Rehabilitation


One Simple Approach to Exercise
Rehabilitation
Written by Roger R. Coleman, DC and Stephan J. Troyanovich, DC   
Tuesday, 15 March 2005 03:07

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.

 
Rehab Made Simple
Rehabilitation
Written by Roger R. Coleman, DC and Stephan J. Troyanovich, DC   
Tuesday, 15 February 2005 01:46

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.

 
A Discussion With Old Friends
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.

 
Post Operative Carpal Tunnel Syndrome (CTS)
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 .

 
Rehab for Busy Schedules
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.

 
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