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Rehabilitation
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Rehabilitation
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Written by Roger R. Coleman, DC and Stephan J. Troyanovich, DC
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Wednesday, 22 June 2005 17:00 |
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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.
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Rehabilitation
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Written by Roger R. Coleman, DC and Stephan J. Troyanovich, DC
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Sunday, 22 May 2005 15:50 |
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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.
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Rehabilitation
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Written by Roger R. Coleman, DC and Stephan J. Troyanovich, DC
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Friday, 22 April 2005 13:45 |
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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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Rehabilitation
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Written by Roger R. Coleman, DC and Stephan J. Troyanovich, DC
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Tuesday, 15 March 2005 03:07 |
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In our last article, we discussed a couple of different methods of cervical extension traction for the rehabilitation of cervical lordosis. In this article, we will discuss extension exercise in the context of rehabilitation of cervical lordosis. Loss of cervical lordosis and loss of cervical motion have both been associated with cervicogenic headaches.1,2 Cervical extension traction and cervical extension exercises are two methods that may be employed in rehabilitation of the normal lordotic curve of the neck with associated headache.
There are two simple ways to perform cervical extension exercises. The easiest and the cheapest method is to simply have the patient perform the motion of cervical extension in the prone position with the weight of the head serving as resistance. The advantages of this exercise are obvious: You always have the equipment with you and it’s free. Typically, the patient would perform multiple sets of 10-20 repetitions of this exercise, taking approximately 1 second for the concentric phase (head extension) and 1 second for the eccentric phase (return to the prone position).
A second method is to use a device that can apply varying resistance for the extension exercise. An example of such a device appears below.
The Noodle™ (patent pending) is about the most versatile tool we know about. If you’re stranded on a desert island with only one simple exercise device, then this is at the top of our list, as it allows exercise for just about every body area. It can also be employed in-office or the patient can purchase it for use at home. Below, it is shown with a patient performing active, resistive cervical extension exercise. In the office setting, the exercise is performed in sets of twenty repetitions to build endurance of the postural muscles. Commonly, a patient would start with 1-2 sets per office visit, working toward the goal of performing five sets at each session.
Of course, like everything else, you need to make sure you know how to use it properly and that there are no contraindications for its use before you begin using it with your patients. It comes with a pretty comprehensive product brochure to provide you with this type of information.
Now, you have two different exercise tools for cervical extension exercises to aid you in improving cervical motion and strengthening the cervical musculature. These two methods are attractive because they work and are low cost and simple. So, let’s see how we can put together the things we discussed here and in our previous article to treat a fictional case of cervicogenic headache:
Mrs. Jones enters your office complaining of headaches that you determine to be cervicogenic in nature. She has a lot of the findings that are common in this type of condition, including neck pain, loss of cervical motion, and loss of the cervical curve. For those of you that want a more complete review of cervicogenic headache, we really like an article by Howard Vernon.1
Some of the things that you have at your disposal to work with these findings are adjustments, traction and exercise. In this case, you decide to do all three.
The combination of these techniques can be used to address the neck pain, the loss of cervical motion and the loss of cervical lordosis. You can combine them in the way you think is best. In this case, everything goes according to plan and the case responds and you got what you always wanted: Simple straightforward care, happy doctor and happy patient.
As we said from the start, we think rehab is usually pretty straightforward and that’s our approach. We tend to favor simple methods over the complex, if both methods work.
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. Vernon H, Steiman I, Hagino C. Cervicogenic dysfunction in muscle contraction headache and migraine: A descriptive study. JMPT 1992;15:418-429.
2. Nagasawa A, Sakakibara T, Takahashi A. Roentgenographic findings of the cervical spine in tension-type headache. Headache 1993;33:90-95.
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.
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Rehabilitation
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Written by Roger R. Coleman, DC and Stephan J. Troyanovich, DC
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Tuesday, 15 February 2005 01:46 |
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If you’ve ever attended a Steve and Roger seminar you probably have heard the statement, “A trained monkey could do what Roger does,” and the follow up, “But there’s never a trained monkey around when you need one, Steve.” So, unless you have a trained monkey around, you may be interested in the simple way that we approach rehab. As you know, a loss of cervical lordosis has been associated with cervicogenic headache, so today we’re going to talk about some simple traction methods that you can use to address that problem. But first, let’s start with the general rules. If there are no contraindications then:
1) If the spine doesn’t have enough range of motion, do something to increase range of motion.
2) If the spine is moved to one side in the AP view, do something that moves it back toward the midline.
3) If the spine doesn’t have enough lordosis, do something to increase the lordosis.
4) If the spine has too much lordosis, do something to reduce the lordosis.
5) If a muscle is too weak, do something to make it stronger.
6) If something is too tight, do something to make it more flexible.
Seems pretty straight forward, and it is. Then, we just reach in the old toolbox and pull out the tool we want for the job at hand.
We’ve roughly divided many of the things we do into categories, based on what we want to use them for. Since our tools do more than one thing, this was very easy. In our toolbox we have three basic areas: adjustments, traction and exercise. Let’s start with adjustments.
Adjustments are the easiest to talk about because we’re just going to give them the once over. Adjustments are something that can be used to try to change alignment and increase motion. Which type of adjustment is best? Who knows? No adjustment technique has proven itself to be the “be all and end all,” so, we’re going to let you pick the adjustment procedures that you think are best for your patient.
Next is traction. At this point we’d like to focus on just the cervical traction methods. There are three types that we like and all of them can be used to help improve the cervical lordosis and provide stretching in the neck. But, before we start, as with anything, make sure that you know how to use the procedure correctly and that it is not contraindicated. For those of you who would like more information, you can contact the manufacturer for the proper use of particular devices, read books on the subject (Steve’s book, Structural Rehabilitation of the Spine & Posture: A Practical Approach, is a good place to start) or attend appropriate classes.
The first type of or tool traction is the Coleman 3 strap cervical traction and it’s the method we both use in our respective offices. Because it has the disadvantage of being a large device, a little expensive, and somewhat more complicated, we’re going to focus on two other traction methods.
Next is the Dakota Traction Method. This type of traction is cheap, small and can be used in the office or sold to the patient for home use. It can be ordered from Matlin Manufacturing. As you can see in Figure 1, the patient is placed on the device and the elastic cord of the head strap can be adjusted to provide varying amounts of pressure.
Then we have the Noodle™ (patent pending). It’s the most versatile device of all. You can do all sorts of exercises with the Noodle™ as well as cervical traction. And, Matlin Mfg. invented it, too, so it’s easy to find. The Noodle™ is usually used for exercise, but you can add a headpiece and also use it for cervical traction. It allows you to place two straps behind the neck just like the Coleman 3 strap cervical traction. For cervical traction, one end of the Noodle™ is properly secured to a wall or door, two straps are behind the neck and a harness-type traction device is placed on the patient with an appropriate weight attached.
The Noodle™ really fits into our idea of rehab. It’s versatile, so you can use it for exercise and traction. It’s also inexpensive and you can use it in the office and sell it to your patients for use at home. It’s a pretty amazing device. Of course, like everything else, you need to make sure you know how to use it properly and that there are no contraindications before you start using it with your patients.
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.
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