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Rehabilitation


Dirty Harry, Scoliosis And You
Rehabilitation
Written by Mark R. Payne D.C.   
Thursday, 23 September 2010 14:21

Dirty Harry, Scoliosis And You

by Dr. Mark R. Payne D.C.

 

A man has got to know his limitations." Clint Eastwood growls the famous line right after administering a lethal case of justice to some villain foolish enough to take on Inspector "Dirty" Harry Callahan. Just goes to show there are some things in life you shouldn’t ever try. Sometimes we have to learn that the hard way in practice and a good example is managing scoliotic patients. I speak with lots of doctors from a wide range of educational backgrounds and practice styles. Some don’t think scoliosis can be managed at all in the chiropractic office. Others are so overly optimistic of their abilities that they recommend extensive corrective care programs for every case only to find out down the road that there’s been little or no change. As is often the case, the truth appears to be somewhere in the middle. Let’s take a brief look at two cases which illustrate some of the factors which might affect your prognosis for a successful outcome.

 

Case # 1: An 8-year-old boy presented with mild neck and shoulder soreness following a motor vehicle accident. Both parents were under care for their injuries and I did a cursory examination of the child upon discovering he was involved in the accident as well. The child’s neck injuries were quite mild, but Adam’s test was positive and his posture was suggestive of scoliosis. I suggested we take films to see what was happening.

X-ray revealed a 12 degree Cobb angle with the apex at L-3. (See Fig.1) I noted what appeared to be a possible leg length deficiency which appeared to be contributing to the curvature and opted to take an A-P femur head view to more accurately measure the amount of leg length inequality. The right leg ultimately measured 5 mm shorter than the left and a 5 mm heel lift was provided. Over the next few weeks, the child was adjusted a few times and rehabbed with simple posture reversal exercises to address the worst aspects of his postural imbalance. On each visit, the parents were tutored on how to properly observe and monitor the child’s exercise at home.

Approximately 6 weeks later, a post care film was taken to see how things were progressing. The results were gratifying with the Cobb angle now reduced to zero degrees. (See Fig. 2) Parents were instructed to make sure the child continued to use the heel lift and exercise three times weekly. Twice annual follow ups were recommended until the child reached skeletal maturity.

 

Factors which contributed to such a successful outcome were:

• A fairly mild curvature ( Cobb angle less than 20 degrees)

• An easily remedied cause (leg length inequality)

• No vertebral wedging/deformity

• Parents who were disciplined about following home care recommendations.

• Early treatment…well before skeletal maturity.

 

Case # 2: 57-year-old female presents with chronic LBP and a prior diagnosis of scoliosis. X Rays revealed a 48° Cobb angle with apex at L-1. (See Fig. 3) Closer inspection revealed severe wedging of vertebrae at multiple levels plus pronounced disc degeneration. Patient was adjusted in our office on a symptomatic basis for 2-3 weeks and given home exercises to help strengthen the area and minimize asymmetrical loading of the spine. Symptomatic management was successful and she now returns as needed for relief of any exacerbations. Corrective care was not recommended, as it seemed highly unlikely to produce significant structural correction.

Factors here which would likely complicate a successful corrective outcome are:

• Large Cobb angle

• Patient well past the age of skeletal maturity

• Significant vertebral remodeling (wedging)

• Advanced disc degeneration

 

Incredibly, this patient had visited another chiropractor earlier who had recommended a year long program of adjustments to correct her problem. Fortunately, the patient had declined to accept the treatment plan which would have been highly unlikely to correct this advanced curvature.

Please don’t misconstrue this to mean I am opposed to corrective care programs. To the contrary; what I am opposed to is any doctor making promises he/she can’t reasonably hope to keep. If you recommend a corrective care program, you must have reasonable professional expectation of a successful outcome. The moral here is to be realistic as to what you can actually deliver before recommending programs of extensive corrective care. Scoliosis cases present with a unique set of variables which can either work in your favor or complicate things greatly. Like it or not, once the growth plates have closed, any vertebral wedging or deformity constitutes permanent change in the spinal architecture. All the adjustments in the world won’t change structural asymmetry which has literally become "set in stone." Yes, you can work wonders with some cases but, ultimately, Dirty Harry was right. We’ve all got to know our limitations.

 
A Runner with the Wrong Orthotics
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Rehabilitation
Written by Dr. Kirk A. Lee, D.C.   
Thursday, 23 September 2010 12:00

A Runner with the Wrong Orthotics

by Dr. Kirk A. Lee, D.C.

 

Today the doctor of chiropractic has many choices when choosing the type of Spinal Pelvic Stabilizers, or custom-made orthotics, to use in his office. We must first and foremost use orthotics from a company that also supports our profession. Secondly, these orthotics must be custom made, semi-flexible and have high doctor-patient satisfaction.

 
Science, Posture and Personal Injury
Rehabilitation
Written by Mark R. Payne D.C.   
Wednesday, 22 September 2010 16:38

Science, Posture and Personal Injury

by Dr. Mark R. Payne D.C.

 

Personal injury patients inevitably present with a unique set of challenges. From a clinical standpoint they are often in more acute, severe pain. Pre existing conditions are extremely commonm and need to be taken into account. Finally, there will almost always be real and legitimate concerns related to any number of "third" parties involved in the chiropractic-legal process. Obviously, the patients have needs and priorities related to their physical health and well being, but building the successful PI practice is often dependent upon the doctor’s ability to fairly meet the legitimate concerns of all parties involved.

I wanted to take this opportunity to discuss some of the scientific literature relevant to postural rehabilitation of the personal injury case. If you intend to step into the chiro-legal arena, it’s vital that you understand what the scientific literature does and doesn’t support. Proper documentation of your rationale for treatment is always of primary concern. In personal injury cases, it is doubly important. Here’s a brief overview of some of the literature available to back you up, should you decide to include postural rehab as a part of your treatment program.

First, the good news:

• There are now several studies indicating that significant disruption of the normal spinal curves is associated with spinal pain and/or headache of cervical origin (Spine ’94, JSD ’98, JMPT ’92, HA ’93).

• Loss of the cervical lordosis has been shown to be a common result of cervical trauma (Spine ’97, SAMJ ’78, JBJS ’63).

• It’s possible to objectively analyze the patient’s postural status using simple, geometric radiographic analysis (See Figs. 1 & 2). These methods have shown a very high degree of both inter and intra examiner reliability in several studies (JMPT ’93, ’92,’95,’98,’03).

• There is also good evidence in the literature to support the need for healthy spinal curves to prevent future onset of problems (JBS ’74, JMPT ’02).

• Finally, we now have proven effective methods of restoring both the cervical and lumbar lordosis. Including postural exercise and traction procedures puts you on firm ground should someone question your methods (APM/R ’04,’02). My point is that radiographic analysis of the patient’s posture is simple, straightforward, and reliable. Such analysis of spinal imbalance is well documented and easily understood by patients and attorneys alike. Simple biomechanical analysis should be a basic part of your work up on every PI patient.

Now for the bad news:

• Many doctors in the field continue using poorly documented methods of X-ray analysis, IF they even bother to measure the X-rays at all. The profession has become so oriented toward "functional" based care that many doctors give little more than passing notice to postural imbalance and fail to document what is often strong prima facie evidence of injury.

• Many doctors continue to use advanced spinal degeneration as justification for questionably long periods of "corrective" care programs often consisting of little more than adjustments or passive therapy. With the exception of one small study which suggests considerable improvement with Activator® Methods (JMPT ’03), there is little evidence that spinal adjustments do very much to improve spinal structure. At this point, postural exercise and traction procedures appear to be the most effective tools for improving patient posture.

• Many doctors are using effective traction and exercise methods to address postural imbalance but making excessive recommendations for care based on erroneous advice from their practice managers or technique gurus. I want to be very clear about my position on this. Just because some particular method appears effective over a given trial period, there is no indication that further treatment will continue to produce improvement at the same rate. In fact, almost any treatment program will reach a point of diminishing return. One popular seminar continues to teach that, if twelve weeks of care is good, then thirty-six weeks must be three times as good. There’s certainly no evidence to support such long programs of care, most of which conveniently include an expensive series of adjustments of little or no proven value.

Such long programs of care are naïve at best and grossly irresponsible at worst. I mention it here because many well meaning doctors are hanging their reputations on such questionable logic. Prolonging care for PI patients beyond that necessary to return them to their pre injury status is not only unfair to third party payors, it’s actually counterproductive in the long run to building a successful PI practice. Building your reputation in the PI arena revolves largely around three basic things: using solid, well documented methods of analysis and treatment, returning the patient to pre injury status as quickly as possible, and keeping professional fees to a level every one involved can live with. Attention to those simple details will likely improve your standing in the community as an ethical doctor who deals fairly with all parties involved.


Dr. Mark Payne is the president of Matlin Mfg., a manufacturer and distributor of postural rehab products since 1988. A full unabridged version of this article with full literature citations is available at www.Matlinmfg.com. To learn more about reliable methods of X-ray analysis, call 1-334-448-1210 for a Free Report, The Best Corrections of Your Career: Measurement of the Lateral Radiographs.*

 

*Special thanks to Dr. Roger Coleman of Coleman Consulting, Othello, WA, for helping with scientific references.

 
Are Knee Injuries Really Knee Injuries?
Rehabilitation
Written by Dr. Kirk A. Lee, D.C.   
Wednesday, 22 September 2010 16:32

Are Knee Injuries Really Knee Injuries?

by Dr. Kirk A. Lee, D.C., C.C.S.P.

 

We see patients in our offices daily with arthritic knees—sometimes bilateral, other times affecting only one leg. Some patients can point to an old football injury or car accident as the probable cause. But, frequently, they cannot tell us why their knee hurts, only that they have a new friend called "Arthur" that causes their knee to swell and hurt.

Each day we are faced with patients whose musculoskeletal complaints may not appear spinal related. Many times no mechanism of injury is retained from our consultation or examination. Orthopedic tests are quite often absent of a positive finding other than maybe a little discomfort. So what is the cause? It is easy to figure out from a diagnostic view of the patient who sustained a direct injury to the knee from a fall, or car accident, or of the athlete who received a traumatic blow to the knee.

In runners, the chief complaint is commonly lower leg pain. This could be determined as tibial stress syndrome (shin splints), or perhaps strains of the soleus and gastrocnemius muscles. The second most common complaint is of the knee—generalized soreness anywhere around the knee to advancing conditions like chondromalacia. The foot is third, with conditions like plantar fascia, bunions, blisters, ankle sprains and strains. Fourth is the hip, followed by the upper leg and, finally, low back conditions. As we look at this list of most common areas of chief complaint, do you feel the order is correct?

When we analyze the gait cycle, we have a good understanding from previous articles and our own general knowledge that the foot is made up of three arches (medial, anterior and lateral) and three distinct segments (rearfoot, midfoot, forefoot). Together, when patients ambulate, they transition from some form of heel strike through midstance followed by toe-off. We know all three arches work together for structural support of the foot. If one arch is affected by misalignment, plastic deformation or wrong or ill-fitting shoes, it will affect the normal movement pattern of the foot. We know that, when the foot goes into its pronation pattern (foot rolling inward), the tibia medially rotates (turns in). This medial rotation can be excessive as in hyper-pronation or restricted as in hyper-supination, or it can be an abnormal movement pattern through the foot, as in a patient who just picks the foot up and sets it down and does not have heel-toe transition. The stresses placed at the knee are excessive.

We also know that subluxation complexes of the spine and pelvis will affect posture and alignment (which in turn affects Q angles), while anteriority and posteriority of the hips affect the anglulation of the femur. When we think about the knee joint, itself, it is a hinge joint. It primarily functions in flexion and extension. It has the simplest joint movement and one of the less stressful joint movement patterns.

When you think about a door hinge and how many times it swings back and forth, what usually causes a door hinge to start to fail? It’s not that it wears out. It’s usually because the door, itself, starts to misalign or the house shifts and the door no longer closes properly, causing angulated stresses on the door hinges. This is no different than what our bodies do. There is no doubt that, "neurologically it is from above-down-inside-out" but, "biomechanically, it is from below-up." Or to put it another way, "When the foot hits the ground, everything changes." These phrases just point out that, in our treatment of patients’ knee conditions, we must always look to what the real cause of the knee condition is and not just look at the knee itself for the treatment of the condition. We must evaluate abnormal patterns in gait and posture, and we must help our patients with treatment plans that can include rehabilitation, specific chiropractic adjustments (CMT), or supportive measures like custom-made Spinal Pelvic Stabilizers. Our patients can be assured they are getting the best we have to offer as doctors of chiropractic.

 


A 1980 graduate of Palmer College of Chiropractic, Dr. Kirk Lee is a member of the Palmer College of Chiropractic Post Graduate Faculty and Parker College of Chiropractic Post Graduate Faculty. He has lectured nationwide on sports injuries and the adolescent athlete, and currently practices in Albion, Michigan. Dr. Lee can be reached at This e-mail address is being protected from spambots. You need JavaScript enabled to view it .

 
Healthy Doctors: Practicing and Preaching
Rehabilitation
Written by Mark R. Payne D.C.   
Wednesday, 22 September 2010 14:57

Healthy Doctors: Practicing and Preaching

by Dr. Mark R. Payne D.C.

 

Can you imagine an overweight doctor counseling patients on nutrition? How about a physician who smokes urging patients to quit? Or a well-intentioned couch potato handing out exercise advice? We’ve all encountered doctors who dispense advice freely but rarely seem to follow it themselves. The inevitable result, of course, is that no one ever takes such advice, or the doctors who dole it out, very seriously.

I know plenty of doctors who recommend extensive programs of corrective care to their patients, but are totally unwilling to put in the effort or discipline needed to really correct their own spinal problems. But there’s a flip side to this coin as well. Over the last few years, I’ve encountered a number of doctors who recommend different standard of care for their patients than for themselves. Here’s an example. A middle aged chiropractor came to our clinic to determine the cause of his chronic neck pain and headaches. The loss of cervical lordosis and associated spinal degeneration was readily apparent. The doctor, a proponent of lengthy programs of adjustment only care, had been adjusted weekly for decades. He was quite aware of the advancing degeneration and lack of correction in his own neck, yet had never altered his own treatment program. Instead, he just continued to drop by a colleague’s office for a quick adjustment whenever his symptoms worsened.

I developed a simple self care program for the doctor consisting of Compression Counterstressing traction and basic posture exercises. I explained that the advanced disc degeneration would make full correction difficult at this point, but that continued traction and exercise should improve the posture, slow further degeneration, and keep symptoms at bay. In just a few weeks, his symptoms were dramatically improved. I spoke with my colleague occasionally and everything seemed fine—at least for a while.

Six months later, he returned to the office. The headaches and neck pain had returned—slowly at first, but gradually increasing until now they were just as bad as ever. You guessed it. Almost as soon as the symptoms disappeared, our friend discontinued traction and exercise and was back into his old routine of getting adjusted whenever symptoms occurred. I have to confess that I was pretty flustered. We were making great progress and, yet, he had lapsed right back into the same old routine. Biting my tongue, I reinforced the importance of dealing with the postural aspects of the problem and politely pointed out that, if thirty years of adjustments hadn’t fixed it yet, it was unlikely more of the same would do much good.

The good doctor is once again feeling better and is working harder at his home rehab program. That would conclude our story except for one little sticking point. Absolutely nothing has changed about the way our friend approaches the treatment of his own patients! Here’s a doctor who has seen first hand that adjustments simply won’t correct some problems. He understands how contracted soft tissues perpetuate postural subluxation and the importance of rehab. He knows all this but hasn’t changed anything in his office.

Instead, it’s just business as usual. Just like always, patients get an exam, a report of findings focused on segmental dysfunction/misalignment, and a fairly lengthy program of "adjustments only" care to correct their problems. There’s no objective analysis. No way, other than symptomatic improvement, to measure progress and certainly no effort to actually rehabilitate and strengthen the spine. Whenever I call his hand, he always says he’s going to implement posture based rehab into his clinic "pretty soon." It would seem that old habits really do die hard.

In the end, much of what we do comes down to little more than habit and routine. Whether we are talking about our own health, how we treat patients or manage our practices, much is done simply out of habit. We do what we do, because it’s what we’ve always done. There’s a certain amount of intellectual inertia which tends to keep us all immobile. We fail to do the things we know are important for our own health. We don’t look objectively at our own treatment outcomes. We postpone learning new skills because we are comfortable in our old rut. We hope the practice will grow and prosper but we never change a thing.

The specific challenges are different for each of us, but the underlying theme here is constant. If you want better results, you’ve got to rise out of the rut. Lip service doesn’t cut it. Only actions count. Some of us need to get off the couch and head to the gym, if we expect our patients to exercise. Maybe we could drop a few pounds if we want to change the way our patients eat. That’s practicing what we preach. But, as we learn and grow, it’s also vital that we share the benefits of our new discoveries with our patients as well. That’s preaching what you practice.

 

mark-paynethDr. Mark Payne is the president of Matlin Mfg., a manufacturer and distributor of postural rehab products since 1988. To request more information on managing the scoliotic patient with postural chi ropractic methods, call 1-334-448-1210 or link to www.MatlinMfg.com.

 
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