|
Rehabilitation
|
|
Rehabilitation
|
|
Written by Roger R. Coleman, DC and Stephan J. Troyanovich, DC
|
|
Saturday, 15 January 2005 00:28 |
|
They’re back! Well, for most of you we are. The majority of you have read at least something one of us has written in anything from a newspaper format to the journal Spine. But, here we are again an in a new forum for us. What we’ve been asked to do is to write about rehab. Now this is something that we like. We’ve (in this column, we will often use the word we to designate something that at least one of us has done; sort of a Borg thing) written and spoken about rehab and even invented rehabilitation devices. But the format that we’d like to use for this column is the format that we use when we lecture. We want to talk to you just like we’d talk to an old friend. That’s right, just to you. Not the doc down the street or a professor in some college or the president of your alma matter. No, we’ve arranged to have this whole magazine sent to thousands of people just so we could have an enriching conversation with you, one of our old friends.
|
Now for some things that we want
you to understand:
1) We’re not any smarter than you are. No one is packing a lot more IQ points than the next guy, and that includes your favorite guru.
2) We do read a lot and we think about what we read. We’re information wonks; we have no lives. (Well, Roger has no life; Steve’s just naturally boring.)
3) We’re into easy, clinically usable, what works, rehabilitation. If you want something complicated, this is not for you.
4) We like low cost. If you have to spend a ton of money on rehab equipment, then only a few people will do rehab. We like to keep costs low.
5) We don’t think that you need 7,523 modules (or whatever number adds up to thousands of dollars) that the guru of the day is pushing, in order to do some good things in the rehab department.
6) One of our pet peeves is when authors have bios that indicate that they have hundreds of articles in “prestigious” journals. Look, this is not like saying billions served. It takes a lot of time to write an article that will be published in a “prestigious” journal. We have a simple suggestion. Go to the National Library of Medicine’s web site and search for the number of articles that the author has in that venue. All the “prestigious” authors we know have more than one or two articles whose abstracts can be found on the National Library of Medicine’s web site. Do the search for our names (one at a time please) and then for some of the other authors you read. The results might be interesting.
7) We take our work seriously, but we don’t take ourselves very seriously. Like we indicated, we know a lot of the “gurus” and we like lots of them. The majority are quite hard working; but for sheer brainpower, we’re all swimming in the same genetic pool. (Although, some days Roger’s standing in the shallow end.)
8) Most importantly, don’t ever do anything that we talk about unless you think it is right, and you feel qualified to do it. You are responsible for your patients. That’s a responsibility that we all take very seriously.
|
If, after you read these columns, you feel that you were having a conversation with old friends, then we’ve succeeded. But, as you know, old friends often indulge in a lot of good-natured banter; so, if we’re poking a little fun at you, just remember that we’re smiling.
Well, now you know a little bit about us, and, next time, we’ll chat about neck-related headaches and some rehab approaches to the problem. So until then, “Thanks, old friend, it’s always great to talk to you. We’ll talk again soon.”
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.
|
|
|
Rehabilitation
|
|
Written by Dr. Mitch Mally
|
|
Saturday, 15 January 2005 00:26 |
|
History and Subjective Complaints
53-year-old male factory worker/forklift operator complains of bilateral hand numbness, burning, tingling and loss of grip strenth in the thumb, index and ring fingers, bilaterally. Nocturnal aggravation of the hands resulted in a workers compensation case. Over the course of 9 years, the patient failed operative recovery: 4 left CTS surgeries, 3 right CTS surgeries and, subsequently, failed 2 ulnar nerve transposition surgeries. Company safety personnel refers patient to Dr. Mally.
Objective Findings
Carpal ligamentous instability, scar tissue proliferation at the palmar crease, bilaterally, decreased sensation on aesthesiometer, 2-point discrimination and depth perception, decrease in bilateral grip strength, positive bilateral Tinel's, Phalen's, Wormser's and Median Nerve compression test. Nerve Conduction Velocity's (NCV) positive; bilateral median nerve latencies.
X-Ray
Radiographic carpal tunner projection (X-POSERtm) revealed left 66% carpal tunnel occlusion and right 75% carpal tunnel occlusion.
Diagnosis
Bilateral Carpal Instability; Bilateral Carpal Tunnel Syndrome; Bilateral Carpal Subluxation.
Treatment
Specialized manipulative decompression of involved carpals bilaterally (Mally Technique), 2 weeks of intensive care with cold laser (830-850 nm).
Nutrition
Anti-inflammatory vitamins (bromelain, papain, trypsin, chymotrypsin, bioflavonoids) and vitamin B6.
Rehab
6 weeks of reconstruction and work hardening.
Addendum
Failed post-op CTS is very high with connective tissue hyperplasia the highest cause of failure. Misdiagnosis leads to erroneous results and, in this case, perfmanent disability and loss of employment. According to the patient, after a short 5 treatments by Dr. Mally, he reports a 98% improvement in feeling and strength. At MMI (Maximum Medical Improvement), no residuals and returns to gainful employment.
For more product and seminar information, email Dr. Mally at
This e-mail address is being protected from spambots. You need JavaScript enabled to view it
.
|
|
Rehabilitation
|
|
Written by Kim D. Christensen, D.C., C.C.S.P., D.A.C.R.B.
|
|
Tuesday, 14 December 2004 23:18 |
|
There have been various recommendations over the years in our profession about the recommended number of repetitions and sets of exercises that patients should perform. To judge for yourself what numbers are best for those in your care, you need to consider several factors — not the least of which is the hectic, fast-paced lives many of your patients already have.
Determine the Goal(s)
People exercise for a variety of reasons. Some do it for enjoyment and relaxation, some for general fitness, and some to improve their appearance. And then there are the athletes, who are trying to excel at a sport or win a competition.
Chiropractors generally have a different approach. We want to help our patients regain an improved level of health. The forms of exercising that work best for body builders, football players, and other athletes are not necessarily ideal for patients. We need to keep this in mind when recommending rehabilitative exercises, especially when we are working with patients who are not used to exercising at all. Because of that, many doctors find that simpler is better. Since the goal is just to get a patient to do the exercise regularly, it’s advisable to keep instructions clear and easy to follow. All patients do a lot better when they know exactly what is expected, and they will tend to do only the minimum necessary.
It All Adds Up
The repetition number (“reps”) means the number of times a patient performs an exercise consecutively, without stopping. In most programs this number is usually somewhere between 5 and 20. “Sets” are a series of reps, defined by the rest period between (which varies from 30 seconds to several minutes). Set recommendations vary from 1 to 3 or 5, or occasionally more. The “total reps” of an exercise can be determined by multiplying the number of reps times the number of sets performed.
The reps and sets can vary, even when the total reps are the same. For example, total reps of 20 can be performed as 2 sets of 10 reps, or 4 sets of 5 reps, or 5 sets of 4 reps. Strength and conditioning specialists, working with exercise physiologists and coaches, have developed a tremendous variety of exercise routines. Some of these have been found to be useful for certain sports, and others have developed from muscle research. The variations are determined to some extent by the athlete’s goal—maximum strength, power, or endurance.
Of course, doing fewer repetitions and fewer sets takes less time, but we obviously want our patients to exercise at least enough to improve their condition. What does the research show?
Research Findings
Since 1962, most exercise recom-mendations have been based on the Berger method1, which consists of 3 sets of 6 repetitions, for 18 total repetitions. Because it was a scientifically based recommendation, as well as being pretty simple for patients to follow, the Berger method has been widely used right up to the present day. While many still believe it is an effective program, an even simpler and easier method has gained popularity lately.
The literature review by Drs. Carpinelli and Otto2 found that there is now a large volume of research which disputes the need for 3 sets of exercise. In fact, they state that, “One set of repetitions has been shown to be as effective as multiple sets, and more time efficient, for increasing muscular strength and hypertrophy in males and females of different ages, for a variety of muscle groups and using various types of exercise equipment.” The article concludes by recommending that by “employing a single-set protocol, individuals can achieve similar results in less time and with less work and a decreased potential for injury.” This has been strong enough evidence for many doctors to change their approach to exercise recommendation.
Less Is More
In many instances, having patients perform just one set of 8 to 12 repetitions of their recommended exercise(s) has proven successful. Since this is only 8 to 12 total repetitions, without the need for rest periods, it can be completed in much less time. Patients are more likely to become consistent with the recommended exercises when the time commitment is less. And this approach has been found to be just as good for getting rapid results.
In many cases, patients can be instructed to perform at least 8 repetitions of the exercise, but they should initially attempt 12. If 12 repetitions can be done fairly easily, have them increase the resistance slightly the next time. When using surgical tubing exercises, this means increasing the starting distance from the door in which the tubing is temporarily attached.
Instruct patients to do their exercises every day, at least initially. This gets them into the habit of doing an exercise, and brings about more rapid change and improvement. And since the patient is being asked for such a minimal time commitment, it’s difficult for him or her to say that there isn’t enough time to exercise on a daily basis
Faster Recovery, Happier Patients
Either the traditional, multi-set exercise program or the newer, single-set protocol can help patients regain muscle function and improve spinal support and posture. However, I find that patients are appreciative when I express an awareness of how busy their schedules are and minimize the time needed for exercising.
Patients are more likely to do the exercises you recommend when they fit into a busy schedule. With only 6 to 12 total repetitions, several exercises can be done in just five or ten minutes.3 This helps ensure acceptance of the entire treatment program, which can lead to rapid progress under your expert care.
Kim Christensen DC, DACRB, CCSP, CSCS, directs the Chiropractic Rehab & Wellness program at PeaceHealth Hospital in Longview, Washington. He is a popular speaker, and participates as a team physician and consultant to high school and university athletic programs. Dr. Christensen is currently a postgraduate faculty member of numerous chiropractic colleges and is the past-president of the American Chiropractic Association (ACA) Rehab Council.
He is a “Certified Strength and Conditioning Specialist,” certified by the National Strength and Conditioning Association. Dr. Christensen is the author of numerous publications and texts on musculoskeletal rehabilitation and nutrition. He can be reached at PeaceHealth Hospital by email at
This e-mail address is being protected from spambots. You need JavaScript enabled to view it
.
References
1. Berger RA. Effect of varied weight training programs on strength. Res Q 1962; 33:168-81.
2. Carpinelli RN, Otto RM. Strength training: single versus multiple sets. Sports Med 1998; 26(2):73-84.
3. Winett RA, Wojcik JR, Fox LD, Herbert WG, Blevins JS, Carpinelli RN. Effects of low volume resistance and cardiovascular training on strength and aerobic capacity in unfit men and women: a demonstration of a threshold model. J Behav Med 2003; 26(3):183-195.
|
|
|
Rehabilitation
|
|
Written by Dr. Mitch Mally
|
|
Tuesday, 14 December 2004 23:16 |
|
A cascade of physiological, biomechanical and biochemical events complicate Acute and Repetitive Injuries. Musculoskeletal pain and range of motion is affected by biomechanical aberration, joint dysfunction, segmental hyper/hypo-mobility and the result of several pathways and stimuli. However, the inflammatory response may be treated anecdotally by ice, compression and elevation. Allopathic recommendations often include anti-inflammatory medication with significant side effects (consumed like candy), cortisone (with lidocaine or marcaine) injections and other more aggressive medicinal aids (nerve block, etc.) are commonly prescribed and administered for patients refractory to care.
Enzymes to the rescue
I recall numerous childhood athletic injuries for which my late doctor, L. C. Winnick, MD, would prescribe ice, elastic bandage and Ananase. Years later, I learned that ananacea, in Latin, translates to pineapple. The effective proteo-lytic enzyme found in the stem of the Hawaiian fruit is otherwise known as bromelain (an enzyme known to help modulate bradykinin activity, reduce excessive fibrin deposition, inhibit pro-inflammatory cytokines and help soft tissue damage). Other common, extremely beneficial enzymes, such as papain and trypsin when combined, are very effective for acute inflammation. However, the body must produce anti-enzymes in order for them to be adequately processed and, as such, after prolonged exposure to high levels of enzymes, the body can no longer produce the required anti-enzymes and build-up occurs.
NOTE: Extended use of these powerful and effective enzymes for acute inflammation is NOT recommended, as the effects can lead to long term complications.1
Natural COX-inhibitors
Prostaglandins, the hormone-like substances responsible for inflammation, are formed from arachadonic acid. The first step in their formation is catalyzed by the enzyme cyclo-oxygenase, or COX. Turmeric, ginger and boswellia extract help inhibit the production of COX. Excessive tissue oxidation can also lead to inflammation related pain. Rosemary extract and a lemon bioflavonoid complex, both powerful antioxidants, help mitigate this inflammatory factor. Bromelain derived from pineapple (ananas bracteur, ananas cosmosus) contains, among other components, various closely related proteases, demonstrating, in vitro and in vivo, anti-edematous, anti-inflammatory, anti-thrombotic and fibrinolytic activities.2
The 1-2 punch
Additional anti-inflammatory support is maximized when coupled with turmeric (inhibits production of leukotrienes), ginger (limits lipoxygenase production), citrus bioflavonoid, rosemary and boswellia. The powerful combination of proteolytic enzymes for acute tissue trauma and subsequent soft tissue de-flaming support, previously noted, has proven cost effective and efficacious as well. This 1-2 punch enhances the acute and chronic recovery process and affords the patient rapid, safe and natural relief of pain due to inflammation. Patients with chronic inflammation and those in the rehabilitation phase of care require a maintenance formula to prevent the post-acute injured tissue from becoming re-inflamed.1
Conclusions
Inflammation is becoming well recognized as the cause of many health problems/conditions and not solely the result. As cause and effect practitioners, we chiropractors pride ourselves on RESULTS. Whether your belief is right- or left-wing, pain management is an integral part of patient care and the most common reason for portal-of-entry in health care today.
This anti-inflammatory protocol is extremely effective in supporting the chiropractic adjustment, as muscles and joints that remain inflamed retard the natural healing process. As you know, patient history clearly demonstrates that patient’s recalcitrant to rapid pain relief will seek alternative pain management. Let the buck (patient) stop here, at your office!
References
1. Seaman DC, David, Clinical Nutrition, 1st Edition, NutrAnalysis Inc.)
2. Bucci, L R. Nutrition Applied to Injury Rehabilitation and Sports Medicine
For more product and seminar information, e-mail Dr. Mally at
This e-mail address is being protected from spambots. You need JavaScript enabled to view it
.
|
|
Rehabilitation
|
|
Written by Kim D. Christensen, D.C., C.C.S.P., D.A.C.R.B.
|
|
Sunday, 14 November 2004 22:53 |
|
Most injuries of the Achilles tendon are not due to a recent acute injury; they have actually developed gradually, over a period of weeks or months. These are “overuse” or “misuse” conditions, and are caused by excessive and/or repetitive motion, often with poor biomechanics. The end result is a microtrauma injury—the body is unable to keep up with the repair and re-strengthening needs, so the tissue begins to fail and becomes symptomatic. If it is not very painful (or when the pain is eliminated by pain-killing drugs), continued stress can eventually lead to complete failure, with a resulting acute tear of the tendon.
The Achilles tendon insertion on the calcaneus is medial to the axis of the subtalar joint, making the calf muscles the most powerful supinators of the subtalar joint.1 Therefore, when excessive pronation occurs, eventually the tendon undergoes overuse degeneration and inflammation. Clement, et al., described how “pronation generates an obligatory internal tibial rotation, which tends to draw the Achilles tendon medially. Through slow motion, high-speed cinematography, we have seen that pronation produces a whipping action or bowstring effect in the Achilles tendon. This whipping action, when exaggerated, may contribute to microtears in the tendon, particularly in its medial aspect, and initiate an inflammatory response.”2 These investigators believe that the control of functional overpronation with corrective orthotic devices is a necessary treatment for most patients with Achilles tendinosis.
Impaired circulation may be a contributing factor to Achilles tendon overuse injuries, especially with tendon tears. The same researchers speculate that “in individuals who overpronate, the conflicting internal and external rotatory forces imparted to the tibia by simultaneous pronation and knee extension may blanch or wring out vessels in the tendon and peritendon, causing vascular impairment and subsequent degenerative changes in the Achilles tendon.”2 This “region of relative avascularity” extends from 2 to 6 cm above the insertion into the calcaneus, and is a common site of rupture of the Achilles tendon. This makes it especially important to ensure good blood flow during the healing of this condition.
The New Paradigm for Care
It’s not surprising that abnormal biomechanics of the foot and ankle can cause problems with the largest tendon in the leg. Symptoms are usually described as diffuse pain in or around the back of the ankle (from the calf to the heel). The pain is aggravated by activity, especially uphill running or climbing stairs, and relieved somewhat by wearing higher-heeled shoes or boots. Palpation will find a tender thickening of the peritendon, and there may be crepitus during plantar and dorsiflexion. Often, a recent increase in activity levels (such as more stair-climbing) or a change in footwear is reported by the patient.
Macroscopically, overused Achilles tendon tissues examined at surgery are dull, slightly brown, and soft, in comparison to normal tendon tissue, which is white, glistening, and firm.3 There is a loss of collagen continuity and an increase in ground substance and cellularity, which is due to fibroblasts and myofibroblasts, and not inflammatory cells.4 This is the reason that anti-inflammatory strategies (such as NSAID’s, drugs and corticosteroid injections) are not indicated for these conditions, and actually may interfere with tendon repair.5 We now know that the condition we usually have described as “tendinitis” is actually better understood as “tendinosis,” and is not due to inflammation, but an underlying degeneration of collagen tissues in response to mechanical overuse.6 This “new paradigm” will help to guide our management of all tendon problems, and provide more effective rehabilitation for Achilles tendons.
Rehab Procedures
When an injury is acute, an initial period of relative rest is needed. Occasionally, the weakened tissues will tear through, resulting in a ruptured Achilles tendon. This may require surgical repair and a period of rest before rehabilitation can begin. During this period, though, exercise of the opposite ankle should be encouraged. Vigorous exercise of the uninvolved contralateral ankle muscles produces a neurological stimulus in the injured muscles (called the “cross-over effect”), and helps to prevent atrophy.7 Initial treatment should also include heel lifts to reduce the strain on the Achilles tendon, and cross-fiber friction to improve circulation. Complete return to function will then require attention to range of motion, functional strength, and orthotic support.
Range of motion. In addition to appropriate foot and ankle adjustments, stretching of the tight and shortened gastrocnemius/soleus muscle complex is a necessary part of Achilles tendon rehabilitation. Gentle stretching should be started early, putting a linear stress on the tendons and stimulating connective tissue repair. The standard is the “runner’s stretch,” performed against a wall. Patients with tightness and pronation will often allow the foot to flare outward while stretching, which forces the medial arch to drop. This tendency must be carefully corrected, with the foot positioned straight ahead and the medial arch kept elevated.8 Even better, is to perform the stretches with corrective orthotics in place.
Functional strength. Isotonic strengthening exercises that focus on the eccentric (negative) component have been shown to improve the healing of tendons and accelerate return to sports participation.9 These exercises are progressed to closed-chain, loaded eccentric exercises, in order to stimulate collagen fiber reorientation and strengthening.10 The patient is instructed to stand on the edge of a stair, do a toe raise up, then drop the involved heel as far as possible, returning by pushing back up with the uninvolved leg.
Conclusion
Achilles tendon injuries can be successfully rehabilitated conservatively. Steroid injections and casting are seldom used these days. Once the local inflammation has been controlled, improved blood flow to the region of relative avascularity is necessary. Correct stretching and strengthening exercises can be demonstrated and monitored in the office.
Kim Christensen DC, DACRB, CCSP, CSCS, directs the Chiropractic Rehab & Wellness program at PeaceHealth Hospital in Longview, Washington. He is a popular speaker, and participates as a team physician and consultant to high school and university athletic programs. Dr. Christensen is currently a postgraduate faculty member of numerous chiropractic colleges and is the past-president of the American Chiropractic Association (ACA) Rehab Council.
He is a “Certified Strength and Conditioning Specialist,” certified by the National Strength and Conditioning Association. Dr. Christensen is the author of numerous publications and texts on musculoskeletal rehabilitation and nutrition. He can be reached at PeaceHealth Hospital by email at
This e-mail address is being protected from spambots. You need JavaScript enabled to view it
.
References:
1. Subotnick SI. Sports Medicine of the Lower Extremity. New York: Churchill Livingstone; 1989. 475.
2. Clement DB et al. Achilles tendinitis and peritendinitis: etiology and treatment. Am J Sports Med 1984; 12:179-184.
3. Astrom M, Rausing A. Chronic achilles tendinopathy: survey of surgical and histopathologic findings. Clin Orthop 1995; 316:151-164.
4. Khan KM et al. Histopathology of common tendinopathies: update and implications for clinical management. Sports Med 1999; 27:393-408.
5. Almekinders LC, Temple JD. Etiology, diagnosis, and treatment of tendonitis: an analysis of the literature. Med Sci Sports Exerc 1998; 30:1183-1190.
6. Khan KM et al. Overuse tendinosis, not tendinitis. Part 1: a new paradigm for a difficult clinical problem. Phys Sportsmed 2000; 28:38-48.
7. Hertling D, Kessler RM. Management of Common Musculoskeletal Disorders. 2nd ed. Philadelphia: JB Lippincott; 1990. 334.
8. Ninos J. Chain reaction: a tight gastroc-soleus group. Strength Cond J 2001; 23:60-61.
9. Niesen-Vertommen Sl et al. The effect of eccentric versus concentric exercise in the management of Achilles tendinitis. Clin J Sport Med 1992; 2:109-113.
10.Alfredson H et al. Heavy-load eccentric calf muscle training for the treatment of chronic Achilles tendinosis. Am J Sports Med 1998; 26:360-366.
|
|
|
|
|
|
|
Page 18 of 21 |
|
|
|
