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Rehabilitation
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Rehabilitation
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Written by Kim D. Christensen, D.C., C.C.S.P., D.A.C.R.B.
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Thursday, 30 January 2003 00:00 |
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The body’s soft connective tissues (such as muscles and ligaments) are generally exposed to stress throughout life. Such structures respond and adapt to the usual amount of stress exposure. Damage occurs when soft tissues are exposed to higher-than-usual stress levels. This can be a single, sudden, excessive stress, or it can be the result of repetitive stress to the muscle or ligament. In either case, the doctor of chiropractic must determine how the damage occurred, and then make appropriate recommendations (rehab following rest, for example) to help the body heal the injury and to prevent a recurrence.
Problems can also develop when these tissues are not exposed to sufficient regular stress to maintain functional health. It’s important to recognize that the soft tissues in the body are normally used in a range of intensity, and that categorizing a patient’s level of use helps in the planning of care and exercise regimens.
The Range of Soft Tissue Use
What we usually consider to be normal use is in the middle of the usage range. At one end is paralysis, where soft tissues are completely unused. Close to paralysis is immobilization, such as in use of a cast or bed rest. The difference between these is that paralysis lacks a neurological stimulus, called “tone,” which is present in immobilized (yet still neurologically intact) muscles and skeletal ligaments.1 Next is sedentarism, when the ligaments and muscles are used only minimally. This is also called the “disuse syndrome”.2 This condition is, unfortunately, becoming more common in all age groups in our rich, advanced society, which has so many labor-saving devices. Normal use can vary widely, but requires the intermittent and regular exercise and use of all muscles and ligaments. Those who are employed in active (often blue-collar) jobs and people who engage in regular, active recreational pursuits fall into the strenuous use category. And then there are the athletes, who are always trying to improve and push their limits by specifically building and strengthening their muscular and skeletal ligament tissues.3 Athletes are at the far end of the continuum, demonstrating the body’s response to progressive overload.
Damage through Overuse
The muscles and ligaments in any of the above categories can be overused and damaged. Less stress is needed to cause injury to tissues in the lower use end of the continuum. After several days of immobilization, or when someone has been on bed rest or is a couch potato, even mildly strenuous effort can be too much. Fitness protects from some injuries, especially overuse conditions of the spine. Athletes, who are regularly pushing their muscles and ligaments, are most likely to end up with either overuse or acute injuries. There are two major categories of excessive stress to ligaments and muscles—repetitive use (chronic, over time),4 and sudden injury (strain or sprain) with tissue tearing.
Repetitive overwhelm. When muscles and ligaments are stressed, they respond by repairing and strengthening. In some cases, however, the physical stress occurs so frequently that this process is overcome, resulting in damage. Examples include runners who quickly increase their mileage, workers who are placed in a new position which requires repetitive movement or bending, and athletes who practice throwing to the point that they injure their shoulders. Even someone taking up walking after years of standing on rigid flooring can quickly overwhelm the foot’s ability to strengthen, developing plastic deformation of the plantar fascia with arch collapse.
Acute injury. Of course, trauma to a ligament or muscle is a single episode of stress which causes damage. When a muscle or ligament is torn, there is immediate pain, followed by swelling and loss of function. Around the spine, this is often a complex injury, since it is inevitable that several layers of both muscles and connective tissues will have been damaged (a “strain/sprain” injury). Understanding of the healing response is necessary for good management of acute injuries to muscles and ligaments, wherever their location.
Healing Response
Whether damaged by repetitive overuse or by acute injury, muscles and ligaments will heal most rapidly and completely when they are cared for properly. A brief period of “relative rest” is important, the amount depending on the extent of injury. This may require a brief period of immobilization of the damaged region, followed by gradual reintroduction of movement and activity.5 Then, reactivation is necessary; this usually requires specific exercise instruction and expert guidance. The patient should be encouraged to return to the level of pre-injury, and then advised on preventing further injury, either by providing additional response time or by improving muscle strength and balance (or both). Exercise tubing (with areas targeted for rehabilitation) and a wobble board are usually helpful adjuncts.
Occasionally, ligaments become damaged and deformed to the point that full repair is not possible. In these cases modification of stress may be necessary, either through changes in activities or through the use of supports, such as knee braces or custom foot orthotics.
Conclusion
It is vitally important to understand the status of a patient’s muscle and ligament tissues prior to injury. It is also necessary to realize how these tissues became overwhelmed. Was it from an acute injury, or can a history of repetitive insult be uncovered? Once the doctor of chiropractic has the information for the “start point” and an understanding of the method of stress damage, proper care can proceed rapidly. This is what separates caring doctors of chiropractic from those providers who prescribe drugs or bed rest for ligament and muscle injuries. TAC
Kim D. Christensen, D.C., C.C.S.P., D.A.C.R.B., 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. He is currently a postgraduate faculty member of numerous chiropractic colleges and is the president of the American Chiropractic Association (ACA) Rehab Council. Dr. Christensen is the author of numerous publications and texts on musculoskeletal rehabilitation and nutrition. He can be reached at Chiropractic Rehabilitation Consulting, 18604 NW 64th Ave., Ridgefield, WA 98642 or by e-mail at
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Rehabilitation
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Written by Dr. John Danchik, D.C., C.C.S.P., F.I.C.C.
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Thursday, 30 January 2003 00:00 |
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Hamstring injuries and athletic running seem to go together. The injuries also tend to reoccur and become chronic. Often, the recovery rate becomes frustrating for the athlete as well as the practitioner. While the etiology remains controversial, the primary causes may be considered, in order to enhance recovery and prevent reinjury.
Main Causes
Some of the most common causes of hamstring muscle strains are:
- muscle fatigue
- muscle strength imbalances
- lack of hamstring flexibility
- insufficient warm-up
Hamstring muscle strain is a non-contact injury that presents in two ways: sudden onset with acute pain (runner pulls up and grabs his/her leg), or a more insidious onset of muscle tightness. Typically the biceps femoris, with or without the semitendinosus, is involved. The area most commonly inflamed is the proximal and lateral musculotendinous junction of the hamstring near the ischial tuberosity.
Acute Phase Treatment
During the acute, painful phase, the goal is to reduce inflammation. Ice works best; don’t use heat. As a general rule, use ice for twenty minutes, every two hours (during the hours the patient is awake), until the pain is gone. A light towel or face cloth should be used to protect the skin, even though it will dissipate some of the cooling effect. This treatment may be utilized from two days to two weeks.
The injured athlete should be advised to maintain a normal walking gait, even if it means walking with a cane or crutch on the opposite side (the toe of the cane or crutch should always be in line with the toe of the injured side). Most athletes aren’t happy with this advice, but to compromise the gait into a hobble will only prolong recovery.
Rehab Protocol
Active knee extension and flexion without resistance should be performed as soon as tolerated by the patient. Some pain may be experienced during this motion, as long as it is not increased pain. When the athlete can perform knee extension and flexion with little to no pain it is usually safe to perform these two range-of-motion exercises against resistance with an at-home rehab system. Be particularly aware of pain. Initially, the range of motion and/or the amount of resistance may be limited. Set them to patient tolerance.
Do the uninvolved side first. An effective protocol is:
• 1 set to fatigue of knee extension (uninvolved side)
• 1 set to fatigue of knee extension (involved side)
• 1 set to fatigue of knee flexion (uninvolved side)
• 1 set to fatigue of knee flexion (involved side)
Repeat the sequence above two more times. This protocol should be done daily at first, and then progressed to twice daily as the patient recovers.
I recommend doing one extra set of knee extension exercises, because according to the hierarchy of strength in the body, the extensor should be slightly stronger than the flexor.
If any soreness develops, follow the rehab exercises with ice. Do not let your patients overwork themselves. Athletes have a tendency to do too much too soon and reinjury occurs. This type of protocol is designed to facilitate neurologic firing into the involved muscle(s) and initial strength gains. As muscles get stronger they will naturally be able to do more. Let pain be your guide. This type of exercise will also build up endurance levels over time.
Proper Stretching Activity
Stretching is important, but only if done correctly. Many people stretch their hamstrings by bending over a propped-up knee and curling their back to touch their forehead to their knee. This will not effectively stretch the upper portion of the hamstrings where the injury site is. Do that stretch, but arch the lower back to create anterior pelvic tilting and lean the body forward, keeping the head level.
Evaluation of Progress
To progress to activity, an athlete should be able to:
- walk without discomfort
- jog straight ahead without discomfort
- run straight ahead without discomfort
- run with change of directions without discomfort
- perform the tasks of his/her athletic activity without discomfort
As with any condition involving the lower extremity, thoroughly evaluate the sacroiliac joints and the spine. Subluxation complexes can create structural imbalances, and muscular imbalances may also be playing a role.
Orthotic Support
You must also look for involvement of the knee and/or foot/ankle complex. Remember that the most common painless biomechanical fault is excessive pronation. Excessive inward rotation of the mid-foot and rear-foot can set up a serial distortion, resulting in structural misalignment and muscle imbalances. Without stabilizing this area with custom-made, flexible orthotics, reinjury will always be a concern, even with the best rehab program. Consult with an established orthotics laboratory about specialized shoe inserts for athletes. TAC
Dr. John Danchik is the seventh inductee to the American Chiropractic Association Sports Hall of Fame. He is the current chairperson of the United States Olympic Committee’s Chiropractic Selection Program. He lectures extensively in the United States and abroad on current trends in sports chiropractic and rehabilitation. Dr. Danchik is associate editor to the Journal of the Neuromusculoskeletal System and the Journal of Chiropractic Sports Injuries and Rehabilitation. He has been in private practice in Massachusetts for 24 years. You may reach Dr. Danchik at (617) 489-1220 or e-mail
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Rehabilitation
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Written by Dr. James P. Cima, D.C.
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Thursday, 30 January 2003 00:00 |
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When treating soft tissue injuries, especially the chronic degenerative ones, you must be well versed in the Triune of Exercise.
I’m not just talking about athletes but about patients as well. They all suffer from some type of soft tissue injury, as well as being subluxated. In fact, why do you think their subluxations persist? Because nobody ever handled the underlying soft tissue injury correctly.
Please remember this: “The nervous system controls function, but the musculoskeletal system supports the nervous system allowing it to function”. When addressing a subluxation, it would behoove you to address the soft tissue, as well, via the Triune of Exercise.
The purpose of the Triune of Exercise is to help repair and rebuild the surrounding soft tissue to compensate for the degenerative joint; and, thus, to some degree, to remodel the soft tissue, restoring normal function to that joint, reducing exacerbations and continued degeneration. This is done through the proper conditioning of the surrounding soft tissue.
The triune consists of:
- Progressive resistance training (weight training)
- Stretching (flexibility conditioning)
- Cardiovascular (“repetitive stamina conditioning”)
In order to condition soft tissue properly you must utilize this approach. If you do not, you cannot treat soft tissue injuries effectively.
Why Stretching is Important
As you may be aware, damaged soft tissue, left untreated, causes the soft tissue to become fibrotic. Fibrotic tissue (scar tissue) causes loss of joint mobility; thus, stretching is extremely important.
Why Cardiovascular Exercise is a Great Conditioner
We all know the importance of cardiovascular exercise for our heart, lung and circulatory tree; but, are you aware of the benefits to our stamina, or the ability to do things repetitively, which often decrease as a result of soft tissue injuries? Whereas, previously, you could run for miles, you find it difficult to walk down the block, due to circulatory disturbance to soft tissue.
Progressive resistance exercises and cardiovascular exercises are extremely important in reducing muscular fatigue and enhancing muscular stamina and endurance.
Why Progressive Resistance (Weight Training) is an Important Conditioner
I saved the best for last.
Muscles lose up to 30-40% of their strength within weeks of an injury and their strength continues to decline, as time goes on. Soft tissue loses flexibility and stamina as well. The best part of weight training is that you can accomplish all three:
- Increased flexibility
- Increased strength, and
- Increased stamina
Weight Training
About 1984, I began to exercise, using weights. At that time, weight training was gaining popularity. I started to see professionals from all fields (tennis, golf, baseball, basketball, etc.) using a specific program that included weights to enhance their performance. Prior to this, the mentality had been (and still is, to many people) that you never wanted to exercise with weights, because you would become “muscle bound” (whatever that means). Also, when you stop working out with weights, all that muscle turns to fat.
In fact, I bet half the doctors reading this article still, to some degree, believe those statements to be true. If you think I’m exaggerating, just go to any state chiropractic convention and look at the physiques of some of the doctors attending. Your physical appearance speaks volumes about you, as a doctor. After all, are we not the doctors that state, “STRUCTURE GOVERNS FUNCTION”?
Some of us look like “LONDON BRIDGE”. You want to be a super success in practice? Start looking like the healthy specimen you are capable of being.
Your body is a billboard (like free advertisement). Your state board should make it a prerequisite that, in order to practice chiropractic, you must understand the concept, and train with weights at least three times per week.
Do you not want this very same thing for your patients? Well, if you are not well versed in the physiological and anatomical relationships between weight training and its effect on function via its effect on structural integrity, then you are missing a big piece of the pie.
I cannot, in this short amount of space, even begin to explain the fundamentals of weight training without doing it a grave injustice, so I won’t even go there. Just realize that weight training, like chiropractic, has a philosophy, science and art. It requires a great deal of understanding, on your part, to be successful using this valuable tool.
Flexibility (Stretching)
Guidelines to Follow When Stretching
When developing a program of stretching for your patients, use stretches that stretch every major muscle group/joint through the respective ranges of motion, and follow the rules below:
- Stretch in the morning, or evening, or both, depending on injuries or tight areas. Each session should last 15-30 minutes.
- Stretching daily helps create a routine (like brushing your teeth) that eventually will become a habit. In fact, I look forward to my morning stretches, which I also use as “quiet time” to get in touch with my mind and body. By the way, the only way to gain flexibility is to stretch daily.
- Taking a hot shower before the stretch loosens the muscles.
- Never perform ballistic or bouncing, hard-type stretches that are painful. These exercises are dangerous and can cause a lot of joint damage.
- Always use a comfortable firm surface; and, if there are low back or neck injuries, use a roll behind your neck and/or a roll behind your knees.
- Always start your stretching in the lying position, then proceed to sitting, then to kneeling, and then into your standing stretches.
- Always use deep, relaxed breathing when stretching.
When stretching a muscle, you must stretch as far as you can comfortably, at which point, you must focus on two things: Breathing, and blending your mind with that muscle, with the focus on relaxing it. When you reach the point in the stretch where the muscle starts to tighten and ache from the stretch, you use breathing and mind/muscle relaxation to gain more stretch in that muscle or joint. Focus on deep, relaxed breathing, gaining a little more stretch on exhalation. In other words, as you exhale, you will be able to push the stretch a little more, and then hold that position while you inhale. Then, when you exhale, you may gain a little more, or hold that position longer. Then, repeat the cycle one more time.
At this point, you can hold the position for another 10-15 seconds, and then release the stretch slowly. Your mental focus should be on consciously relaxing that muscle or joint, by visualizing the muscle relaxing.
This process can be repeated two more times, if needed, and you will get a further stretch by the third time.
At some point, you will notice that you hit your sticking point—you cannot stretch any further. You may have pain or the muscle may start to cramp. In this case, you should stop the stretch and slowly bring the muscle or joint out of the stretch. I also recommend that you lightly massage the muscle or joint that you are working while you are stretching that muscle or joint. Always spend more time on the tight muscle or the tighter side.
Cardiovascular Exercises
- Walking
- Jogging
- Dancing
- Swimming
- Cycling
- Skating
- Aerobic classes
- Climbing
- Cross-country skiing
- Rowing
Progress resistance performed one set after another with little or no rest (circuit training)
Guidelines to Follow When Creating an Aerobic Program for Your Patients
- Make sure that the exercise fits the patient. Overweight patients or patients with knee injuries, etc., should not jog, play basketball, etc.
- Monitor and keep score of their pro-gress. When it comes to measuring your patients’ cardiovascular performance, their pulse and respiratory rates must be determined. This is what you should measure—not how much weight they are losing. It is interesting to note that most people do cardiovascular exercise for weight loss, which is not the purpose when measuring cardiovascular performance. As you condition your body properly, cardiovascular exercise will cause the weight to come off, provided you are eating right and intensifying your conditioning, using your pulse and respiratory rates as indicators. You must be able to take the following measurements:
· Resting heart/pulse rate.
· Target heart/pulse rate (approximately 60-80% higher than the resting rate).
· Resting respiratory rate.
· Target respiratory rate (approximately 60-80% higher than the resting rate)
- There are three phases of cardiovascular training that patients must go through.
· Warm-Up Phase: This portion takes five-to-ten minutes, as you approach your target heart rate.
· Maximum-Effort Phase: This takes from ten-to-twenty minutes. When achieving higher levels of conditioning, you want to intensify your routine by using methods other than time (how long you work out). Grueling sessions lasting hours at a time, or working out countless hours during the week lead to burnout and poor results.
There are other ways to intensify your cardiovascular program; wind sprints are an excellent example. This procedure is not for the beginner, but for the athlete, or someone already in good condition. Wind sprints are performed toward the end of maximum effort when you increase your speed to the point of labored breathing, which takes focus and perseverance. Sustain this level for as long as you can and then slow back down to your maximum-effort level. Once you catch your breath, you repeat the sprint two or three more times. Please note that wind sprints will take your target heart rate over 100 percent, so be careful. For those just starting out, the goal is to nudge the target rate up over time.
How much time? That depends on your age, your condition, your diet, etc. Just continually push the envelope and reach higher target heart rates for up to 40 minutes and then you will be ready for wind sprints.
· Cool-Down Phase: This takes five to 10 minutes, as you slow your pace and come to the end of your routine.
- How often should your patient perform cardiovascular conditioning? Three or four aerobic workouts per week are sufficient for most people. Any more, and you are causing too much stress on the body.
Remember, it is not how many times or how long you exercise; it is the intensity of your exercise sessions. And, there you have it: An exercise program that will support and improve sports injuries, degeneration, and joint damage. TAC
Dr. James Cima has been teaching, and writing on this subject for 20 years. Dr. Cima also teaches seminars and has created a software package for the doctors to help them assess their patients’ needs. For more information, call toll free 1-877-627-2770 or fax 561-624-3871, or e-mail Dr. Cima at
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Rehabilitation
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Written by Kim D. Christensen, D.C., C.C.S.P., D.A.C.R.B.
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Saturday, 30 November 2002 00:00 |
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Children, like adults, often need to do some exercises as part of their chiropractic treatment. But, how safe is exercise for children, especially exercise with resistance? How much weight is appropriate for a growing body? And which exercises are most effective? Because of these and similar questions, doctors of chiropractic may hesitate to recommend exercises for their younger patients. Let’s see if we can arrive at a reasoned response, based on experience and useful consensus information.
Passing Phases
Prepubescence is the phase of childhood prior to the onset of secondary sex characteristics. Rapid, but variable growth occurs during this period, with open physes and changing muscle and ligament lengths. Adolescence begins with the onset of secondary sex characteristics and continues until physical and skeletal maturity. Selecting the best exercise approach for each child’s situation is important, since needs may vary during growth.1 However, all children should be encouraged to engage in frequent and regular fitness activities.
Exercise Benefits
The benefits of physical activity in youth include fitness, weight control, and the development of habits having the potential to span a lifetime. One study systematically determined the amount of moderate-to-vigorous physical activity students obtain during elementary and middle-school physical education classes (time spent performing moderate-to-vigorous physical activity compared to total class time). The researchers concluded that the amount of physical activity observed (elementary schools, 8.6%; middle schools, 16.1%) was significantly less than the estimated national average of 27%, and far below the national recommendation of a minimum of 50%.2
A review of current youth fitness data indicates that children in the United States are fatter, slower, and weaker than children in other developed nations. Also, children in the United States appear to be developing a sedentary lifestyle at earlier ages. A low level of exercise is a contributing factor for childhood obesity and hypertension, and predisposes the individual to premature death from coronary heart disease.3 Fortunately, through intervention in children and adolescents in the form of education and motivation, exercise levels may be increased to the recommended minimum of thirty minutes on most days.4
Safety Issues
High-intensity resistance training appears to be effective in increasing strength in preadolescents. Children make similar relative, but smaller, absolute strength gains when compared with adolescents and young adults. Resistance training appears to have little, if any, hypertrophic effect, but, rather, has been associated with increased levels of neuromuscular activation. Researchers have found that the risk of injury from prudently prescribed and closely supervised resistance training appears to be low during preadolescence.5 In 1993, Mazur, et al., reviewed the types and causes of injuries to preadolescents and adolescents resulting from weight lifting/training. The researchers concluded that “prepubescent and older athletes who are well-trained and supervised appear to have low injury rates in strength training programs.” 6
A risk that must be considered in the immature skeleton is the susceptibility of the growth cartilage of the epiphyseal plates (physes). Weight training in a submaximal controlled, supervised situation is beneficial to bone deposition. Strength training can be a valuable and safe mode of exercise provided 1) instructors are properly educated; 2) participants are properly instructed; and 3) the absolute necessity of avoiding maximal lifts is reinforced.7
The most important factors in avoiding injury in children who are doing resistance exercises are proper performance of the exercise; avoiding overload by focusing on repetitions, not weight; enforcing rest periods during exercise; and resistance training only twice a week. Exercise tubing is an excellent tool for strength training of children, since the risks of injury are minimized, and a spotter or expensive equipment is not needed.
Training Balance and Coordination
For many children, it is more important to learn the fine neurological control necessary for accurate spinal and full body performance than to simply build strength. Better balance and coordination will often result in improved physical function, both in daily and in sports activities. This may entail performing exercises while standing on one leg, with the eyes closed, while standing on a mini-tramp, or using a rocker board. The advantage of these balance exercises is seen when children engage in sports activities and perform at advanced levels for their age group.
All exercises are most effective when done in an upright, weight-bearing position, since the entire body is in a closed chain position during the 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 in the long run, particularly for children who are interested in becoming competitive athletes.
Corrective Postural Exercises
Children’s spinal problems are often associated with poor postural support. A spinal asymmetry, such as scoliosis and kyphosis, is invariably accompanied by neuromuscular imbalance. This may be compounded by poor postural habits and tendencies to “slump.” One important factor in chiropractic treatment is the correction of any loss of the normal upright alignment of the pelvis and spine. In addition to general strengthening and coordination exercises, patients (including children) should be shown corrective exercises that are specific for the postural imbalances they have developed. For instance, when the pelvis is carried flexed forward, a patient of any age will need to retrain with resisted pelvic extension exercises. Likewise, when there is a forward head, posterior translation exercises for the cervical region are very important.
Whenever a child shows evidence of abnormal gait or begins to develop lower extremity complaints, a careful evaluation for the need for shoe inserts is warranted. Custom-fitted orthotics can improve performance and spinal alignment by ensuring proper lower extremity alignment, and reduce overuse injuries by providing additional shock absorption.
Conclusion
A well-designed exercise program for children who need to strengthen, develop better coordination, and improve postural support will allow the doctor of chiropractic to provide cost-efficient pediatric spinal care. Exercises performed with the spine upright and functional can specifically train and condition all the involved structures to work together smoothly. In some children, orthotic support is necessary to help ensure correct alignment from the lower extremities. The end result is a more effective rehab component and young patients who will make a rapid response to their chiropractic care. With a few common sense precautions and careful supervision, children are capable of performing rehabilitative exercises very safely. TAC
References
- American College of Sports Medicine. Guidelines for Exercise Testing and Prescription, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2000.
- Simons-Morton BG, Taylor WC, et al. Observed levels of elementary and middle school children’s physical activity during physical education classes. Prevent Med 1994; 23:437-441.
- Cunnane SC. Childhood origins of lifestyle-related risk factors for coronary heart disease in adulthood. Nutr Health 1993; 9:107-115.
- US Dept. of Health and Human Services. Physical Activity and Health: a Report of the Surgeon General. Atlanta:1996.
- Blimke CJ. Resistance training during preadolescence: issues and controversies. Sports Med 1993; 15:389-407.
- Mazur LJ, Etman RJ, Risser WL. Weight-training injuries: common injuries and preventative methods. Sports Med 1993; 16:57-63.
- Schafer J. Prepubescent and adolescent weight training: is it safe? Is it beneficial? Natl Strength Conditioning Assoc J 1991; 13:39-45..
Kim D. Christensen, D.C., C.C.S.P., D.A.C.R.B., 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. He is currently a postgraduate faculty member of numerous chiropractic colleges and is the president of the American Chiropractic Association (ACA) Rehab Council. Dr. Christensen is the author of numerous publications and texts on musculoskeletal rehabilitation and nutrition. He can be reached at Chiropractic Rehabilitation Consulting, 18604 NW 64th Ave., Ridgefield, WA 98642 or by e-mail at
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