Rehabilitation


Simple, Effective, Home Traction for the Cervical Lordosis
Rehabilitation
Written by Dr. Mark R. Payne, D.C.   
Wednesday, 28 May 2008 10:18

In our March article, we discussed how the physical properties of tight, contracted, paraspinal tissues create resistance to the corrective forces of your adjustments. Last month, I showed you a great example of how one case of scoliosis was successfully managed using simple blocking techniques to introduce sustained stretching forces into the spine. In this article, I want to discuss one effective way to apply the same principles of sustained stretching to correct the cervical lordosis.

Most of your adult patients will present with spines held in sub-optimal postures for many years. The longer your patient has labored under the demands of abnormal posture, the more likely he or she is to have adaptation and contraction of the surrounding soft tissues. Once this occurs, the visco-plastic characteristics of the contracted tissues will sabotage your attempts to adjust the spine back toward normal structure. Shortened and contracted soft tissues simply won’t yield to the rapid on-off forces of traditional adjustments. They require time to stretch. To correct these patients, you need a different tool set.

In a previous article, I mentioned that corrective forces should generally be applied for twenty to thirty minutes daily for effective stretch to occur. Two thoughts should leap immediately to your mind here. First, you definitely don’t want to do this by hand and, secondly, it isn’t practical for patients to traction every single day in your office for thirty minutes. If you are really serious about having your patients perform extension traction on a daily basis, much of the work will need to be done at home. There are a number of devices on the market which attempt to restore the lordosis, many of which will work very well. In a shameless act of self promotion, I want to discuss a simple but very effective home traction device manufactured by my company. It’s called the Dakota Traction™ (See Fig.1). Please consider it as just one item for your bag of tricks. Here’s how it works.

One method shown effective in restoring the cervical lordosis is called "extension-compression" traction. So named because the head is extended backward and compressed downward (caudally), the method actually only produces compression loading on the posterior motor units. The anterior motor unit is actually unloaded to create tensile stretch in the anterior soft tissues (See Fig.2). Traction force is provided by a simple, padded elastic band which passes over the forehead. The amount of force can be easily adjusted as needed for patient comfort. In my experience, extension-compression methods are generally well tolerated by about 75 percent of patients. Those patients who find the method uncomfortable may require an alternative method to achieve correction.

Patients generally begin with only a few ounces of force for two or three minutes daily. Patients should gradually increase daily treatment times, as able, until they can comfortably handle twenty to thirty minutes daily. Only after the patient has reached the target time is the traction force increased slightly by tightening the elastic cord. Remember, our goal here is to simply apply gentle stretching force for sufficient time to allow viscous and plastic deformation to take place. I am aware some authorities promote the use of much higher amounts of force to vigorously stretch the neck into lordosis, but I caution all doctors to err on the side of caution here. After all, most of your patients with chronic loss of the cervical lordosis have had their problems for years. It makes no sense to try to hurry the process and, in fact, may be very counterproductive, possibly even dangerous, to do so.

A brief word of caution is appropriate here. Full extension of the head and neck may be contraindicated in certain individuals. Examples of conditions which might increase the risk of complications include, but are not limited to, history of STROKE or cerebrovascular accident, high blood pressure, vertebral/carotid artery disease, diabetes, atheroslerosis, disc protrusion/prolapse, Down’s syndrome, spinal stenosis, spinal fracture or instability, malignancy and/or infection of the cord or column, and advanced osteoporosis. Other symptoms which would contraindicate further use of extension traction methods, particularly if produced or lateralization of pain into the extremities, numbness, paresthesia, muscular weakness, loss of coordination or function, ataxia, visual disturbances, or any other neurological symptoms.

We have developed a suggested protocol to help screen for individuals who may be at higher risk for complications. Although no screening procedure can guarantee safety for any particular individual, it is important we do everything in our power to minimize risk to our patients. I strongly recommend all patients be thoroughly screened prior to treatment. Extension traction procedures have demonstrated a remarkable record of safety for over two decades now. Let’s keep it that way.

Next month I’ll discuss alternatives for patients who simply can’t handle extension-compression traction.

 

Dr. Mark R. Payne is the president of Matlin Mfg., a manufacturer and distributor of postural rehab products since 1988. To download a full and unabridged version of this article, link to www.MatlinMfg.com. In the meantime, interested doctors should call for a free copy of screening protocol we use in our office. Please call us at 1-334-448-1210 to request your free copy.

 
Postural Rehab: The Problem with Physics… Why We Fail.
Rehabilitation
Written by Dr. Mark R. Payne, D.C.   
Friday, 28 March 2008 15:13

Last issue, i documented the ineffectiveness of traditional adjustments to substantially change spinal structure. I would like to explain one key reason why adjustments, typically, produce very little structural change. Once you understand how the laws of physics sabotage your adjustments, you’ll be well on your way to making the best corrections of your career.

The problem with physics is that personal opinions don’t matter. It doesn’t matter what they taught us in school, what our practice manager said, or what we happen to believe. Want to know why your adjustments can’t change spinal structure consistently? The answer is painfully obvious when you consider the basic mechanical characteristics of the spine. Most of us had some exposure to basic physical principles in our pre-chiropractic education. Apparently, someone just forgot to tell us how to actually apply them.

The spine is a bony column within an ocean of soft tissue. Posture may be adversely impacted due to injury/deconditioning of the column, the surrounding tissues, or other structures along the kinetic chain. Once injured, the body may adapt and compensate in numerous ways. Surrounding muscles may weaken or become tight/overactive. Supporting ligaments, tendons, and fascia may be overstretched or chronically shortened. Discs degenerate under abnormal loading. Patients compensate for pain or weakness by developing new, often less efficient, ways to move. The nervous system learns new motor habits. The brain slowly adapts to a new perception of what is normal. As you already know, most of this happens so gradually that the patient often has little or no awareness of how off balance and weakened they have become.

Into this complicated collision of cause and effect, action and reaction, steps the bright eyed, bushy-tailed, and hopelessly optimistic young doctor. Armed with only an adjustment, you wade into battle against the effects of time. Undeterred, you find the most dysfunctional joint(s) and give it your best shot. The adjustment is delivered in a fraction of a second. The timing is perfect. The spine yields. The segment moves. The joint cavitates. It’s all so reassuring. It feels so real. But, it’s what you don’t feel that is more important. Because, by the time your hand leaves the spine, the elastic properties of the surrounding soft tissues rebound the spine right back to its original position.

You probably recall terms like "elasticity," "viscosity," and "plasticity" from your high school physics class. Elasticity is pretty self explanatory. It’s the tendency of matter, in this case the paraspinal tissues, to snap back once the force of your adjustment is removed. Think of a rubber band. It responds instantly to stretching forces but the change is only temporary. Viscosity describes the tendency of some thick liquid substances to slowly "flow" and remodel over time. Think of thick motor oil or, if you’re from the South, that last drop of molasses which always seems to find its way out of your biscuit onto your lap. Viscous materials move slowly over time with almost no force required. And, unlike elastic materials, the change is permanent. Finally, plasticity describes the nature of semi-solid substances to also permanently remodel, once the applied force exceeds a certain "yielding point." A good example of a highly plastic material is a block of modeling clay which yields to the force of the sculptor and then permanently retains the new shape.

As it turns out, all living tissues possess some combination of these three properties. Bone, for example, isn’t particularly elastic. Some ligaments have high elastin content and are, therefore (duh!), very "elastic". Tissues with higher water content tend to be more viscous, since water is a highly viscous material. Discs have less elastin and water and are, therefore, more plastic in nature. Taken as a whole, the large ligaments, muscles, and tendons surrounding the spine tend to be mostly viscous and elastic (viscoelastic). As we’ve seen, the more elastic components are resistant to permanent change. But, what if we could address the viscous and, to a lesser extent, plastic elements?

As it turns out, the only way to effectively stretch the surrounding tissues is to apply continuous force over time. Time, the very thing we need most, is the one thing our rapid adjustments can’t provide. To stretch the tissues, we’ll need to apply sustained corrective forces continuously for 20-30 minutes daily. That’s going to require a few basic tools, unless you want to manually hold that stretch on every patient. Life’s way too short for that!

 

Dr. Mark Payne is the president of Matlin Mfg., a manufacturer and distributor of postural rehab products since 1988. To download a full and unabridged version of this article, link to www.MatlinMfg.com. Interested doctors may contact our office for my FREE REPORT, Suggested Screening Procedures for Patient Safety.

If you are interested in learning more on the subject, call our office. I’ll be glad to share how you can improve your corrective care outcomes by 200-300 percent over adjusting alone without changing your technique or spending a fortune. Contact us at 1-334-448-1210 for your Free Report on patient safety.  

 
Foot Problems and Athletic Injuries
Rehabilitation
Written by Dr. Kirk A. Lee, D.C., C.C.S.P.   
Friday, 28 March 2008 15:10

Foot position and alignment are important factors that must be considered in our active population. As we encourage more of our patients to walk, jog, and exercise, we need to be prepared for the "side effects" of our recommendations if any foot problems exist.

For example, a 1998 study of runners found that those who pronated more while running had a much greater likelihood of developing a sport-related injury.1 While this isn’t surprising to most of us who have been treating athletes, it helps us to explain why custom-made, stabilizing orthotics can be so helpful in preventing athletic injuries.

This retrospective study looked back at the characteristics of athletes who reported recent foot and leg overuse problems and compared them with a control group. The researchers were interested in finding whether excessive pronation (using a method of measuring pronation while weightbearing) correlated with the possibility of developing various types of "overload" sports injuries.

 

Overuse/Overload Injuries

 

The clinical conditions evaluated in this study are known as "overuse," or "overload" injuries. These injuries develop when the body is unable to strengthen and rebuild in response to strenuous and repetitive athletic or work activities. In this study, sixty-six injured athletes who ran at least once a week—and who had no history of traumatic or metabolic factors to their overuse injury—were the study group. Another (control) group of 216 athletes were matched who had no symptoms of overuse injuries.

The amount of pronation during standing and while running at "regular speed" was determined by measuring the angles of their footprints. This inexpensive method of determining the amount of pronation during functional activities (plantar prints) had been previously investigated.2 One of the advantages of this method of measuring pronation is that it can be done without X-rays (no radiation exposure) and is not time consuming.

The investigators found that athletes with more pronation had a much greater likelihood of having sustained an overuse athletic injury. They also established that the amount of pronation seen in the standing, weightbearing footprint was the more predictive of developing an overuse injury. This study reminds us that it is very important to athletic performance and for injury prevention to check the alignment of patients’ feet in the standing position.

 

Knee Pain Study

 

The researchers in another study performed a visual assessment of the feet of seventy-seven athletes while they were standing.3 After classifying the feet as obviously pronated, obviously supinated, or neutral (based on agreed-upon mandatory criteria), the investigators inquired into the history of knee pain. Those athletes who answered "yes" to the question of knee pain were more than twice as likely to have an abnormal foot alignment. This study found that "athletes with excessively pronated or supinated foot types may be more susceptible to knee pain than athletes with neutral foot types." Since knee injuries can often ruin athletic aspirations, controlling pronation and absorbing the shock of supination could be crucial for many athletic patients.

 

Anticipating ACL Injuries

 

Some knee injuries seem so sudden and unpredictable that prevention would appear to be impossible. This may not actually be the case with many acute injuries to the anterior cruciate ligament (ACL). An important study looked at pronation in athletes and found a higher risk of injury to the ACL in those with hyperpronation.4 These researchers looked at the amount of arch collapse to determine the tendency to excessive pronation. They used the "navicular drop test," which is another easy method to assess a patient’s foot and can be done quickly in the office. "Postural Stability Indicator" (PSI) cards—which explain how to do the test and also record your findings—are available free, just by dialing 1-800-553-4860.

When the researchers compared fifty subjects who had sustained an arthroscopically diagnosed rupture of their ACL with fifty uninjured matched controls, they found that higher scores on the navicular drop test correlated with a history of ACL injury. Since the score on the navicular drop test increases with greater amounts of pronation, and especially with collapse of the medial arch, they were able to conclude that abnormal foot alignment predisposed an athlete to knee injury. In fact, they stated that "hyperpronation of the foot and ankle complex may increase the risk of injury to the ACL."

 

Conclusion

 

These retrospective studies clearly demonstrate the correlation between foot position and function, and various biomechanical problems and injuries. Talk to your patients about these factors, and explain why they should be evaluated for custom-made orthotics. I have found that most patients, and athletes in particular, appreciate it when their doctors demonstrate their expertise by discussing research findings which can help improve performance and prevent future problems and injuries.

Kirk A. Lee, DC, CCSP, is a 1980 graduate of Palmer College of Chiropractic and a member of the Palmer College of Chiropractic Post Graduate Faculty. He currently practices in Albion, Michigan. Dr. Lee has lectured nationwide on sports injuries and is a featured speaker for Foot Levelers’ 2008 Spring Seminar Series (call 1-800-553-4860 for information and registration).

 

References

1. Busseuil C, Freychat P, Guedj EB, Lacour JR. Rearfoot-forefoot orientation and traumatic risk for runners. Foot & Ankle Intl 1998; 19(1):32-37.

2. Freychat P, Belli A, Carret JP, Lacour JR. Relationship between rearfoot and forefoot orientation and ground reaction forces during running. Med Sci Sports Exerc 1996; 28(2):225-232.

3. Dahle LK et al. Visual assessment of foot type and relationship of foot type to lower extremity injury. J Orthop Sports Phys Ther 1991; 14:70-74.

4. Beckett ME et al. Incidence of hyperpronation in the ACL injured knee: a clinical perspective. J Athl Train 1992; 27:58-62.

 

 
What Works/ What Doesn’t
Rehabilitation
Written by Dr. Mark R. Payne, D.C.   
Friday, 29 February 2008 15:28

Everyday, countless patients consult chiropractors seeking a solution for their problems. While some doctors confine themselves to purely symptomatic care, others will recommend treatment well beyond simple relief of pain. Such programs are typically geared toward "correcting the cause" of trouble and often require a considerable commitment of time and money by the patient. Unfortunately, many such programs which rely heavily on a lengthy series of adjustments to "correct" the spine will be doomed to failure.

The ugly truth for chiropractic is that our traditional methods of adjusting the spine do very little to restore normal spinal alignment. Traditional chiropractic care has helped millions to live healthier, happier lives and you can definitely count me as a true "believer." Unfortunately, regardless of what we may believe, numerous studies in reputable, peer reviewed journals have failed to show significant spinal correction from adjustments alone. Correction of spinal misalignment/subluxation has been our profession’s raison d’être since day one. The fact that our main method of treatment, the chiropractic adjustment, does very little to actually correct the underlying structure of the spine is problematic for "corrective care" practitioners, unless they are willing to embrace more effective methods of rehabilitating spinal posture.

Let’s take a very common postural problem, loss of the normal cervical lordosis, as an example. Many chiropractors will X-Ray their patient, detect a chronic loss of cervical lordosis, and prescribe a lengthy regimen of adjustments to address the problem. All of which is fine, as long as both doctor and patient can reasonably expect a positive outcome. Most of the techniques studied to date appear to yield only about four or five degrees of correction on average. The cold, hard truth is that we have very little evidence to demonstrate that ANY method of adjusting is particularly effective at restoring the cervical lordosis. In spite of this, many well-meaning doctors continue to recommend long, protracted programs of adjustments which have little chance of success, simply because that is the way they were trained and they aren’t aware of other treatment options.

So, if adjustments alone aren’t getting the job done, are there other methods we might use to obtain better corrective care outcomes? A 1994 study in the Journal of Manipulative and Physiological Therapeutics shed new light on what might actually work in terms of correcting the cervical curves. The study, the first of its kind, looked at three treatment groups. Group one consisted of thirty-five patients treated using diversified manipulation and drop table adjusting in combination with cervical extension traction methods. Group two received identical adjustment without extension traction and, finally, a third control group received no treatment. At the end of the study (ten to fourteen weeks later), twenty-nine of thirty-five patients in the treatment group one (the traction and adjustment group) had a lordotic curve compared to eleven of thirty-five prior to treatment. The average improvement in curve values was 13.2 degrees. That’s roughly 300 percent better than the four or five degrees of correction typically obtained with adjustments only! Since the original study in 1994, two additional studies produced similar results supporting the use of extension traction methods to restore the normal cervical lordosis.

Caution: Extension traction involves applying traction force with the head and neck in full backward extension relative to the thorax, not simply stretching the spine along the long axis as with typical medical type traction. Pronounced extension movements of the head and neck may be contraindicated for certain patients. I strongly caution all doctors to carefully screen their patients before using any form of cervical extension traction.

 

In my next article, I’ll cover some of the reasons underlying why it is so difficult to actually achieve meaningful structural corrections with adjustments alone. Between now and then, please take a moment to consider this: For decades, chiropractors have struggled to correct the spine by simply adjusting the column back toward proper alignment. Now, a hundred years into our profession, we are finally starting to understand what it takes to actually deliver on the promise of corrective chiropractic care.

 

Dr. Mark Payne is the president of Matlin Mfg., a manufacturer and distributor of postural rehab products since 1988. To download a full and unabridged version of this article, link to www.MatlinMfg.com. Interested doctors may contact our office for my FREE REPORT, Suggested Screening Procedures for Patient Safety.

If you are interested in learning more on the subject, call our office. I’ll be glad to share how you can improve your corrective care outcomes by 200-300 percent over adjusting alone without changing your technique or spending a fortune. Contact us at 1-334-448-1210 for your Free Report on patient safety.  

 
Dueling Paradigms: Why every chiropractor should embrace postural rehabilitation concepts
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Rehabilitation
Written by Dr. Mark R. Payne, D.C.   
Tuesday, 01 January 2008 08:38

The seventies and eighties brought huge changes to chiropractic. In the early years, chiropractic was founded around a paradigm of restoring normal spinal alignment (structure), thereby allowing the patient to return to a more optimum state of health (function). Many more traditional chiropractors continue to view patient care strictly within this "structural" paradigm. Consider this from the International Chiropractors Association: "Abnormalities and misalignments of the spine, defined as subluxation(s) in chiropractic science, can and do distort the normal function of the nervous system and may create serious negative health consequences."

In the late seventies, everything changed with the sweeping introduction of the "new paradigm" in chiropractic. Popularized largely by proponents of motion palpation methods, the new paradigm emphasized the importance of restoring normal spinal motion (function) as opposed to more traditional concepts of attempting to correct abnormal spinal structure (alignment). Many doctors were frustrated with the difficulties of actually changing spinal structure and studies were showing that traditional adjustments did very little to actually correct spinal misalignment. In short, the new paradigm found a very willing audience, particularly within many academic circles. With the introduction of the new paradigm, subluxation has come to be viewed almost exclusively as a problem of function (motion). For a sizeable portion of our profession, the importance of healthy spinal structure has become somewhat of a philosophical dinosaur consigned to the bone yard of philosophy.

For a while, it seemed so simple. No need to worry about pesky post care X-rays showing little or no correction; just make sure the joints felt mobile and everything would turn out fine. Of course, things weren’t that simple. They rarely are. Doctors in the field continued to see patients return with the same old symptoms. Misaligned spines continued to degenerate. Restoring joint mobility was one thing, but keeping the spine mobile and healthy was quite another.

Where the new paradigm fell short was in assuming that normal spinal motion is possible within the framework of sub normal spinal alignment. We now know this isn’t possible. In biomechanical systems such as the spine, motion is certainly a very important measure of function, but it definitely doesn’t stand alone. As it turns out, the intricate coupling patterns of vertebral motion are inseparably linked to the overall architecture of the spinal column. Structure and function, it seems, are just two sides of the same coin.

Consider the two postures in Fig.1 and Fig.2. The patient in Fig. 1 demonstrates a fairly normal posture with the head well centered over the shoulders. The patient in Fig.2 demonstrates forward head posture due to loss of the cervical lordosis. It would be illogical to think the hypolordotic neck would exhibit the same quality of intersegmental motion as the normal neck. Likewise, it is obvious that these two spines will have very different loading factors on the joints’ surfaces. Surrounding musculature is forced to work differently as the origins and insertions change orientation respective to each other. There is a great deal of research to now indicate that healthy structure (posture) is essential for a number of reasons and that structure is intimately wedded to function.

So why start a column about postural rehab with a discussion of two wildly differing paradigms? Simple…. Chiropractic’s "Dueling Paradigms" are at the heart of many of the issues which continue to divide us professionally. Perpetuation of this false dichotomy fosters intraprofessional tension and weakens us politically and financially. Both approaches have value to the clinician and rigid adherence to either paradigm drastically limits your ability to understand and help complex cases. Trying to separate structure and function is totally unnecessary and scientifically unsound. In many cases, it creates a type of professional tunnel vision which can unintentionally shortchange our patients as we seek the cause of their health issues. It is vital that we look at patients from both sides of the equation.

We know a lot more about correcting posture than we did thirty years ago. Today’s doctor has a number of tools available to help achieve real, measurable corrections which simply weren’t possible when our profession first embraced the "new paradigm." I think you’ll find that incorporating postural rehab will bring with it a number of benefits, regardless of your present mode of practice. Most of the treatment and analytical methods we’ll be covering are easily grasped without the need for extensive training, will cost little or nothing to implement, and can be readily applied by doctors of all techniques. From a more practical perspective, you’ll find the straightforward concepts of postural rehab to be very understandable for your patients. For well over a hundred years, chiropractic patients have intuitively grasped the connection between spinal structure and health.

In subsequent issues, I’ll try to share concepts from both paradigms to help you achieve the best corrections of your career. Best of all, I get a chance to show you some of the methods by which doctors of all techniques can easily start to apply proven methods of postural analysis and rehab without investing a fortune in dollars or time. Hopefully, some of the tools and methods we’ll cover in future issues will help make real and substantial structural corrections a practical reality in your practice.

 

Dr. Mark Payne is the president of Matlin Mfg., a manufacturer and distributor of postural rehab products since 1988. To download a full and unabridged version of this article, link to www.MatlinMfg.com or call 1-334-448-1210.

 
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