The Functional Approach to Rehab Exercise
Written by Kim D. Christensen, D.C., C.C.S.P., D.A.C.R.B.   
Saturday, 03 April 2004 17:46

Selecting the ideal exercises for patients with back conditions requires judgment based on clinical experience and scientific evidence.  There are several approaches to rehabilitation, and many different types of exercises are available; however, patients have a limited amount of time, willingness, and enthusiasm to exercise.  Therefore, we must always try to give our patients the most effective exercises for their condition.  But, what are the “best” exercises for chiropractic patients?



What to Look for


The best exercises for a specific problem are those that will be rapidly effective, easy to learn and perform, and are safe.  The exercises must help the patient to regain normal alignment and easy, natural movement.  And the end result should include a decreased chance of similar, recurring problems.



A successful and appropriate rehabilitative program can be designed without the need for expensive, joint-specific equipment.  While isokinetic machines are useful in the research lab, current rehab concepts consider such equipment to be unnecessary.  In fact, the low-tech approach can be very effective for the treatment of most spinal conditions.  Additional personnel, fancy equipment, more office space, and extra time are not necessary.  With an understanding of normal spinal function, knowledge of the involved muscles, and some updating of exercise concepts, chiropractors can effectively rehab their patients with simple home exercise equipment.



Specific Adaptation to Imposed Demands


The “SAID” concept is one of the underlying tenets of the strength and conditioning field. 1  It describes the observation that our bodies will predictably change in response to the demands that are placed on them.  If we frequently perform aerobic activities, then our lungs, hearts, and muscles become more efficient at taking in and processing oxygen.  When we spend more time in activities requiring force and providing resistance, our bodies develop more muscle mass, and we become stronger.  And, if we practice our balance and coordination, we improve our ability to function easier on an unstable surface (such as on a rolling ship or a pair of skates).  In fact, these improvements in our abilities are quite specific, and we become better at doing whatever it is that we do most often.



It has taken quite a while for specialists in the treatment of spinal problems to incorporate this idea into neck and back rehab programs.  Recently, some chiropractors have begun to use the same thought processes to design spinal exercises that we have used for decades to determine appropriate x-ray positions.  We recognize that the spine functions very differently when it is not weight-bearing.  We now know that the best way to help our patients return to normal function is with exercises that imitate as closely as possible the real conditions under which the spine must function day after day.  That certainly must include the specific stress of gravity in the upright position.


Kinetic Chain Exercises


When the spine is bearing weight it is part of a closed kinetic chain.  This is the manner in which we use the joints and connective tissue of the spine during most daily and sports activities, and it requires the co-contraction of accessory and stabilizing muscles.  Weaker or injured muscles can be quickly strengthened with the additional use of isotonic resistance to stimulate increases in strength.  Isotonic resistance can come from a machine, from weights, from elastic tubing, or just using the weight of the body.  More important than the equipment used is whether the spinal support structures are exercised in an open or a closed-chain position. 



Open-chain exercises for the spine are done non-weight bearing, while either lying on the ground or immersed in water (which removes much of the effect of gravity).  Both floor-based and water-based exercises have some limited usefulness, primarily during the acute stage.


A good example of this is a study comparing closed vs. open kinetic chain exercises for the training of the thigh muscles.  Augustsson et al. wanted to improve their subjects’ vertical jump height. 2  Two groups exercised twice a week at maximal resistance – one group doing closed-chain exercises (barbell squats), and the other working on the knee extension and hip adduction weight machines (open-chain exercising).  At the end of six weeks both groups had gained considerable strength, but the closed-chain exercisers were the only ones who improved significantly in the vertical jump.  Since jumping is a closed-chain activity, the SAID concept tells us to expect that closed-chain exercising will be more effective.


Functional Position Exercise


We know that the origins and insertions of many muscles change when going from standing to lying down.  Certainly the proprioceptive input from receptors in the muscles, connective tissues, and joint capsules is very different between the two positions.  This is why it is so important to bring neck and back rehab exercises closer to real-life positions, and it explains why patients make much more rapid progress when they are taught to exercise in a functional (upright) position.



By staying up off the floor, exercising in a weight-bearing position is actually easier for most patients.  In addition to being more focused and practical, upright exercising trains and strengthens the spine to perform better in everyday activities.  Patients like the idea of doing exercises that clearly prepare them for better function during normal activities of daily life.



The Value of Balance Exercises


For many athletes (whether recreational or competitive), it is important to regain the fine neurological control necessary for accurate spinal and full body performance.  This means that about five to ten minutes of each workout should be spent exercising while standing on one leg, with the eyes closed, while standing on a mini-tramp, or using a special rocker board.  The advantage of these balance exercises is seen when athletic patients return to sports activities and can perform at high levels without consciously having to protect their backs.  Back exercises done on a rocker board or while standing on one leg are can be considered more useful than those done on a gym ball, since the entire body is in a closed-chain position during the exercises.  The stabilizing muscles, the co-contractors, and the antagonist muscles all have to coordinate with the major movers during movements that are performed during closed-chain exercising.  This makes these types of exercises very valuable in the long run, particularly for competitive athletes.



Functional Alignment


Many chronic spinal problems develop secondary to an imbalance in weight-bearing alignment of the lower extremities.  In fact, lower extremity misalignments -- such as leg length discrepancies and pronation problems -- are frequently associated with chronic pelvis and low back symptoms. 3  Any of these that are present will need to be addressed in order to resolve the patient’s current symptoms and to prevent future back problems.  The effects of weight bearing and the alignment of the kinetic chain must be considered. 




Selecting the best exercise approach for each patient’s back problem is important.  A well-designed exercise program allows the doctor of chiropractic to provide cost-efficient, yet very effective rehabilitation care.  Exercises performed with the spine upright (standing or sitting) specifically train and condition all the involved structures to work together smoothly.  The end result is a more effective rehab component and patients who make a rapid response to their chiropractic care.  






1. Fleck SJ, Kraemer WJ. Designing Resistance Training Programs. Champaign, IL: Human Kinetics, 1987.


2. Augustsson J et al. Weight training of the thigh muscles using closed vs. open kinetic chain exercises: a comparison of performance enhancement. J Orthop Sports Phys Therap 1998; 27:3-8.


3. Rothbart BA, Estabrook L. Excessive pronation: a major biomechanical determinant in the development of chondromalacia and pelvic lists. J Manip Physiol Therap 1988; 11:373-379.


About The Author


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 .

Getting Hip Muscles Back in Balance
Written by Kim D. Christensen, D.C., C.C.S.P., D.A.C.R.B.   
Saturday, 28 February 2004 00:00

The hip muscles form a vital link in the lower extremity kinetic chain by transferring ground-reaction forces from the legs to the trunk during gait.  These muscle groups supply coordinated propulsion and provide balanced stability for the pelvis and spine.  However, through repetitive use patterns and after injuries, it is not unusual for some of these muscles to develop shortening and/or weakness.  A comprehensive care program must include exercises to address these imbalances.



An appropriate and successful exercise program to rebalance the hip muscles does not require expensive, joint-specific equipment.  The low-tech approach can be very effective for the treatment of most hip and pelvic conditions.  With a few simple stretches (properly performed) and some home resistance exercises, the hip muscles can be easily strengthened and rebalanced.




The Hip Rotators and the Pelvis

The role of the hip rotator muscles is frequently overlooked when addressing prevention and rehabilitation of lumbar spine injuries.  Deconditioned and/or shortened hip rotators contribute to abnormal lumbopelvic posture and cause compensatory motion in the lumbar spine during daily activities.1  This is particularly important during strenuous and competitive athletic efforts.  The detrimental effects of inadequately conditioned and prepared hip rotators predisposes the athlete to lumbar spine injuries,2 many of which are eventually seen by the sports-oriented doctor of chiropractic.




Deficits of flexibility and strength in the hip rotators can add substantial stress to the pelvis and sacroiliac joint, as well as the lumbar and even thoracic spinal regions.3  For instance, there may be an anteverted (forward flexed) pelvis in conjunction with limited external hip rotation.  In such cases, a combination of stretching and strengthening will be necessary for a complete response to chiropractic care.  The chiropractic correction of the flexed pelvis will help to provide greater external hip rotation.  On the other hand, if the flexed pelvis is secondary to shortened hip rotator muscles, then corrective exercises to increase the range of motion of the hip internal rotators will be needed.  This can be accomplished by stretching the shortened internal rotators and strengthening the antagonist external rotator muscles.




Stretching and Increasing Motion

Tightness of the external rotator muscles will limit internal rotation of the hip, while shortening of the internal rotators decreases external hip rotation.  For some hip problems, improving the flexibility of short and tight muscles is necessary.  Frequent, gentle, and sustained stretching of either the internal or external rotators should be demonstrated to the patient, who can usually start the stretching immediately, even in the early stages of chiropractic treatment.




Piriformis syndrome and iliotibial band syndrome are two hip conditions that benefit from specific stretching exercises.  In both of these, tight muscles contribute to an overuse condition that irritates sensitive tissues.  Care must include inward rotation stretches for the piriformis muscle, corrections of subluxations and biomechanical faults of the pelvis, as well as predisposing factors such as an anatomically short leg and/or foot pronation.4  Correction of abnormal biomechanics such as leg length discrepancies must also be part of the care program.5




Resistance Strengthening

Weaker or injured muscles can be quickly strengthened with the use of isotonic resistance exercises.  The resistance can come from a machine, from weights, from elastic tubing, or just using the weight of the body.  Since the hip functions as part of a closed kinetic chain during most daily and sports activities, weight-bearing exercises, which require the co-contraction of accessory and stabilizing muscles, can be most effective.  Open chain exercising (done with the foot and lower leg freely moving) is most helpful in the early stages of hip strengthening, to reduce the stress on the surrounding muscles after an injury.  With athletes, exercise selection should also consider the sport-specific movement patterns.  Kickers (such as soccer players and martial artists) can concentrate on open chain strengthening, while runners and golfers will benefit more from closed chain exercises.




Open chain exercises.  Open chain exercising can be started very early with a symptomatic hip, since it doesn’t require the musculoskeletal structures to bear the weight of the body.  The easiest method is to rotate the entire leg against the resistance of elastic tubing.  Initial exercising should be done with a limited amount of movement, within a pain-free range of motion.  These exercises are particularly useful for patients who have an injured rotator muscle, or even a “snapping hip.”  Strengthening of the muscle and tendon involved in a snapping hip (such as the tensor fascia lata, iliopsoas, or biceps femoris muscles) is, maybe, more useful than stretching for resolving the snapping.6  Rehab for patients with any evidence of degenerative arthritis of the hip should also start with open chain exercising, since the joint is more safely exercised when the damaged cartilage is not bearing weight directly.  As the patient progresses, additional resistance can safely be supplied with heavier tubing.




Closed chain exercises.  Weight-bearing strengthening exercises, with the foot on the floor, should be included when an athlete is preparing to return to sports activities.  Examples of closed chain exercises for the hip rotators include partial squats, lunges (especially to the side), and single-leg body rotations.  Initially, body weight is sufficient.  Resistance can be gradually and progressively increased with the use of hand weights or elastic tubing.  The particular benefit from closed chain exercises is their ability to re-train the co-contractions of accessory hip support muscles.




Functional Hip Alignment

A major underlying reason for developing an imbalance in the hip rotator muscles is an imbalance in weight-bearing alignment of the lower extremities.  Alignment problems need to be addressed in order to prevent recurring hip muscle imbalances and eventual joint arthritis.  Leg length discrepancies and foot pronation problems are frequently found in association with symptomatic muscle imbalances such as iliotibial band syndrome, and piriformis syndrome.  Osteoarthritis is much more common in the hip joint of a longer leg.7  Recurrent muscle strains (especially hamstring and groin pulls) can be an indicator of asymmetry in structural alignment.  The use of custom-made orthotics and/or heel lifts is often necessary in order to establish long-term balance in the hip muscles.





Early in their treatment, patients with hip complaints and sports injuries should be started on appropriate and progressive rehabilitative programs that include muscle stretching and strengthening.8  These rehab techniques are easy and accessible, since they do not require expensive equipment or great time commitments.  It isn’t difficult to select the best exercise approach for each patient’s hip problem.  A home exercise program which is closely monitored allows the doctor of chiropractic to provide rehabilitative care which is cost efficient and effective.




Muscle alignment problems are frequently found in association with chronic and/or recurring hip imbalances.  Therefore, patients must be screened for excessive leg length discrepancies and/or pronation.  Proper alignment and support of the lower extremities will lead to muscles that are strengthened and lengthened, and hip joints that work smoothly. 




Kim D. Christensen, DC, CCSP, CSCS, DACRB, founded the SportsMedicine & Rehab Clinics of 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 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 Chiropractic Rehabilitation Assoc.,, 18604 NW 64th Avenue, Ridgefield, WA 98642 or by email at This e-mail address is being protected from spambots. You need JavaScript enabled to view it .






  1. Hruska R. Pelvic stability: influences of lower extremity kinematics. Biomechanics 1998; 5:23-29.
  2. Regan DP. Implications of hip rotators in lumbar spine injuries. Strength Cond J 2000; 22(6):7-13.
  3. Ninos J. A chain reaction: the hip rotators. Strength Cond J 2001; 23(2):26-27.
  4. Souza TA. Differential Diagnosis for the Chiropractor: Protocols and Algorithms. Gaithersburg, MD: Aspen Publishers, 1998:134.
  5. Subotnick SI. Sports Medicine of the Lower Extremity. New York: Churchill Livingstone, 1989:312.
  6. Souza TA. Differential Diagnosis for the Chiropractor: Protocols and Algorithms. Gaithersburg, MD: Aspen Publishers, 1998:265.
  7. Friberg O. Clinical symptoms and biomechanics of lumbar spine and hip joint in leg length inequality. Spine 1983; 8:643-645.
  8. Heiser JR. Rehabilitation of lower extremity athletic injuries. Contemp Podiat Phys 1992; Aug:20-27.

Osteoporosis and Spinal Exercise
Written by Kim D. Christensen, D.C., C.C.S.P., D.A.C.R.B.   
Sunday, 30 November 2003 00:00

As the population ages and becomes more sedentary, we will be seeing more of our patients affected by osteoporosis and its complications.  Initially, there is a reduction in bone mass (osteopenia), which is considered a universal phenomenon of aging.  However, when the condition progresses to osteoporosis, bone strength is compromised, and fractures develop with trivial (or no) trauma.  These fractures may affect the extremities, the hip, and the spine.  Physical activity and exercise have been shown to provide significant protection from osteoporosis1 and fractures.2  We have a duty to identify those patients who are at risk of fracture, and to provide exercise recommendations that will decrease that risk.  We can tailor exercise programs to prevent the spinal complications of osteoporosis, such as kyphosis, vertebral wedging, and compression fractures.

Benefits of Exercise to Bone

As recalled from the principle known as Wolff’s Law, bone density and strength are a function of the magnitude and direction of the mechanical stresses that act on bone.3  Assuming the availability of necessary nutrients, stimulus to the osteoblasts results in a net gain in bone mass.  Exercise is a form of repetitive loading that facilitates osteoblastic activity, thereby helping to maintain a positive balance between bone formation and bone resorption.4  Even a moderate amount of exercise that is recommended for general wellness (a minimum of thirty minutes on most days) is helpful in preventing osteoporosis.5

Exercise Types

Aerobic/endurance.  Walking and swimming are two of the most commonly recommended forms of exercise for the elderly.  While improved aerobic capacity is generally beneficial for most older patients, we mustn’t expect any skeletal improvement.  Bone mineral density can be increased by walking, but only when it is done above the anaerobic threshold.6  It is unlikely that most older women, especially sedentary women, will be willing to walk at this intensity.  As for swimming, there is no significant difference in bone mass between women participating in a regular swimming program and women who don’t swim.7  This is also true of a standard weightbearing, water-based exercise program (aquacise).8
Impact/weightbearing.  In order to create sufficient stimulus to increase bone density, exercise needs to be weightbearing and have some impact.  This can be as simple as step-training (ten minutes stepping up and down from an eight-inch high step).1  Use caution when recommending impact exercise to elderly patients.
All exercises are more effective when done in an upright, weight-bearing position, since the entire body is in a closed-chain position during training.  The stabilizing muscles, the co-contractors, and the antagonist muscles all learn to coordinate with the major movers during movements that are performed during closed chain exercising.  This makes these types of exercises very valuable for the elderly—not just for increasing bone density, but also for preventing stumbles and falls.
Resistance/strength.  High-intensity resistance training has been found to be safe and quite effective in increasing strength and function in the elderly.9  Older patients make similar relative, but smaller absolute, strength gains when compared with younger adults.  Weight training in a submaximal controlled, supervised situation can also preserve10 and even increase11 bone deposition.  Strength training recommendations should be an integral part of chiropractic treatment for older and osteoporotic patients.  Exercise tubing is an excellent tool for strength training of the elderly, since the risks of injury are minimized, and a spotter or expensive equipment is not needed.

Spinal Osteoporosis

Spinal X-rays often reveal osteopenia and osteoporosis.  By the time changes are visible on X-ray, however, substantial bone loss has already occurred.  The most common fractures due to osteoporosis are vertebral fractures, and yet less than a third u u of all vertebral fractures are clinically diagnosed.12  These skeletal of all vertebral fractures are clinically diagnosed.12  These skeletal changes can have a significant impact on posture and our ability to handle subluxation complexes.  Specific rehabilitative exercises should be recommended to relieve the postural strain on the spine and to prevent further wedging and compression fractures.  Avoiding exercise is the worst approach for an aging patient with osteoporosis.  Back strengthening exercise constitutes a powerful intervention for reducing pain and increasing functional capacity.
A warning:  Some of the commonly used back exercises may  contribute to increased symptoms.  For patients with spinal osteoporosis, harmful activity places an anterior load on the vertebral bodies.  Patient education must emphasize the dangers of lifting in flexion, and of, possibly, flexion exercises.  In fact, one exercise study13 found an increase in new vertebral deformities when postmenopausal women performed flexion exercises (such as forward stretches and abdominal curls), while those who performed only spinal extension exercises had a significant reduction in the number of vertebral compressions.

Corrective Spinal Exercises

Spinal osteoporosis is often associated with poor postural support, specifically an increase in the thoracic kyphosis.  This posture is secondary to many decades of flexed activities, and may be compounded by poor posture habits and tendencies to slump.  One important factor in chiropractic care is to correct any loss of the normal upright alignment of the pelvis and spine.  In addition to general strengthening and coordination exercises, all patients (especially the elderly) should be given corrective exercises that are specific for the postural imbalances they have developed. 


A well-designed exercise program can improve posture, help to reduce bone loss, and prevent fractures, while also reducing symptoms.  Exercises performed with the spine upright (standing or sitting) can specifically train and condition all the involved structures to work together smoothly.  The end result is an effective rehab component for osteoporosis and aging patients who will make a rapid response to their chiropractic care.


Kim D. Christensen, DC, CCSP, CSCS, DACRB, founded the SportsMedicine & Rehab Clinics of 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 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 Chiropractic Rehabilitation Assoc., 18604 NW 64th Avenue, Ridgefield, WA 98642 or by email at This e-mail address is being protected from spambots. You need JavaScript enabled to view it .

1. Chien MY, Wu YT, Hsu AT, et al. Efficacy of a 24-week aerobic exercise program for osteopenic postmenopausal women. Calcif Tissue Int. 2000; 67:443-448.
2. Campbell AJ, Robertson MC, Gardner MM, et al. Randomised controlled trial of a general practice programme of home based exercise to prevent falls in elderly women. Br Med J. 1997; 315:1065-1069.
3. Davies GJ. A Compendium of Isokinetics in Clinical Usage. La Crosse, WI: S & S Publishers; 1984.
4. Pirnay FM. Bone mineral content and physical activity. Int J Sports Med. 1987; 8:331-335.
5. US Dept. of Health and Human Services. Physical Activity and Health: A Report of the Surgeon General. Atlanta: 1996. 
6. Hatori M, Hasegawa A, Adachi H, et al. The effects of walking at the anaerobic threshold level on vertebral bone loss in postmenopausal women. Calcif Tissue Int. 1993; 52:411-414.
7. Orwoll ES, Ferar J, Oviatt SK, et al. The relationship of swimming exercise to bone mass in men and women. Arch Intern Med. 1989; 149:2197-2200.
8. Bravo G, Gauthier P, Roy PM, et al. A weight-bearing, water-based exercise program for osteopenic women: its impact on bone, functional fitness, and well-being. Arch Phys Med Rehabil. 1997; 78:1375-1380.
9. Fiatarone MA, Marks EC, Ryan ND, et al. High-intensity strength training in nonagenarians: effects on skeletal muscle. JAMA. 1990; 263:3029-3034.
10. Nelson ME, Fiatarone MA, Morganti CM, et al. Effects of high-intensity strength training on multiple risk factors for osteoporotic fractures. JAMA. 1994; 272:1909-1914.
11. Kerr D, Ackland T, Maslen B, et al. Resistance training over 2 years increases bone mass in calcium-replete postmenopausal women. J Bone Miner Res. 2001; 16:175-181.
12. Ross PD. Clinical consequences of vertebral fractures. Am J Med. 1997; 103:30S-43S.
13. Sinaki M, Mikkelsen BA. Postmenopausal spinal osteoporosis: flexion versus extension exercises. Arch Phys Med Rehabil. 1984; 65:593-596.

Diagnostics Used for Sports and Rehab Facilities
Written by Aadam Z. Quraishi, M. D.   
Tuesday, 30 September 2003 00:00

Having a sport and rehab facility demands great expertise and close attention to detail in treatment protocols.  In such settings, doctors often rely on objective findings of manual testing.  Nonetheless, given the explosive level of technology available today, it is ludicrous for any doctor to rely strictly on “manual findings.”  One of the greatest sources of objective findings available, to date, to all doctors but especially in rehab and sport facility settings is the use of diagnostic radiology.  Indeed, the information that can be gathered using diagnostic radiology is very impressive. 

What is the benefit of diagnostic radiology?
After a thorough physical examination has been done and the need for the X-rays has been established, X-rays are sent to a specialized company which uses highly technical equipment and techniques to produce computerized enhancement of the radiographic plain films.  One of the enhancements is called digital radiographic mensuration.  The X-rays are scanned, and multiple landmarks are selected and stored in a location separate from the image.  The numbered data, “landmarks,” are later used to reconstruct a variety of biomechanical relationships and measurements that are useful to the doctor and the patient.  The diagnostic analyses, as well as biomechanical data, are extracted from these plain film radiographs and are then displayed on high-resolution monitors using comparative standards and technical procedures.  These visuals of radiographic imaging are used objectively to analyze the biomechanical properties of the spine.  At least fifty-nine biomechanical analyses for diagnostic purposes can be performed on such instruments.  (See Table 1 to for a list of a few examples)
Using highly technical equipment and techniques produces computerized enhancement of the radiographic plain films, that can then be used to perform at least fifty-nine biomechanical analyses for diagnostic purposes. Here are some Examples:

  • Atlas Skull Line
  • Stress Line 
  • Skull Line Baselines 
  • Thoracic Apex                          
  • Baseline Atlas                         
  • Stenosis
  • Spinal Length 
  • Occiput Angle  
  • Ferguson’s Angle 
  • Sacrum Angle
  • Penning’s Range of Motion 
  • Thoracic Kyphosis  
  • Jackson’s Angle 
  • Lumbar Instability  
  • Motion Segment Integrity 
  • Vertebral Offset 
  • George’s Line 
  • Atlas/Axis Angle  
  • Lumbar Gravity Line 
  • Vertebral Body Rotation 
  • Pelvic Rotation 
  • Lumbar Lordosis  
  • Cobb’s Angle 
  • Spondylolisthesis

It becomes medically necessary for a sports and rehab facility to fully assess the degree of injury and its effect on the patient’s health and future well-being.  Reports obtained from digital analysis include impairment ratings, per the American Medical Association (AMA) Guides to the Evaluation of Permanent Impairment. 

Defining “disability”
American Medical Association Guides evaluate Medical Disability as well as Permanent Impairment.  The term disability has historically referred to a broad category of individuals with diverse limitations and the ability to meet social or occupational demands.  However, it is more accurate to refer to the specific activity or role the “disabled” individual is unable to perform.  Several organizations are moving away from the term disability and, instead, are referring to specific activity limitations to encourage an emphasis on the specific activities the individual can perform and to identify how the environment can be altered to enable the individual to perform the activities associated with various social or occupational roles.  Nonetheless, Guides to the Evaluation of Permanent Impairment defines disability as “an alteration of an individual’s capacity to meet personal, social, or occupational demands or statutory or regulatory requirements because of an impairment”.  (American Medical Association. Guides to the Evaluation of Permanent Impairment. 5th  ed. Chicago, Ill: American Medical Association; 1993)

What are the benefits to the patients?
We live in an age when patients are particular about their health care needs and are demanding that their doctors under- u u stand not only the need for specific treatment, but also the findings of the objective testing.
Using diagnostic radiology will bring the following benefits to the patient:

  • Films read by a board certified radiologist 
  • Photographic reproduction of the patient’s film images, printed with complete measurements and displayed next to comparatively normal images, should be shown to the patient to explain the findings and insure patient retention.  If the healthcare practitioner has expertise and is well acquainted with the individual’s activities and needs, then he or she must express an opinion about the presence or absence of the specific disability and how this will impact the patient’s daily activities.

Benefits to a Rehab Center
Rehab centers are often made up of exercise physiologists, body trainers, physical therapists (Pt’s), Pt aids, Pt assistants, chiropractic practitioners and others.  These sports and rehabilitation oriented practitioners, although very knowledgeable in assessing a patient’s diagnosis, can greatly benefit by the highly technical, yet diversified, information which is gathered from diagnostic radiology.
Because every patient’s injury or disease is different and every patient responds differently to treatment, the information obtained from the digital analysis of radiographic images can prove or disprove the necessity for further treatment.  This information is then used to customize the most effective treatment protocol for the patient’s injury and/or disease and may cut down on or eliminate unnecessary treatment.
Biomechanical measurements are vital and are critical to the appropriate diagnosis analysis, treatment, and prognosis of the sports injury patient in a clinical environment.  With accurate measurements, a fundamental base line can be determined and can further be explored for an accurate and reliable assessment of the patient’s condition and outcome potential. 
There is also a financial benefit, since the referring doctor gets reimbursed u  u for the professional confirmatory component above and beyond the X-ray coding.

Below are a few samples of indications for diagnostic radiology.

  • Sprains/ Strains
  • Trauma
  • Motor vehicular accidents
  • Sports induced injuries
  • Work related injuries

On a side note, and as a fundamental basis, DC’s often deal with the dynamics of the musculoskeletal system, whether or not the clinical neurological components exist. 
Simply stated, the science of chiropractic is founded on the premise that adequate nerve supply is of prime importance in regulating body function.  Hence, radiographic measurements obtained from diagnostic radiology and utilized in a rehab facility can:

  • Increase Personal Injury referral
  • Enhance reputation
  • Increase patient compliance
  • Support insurance claims with scientific medical proof
  • Provide attorneys with professional documentation
  • Increase collections 

How to implement diagnostic radiology

  1. Determine need for X-rays.
  2. Take flexion/extension study of cervical or lumbar area (or both, if needed).
  3. Referring doctor reads films and gives brief impression to patient.
  4. Films are sent for digitization and for impression by Board Certified Radiologist (licensed in the state where patient is being treated).
  5. Analysis is done and returned to referring doctor.
  6. Treatment protocol is established and information is given over to patient.
  7. Service is billed for consultation to proper carrier.

In conclusion, other procedures (i.e., NCV, SSEP, MRI, US, Electromyography, etc.) should always be correlated to clinical history, physical examination and radiographic findings for a more comprehensive and complete picture of the patient’s status.  Digitized radiology has shown reliability, accuracy and benefit paralleled to this time in history with respect to spinal radiographic analysis.  In determining need for treatment, type of treatment to be administered, and/or monitoring of changes of treatment resulting from re-injury, for prognosis, digitized analysis for radiology is an effective outcome assessment device and methodology for chiropractic services in a rehab facility.

Aadam Quraishi, MD, was a clinical instructor at New York University Medical Center.  He is board certified in radi-ology and has additional fellowship trained qualifications.  He has seventeen years of medical practice experience.
Dr. Quraishi specializes in Vascular and Interventional Radiology MRI (Neuro and Musculosketal), MRA Mammography, Breast Localization, Nuclear Medicine CT and Ultrasound.  Dr. Quraishi has board certification in Diagnostic Radiology, and can be contacted at
This e-mail address is being protected from spambots. You need JavaScript enabled to view it For more information and/or sample reports, go to

Step-by-Step Rehab Center
Written by Daniel Dahan, D.C.   
Tuesday, 30 September 2003 00:00

About 83 million people in the U.S. (42% of the adult population) used at least one alternative therapy in 1997.  Usage among those 35-40-years-old is even higher, at 50%.

The estimated number of visits in 1997 to providers of “unconventional therapy”  (629 million) was greater than the number of visits to all primary care medical doctors nationwide (386 million).
Americans spent $21 billion out-of-pocket on visits to alternative practitioners in 1997 (an increase of 45% over 1990’s total).  This does not include money spent on retail products, such as herbal products ($5.1 billion), books, classes and equipment ($4.7 billion).  By comparison, out-of-pocket expenditures for physician visits were $29.3 billion and for hospitalizations were $9.1 billion.

We have to ask why 42.1 percent of U.S. citizens surveyed used at least one of sixteen alternative medicine practitioners, increasing from 427 million in 1990 to 629 million in 1997, exceeding the total visits to primary care physicians.  What is of greater interest is that these statistics have continued to increase—by 3.6% between the years of 2001 and 2002. 

None of these statistics, however, come close to the billions Americans spend on exercise and fitness.  Over 50% of the American population is overweight and the number is growing.  What does this all mean for the primary healthcare provider such as a DC?  The DC, basically, has to be prepared to diversify his/her services and, most of all, create a center where exercise and rehabilitative therapy are key components.
DC’s have always looked for ways to increase their income, often by learning new techniques or buying some expensive piece of diagnostic equipment.  While these can be valuable investments, they are not as effective as knowing how to establish, manage and/or promote a rehab center.

Following are the basic protocols, which have to be put into place to establish a rehab center. (See Table 1).

Table 1. basic protocols to establish a rehab center
1. Necessary Education:  Proficiency in sports medicine.
2. Professional Staff:  Exercise physiologist, physical therapist, physical therapist aide, and/or assistant, fitness trainer, massage therapist.
3. Equipment: Minimum equipment necessary is a full body station, treadmill, enlarged physical therapy table, various weights, stationary bike, exercise mats.  Miscellaneous:  towels, theraband, cold packs, etc.
Approximate initial cost of total equipment, between $10,000 to $15,000
Certification is a must for all professionals
Ideal size room, 800 sq. ft.

Table 2. Most Common Scenario Used in Rehab Facility
1. Doctor initial exam
2. X-Ray/ancillary services
3. Treatment protocol established and started
4. Diagnostic testing
5. Rehab with PT (4 weeks)
6. Re-exam to update or change diagnosis
7. Rehab with PT (4-8 weeks)
8. Discharge

Table 3. 10 Steps to Opening Date
1. Plan out (draw out) rehab room space
2. Interview and hire professional staff
3. Design marketing plan (newspaper ads, coupons, flyers, etc.) and allocate marketing budget ($3,000 to $5,000)
4. Purchase equipment (ask accountant if leasing is better option)
5. Understand billing codes and implement rehab form
(See Table 4)
6. Create appointment script for front desk
7. Train office staff
8. Send letter to all local businesses
9. Send announcement letter to all active patients
10.Have grand opening day (balloons, prizes, music…)

Expected Reimbursement in Rehab Exercise Facility
The above scenario is by far the most practical flow that will allow the highest reimbursement.  It is important to take into consideration that insurance companies do not approve “medical maintenance care”.  Insurance companies will pay for treatment, but not for exercise physiology and/or rehabilitative medicine when used to enhance a patient’s stamina or endurance.  Insurance companies are interested in treating patients and rehabilitating them, given serious practice medical diagnosis.

Table 4. reimbursements for rehab patients
Total reimbursements for rehab patients vary between $4,500 to $6,500. CPT codes most often used are as follows:
97535   Activities of Daily Living
97112   Neuromuscular Re-education of movement, balance, coordination, kinesthetic sense, Posture, and/or proprioception for sitting and/or standing activities
97110   Therapeutic procedure, each  15 min., therapeutic exercise to develop strength and endurance, range of motion and flexibility.
97530   Therapeutic activities, direct patient contact by the provider, each 15 min.
97799   Unlisted Physical Medicine/Rehab service or procedure
97139   Unlisted Therapeutic Procedure (specify)
97150   Therapeutic procedure(s), group (2 or more individuals)
97750   Physical Performance Test or Measurement w/report
97504   Orthotic(s) fitting and training, upper and lower extremities, each 15 min.
97520   Prosthetic Training, each 15 min.
97140   Manual Therapy techniques (Manual Traction), each 15 min.
97124   Massage Therapy, including effleurage, petrissage, and/or tapotement
97113   Aquatic Therapy with therapeutic exercises
97537   Community/Work Reintegration Training, direct contact, each 15 min.
97542   Wheelchair Management/Propulsion Training, each 15 min.
97703   Checkout for orthotic/prosthetic use established patient, each 15 min.
97545   Work Hardening/Conditioning (initial 2 hrs.)
97546   Each additional hour (list separately in addition to code for primary procedure).  (Use 97546 in conjunction with code 97545)
97116   Gait Training
95833   Total Evaluation of Body w/o Hands
95834   Total Evaluation of body w/ Hands
95851   ROM Measure w/Report, each extremity
95852   Hand w/ or w/o Comparison to Normal Side

Objective Testing That Can Be Used to Support Medical Necessity and Enhance Medical Records
1. X-Rays
2. Digitized Radiographic Mensurations
3. MRI
4. Neurological Diagnostic Testing

General Discussion
Overall, a rehabilitation center is a great addition for any practitioner.  Using diversified healthcare, the doctor has the ability to promote the best treatment protocol available.  The core problem in healthcare today lies in the fact that there are currently not significant entities that can provide quality care at sufficiently low prices on a large enough scale to service the overwhelming needs of the population.
By creating a rehab sport center, a clinic will provide a viable solution to the healthcare crisis, by integrating the skills of the chiropractor and various other healthcare practitioners, such as exercise physiologist, physical therapist, etc., leading to the development of a profitable venture.  This, by all means, is the wave of the future.

Dr. Daniel H. Dahan owned and operated one of the most successful clinics in Southern California.  As previous chairman of the West Coast Medical Advisory Board and writer/editor for the Sun’s Weekly Health Column, Dr. Dahan, the President of Practice Perfect, developed a successful management and consulting health care system for doctors throughout the United States.  His seminars are rated among the best and most proliferate lectures in the country.  Dr. Dahan has taught over 4700 doctors and integrated 800+ offices in 45 states.  He can be contacted at This e-mail address is being protected from spambots. You need JavaScript enabled to view it For more information, go to


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