines are drawn down the posterior body margin of C2 and up the posterior body margin of C7 on the neutral lateral cervical X-ray. Then, using a protractor, the angle at which they cross can be measured. This simple method allows you to measure the magnitude of your patient’s lordotic curve and also allows you (with the addition of comparative post-treatment film) to know if your efforts to improve the lordosis are working.

The following illustration demonstrates a pre-treatment radiograph (figure 1) and a post-treatment radiograph (figure 2).  Note how the lines are drawn along the posterior body margins of C2 and C7 and the angle at which they cross.

Now we have a simple way to measure lordosis.  But, the next question that arises is, “What is the magnitude of a normal lordosis?”  The answer could certainly be debated, but it appears that, if we look to the literature,4,5 we can come up with a reasonable range of 21 to 34 degrees for healthy individuals.

Loss of cervical lordosis is a common finding in cases involving headaches and/or following auto accidents. For those of you who have been following our little column, you now have been exposed to simple, inexpensive methods to work with cases of hypolordosis and an easy method to determine if your care has been successful.

References

1.Vernon H, Steiman I, Hagino C. Cervicogenic dysfunction in muscle contraction headache and migraine: A descriptive study. J Manipulative Physiol Ther 1992;15:418-29.

2.Nagasawa A, Sakakibara T., Takahashi A. Roentgenographic findings of the cervical spine in tension-type headache. Headache 1993;33:90-95.

3. Troyanovich SJ, Coleman RR.  Origins of the use of mechanical traction for reduction of the chiropractic subluxation.  Chiropractic History.  2004;24(2):1-10.

4. Gore DR, Sepic SB, Gardner GM. Roentgenographic findings of the cervical spine in asymptomatic people. Spine 1986;6:521-4

5. Harrison DD, Janik TJ. Troyanovich SJ, Holland B. Comparisons of lordotic cervical spine curvatures to a theoretical ideal model of the static sagittal cervical spine. Spine 1996;21:667-75.

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.

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.

 
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