Rehabilitation


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Rehabilitation
Written by Dr. Mark R. Payne D.C.   
Friday, 25 September 2009 09:14

I’ve already addressed some basics of building the corrective care practice in both the May (Depression Era Marketing), and July (Building the Family Practice) issues. Now, let’s touch on a super powerful internal marketing tool for building both patient retention and new patient referrals. Oh, and best of all, this one won’t cost a dime.

One of the most critical opportunities you’ll ever have to position yourself and your practice occurs during the report of findings. You’ll never have this opportunity again, yet many doctors walk in with absolutely no concise plan as to what they are going to say. I’ve visited lots of clinics and it’s not pretty. Inevitably, the report degenerates into some sort of vague rambling conversation with too much small talk, too many big words, and the doctor doing too much talking and not enough listening. No wonder patients don’t follow through with care or refer their friends.

Red-Line-Black-Line-Visual

In July’s article, I suggested focusing patient education/management around three basic areas: 1) plain talk without medical jargon, 2) establishing clear cut goals, and 3) empowering patients with choice and responsibility. Some of the most successful corrective care offices in the country are doing all that in a simple but powerful report of findings. An effective Report of Findings (ROF) emphasizes three key communication points supported with effective visualization: a) describe (show) the problem, b) explain treatment options, and c) establish THEIR goals for treatment. Here’s the generic version of my report. I’ll assume you have determined the patient is an appropriate candidate for postural rehab with reasonable chance for a successful outcome.

3-Areas

 

Rof.jpg

 

Step One: Describe the Problem

"Mrs. Jones- This picture is looking at your neck from the side, so you are facing to the left. Okay?" (Make sure they really understand.) "I drew a black line down the back of your neck bones so you could see more clearly how your neck is shaped. This black line is how you generally hold your neck when you’re upright. In other words, this X-ray is really just a picture of your posture. Understand?" (Get agreement again here.) "The red line represents approximately how you should be holding your neck. You can see here that your neck is too straight when it should have a lot more curve in it?" Is that clear?" (Wait for acknowledgment.) "I think this straightening of your neck is the underlying cause of your problems."

 

Step Two: Explain Treatment Options

"Now that we know what is wrong, there are basically two ways we can treat this. The first thing we need to do is get you feeling better. Everyone’s a little different, but that generally takes two to four weeks. I’ll probably need to treat you two or three times weekly until you feel better. I call these first few weeks of treatment "Relief Care" because that’s what it’s about...just trying to help you feel better."

"Once you feel better, there are two ways we can handle things. You can either: a) discontinue care and just check back whenever your pain returns, or b) you can follow through to help me actually rehab your spine back into better shape. I call this "Corrective Care." If you choose corrective care, most of the rehab can actually be done by you, at home. However, you should know that it generally involves a couple of extra weeks of care in the office while we teach you how to do the necessary home care plus occasional follow ups so we can monitor your progress and make any needed changes to your program. Does that make sense? Any questions?" (Handle any questions.)

 

Step Three: Establish Treatment Goals

"Mrs. Jones, I work for you. I’m happy to take care of you whether you choose relief only or relief plus correction. In other words, if you want me to just patch things up for now, I can do that. Or, once you are feeling better, if you want follow through to help me get this problem fixed, we can do that as well. You just need to tell me which way makes the most sense to you so I know exactly what to do for you. Then we can get started today with your care."

Now, here’s the key. Once you’ve explained the problems and options for treatment, just step back and allow the patients to establish their own goals for treatment according to what feels best for them. Nothing turns patients off faster than trying to steer them toward corrective care. Patients will immediately (and generally correctly) interpret such attempts as self serving on the part of the doctor. On the other hand, granting patients the respect and autonomy to make their own health care choices goes a long way toward gaining their respect and trust. Many times, even the most adamant relief care patients are more open to corrective care concepts, once they feel better and trust you.

The whole report only takes about five minutes and the exact verbiage probably isn’t as important as just doing it the same way every time. Find a way that works for you and put it to memory. In today’s economy, effective patient communication and education are too important to leave to chance.


Dr.-Mark-R-PayneDr. Mark Payne is the president of Matlin Mfg., a manufacturer and distributor of postural rehab products since 1988. To request more information on postural chiropractic methods, call 1-334-448-1210 or link to www.MatlinMfg.com

 
Extension Traction: Good for Discs?
Rehabilitation
Written by Dr. Mark R. Payne D.C.   
Friday, 21 August 2009 14:20

Chiropractors have long used spinal traction methods to relieve abnormal pressure and bulging of the IVD. The more popular methods have employed long axis traction and/or flexion distraction to relieve IVD (intervertebral disc) pressure. Consequently, many doctors are reluctant to employ extension traction methods which seem so radically different. I'm frequently asked if extension traction is good for injured discs and the answer is unequivocally, yes and no. The reason for my ambiguity is hidden in a text you probably studied in college.

 

In 1978, White and Panjabi described the finer points of spinal motion in their landmark text, Clinical Biomechanics of the Spine. Just in case your memory is a bit fuzzy (like mine), here's what's pertinent to our discussion. The axis of vertebral motion during extension varies widely from one area of the spine to another. Consequently, the effect of extension traction on the disc may vary widely from area to area as well. For instance, the axis of motion in the cervical spine is in the anterior portion of the disc whereas, in the lumbars, it's located posterior to the disc in the anterior portion of the spinal canal. Here's why this is relevant.   

 

Under normal conditions, when the spine extends about the red axis seen here, the entire disc space opens up. The result, of course, is that mechanical loading onto the disc is reduced while the facet joints bear more weight and begin to slide over one another. In other words, the amount of pressure onto the disc is dramatically reduced during extension. Seen in this light, it's easy to visualize how spinal extension can be an effective tool for relieving pressure on the disc and promoting a reduction of disc bulging toward the posterior. This unloading of the disc in extension is no doubt responsible for much of the success associated with the famous McKenzie methods of lumbar extension exercise.

 

Conversely, the axis of motion during flexion (Yellow dot in Fig.1) is well forward in the disc, producing increased loading of the anterior disc space and unloading of the posterior portion of the disc. This large difference in the two axes of motion may explain why popular flexion-traction techniques, such as those developed by chiropractic pioneer James Cox, have also been so successful in helping to reduce the symptoms associated with bulging or herniated lumbar discs. Once you start to understand the underlying mechanics, it seems that both flexion and extension movements may have real utility as we attempt to reduce lumbar disc herniation. Unfortunately, many chiropractors still think of lumbar traction only in terms of simple long axis stretching or "decompression."  

 

Okay...so it's simple then. Both, flexion and extension are just dandy for the lumbar discs...right? Well...yes and no. In a perfect world, we could simply measure the spine, determine if it is hyper or hypolordotic and then prescribe flexion or extension traction or exercise as indicated. Unfortunately, things are rarely that simple. As it turns out, the actual axis of motion for any individual may vary wildly if the disc is degenerated or injured. As a result, regardless of the patient's posture, it may be difficult to predetermine whether flexion or extension will be most beneficial in reducing disc symptoms. So, in keeping with the best traditions of science, I generally resort to trial and error. For example, if the L-spine is hypolordotic, I will generally try extension traction/exercise first. If extension is well tolerated, great! But if not, then I'll switch to flexion movements. My goal is always to stabilize the patient symptomatically prior to concerning myself too much about long term spinal correction. On the other hand, a hyperlordotic spine may encourage me to try flexion movements initially; but, if that doesn't work, you can be assured I'll switch to extension as I try to relieve the disc symptoms.

 

Okay...so what about the cervical spine, you say? Does it follow then that extension traction is necessarily a good thing for injured cervical discs as well? Unfortunately, the answer is probably, no. Fig. 3 shows the axes of motion during extension (red) and flexion (yellow) for the cervical vertebrae. As you can see, extension of the vertebrae around either axis will probably result in increased loading on the posterior disc space. While this is a motion well tolerated by healthy discs, it's not a great thing to be doing to a bulging or herniated disc. With this in mind, I have always taught that cervical disc symptoms should be considered a contraindication to extension traction methods.

 

Conclusion

The use of extension methods for disc decompression is foreign to many doctors. Hopefully, this article has stimulated your thoughts as to how extension movements may have a useful role as well in the treatment of lumbar disc disorders. Regardless of what method you choose, it bears remembering that any procedure which provokes or increases radicular pain should be discontinued or modified immediately. In other words, if it hurts when you do that, don't do that. 

Dr.-Mark-PayneDr. Mark Payne is the president of Matlin Mfg., a manufacturer and distributor of postural rehab products since 1988. For a Free, unabridged copy of this article or other information on postural chiropractic, please contact Matlin Mfg. Inc. at 1-334 448 1210.

 

 
Rehabilitation for Patients with Herniated Discs
Rehabilitation
Written by Dr. Benjamin Griffes, M.A., D.C.   
Friday, 21 August 2009 14:05

Rehabilitation of the patient with a herniated disc consists of improving their strength and flexibility while, at the same time, addressing their posture and habits. You must reorient yourself to think about low back problems in a functional way rather than a pathoanatomical way.1 The focus should be on restoring correct posture and normal productivity, achieved by teaching your patients the proper way to engage in their normal activities, while acknowledging the origins of herniations. McGill, in Low Back Disorders, makes four general conclusions from his research that most herniations come from extreme deviated posture, repeated loading of the spine over thousands of times, and the sitting posture in sedentary occupations.2

Patients-Fig-1 

In order to prevent further herniation and low back dysfunction, the patient must relearn how to sit and stand properly, strengthen weak muscles and lengthen restrictive muscles and fascia. Specifically with disc herniations, you do not want to increase the compression forces on the discs with unnecessary loading, so it’s preferable not to prescribe sit-ups or exercises which put the spine in extreme flexion, or with extreme extension, like "reverse sit-ups" and the "Superman." Instead, you want to teach your patients to do the "Bird Dog" (Fig. 1) and Side Bridges (Fig. 2). Both exercises are two of the safest and most effective core stabilization exercises anyone can do.

 

Patients-Fig-2
 

 

Functionally, it is strongly recommended not to do any flexing of the spine immediately upon rising in the morning or after long periods of driving. A patient of mine complained that he was getting back pain every morning after he got up, lasting about 45 minutes. We figured out that he bent over the sink and brushed his teeth every morning, then took a shower. I had him change his habit and shower first, then brush the teeth. Within the week, his low back pain disappeared. One reason you feel stiffer in the morning is because, while lying horizontal for 6 to 8 hours, the extracellular fluid in the body pools in the joints, and movement redistributes it.

Patients-Fig-3a.

There is also the variable of "internal friction" within the joints caused by prolonged static posture, seen in truck drivers and athletes who sit on the bench for long periods.3 Because a high percentage of chronic low back pain is due to a sedentary lifestyle, it is imperative that you teach your patients to sit properly and to take frequent breaks. I have always taught my patients to establish a "neutral posture" while sitting (and standing); but there is also the philosophy that there is no ideal sitting posture and it is better to employ a "variable" posture which reduces the risk of tissue overload.4 It is repetitive immobility, replicated on a daily basis that leads to chronic postural overload and adaptive shortening of the muscles and fascia. Kendall, in Posture and Pain, notes that "normal joint range for adults should provide an effective balance between motion and stability. A joint which is either too limited in range or not sufficiently limited is vulnerable to strain."5  

Patients-Fig-3b 

This promotes the need for both a trunk stabilization program and a daily stretching program. Stretching should become a habit, like brushing your teeth. Without any stretching, you and your patients continue to promote a pattern of restricted movement and muscle fatigue. Guyton points out in Medical Physiology that muscle fatigue comes from prolonged and strong contraction of a muscle. This causes the interruption of blood flow, which leads to muscle fatigue due to a loss of the nutrient supply and lack of oxygen.6

I recommend four basic back stretches that should be done daily. They are the Cat/Camel (Fig.3), lateral side bends, and back rotation. These stretches minimize the compressive load on the spine and move the spine through all ranges of motion. The fourth stretch is The Lunge, which stretches the psoas muscle, a major hip flexor and postural muscle. It has a tendency to tighten and shorten with prolonged sitting, leading to weakness, and the Lunge stretch helps to keep it lengthened and balanced. Consider, then, that a key element of your care is the education of your patients. This means that you must address their posture, habits, strength and flexibility, and to make sure they do not engage in any activity which will increase the compressive forces on the spine, be it active or passive.

Dr.-Benjamin-GriffesBenjamin Griffes, M.A., D.C., shares his time between Tarzana and Thousand Oaks, CA, offices when he’s not lecturing or writing on health, fitness, stretching and proper posture. A 1990 graduate of Cleveland Chiropractic College, he also has a Master's Degree in Physical Education/Sportsmedicine from California State University Northridge. He is the author and producer of Stretching for Life products ( www.Stretching4Life.com ) and recently joined Your Best Form ( www.YourBestForm.com ) as Chief Health Advisor.

 
C.R.A.C. Traction: Kicking Corrective Care into High Gear
Rehabilitation
Written by Dr. Mark R. Payne, D.C.   
Wednesday, 24 September 2008 17:10

Feeling frustrated with the long time frames required for corrective care programs?

Maybe you should try a little C.R.A.C. No…I’m not recommending you seek solace in some vicious street drug. Instead, you might want to try combining a well accepted muscle stretching technique with extension traction to speed up the corrective process. Here’s how it works.

The acronym C.R.A.C. (Contract-Relax-Antagonist Contract) normally refers to an effective method of assisted stretching. The method has a simple three-step sequence in which the patient is instructed to;

  1.  Contract the shortened muscle (the agonist) for 8-10 seconds.
  2.  Relax
  3.  Contract the antagonist of the shortened muscle, followed by the therapist’s applying stretch force to the agonist.

When used in conjunction with extension traction, the stretching efforts of the therapist are replaced by the applied force of the extension traction unit.

 

Here’s how I have used the C.R.A.C. method in combination with the Dakota Traction. The patient is first positioned properly on the fulcrum with the head free-hanging and the headband in place over the forehead. Tip: I prefer patients to have already been using the Dakota Traction for a week or two, just to make sure they can tolerate the extension traction process without undue discomfort.

During the first few minutes of each traction session, patients are instructed to perform the following movements to initiate the C.R.A.C. sequence.

I typically instruct patients to repeat the entire sequence six to eight times and then simply relax for their full traction session of 20-30 minutes (or according to their tolerance).

 

 

The method works by virtue of Sherrington’s Law of reciprocal inhibition, in which the taut/contracted flexors are "tricked" into relaxing by contracting the extensors. C.R.A.C. stretching has been around for a long time and appears to be a very effective way to lengthen taut or shortened musculature. Years ago, I began experimenting with combining the C.R.A.C. method of inducing muscular relaxation with various types of cervical extension traction. My idea was that, if the patient’s loss of cervical lordosis was primarily due to contracted musculature on the anterior neck, it might be possible to speed up the process of correcting the lordosis by incorporating more efficient ways of addressing the taut musculature. My results were very encouraging. I found that some (not all) patients were achieving dramatic corrections, with just five-minute applications that would have normally taken months to accomplish.

 

 

Those poor souls who have followed my columns so far may recall that I am always emphasizing the importance of applying sustained corrective forces for 20-30 minutes daily over a period of three or four months in order to correct the lordosis. Yet here were some patients getting phenomenal corrections in a fraction of the time. As it turns out, the sustained periods of loading, so vital to stretch non contractile tissues, aren’t necessarily the quickest way to stretch contracted musculature. C.R.A.C. traction can offer a practical way to speed up the process when you suspect muscle to be the primary tissue perpetuating your patient’s poor posture. My results were very encouraging. Although there is no published research on this particular combination, both methods are safe and effective. Using them in tandem is safe, logical and, best of all, won’t cost you a penny extra to try.

My personal experience with the method is that about 25-30 percent of patients will show VERY rapid corrections with C.R.A.C. traction. Those patients who are responding well will often exhibit dramatic changes in their forward head posture within just a week or two as opposed to the normal 10-12 weeks we would anticipate in most cases. In my experience, these changes in forward head posture always correlated well with improvement of the lordosis upon re-X-ray. It seems intuitive that these rapid responders must have a fairly significant muscular component as a perpetuating factor of their abnormal head postures.

And what about those who don’t respond? They just continue to progress in the slow and steady manner we have come to expect when applying corrective traction. Most likely, these non responders are those patients with a greater degree of non contractile tissue adaptation and will respond as usual to the long term application of sustained traction force. No doubt, many patients actually have postural adaptation of both muscular and non contractile tissues to varying degrees. With this in mind, and because there is really no downside to the method, I often incorporate the C.R.A.C. sequence with my extension traction methods to help remove any muscular resistance as quickly as possible. If you’ve been frustrated with long corrective care programs, I suggest you just try a little C.R.A.C. You’ll be feeling better in a week or two.

 

Dr. Mark Payne is the president of Matlin Mfg., a manufacturer and distributor of postural rehab products since 1988. To request more information on postural chiropractic methods, call 1-334-448-1210 or link to www.MatlinMfg.com.

 
Preventing Injury during Summer Activities
Rehabilitation
Written by Dr. Kirk A. Lee, D.C., C.C.S.P.   
Wednesday, 24 September 2008 17:06

With the approach of summer, more of our patients are turning their attention to getting outdoors and exercising. Activities can range from walking to the mailbox to running local 5K races. Regardless of our patients’ activity levels, an important factor in keeping them out of pain is addressing the shoes they are wearing.

Different Activities, Different Needs

Commonly, someone who begins a walking or running program may not take into consideration the equipment necessary to embark on their journey. They wear the same shoes that they wear to mow the lawn or take the garbage out. For someone who is only going to walk or jog a couple blocks, this may be alright; but, for anyone who is going to consider ramping up the mileage, the correct shoe types are essential.

The Three Types of Feet

Normally, we believe that people can have one of two types of feet; those that are flat and those that are not. Technically, this is incorrect; we actually have three types of feet. The first type is a supinated foot, which is usually associated with the higher arch and weight distribution that is a bit more lateral. This foot also demonstrates a footprint of a "C" shape. The second type is referred to as a neutral foot, which has a slight or semi-curve to it, and still maintains an arch upon sight inspection. This foot will have weight distribution that usually transitions through the midline of the foot. The third foot type is the flat foot or hyperpronated foot. This imprint is usually wider and straighter in appearance.

Keeping these points in mind, running shoes are designed the same way. Once you know your foot type, you should make sure your running shoes match accordingly. The supinated shoe is usually narrower and has a curved last. The neutral shoe will have a semi-curve to its last, while the hyper-pronated shoe is usually straight. In literature, you will see this shoe referred to as the "motion-control" shoe. This terminology comes from the shoes being designed to support the foot and prevent excessive hyperpronation. 

What Type Are You?

How do we determine which foot types we are? You could always wet your feet and step onto a piece of dark construction paper or a brown grocery bag. The best clinical way is to use a digital scanner. By scanning your patients’ feet, this will not only show you the foot types they possess, but may also show weight bearing imbalances that affect the normal movement pattern of the foot. These imbalances are a result of a breakdown of the anterior, lateral, or medial arches. One or all three of the arches can become involved. Visually, a patient may appear to have some form of an arch; but, on scanning, it actually shows a breakdown. This can be more visual after the foot has been weight bearing and has not been supported properly. This results in what is referred to as plastic deformation, where the aponeurosa of the plantar fascia can no longer maintain its normal length due to being overstretched from repetitive microtrauma.

Now, what?

Once we have determined our foot type, we need to determine whether or not there is a need for custom-made flexible orthotics based on the scanner results. Keep in mind the importance of making sure the orthotics fit properly into the patient’s running shoes. We want to make sure the patient first takes out the store insole. This allows orthotics to fit more securely within the shoe. It is also very important, in future purchases of shoes, that our patients make sure they take their orthotics with them to place them into any new shoes they may purchase.

Another important component of the shoe structure is the shock absorbency and rigidity of the shoe. A shoe designed for a supinator is usually designed with more shock absorbency. This is due to the supinated foot’s being a very rigid foot which will absorb a lot of stress. The neutral foot and the hyperpronated foot disburse a lot of the stress they receive due to their being more flexible.

Often I am asked, will the motion control shoe be enough to support the foot when it hyperpronates? The answer is no, the reason being that, even though the shoe is designed to control the hyperpronation or medial rolling of the midfoot, it still is not designed to support all the arches as a custom-made flexible orthotic would. A great custom-made flexible orthotic and a great shoe are a perfect combination to help our runners and walkers get the best benefits to allow them to participate in a pain-free, active lifestyle.

 

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 .

 
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