T his quote from Ken Hutchins, researcher and President of Super Slow Exercise Guild, represents the common thread binding the various health care disciplines. Orthopedic surgeons, chiropractors, physical therapists, athletic trainers and others involved in the delivery of health care services may differ on a particular approach to an athletic or industrial injury in the corrective context. But, in the restorative or rehabilitation context, it is generally agreed that passive care will only take the patient to a certain level, usually below the functional level needed to return to competition or prevent further injury. Without a properly designed exercise program to increase the tensile strength of the injured tissue, rehabilitate the neurological elements of the injury, and increase strength and mobility in the kinetic chain, we only place the athlete in a position where re injury can and, most likely, will occur.1,10
With the above in mind, we find ourselves in a difficult position as health care providers. With a shrinking health care dollar, a health care model focused on symptom reduction, insurance companies who have placed corporate profits above needed services, and a system driven by the pharmaceutical industry which contributes significantly to our elected officials, how do we provide these needed rehabilitation services in a cost effective manner. We can no longer invest in expensive resistance equipment and a staff to administer the programs. Yet, there is a compelling need. The challenge is how to meet the need in a cost effective manner that gives a reasonably good chance for a positive outcome.
We know through research that gripping causes recruitment and tight gripping actually can cause vascular problems.
I believe there are presently products and companies that allow us to serve the patient in the area of active care protocols at minimal cost with evidence based protocols. Exercise systems utilizing surgical tubing or bands,12 grip free cuffs3, and stability balls offer resistance training with neurological inroads for every orthopedic and sports injury based on scientifically defensible protocols.7
In rehabilitation, we want to amplify a number of factors. One is isolation. In an exercise rehabilitation program, recruitment is the enemy of isolation. When recruitment occurs, the targeted tissue suffers from both a somatic and neurological standpoint. We know through research that gripping causes recruitment and tight gripping actually can cause vascular problems. Noted author Rene’ Calliett, MD, points out in his book on shoulder injuries that gripping while performing Codman’s passive motion exercises actually activates the shoulder muscles, thus decreasing the effectiveness of the program.1,2 Dave Lemke noted EMG tech and NMT from San Antonio in research done at Northern Idaho Bio Performance Institute demonstrated a 300-500% greater EMG activity in the targeted muscles using grip free technology.3 We further know, through research, that exercise done on an unstable base amplifies the input to the nervous system and enhances outcomes.4,5 Surgical tubing or bands provide variable resistance that research has determined to be necessary to optimize strength based on the kinesiological principle that all joints move in a circular pattern and the forces generated vary according to the movement arm (the distance from the fulcrum). Remember weight times arm equals moments of force. Stability balls or discs offer an unstable base. Utilizing the above, we have all the elements necessary to develop an evidenced based rehabilitation protocol for our patients.
So, what’s the bottom line? Health care providers who deal with soft tissue and athletic injuries MUST be involved in active care protocols.8,10,11 In fact, every Chiropractor, Physical Therapist, and Athletic Trainer, if we are to responsibly treat our patients, must, in the course of patient care, be able to transition a patient into an active care protocol. The days of just articular joint manipulation, soft tissue treatments, or passive modalities throughout the course of care are over. Science has taught us the need for active care protocols to move our patients to the next level.6. If we fail to properly rehabilitate, we have, in the final analysis, failed the patient.9,13
Here is the practical approach I have adopted. I must first state that I recently sold my entire Nautilus/Hammer fitness center. This was primarily due to decreased reimbursements and constraints placed on us by managed care companies, such as limitations on the number of visits ( forgetting that research has shown it takes a minimum of 3 months of active care to reverse the glycolytic changes in the somatic tissue secondary to a low back sprain).4 In addition, multiple co pays, high deductibles and the current economic climate make it almost impossible to provide the needed rehabilitation services we once were able to deliver in house. But with systems and products available to the practitioner, we can still provide the services in an evidenced based program that is cost effective and will provide the same outcomes as the more sophisticated rehab centers. Remember, results are what counts.
These systems will cost the practitioner a minimal amount, and can be sold to the patient at a reasonable margin. They have all the necessary equipment to provide a total body workout or a rehabilitation program. In fact, once rehab is completed, they can then be used in a maintenance or supportive care program.5,8,13 There are applications on file to get some of these systems qualified as durable medical equipment, which will save the patient a portion of the cost. But, it is a great deal regardless, about the cost of one visit to the Physical Therapist or two months membership in a gym. The physician gives the patient home exercises specific to the injury to be performed concurrent with any passive treatment delivered in the clinic. On subsequent visits, as symptoms permit, the exercises are expanded on in both increased range of motion and resistance. You bill the 97110 code with each visit that includes the addition of exercises or the modification of exercises. The administration of the program does require the practitioner to gain training in exercise rehabilitation. This is necessary to guarantee desired outcomes in a safe manner. Companies are developing these programs and instruction in seminar formats to prepare the practitioner to develop active care protocols in his or her practice.
The health care system is broken in terms of the model that provides money and services ad infinitum to a drug based approach to every injury, ignoring the evidence that no drug can do for the patient what a properly administered exercise program can do in areas of providing quality of life and functional return to activity. The program outlined above, utilizing already available products, can meet all the needs of the patient in a cost effective manner.
Dr. Dolbin is certified as strength and conditioning specialist (NSCA), and a certified fitness instructor (NSPA). He has served as the Chiropractor for the Villanova University sports medicine department from 1993 to 2003, and was Chiropractor for the University of Maryland gymnastic team from 1997 to 2002 For more information you may contact Dr. Dolbin at
1. Calliet, Rene: Soft Tissue Pain and Disability: Ch. 6 Pg. 155-156
2. Rubin: An Exercise Program for Shoulder Disability: Cal. Med. 106: 39-43
3. Kemke, David NMT, sEmg. Northern Idaho Bioperformance Institute. Study on Grip free Reisitance training.
4. Active Therapy for Chronic Low Back Pain: Spine, 2001 Apr 15; 26(8): 9009-19
5. Evaluation of Functional and Neuromuscular changes after Exercise Rehabilitation for Low Back Pain using a Swiss Ball. J Manipulative and Physio. Therapeutics 2006 Sep; 29(7): 550-60
6. The Efficacy of Active Rehabilitation in Chronic Low Back Pain. Spine: 1999 May 15,24(10): 1034-42
7. Muscle activation changes after exercise Rehabilitation for Chronic Low Back Pain. Arch Physical Med. Rehabilitation. 2008 Jul; 89(7): 1305-13
8. Active Therapy for Chronic Low Back Pain. Effects on Muscle Activation, fatigability and Strength. Spine. 2001 April 15;26(8): 897-908
9. Back and hip Extensor strength in Chronic Low Back Patients. Arch Phys Med Rehabilitation. 1998 April; 79(4); 412-7
10. The Association of Low Back Pain, Neuromuscular Imbalance and Trunk extension strength in Athletes. Spine J. 2006 Nov-Dec; 6(6); 673-83
11. The Efficacy of Active Rehabilitation in Chronic Low Back Pain. Spine. 1999 May 15;(10): 1034-42
12. Posterior Cuff Strengthening Using Theraband in a Functional Diagonal Pattern in Collegiate baseball Pitchers. J Athletic Train. 1993. Winter; 28(4) 346-354.
13. Neuromuscular Fatigue during modified Biering-Sorensen Test in Subjects with and without Low back Pain. Journal of Sports Science and Medicine (2007) 6, 549-559.