Category: Rehabilitation

There have been various recommendations over the years in our profession about the recommended number of repetitions and sets of exercises that patients should perform.  To judge for yourself what numbers are best for those in your care, you need to consider several factors — not the least of which is the hectic, fast-paced lives many of your patients already have.

Determine the Goal(s)

People exercise for a variety of reasons.  Some do it for enjoyment and relaxation, some for general fitness, and some to improve their appearance.  And then there are the athletes, who are trying to excel at a sport or win a competition.

Chiropractors generally have a different approach.  We want to help our patients regain an improved level of health.  The forms of exercising that work best for body builders, football players, and other athletes are not necessarily ideal for patients.  We need to keep this in mind when recommending rehabilitative exercises, especially when we are working with patients who are not used to exercising at all.  Because of that, many doctors find that simpler is better.  Since the goal is just to get a patient to do the exercise regularly, it’s advisable to keep instructions clear and easy to follow.  All patients do a lot better when they know exactly what is expected, and they will tend to do only the minimum necessary. 
 
It All Adds Up

The repetition number (“reps”) means the number of times a patient performs an exercise consecutively, without stopping.  In most programs this number is usually somewhere between 5 and 20.  “Sets” are a series of reps, defined by the rest period between (which varies from 30 seconds to several minutes).  Set recommendations vary from 1 to 3 or 5, or occasionally more.  The “total reps” of an exercise can be determined by multiplying the number of reps times the number of sets performed.

The reps and sets can vary, even when the total reps are the same.  For example, total reps of 20 can be performed as 2 sets of 10 reps, or 4 sets of 5 reps, or 5 sets of 4 reps.   Strength and conditioning specialists, working with exercise physiologists and coaches, have developed a tremendous variety of exercise routines.  Some of these have been found to be useful for certain sports, and others have developed from muscle research.  The variations are determined to some extent by the athlete’s goal—maximum strength, power, or endurance.

Of course, doing fewer repetitions and fewer sets takes less time, but we obviously want our patients to exercise at least enough to improve their condition.  What does the research show?
 
Research Findings

Since 1962, most exercise recom-mendations have been based on the Berger method1, which consists of 3 sets of 6 repetitions, for 18 total repetitions.  Because it was a scientifically based recommendation, as well as being pretty simple for patients to follow, the Berger method has been widely used right up to the present day.  While many still believe it is an effective program, an even simpler and easier method has gained popularity lately.

The literature review by Drs. Carpinelli and Otto² found that there is now a large volume of research which disputes the need for 3 sets of exercise.  In fact, they state that, “One set of repetitions has been shown to be as effective as multiple sets, and more time efficient, for increasing muscular strength and hypertrophy in males and females of different ages, for a variety of muscle groups and using various types of exercise equipment.”  The article concludes by recommending that by “employing a single-set protocol, individuals can achieve similar results in less time and with less work and a decreased potential for injury.”  This has been strong enough evidence for many doctors to change their approach to exercise recommendation.

Less Is More

In many instances, having patients perform just one set of 8 to 12 repetitions of their recommended exercise(s) has proven successful.  Since this is only 8 to 12 total repetitions, without the need for rest periods, it can be completed in much less time.  Patients are more likely to become consistent with the recommended exercises when the time commitment is less.  And this approach has been found to be just as good for getting rapid results.

In many cases, patients can be instructed to perform at least 8 repetitions of the exercise, but they should initially attempt 12.  If 12 repetitions can be done fairly easily, have them increase the resistance slightly the next time.  When using surgical tubing exercises, this means increasing the starting distance from the door in which the tubing is temporarily attached.

Instruct patients to do their exercises every day, at least initially.  This gets them into the habit of doing an exercise, and brings about more rapid change and improvement.  And since the patient is being asked for such a minimal time commitment, it’s difficult for him or her to say that there isn’t enough time to exercise on a daily basis

Faster Recovery, Happier Patients

Either the traditional, multi-set exercise program or the newer, single-set protocol can help patients regain muscle function and improve spinal support and posture.  However, I find that patients are appreciative when I express an awareness of how busy their schedules are and minimize the time needed for exercising.

Patients are more likely to do the exercises you recommend when they fit into a busy schedule.  With only 6 to 12 total repetitions, several exercises can be done in just five or ten minutes.³  This helps ensure acceptance of the entire treatment program, which can lead to rapid progress under your expert care.

Kim Christensen DC, DACRB, CCSP, CSCS, directs the Chiropractic Rehab & Wellness program at PeaceHealth Hospital in Longview, Washington.  He is a popular speaker, and participates as a team physician and consultant to high school and university athletic programs.  Dr. Christensen is currently a postgraduate faculty member of numerous chiropractic colleges and is the past-president of the American Chiropractic Association (ACA) Rehab Council.

He is a “Certified Strength and Conditioning Specialist,” certified by the National Strength and Conditioning Association.  Dr. Christensen is the author of numerous publications and texts on musculoskeletal rehabilitation and nutrition.  He can be  reached at PeaceHealth Hospital by email at [email protected].

References

1.  Berger RA. Effect of varied weight training programs on strength. Res Q 1962; 33:168-81.
2.  Carpinelli RN, Otto RM. Strength training: single versus multiple sets. Sports Med 1998; 26(2):73-84.
3.  Winett RA, Wojcik JR, Fox LD, Herbert WG, Blevins JS, Carpinelli RN. Effects of low volume resistance and cardiovascular training on strength and aerobic capacity in unfit men and women: a demonstration of a threshold model. J Behav Med 2003; 26(3):183-195.

A cascade of physiological, biomechanical and biochemical events complicate Acute and Repetitive Injuries. Musculoskeletal pain and range of motion is affected by biomechanical aberration, joint dysfunction, segmental hyper/hypo-mobility and the result of several pathways and stimuli. However, the inflammatory response may be treated anecdotally by ice, compression and elevation. Allopathic recommendations often include anti-inflammatory medication with significant side effects (consumed like candy), cortisone (with lidocaine or marcaine) injections and other more aggressive medicinal aids (nerve block, etc.) are commonly prescribed and administered for patients refractory to care.

Enzymes to the rescue

I recall numerous childhood athletic injuries for which my late doctor, L. C. Winnick, MD, would prescribe ice, elastic bandage and Ananase. Years later, I learned that ananacea, in Latin, translates to pineapple. The effective proteo-lytic enzyme found in the stem of the Hawaiian fruit is otherwise known as bromelain (an enzyme known to help modulate bradykinin activity, reduce excessive fibrin deposition, inhibit pro-inflammatory cytokines and help soft tissue damage). Other common, extremely beneficial enzymes, such as papain and trypsin when combined, are very effective for acute inflammation. However, the body must produce anti-enzymes  in order for them to be adequately processed and, as such, after prolonged exposure to high levels of enzymes, the body can no longer produce the required anti-enzymes and build-up occurs.

NOTE:  Extended use of these powerful and effective enzymes for acute inflammation is NOT recommended, as the effects can lead to long term complications.¹

Natural COX-inhibitors

Prostaglandins, the hormone-like substances responsible for inflammation, are formed from arachadonic acid. The first step in their formation is catalyzed by the enzyme cyclo-oxygenase, or COX. Turmeric, ginger and boswellia extract help inhibit the production of COX. Excessive tissue oxidation can also lead to inflammation related pain. Rosemary extract and a lemon bioflavonoid complex, both powerful antioxidants, help mitigate this inflammatory factor. Bromelain derived from pineapple (ananas bracteur, ananas cosmosus) contains, among other components, various closely related proteases, demonstrating, in vitro and in vivo, anti-edematous, anti-inflammatory, anti-thrombotic and fibrinolytic activities.²

The 1-2 punch

Additional anti-inflammatory support is maximized when coupled with turmeric (inhibits production of leukotrienes), ginger (limits lipoxygenase production), citrus bioflavonoid, rosemary and boswellia. The powerful combination of proteolytic enzymes for acute tissue trauma and subsequent soft tissue de-flaming support, previously noted, has proven cost effective and efficacious as well. This 1-2 punch enhances the acute and chronic recovery process and affords the patient rapid, safe and natural relief of pain due to inflammation. Patients with chronic inflammation and those in the rehabilitation phase of care require a maintenance formula to prevent the post-acute injured tissue from becoming re-inflamed.¹

Conclusions

Inflammation is becoming well recognized as the cause of many health problems/conditions and not solely the result. As cause and effect practitioners, we chiropractors pride ourselves on RESULTS. Whether your belief is right- or left-wing, pain management is an integral part of patient care and the most common reason for portal-of-entry in health care today.

This anti-inflammatory protocol is extremely effective in supporting the chiropractic adjustment, as muscles and joints that remain inflamed retard the natural healing process. As you know, patient history clearly demonstrates that patient’s recalcitrant to rapid pain relief will seek alternative pain management. Let the buck (patient) stop here, at your office!

References

1.  Seaman DC, David, Clinical Nutrition, 1st Edition, NutrAnalysis Inc.)
2.  Bucci, L R. Nutrition Applied to Injury Rehabilitation and Sports Medicine

For more product and seminar information, e-mail Dr. Mally at [email protected].

Most injuries of the Achilles tendon are not due to a recent acute injury; they have actually developed gradually, over a period of weeks or months.  These are “overuse” or “misuse” conditions, and are caused by excessive and/or repetitive motion, often with poor biomechanics.  The end result is a microtrauma injury—the body is unable to keep up with the repair and re-strengthening needs, so the tissue begins to fail and becomes symptomatic.  If it is not very painful (or when the pain is eliminated by pain-killing drugs), continued stress can eventually lead to complete failure, with a resulting acute tear of the tendon.

The Achilles tendon insertion on the calcaneus is medial to the axis of the subtalar joint, making the calf muscles the most powerful supinators of the subtalar joint.¹ Therefore, when excessive pronation occurs, eventually the tendon undergoes overuse degeneration and inflammation.  Clement, et al., described how “pronation generates an obligatory internal tibial rotation, which tends to draw the Achilles tendon medially.  Through slow motion, high-speed cinematography, we have seen that pronation produces a whipping action or bowstring effect in the Achilles tendon.  This whipping action, when exaggerated, may contribute to microtears in the tendon, particularly in its medial aspect, and initiate an inflammatory response.”² These investigators believe that the control of functional overpronation with corrective orthotic devices is a necessary treatment for most patients with Achilles tendinosis.

Impaired circulation may be a contributing factor to Achilles tendon overuse injuries, especially with tendon tears.  The same researchers speculate that “in individuals who overpronate, the conflicting internal and external rotatory forces imparted to the tibia by simultaneous pronation and knee extension may blanch or wring out vessels in the tendon and peritendon, causing vascular impairment and subsequent degenerative changes in the Achilles tendon.”² This “region of relative avascularity” extends from 2 to 6 cm above the insertion into the calcaneus, and is a common site of rupture of the Achilles tendon.  This makes it especially important to ensure good blood flow during the healing of this condition. 

The New Paradigm for Care

It’s not surprising that abnormal biomechanics of the foot and ankle can cause problems with the largest tendon in the leg.  Symptoms are usually described as diffuse pain in or around the back of the ankle (from the calf to the heel).  The pain is aggravated by activity, especially uphill running or climbing stairs, and relieved somewhat by wearing higher-heeled shoes or boots.  Palpation will find a tender thickening of the peritendon, and there may be crepitus during plantar and dorsiflexion.  Often, a recent increase in activity levels (such as more stair-climbing) or a change in footwear is reported by the patient.

Macroscopically, overused Achilles tendon tissues examined at surgery are dull, slightly brown, and soft, in comparison to normal tendon tissue, which is white, glistening, and firm.³  There is a loss of collagen continuity and an increase in ground substance and cellularity, which is due to fibroblasts and myofibroblasts, and not inflammatory cells.⁴  This is the reason that anti-inflammatory strategies (such as NSAID’s, drugs and corticosteroid injections) are not indicated for these conditions, and actually may interfere with tendon repair.⁵  We now know that the condition we usually have described as “tendinitis” is actually better understood as “tendinosis,” and is not due to inflammation, but an underlying degeneration of collagen tissues in response to mechanical overuse.⁶  This “new paradigm” will help to guide our management of all tendon problems, and provide more effective rehabilitation for Achilles tendons.

Rehab Procedures

When an injury is acute, an initial period of relative rest is needed.  Occasionally, the weakened tissues will tear through, resulting in a ruptured Achilles tendon.  This may require surgical repair and a period of rest before rehabilitation can begin.  During this period, though, exercise of the opposite ankle should be encouraged.  Vigorous exercise of the uninvolved contralateral ankle muscles produces a neurological stimulus in the injured muscles (called the “cross-over effect”), and helps to prevent atrophy.⁷  Initial treatment should also include heel lifts to reduce the strain on the Achilles tendon, and cross-fiber friction to improve circulation.  Complete return to function will then require attention to range of motion, functional strength, and orthotic support.

Range of motion.  In addition to appropriate foot and ankle adjustments, stretching of the tight and shortened gastrocnemius/soleus muscle complex is a necessary part of Achilles tendon rehabilitation.  Gentle stretching should be started early, putting a linear stress on the tendons and stimulating connective tissue repair.  The standard is the “runner’s stretch,” performed against a wall.  Patients with tightness and pronation will often allow the foot to flare outward while stretching, which forces the medial arch to drop.  This tendency must be carefully corrected, with the foot positioned straight ahead and the medial arch kept elevated.⁸ Even better, is to perform the stretches with corrective orthotics in place.

Functional strength.  Isotonic strengthening exercises that focus on the eccentric (negative) component have been shown to improve the healing of tendons and accelerate return to sports participation.⁹ These exercises are progressed to closed-chain, loaded eccentric exercises, in order to stimulate collagen fiber reorientation and strengthening.¹⁰  The patient is instructed to stand on the edge of a stair, do a toe raise up, then drop the involved heel as far as possible, returning by pushing back up with the uninvolved leg.

Conclusion

Achilles tendon injuries can be successfully rehabilitated conservatively.  Steroid injections and casting are seldom used these days.  Once the local inflammation has been controlled, improved blood flow to the region of relative avascularity is necessary.  Correct stretching and strengthening exercises can be demonstrated and monitored in the office. 

Kim Christensen DC, DACRB, CCSP, CSCS, directs the Chiropractic Rehab & Wellness program at PeaceHealth Hospital in Longview, Washington.  He is a popular speaker, and participates as a team physician and consultant to high school and university athletic programs.  Dr. Christensen is currently a postgraduate faculty member of numerous chiropractic colleges and is the past-president of the American Chiropractic Association (ACA) Rehab Council.

He is a “Certified Strength and Conditioning Specialist,” certified by the National Strength and Conditioning Association.  Dr. Christensen is the author of numerous publications and texts on musculoskeletal rehabilitation and nutrition.  He can be  reached at PeaceHealth Hospital by email at [email protected].

References:

1. Subotnick SI. Sports Medicine of the Lower Extremity. New York: Churchill Livingstone; 1989. 475.
2. Clement DB et al. Achilles tendinitis and peritendinitis: etiology and treatment. Am J Sports Med 1984; 12:179-184.
3. Astrom M, Rausing A. Chronic achilles tendinopathy: survey of surgical and histopathologic findings. Clin Orthop 1995; 316:151-164.
4. Khan KM et al. Histopathology of common tendinopathies: update and implications for clinical management. Sports Med 1999; 27:393-408.
5. Almekinders LC, Temple JD. Etiology, diagnosis, and treatment of tendonitis: an analysis of the literature. Med Sci Sports Exerc 1998; 30:1183-1190.
6.  Khan KM et al. Overuse tendinosis, not tendinitis. Part 1: a new paradigm for a difficult clinical problem. Phys Sportsmed 2000; 28:38-48.
7. Hertling D, Kessler RM. Management of Common Musculoskeletal Disorders. 2nd ed. Philadelphia: JB Lippincott; 1990. 334.
8.  Ninos J. Chain reaction: a tight gastroc-soleus group. Strength Cond J 2001; 23:60-61.
9. Niesen-Vertommen Sl et al. The effect of eccentric versus concentric exercise in the management of Achilles tendinitis. Clin J Sport Med 1992; 2:109-113.
10.Alfredson H et al. Heavy-load eccentric calf muscle training for the treatment of chronic Achilles tendinosis. Am J Sports Med 1998; 26:360-366.

People who present with whiplash injuries (Cervical Acceleration-Deacceleration) often do not respond completely to care.  In fact, persisting symptoms are common in this group.¹  One review found that “between 14% and 42% of patients with whiplash injuries have chronic neck pain and that approximately 10% of this group experience constant, severe pain.”²  In fact, there is over 50 years of literature demonstrating this fact.

Doctors of chiropractic who incorporate rehab exercises can provide “multimodal care” to whiplash patients, in order to minimize the risk of long-term problems.  This has been defined in the previously referenced study as care that applies manual procedures (spinal manipulation, mobilization, and massage), along with physical training to improve muscle strength and endurance, including sport activities.  Multimodal care has been found to be effective in preventing many of the persisting symptoms of “late whiplash syndrome.”^2,3

Injury Biomechanics

Recent research has defined the mechanism of this spinal injury more accurately.  Panjabi and his co-workers have clarified the intervertebral kinematics and quantified the functional injuries to the soft tissues.⁴  Dr. Panjabi’s group found a much more complex injury mechanism than cervical hyperflexion/hyperextension.  They documented very clearly that, initially, the spine translates (a straight-line motion), with practically no head extension.  They described an “S-shaped curve resulting in local extension of the lower cervical spine with upper cervical spine flexion.”

This helps to explain the constellation of injuries we see in patients who have been struck from behind.  In fact, even at low speeds, the nervous system is “jolted” during this translation movement.  A jolt is “a sudden, unexpected, forced stretching and/or reflex contraction of skeletal muscle induced by a barrage of impulses from receptors in muscle spindles and joint capsules.”⁵  Active rehabilitation takes this biomechanical and neurological information into account when planning a rehabilitation program.

Active Whiplash Rehabilitation

Many studies using various exercise approaches have demonstrated the benefits of the active approach.⁶  Traditionally, patients are told to spend much of their exercise sessions on the stretching of tight muscles.  Unfortunately, stretching exercises, whether at home or in the clinic, may demonstrate little or questionable therapeutic value.⁷  Dynamic exercise with progressive resistance to stimulate the muscles and the nerves is a useful form of active exercise.⁸

A rational approach to auto-related CAD injury is to give consideration to the following:⁹

· Range of active motion of the injured spinal regions
· Strength of the related musculature
· Postural control and balance of opposing soft tissues
· General muscular power (for daily activities)
· General aerobic fitness and endurance.

Loss of Support Strength

When injured, the soft tissues of the neck no longer provide adequate support for the movements and weight of the head (12 to 15 pounds).  Graduated resistance exercise is an efficient method to progressively stimulate these important muscles to strengthen and return to full function.  During isotonic exercising, the joints move (stimulating the mechanoreceptors), and the opposing muscles relax through reciprocal inhibition.

Posture and Movement Abnormalities

Patients with a history of neck trauma often have multiple, significant limitations in their ranges of cervical motion, in comparison to those with no such history.¹⁰  Whiplash patients also have problems with proper re-positioning of their necks.¹¹  Now that we understand the mechanism of the injury better, it’s not surprising that many whiplash patients demonstrate an obvious Anterior Translation postural imbalance.This posture is secondary to the damaging “S-curve” motion that injured the lower and upper spinal regions in very different vectors.

Once in the forward head posture, a constant strain develops in the muscles of the neck and especially the upper back because of the forward leverage of the heavy head.  Without correction, this posture may develop into a chronic myofascitis in the muscles of the upper back and shoulder girdles.  If left untreated, the patient is likely to develop a permanent limitation that affects many activities of daily living.  Initially, the patient can perform a series of active exercises to slowly stimulate the corrective musculature as demonstrated in Figure 1 thru 6 (Outcomes Assessment 2004 available thru FCER). An effective exercise to correct this postural imbalance is the Posterior Translation exercise performed against isotonic resistance in a position of function such as the Necksys System.

Conclusion

An appropriate and progressive rehab program should be initiated early in the care of patients with whiplash-type injuries.  Dynamic rehab techniques for the cervical region that don’t require expensive equipment or great time commitments are easily implemented.  A closely monitored home exercise program allows the doctor of chiropractic to provide cost-efficient, yet very effective, rehabilitation care.

Kim Christensen DC, DACRB, CCSP, CSCS, directs the Chiropractic Rehab & Wellness program at PeaceHealth Hospital in Longview, Washington.  He is a popular speaker, and participates as a team physician and consultant to high school and university athletic programs.  Dr. Christensen is currently a postgraduate faculty member of numerous chiropractic colleges and is the past-president of the American Chiropractic Association (ACA) Rehab Council.

He is a “Certified Strength and Conditioning Specialist,” certified by the National Strength and Conditioning Association.  Dr. Christensen is the author of numerous publications and texts on musculoskeletal rehabilitation and nutrition.  He can be  reached at PeaceHealth Hospital by email at [email protected].

References

1. Hagstrom Y, Carlsson RTP. Prolonged functional impairments after whiplash injury. Scand J Rehab Med 1996; 28:139-146.

2. Vendrig AA, van Akkerveeken PF, McWhorter KR. Results of a multimodal treatment program for patients with chronic symptoms after a whiplash injury of the neck. Spine 2000; 25:238-244.

3. Provinciali L, Baroni M, Illuminati L, Ceravola MG. Multimodal treatment to prevent the late whiplash syndrome. Scand J Rehab Med 1996; 28:105-111.

4. Grauer JN, Panjabi MM, Cholewicki J et al. Whiplash produces an S-shaped curvature of the neck with hyperextension at lower levels. Spine 1997; 22:2489-2494.

6. Jordan A, Ostergaard K. Rehabilitation of neck/shoulder patients in primary health care clinics. J Manip Physiol Ther 1996; 19:32-35.

7. Wilkinson A. Stretching the truth: a review of the literature on muscle stretching. Aust J Physiother 1992; 38:283-291.

8. Berg HE, Berggren G, Tesch PA. Dynamic neck strength training: effect on pain and function. Arch Phys Med Rehabil 1994; 75:661-665.

9. Ameis A. Cervical whiplash: considerations in the rehabilitation of cervical myofascial injury. Can Fam Phys 1986; 32:1871-1877.

10. Osterbauer PJ, Long K, Ribaudo TA et al. Three-dimensional head kinematics and cervical range of motion in the diagnosis of patients with neck trauma. J Manip Physiol Ther 1996; 19:231-237.

11. Heikkila H, Astrom PG. Cervicocephalic kinesthetic sensibility in patients with whiplash injury. Scand J Rehab Med 1996; 28:133-138.

One of the underlying principles in physical rehabilitation is that the body responds positively to the increased stresses placed upon it.  This is the whole reason for asking muscles to lift more weight, for asking tendons to pull more tension, and for asking joints to undergo more movement.  We have a mechanism for developing and improving our physical capabilities when we place increased, yet controlled, stresses on our bodies.  On the other hand, increased physical stress is often the cause of symptomatic conditions and physical breakdown.  What is the difference?  Actually, several have been identified.

Progressive Overload

Gradual and paced overloading of res-ponsive tissues is the essential principle that underlies the benefits of exercise training.  Benefits accrue as the normal recuperative processes of the body respond and improve in function; this includes more strength, better flexibility, increased endurance, and improved coordination.  Our goal is to stimulate these beneficial improvements, while avoiding any excessive strain on the involved tissues.  Proper instruction, continued monitoring, and specific corrections are necessary factors preventing overload injuries.

There are three categories of exercise errors that indicate excessive loading of involved tissues.  By paying attention to our patients as they perform their exercises, we can identify these problems early on, and make appropriate recommendations.  Most problems with exercises are associated with a “loss of form.”¹  This somewhat nebulous problem can be defined as consisting of three problems, all of which are easily identified by a doctor of chiropractic.  These include problems with posture, alignment, and range of motion.

Posture.  Be on the lookout for abnormal or imbalanced postures during exercising.  Whether the patient is strengthening, stretching, or walking, hyperextensions and lateral shifts indicate an overload situation.  This is easily seen during cervical training, when patients strain and push their heads forward, instead of maintaining a balanced alignment throughout their exercise.

Alignment.  The more subtle deviation of misalignment during exercising relates primarily to the extremities.  This can be especially noticed in the feet (toe-out), ankles (excessive pronation), and knees (knock-knees).  These are all indicators that additional exercising in these conditions will likely bring about a recurrence of symptoms, rather than improvement.  Addressing the align-ments and asymmetries is paramount for progress, and may require custom-made orthotics.

Range of Motion.  Any limitation in movement range during an exercise should prompt a search for the underlying cause.  This may be a reasonable self-protective response due to recent injury, or (more commonly) an inappropriate fear response.  It is also possible that the patient is placing excessive loads on sensitive tissues that are incapable of handling that amount of stress in their current state.

Rehab Solutions

Excessive loading, whether of resistance, flexibility, endurance, or proprioceptive exercises, is never helpful, and can be counter-productive.  Five solutions for this all start with the letter “R”:  Rest, Range, Rate, Resistance, and Repetitions.²

Rest.  By increasing the rest period between exercises, or between sets, we allow the body to recharge and to better handle the overload.  This is often the simplest of the solutions, as sufficient rest is frequently all that’s needed to avoid rehab overload.

Range.  Controlling the range of an exercise or a stretch may be needed, especially in the initial phases of rehab.  Particularly after an injury, connective tissues may be easily aggravated by forcing too much range.  This is where the body can often let us know when we have gone too far, since it will give us a pain message.  Initially, we should recommend that exercises be performed only within a pain-free range of motion.

Rate.  Slowing down the pace of an exercise and incorporating a relaxed breathing cycle will often reduce exercise stress significantly.  In fact, slow and controlled exercising stimulates more neurologic control and re-training without overstressing tissues.

Resistance.  Whether using exercise bands, weights, or machines, careful control of the amount of resistance is important.  Isotonic strengthening exercises that focus on the eccentric (negative) component have been shown to improve the healing of tendons and accelerate return to sports participation.³  However, excessive resistance can quickly produce the problems in posture, alignment, and range of motion described above, resulting in a poor response to care.

Repetitions.  And, finally, one of the easiest ways we can overload our patients is to recommend too many repetitions of too many exercises.  It is far better that a few repetitions of a few exercises be done regularly and consistently, and be interspersed with sufficient rest.

When we keep our eyes peeled for the three types of  “loss of form”, and then carefully control the five “R’s” of rehab training, we can avoid exercise overload and ensure a smooth response to chiropractic rehabilitation training.

Kim Christensen DC, DACRB, CCSP, CSCS, directs the Chiropractic Rehab & Wellness program at PeaceHealth Hospital in Longview, Washington.  He is a popular speaker, and participates as a team physician and consultant to high school and university athletic programs.  Dr. Christensen is currently a postgraduate faculty member of numerous chiropractic colleges and is the past-president of the American Chiropractic Association (ACA) Rehab Council.

He is a “Certified Strength and Conditioning Specialist,” certified by the National Strength and Conditioning Association.  Dr. Christensen is the author of numerous publications and texts on musculoskeletal rehabilitation and nutrition.  He can be  reached at PeaceHealth Hospital by email at [email protected].

References

1. Mullineaux M. Strength conditioning: developing your teaching technique. Strength Cond J 2001; 23:17-19.
2. Mullineaux M, Rowe L. Manipulating training variables for safety and effectiveness. Strength Cond J 2003; 25:33-36.
3. Niesen-Vertommen Sl, et al. The effect of eccentric versus concentric exercise in the management of Achilles tendinitis. Clin J Sport Med 1992; 2:109-113.

Current research describes the advantage of early, progressive rehabilitation exercise for many types of joint conditions.^1-6  These benefits include: restoration of range of motion; decreased pain and swelling; decreased neural inhibition; quicker return of muscle function; and improved performance in sports and all daily activities.  Some studies even speculate that early rehabilitation programs may reduce the number of joint re-injuries.^7-9

Contemporary concepts in joint rehabilitation emphasize functional activities and re-training of normal loading and movement patterns.  It is especially important to regain full neurological coordination of the surrounding muscles and connective tissues, because that is the true source of joint stability.  An important component in addressing these needs can be the frequent use of exercise tubing.

The Values of Functional Rehab and Elastic Tubing

The proprioceptive input from receptors in the muscles, connective tissues, and joint capsules differs when going from standing to lying down.  That is why it is so important to bring joint rehab exercises closer to real-life positions, and it explains why patients can progress much more quickly when they are instructed to exercise in a functional position.

Exercises done on the floor, on a weight bench, or constrained by a machine may not train muscles and joints to function optimally during usual daily or sports activities.  The neurological patterns that are developed on the floor or in a pool are considered preliminary to the joint function during upright demands.  Learning new skills and movement habits in a machine doesn’t always translate to better functioning during regular, independent activities, or improved sports performance.  Some of the time patients spend on open chain exercises for their lower extremities may be unnecessary.  In addition, it’s expensive to get patients into a facility with machines, or a pool to exercise.

Elastic tubing allows patients to exercise in a weight-bearing, functional position that has been shown to be both effective and safe.³  It has the additional benefit of being easier for most patients.  In addition to being more focused and practical, upright exercising trains and strengthens the joints to perform better in everyday activities. 

• Resistance Variation: Elastic tubing provides a unique form of exercise.  The actual amount of resistance varies significantly with the amount of stretch applied to the tubing.¹⁰  This attribute is used most effectively by initiating the rehab program with some slack in the tubing, thereby ensuring relatively low resistance.  As the patient improves, the exercise is performed with less slack, increasing the resistance gradually and safely.  Eventually, the exercise effort progresses to starting with some “pre-stretch,” in order to stimulate and activate a more widespread neurological response to the exercise movement.  In this way, most patients are able to advance through their entire joint rehab program with just one exercise tubing design, rather than having to purchase several different levels. When provided to a patient, the exercise tubing generally needs to be accompanied by a strap device and/or handles, along with an illustrated, descriptive exercise booklet.  It should also be packaged with a system for temporary, but dependable, attachment to a door or wall (such as straps or clips).  Even with these additional necessary items, exercise tubing is both lightweight and inexpensive.  It is easily carried on business and vacation trips to provide continuous rehab.

• Aditional Advantages: Exercise tubing is also very non-threatening, and has been used extensively in home-based exercise programs for older adults.¹¹  Since setup is easy to learn, and requires little manual dexterity, it can be used by patients with no gym experience.¹²  An additional benefit is being able to customize sports equipment with elastic tubing to provide very sport-specific joint rehab.  Exercise tubing is commonly used with tennis racquets and golf clubs to enhance performance and prevent injury.¹³

Early Involvement for Best Results

Appropriate and progressive rehab programs should be started early in the treatment of patients with joint conditions—both acute and chronic.  Retraining programs using simple, isotonic resistance techniques are readily available, none of which require expensive equipment or great time commitments.  A closely monitored home exercise program using exercise tubing is recommended, since this allows the doctor of chiropractic to provide cost-efficient, effective, and specific rehabilitative care. TAC

Kim Christensen DC, DACRB, CCSP, CSCS, directs the Chiropractic Rehab & Wellness program at PeaceHealth Hospital in Longview, Washington.  He is a popular speaker, and participates as a team physician and consultant to high school and university athletic programs.  Dr. Christensen is currently a postgraduate faculty member of numerous chiropractic colleges and is the past-president of the American Chiropractic Association (ACA) Rehab Council.

He is a “Certified Strength and Conditioning Specialist,” certified by the National Strength and Conditioning Association.  Dr. Christensen is the author of numerous publications and texts on musculoskeletal rehabilitation and nutrition.  He can be reached at PeaceHealth Hospital by email at [email protected].

References

1. Lill H, Korner J, Rose T, Hepp P et al. Fracture-dislocations of the elbow joint—strategy for treatment and results. Arch Orthop Trauma Surg 2001; 121(1-2):31-37.
2. Carpenter DM, Nelson BW. Low back strengthening for the prevention and treatment of low back pain. Med Sci Sports Exerc 1999; 31(1):18-24.
3. Glasoe WM, Allen MK, Awtry BF, Yack HJ. Weight-bearing immobilization and early exercise treatment following a grade II lateral ankle sprain. J Orthop Sports Phys Ther 1999; 29(7):394-399.
4. Shrader JA. Nonsurgical management of the foot and ankle affected by rheumatoid arthritis. J Orthop Sports Phys Ther 1999; 29(12):703-717.
5. Wolfe MW, Uhl TL, Mattacola CG, McCluskey LC. Management of ankle sprains. Am Fam Physician 2001; 63(1):93-104.
6. Lynch SA, Renstrom PA. Treatment of acute lateral ankle ligament rupture in the athlete. Conservative versus surgical treatment. Sports Med 1999; 27(1):61-71.
7. Barkler EH, Magnusson SP, Becher K, Bieler T, et al. The effect of supervised rehabilitation on ankle joint function and the risk of recurrence after acute ankle distorsion. Ugeskr Laeger 2001; 163(23):3223-3226.
8. Holme E, Magnusson SP, Becher K, Bieler T, et al. The effect of supervised rehabilitation on strength, postural sway, position sense and re-injury risk after acute ankle ligament sprain. Scand J Med Sci Sports 1999; 9(2):104-109.
9. Cleeman E, Flatow EL. Shoulder dislocations in the young patient. Orthop Clin North Am 2000; 31(2):217-229.
10. Hughes CJ, Hurd K, Jones A, Sprigle S. Resistance properties of tubing during shoulder abduction exercise. J Orthop Sports Phys Ther 1999; 29:413-420.
11. Mikesky AE, Topp R, Wigglesworth JK, Harsha DM, et al. Efficacy of a home-based training program for older adults using elastic tubing. Eur J Appl Physiol Occup Physiol 1994; 69(4):316-320.
12. Skelton DA, Young A, Grieg CA, Malbut KE. Effects of resistance training on strength, power, and selected functional abilities of women aged 75 and older. J Am Geriatr Soc 1995; 43:1081-1087.
13. Lindsay DM, Horton JF, Vandervoort AA. A review of injury characteristics, aging factors and prevention programmes for the older golfer. Sports Med 2000; 30:89-103.

Selecting the ideal exercises for patients with back conditions requires judgment based on clinical experience and scientific evidence.  There are several approaches to rehabilitation, and many different types of exercises are available; however, patients have a limited amount of time, willingness, and enthusiasm to exercise.  Therefore, we must always try to give our patients the most effective exercises for their condition.  But, what are the “best” exercises for chiropractic patients?

 

 

What to Look for

 

The best exercises for a specific problem are those that will be rapidly effective, easy to learn and perform, and are safe.  The exercises must help the patient to regain normal alignment and easy, natural movement.  And the end result should include a decreased chance of similar, recurring problems.

 

 

A successful and appropriate rehabilitative program can be designed without the need for expensive, joint-specific equipment.  While isokinetic machines are useful in the research lab, current rehab concepts consider such equipment to be unnecessary.  In fact, the low-tech approach can be very effective for the treatment of most spinal conditions.  Additional personnel, fancy equipment, more office space, and extra time are not necessary.  With an understanding of normal spinal function, knowledge of the involved muscles, and some updating of exercise concepts, chiropractors can effectively rehab their patients with simple home exercise equipment.

 

 

Specific Adaptation to Imposed Demands

 

The “SAID” concept is one of the underlying tenets of the strength and conditioning field. 1  It describes the observation that our bodies will predictably change in response to the demands that are placed on them.  If we frequently perform aerobic activities, then our lungs, hearts, and muscles become more efficient at taking in and processing oxygen.  When we spend more time in activities requiring force and providing resistance, our bodies develop more muscle mass, and we become stronger.  And, if we practice our balance and coordination, we improve our ability to function easier on an unstable surface (such as on a rolling ship or a pair of skates).  In fact, these improvements in our abilities are quite specific, and we become better at doing whatever it is that we do most often.

 

 

It has taken quite a while for specialists in the treatment of spinal problems to incorporate this idea into neck and back rehab programs.  Recently, some chiropractors have begun to use the same thought processes to design spinal exercises that we have used for decades to determine appropriate x-ray positions.  We recognize that the spine functions very differently when it is not weight-bearing.  We now know that the best way to help our patients return to normal function is with exercises that imitate as closely as possible the real conditions under which the spine must function day after day.  That certainly must include the specific stress of gravity in the upright position.

   

Kinetic Chain Exercises

 

When the spine is bearing weight it is part of a closed kinetic chain.  This is the manner in which we use the joints and connective tissue of the spine during most daily and sports activities, and it requires the co-contraction of accessory and stabilizing muscles.  Weaker or injured muscles can be quickly strengthened with the additional use of isotonic resistance to stimulate increases in strength.  Isotonic resistance can come from a machine, from weights, from elastic tubing, or just using the weight of the body.  More important than the equipment used is whether the spinal support structures are exercised in an open or a closed-chain position. 

 

 

Open-chain exercises for the spine are done non-weight bearing, while either lying on the ground or immersed in water (which removes much of the effect of gravity).  Both floor-based and water-based exercises have some limited usefulness, primarily during the acute stage.

   

A good example of this is a study comparing closed vs. open kinetic chain exercises for the training of the thigh muscles.  Augustsson et al. wanted to improve their subjects’ vertical jump height. 2  Two groups exercised twice a week at maximal resistance – one group doing closed-chain exercises (barbell squats), and the other working on the knee extension and hip adduction weight machines (open-chain exercising).  At the end of six weeks both groups had gained considerable strength, but the closed-chain exercisers were the only ones who improved significantly in the vertical jump.  Since jumping is a closed-chain activity, the SAID concept tells us to expect that closed-chain exercising will be more effective.

   

Functional Position Exercise

 

We know that the origins and insertions of many muscles change when going from standing to lying down.  Certainly the proprioceptive input from receptors in the muscles, connective tissues, and joint capsules is very different between the two positions.  This is why it is so important to bring neck and back rehab exercises closer to real-life positions, and it explains why patients make much more rapid progress when they are taught to exercise in a functional (upright) position.

 

 

By staying up off the floor, exercising in a weight-bearing position is actually easier for most patients.  In addition to being more focused and practical, upright exercising trains and strengthens the spine to perform better in everyday activities.  Patients like the idea of doing exercises that clearly prepare them for better function during normal activities of daily life.

 

 

The Value of Balance Exercises

 

For many athletes (whether recreational or competitive), it is important to regain the fine neurological control necessary for accurate spinal and full body performance.  This means that about five to ten minutes of each workout should be spent exercising while standing on one leg, with the eyes closed, while standing on a mini-tramp, or using a special rocker board.  The advantage of these balance exercises is seen when athletic patients return to sports activities and can perform at high levels without consciously having to protect their backs.  Back exercises done on a rocker board or while standing on one leg are can be considered more useful than those done on a gym ball, since the entire body is in a closed-chain position during the exercises.  The stabilizing muscles, the co-contractors, and the antagonist muscles all have 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 competitive athletes.

 

 

Functional Alignment

 

Many chronic spinal problems develop secondary to an imbalance in weight-bearing alignment of the lower extremities.  In fact, lower extremity misalignments — such as leg length discrepancies and pronation problems — are frequently associated with chronic pelvis and low back symptoms. 3  Any of these that are present will need to be addressed in order to resolve the patient’s current symptoms and to prevent future back problems.  The effects of weight bearing and the alignment of the kinetic chain must be considered. 

 

Conclusion

 

Selecting the best exercise approach for each patient’s back problem is important.  A well-designed exercise program allows the doctor of chiropractic to provide cost-efficient, yet very effective rehabilitation care.  Exercises performed with the spine upright (standing or sitting) specifically train and condition all the involved structures to work together smoothly.  The end result is a more effective rehab component and patients who make a rapid response to their chiropractic care.  

 

 

 

References

 

1. Fleck SJ, Kraemer WJ. Designing Resistance Training Programs. Champaign, IL: Human Kinetics, 1987.

 

2. Augustsson J et al. Weight training of the thigh muscles using closed vs. open kinetic chain exercises: a comparison of performance enhancement. J Orthop Sports Phys Therap 1998; 27:3-8.

 

3. Rothbart BA, Estabrook L. Excessive pronation: a major biomechanical determinant in the development of chondromalacia and pelvic lists. J Manip Physiol Therap 1988; 11:373-379.

 

About The Author

 

Kim Christensen DC, DACRB, CCSP, CSCS directs the Chiropractic Rehab & Wellness program at PeaceHealth Hospital in Longview Washington. He is a popular speaker, and participates as a team physician and consultant to high school and university athletic programs.  Dr. Christensen is currently a postgraduate faculty member of numerous chiropractic colleges and is the past-president of the American Chiropractic Association (ACA) Rehab Council.  He is a “Certified Strength and Conditioning Specialist,” certified by the National Strength and Conditioning Association.  Dr. Christensen is the author of numerous publications and texts on musculoskeletal rehabilitation and nutrition.  He can be reached at PeaceHealth Hospital by email at [email protected].

The hip muscles form a vital link in the lower extremity kinetic chain by transferring ground-reaction forces from the legs to the trunk during gait.  These muscle groups supply coordinated propulsion and provide balanced stability for the pelvis and spine.  However, through repetitive use patterns and after injuries, it is not unusual for some of these muscles to develop shortening and/or weakness.  A comprehensive care program must include exercises to address these imbalances.

 

 

An appropriate and successful exercise program to rebalance the hip muscles does not require expensive, joint-specific equipment.  The low-tech approach can be very effective for the treatment of most hip and pelvic conditions.  With a few simple stretches (properly performed) and some home resistance exercises, the hip muscles can be easily strengthened and rebalanced.

 

 

 

The Hip Rotators and the Pelvis

The role of the hip rotator muscles is frequently overlooked when addressing prevention and rehabilitation of lumbar spine injuries.  Deconditioned and/or shortened hip rotators contribute to abnormal lumbopelvic posture and cause compensatory motion in the lumbar spine during daily activities.¹  This is particularly important during strenuous and competitive athletic efforts.  The detrimental effects of inadequately conditioned and prepared hip rotators predisposes the athlete to lumbar spine injuries,² many of which are eventually seen by the sports-oriented doctor of chiropractic.

 

 

 

Deficits of flexibility and strength in the hip rotators can add substantial stress to the pelvis and sacroiliac joint, as well as the lumbar and even thoracic spinal regions.³  For instance, there may be an anteverted (forward flexed) pelvis in conjunction with limited external hip rotation.  In such cases, a combination of stretching and strengthening will be necessary for a complete response to chiropractic care.  The chiropractic correction of the flexed pelvis will help to provide greater external hip rotation.  On the other hand, if the flexed pelvis is secondary to shortened hip rotator muscles, then corrective exercises to increase the range of motion of the hip internal rotators will be needed.  This can be accomplished by stretching the shortened internal rotators and strengthening the antagonist external rotator muscles.

 

 

 

Stretching and Increasing Motion

Tightness of the external rotator muscles will limit internal rotation of the hip, while shortening of the internal rotators decreases external hip rotation.  For some hip problems, improving the flexibility of short and tight muscles is necessary.  Frequent, gentle, and sustained stretching of either the internal or external rotators should be demonstrated to the patient, who can usually start the stretching immediately, even in the early stages of chiropractic treatment.

 

 

 

Piriformis syndrome and iliotibial band syndrome are two hip conditions that benefit from specific stretching exercises.  In both of these, tight muscles contribute to an overuse condition that irritates sensitive tissues.  Care must include inward rotation stretches for the piriformis muscle, corrections of subluxations and biomechanical faults of the pelvis, as well as predisposing factors such as an anatomically short leg and/or foot pronation.⁴  Correction of abnormal biomechanics such as leg length discrepancies must also be part of the care program.⁵

 

 

 

Resistance Strengthening

Weaker or injured muscles can be quickly strengthened with the use of isotonic resistance exercises.  The resistance can come from a machine, from weights, from elastic tubing, or just using the weight of the body.  Since the hip functions as part of a closed kinetic chain during most daily and sports activities, weight-bearing exercises, which require the co-contraction of accessory and stabilizing muscles, can be most effective.  Open chain exercising (done with the foot and lower leg freely moving) is most helpful in the early stages of hip strengthening, to reduce the stress on the surrounding muscles after an injury.  With athletes, exercise selection should also consider the sport-specific movement patterns.  Kickers (such as soccer players and martial artists) can concentrate on open chain strengthening, while runners and golfers will benefit more from closed chain exercises.

 

 

 

Open chain exercises.  Open chain exercising can be started very early with a symptomatic hip, since it doesn’t require the musculoskeletal structures to bear the weight of the body.  The easiest method is to rotate the entire leg against the resistance of elastic tubing.  Initial exercising should be done with a limited amount of movement, within a pain-free range of motion.  These exercises are particularly useful for patients who have an injured rotator muscle, or even a “snapping hip.”  Strengthening of the muscle and tendon involved in a snapping hip (such as the tensor fascia lata, iliopsoas, or biceps femoris muscles) is, maybe, more useful than stretching for resolving the snapping.⁶  Rehab for patients with any evidence of degenerative arthritis of the hip should also start with open chain exercising, since the joint is more safely exercised when the damaged cartilage is not bearing weight directly.  As the patient progresses, additional resistance can safely be supplied with heavier tubing.

 

 

 

Closed chain exercises.  Weight-bearing strengthening exercises, with the foot on the floor, should be included when an athlete is preparing to return to sports activities.  Examples of closed chain exercises for the hip rotators include partial squats, lunges (especially to the side), and single-leg body rotations.  Initially, body weight is sufficient.  Resistance can be gradually and progressively increased with the use of hand weights or elastic tubing.  The particular benefit from closed chain exercises is their ability to re-train the co-contractions of accessory hip support muscles.

 

 

 

Functional Hip Alignment

A major underlying reason for developing an imbalance in the hip rotator muscles is an imbalance in weight-bearing alignment of the lower extremities.  Alignment problems need to be addressed in order to prevent recurring hip muscle imbalances and eventual joint arthritis.  Leg length discrepancies and foot pronation problems are frequently found in association with symptomatic muscle imbalances such as iliotibial band syndrome, and piriformis syndrome.  Osteoarthritis is much more common in the hip joint of a longer leg.⁷  Recurrent muscle strains (especially hamstring and groin pulls) can be an indicator of asymmetry in structural alignment.  The use of custom-made orthotics and/or heel lifts is often necessary in order to establish long-term balance in the hip muscles.

 

 

 

Conclusion

Early in their treatment, patients with hip complaints and sports injuries should be started on appropriate and progressive rehabilitative programs that include muscle stretching and strengthening.⁸  These rehab techniques are easy and accessible, since they do not require expensive equipment or great time commitments.  It isn’t difficult to select the best exercise approach for each patient’s hip problem.  A home exercise program which is closely monitored allows the doctor of chiropractic to provide rehabilitative care which is cost efficient and effective.

 

 

 

Muscle alignment problems are frequently found in association with chronic and/or recurring hip imbalances.  Therefore, patients must be screened for excessive leg length discrepancies and/or pronation.  Proper alignment and support of the lower extremities will lead to muscles that are strengthened and lengthened, and hip joints that work smoothly. 

 

 

 

Kim D. Christensen, DC, CCSP, CSCS, DACRB, 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.  Dr. Christensen is currently a postgraduate faculty member of numerous chiropractic colleges and is the president of the American Chiropractic Association (ACA) Rehab Council.  He is a “Certified Strength and Conditioning Specialist,” certified by the National Strength and Conditioning Association.  Dr. Christensen is the author of numerous publications and texts on musculoskeletal rehabilitation and nutrition.  He can be reached at Chiropractic Rehabilitation Assoc.,, 18604 NW 64th Avenue, Ridgefield, WA 98642 or by email at [email protected].

 

 

 

References

 

1. Hruska R. Pelvic stability: influences of lower extremity kinematics. Biomechanics 1998; 5:23-29.
2. Regan DP. Implications of hip rotators in lumbar spine injuries. Strength Cond J 2000; 22(6):7-13.
3. Ninos J. A chain reaction: the hip rotators. Strength Cond J 2001; 23(2):26-27.
4. Souza TA. Differential Diagnosis for the Chiropractor: Protocols and Algorithms. Gaithersburg, MD: Aspen Publishers, 1998:134.
5. Subotnick SI. Sports Medicine of the Lower Extremity. New York: Churchill Livingstone, 1989:312.
6. Souza TA. Differential Diagnosis for the Chiropractor: Protocols and Algorithms. Gaithersburg, MD: Aspen Publishers, 1998:265.
7. Friberg O. Clinical symptoms and biomechanics of lumbar spine and hip joint in leg length inequality. Spine 1983; 8:643-645.
8. Heiser JR. Rehabilitation of lower extremity athletic injuries. Contemp Podiat Phys 1992; Aug:20-27.

As the population ages and becomes more sedentary, we will be seeing more of our patients affected by osteoporosis and its complications.  Initially, there is a reduction in bone mass (osteopenia), which is considered a universal phenomenon of aging.  However, when the condition progresses to osteoporosis, bone strength is compromised, and fractures develop with trivial (or no) trauma.  These fractures may affect the extremities, the hip, and the spine.  Physical activity and exercise have been shown to provide significant protection from osteoporosis1 and fractures.2  We have a duty to identify those patients who are at risk of fracture, and to provide exercise recommendations that will decrease that risk.  We can tailor exercise programs to prevent the spinal complications of osteoporosis, such as kyphosis, vertebral wedging, and compression fractures.

Benefits of Exercise to Bone

As recalled from the principle known as Wolff’s Law, bone density and strength are a function of the magnitude and direction of the mechanical stresses that act on bone.3  Assuming the availability of necessary nutrients, stimulus to the osteoblasts results in a net gain in bone mass.  Exercise is a form of repetitive loading that facilitates osteoblastic activity, thereby helping to maintain a positive balance between bone formation and bone resorption.4  Even a moderate amount of exercise that is recommended for general wellness (a minimum of thirty minutes on most days) is helpful in preventing osteoporosis.5

Exercise Types

Aerobic/endurance.  Walking and swimming are two of the most commonly recommended forms of exercise for the elderly.  While improved aerobic capacity is generally beneficial for most older patients, we mustn’t expect any skeletal improvement.  Bone mineral density can be increased by walking, but only when it is done above the anaerobic threshold.6  It is unlikely that most older women, especially sedentary women, will be willing to walk at this intensity.  As for swimming, there is no significant difference in bone mass between women participating in a regular swimming program and women who don’t swim.7  This is also true of a standard weightbearing, water-based exercise program (aquacise).8
Impact/weightbearing.  In order to create sufficient stimulus to increase bone density, exercise needs to be weightbearing and have some impact.  This can be as simple as step-training (ten minutes stepping up and down from an eight-inch high step).1  Use caution when recommending impact exercise to elderly patients.
All exercises are more effective when done in an upright, weight-bearing position, since the entire body is in a closed-chain position during 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 for the elderly—not just for increasing bone density, but also for preventing stumbles and falls.
Resistance/strength.  High-intensity resistance training has been found to be safe and quite effective in increasing strength and function in the elderly.9  Older patients make similar relative, but smaller absolute, strength gains when compared with younger adults.  Weight training in a submaximal controlled, supervised situation can also preserve10 and even increase11 bone deposition.  Strength training recommendations should be an integral part of chiropractic treatment for older and osteoporotic patients.  Exercise tubing is an excellent tool for strength training of the elderly, since the risks of injury are minimized, and a spotter or expensive equipment is not needed.

Spinal Osteoporosis

Spinal X-rays often reveal osteopenia and osteoporosis.  By the time changes are visible on X-ray, however, substantial bone loss has already occurred.  The most common fractures due to osteoporosis are vertebral fractures, and yet less than a third u u of all vertebral fractures are clinically diagnosed.12  These skeletal of all vertebral fractures are clinically diagnosed.12  These skeletal changes can have a significant impact on posture and our ability to handle subluxation complexes.  Specific rehabilitative exercises should be recommended to relieve the postural strain on the spine and to prevent further wedging and compression fractures.  Avoiding exercise is the worst approach for an aging patient with osteoporosis.  Back strengthening exercise constitutes a powerful intervention for reducing pain and increasing functional capacity.
A warning:  Some of the commonly used back exercises may  contribute to increased symptoms.  For patients with spinal osteoporosis, harmful activity places an anterior load on the vertebral bodies.  Patient education must emphasize the dangers of lifting in flexion, and of, possibly, flexion exercises.  In fact, one exercise study13 found an increase in new vertebral deformities when postmenopausal women performed flexion exercises (such as forward stretches and abdominal curls), while those who performed only spinal extension exercises had a significant reduction in the number of vertebral compressions.

Corrective Spinal Exercises

Spinal osteoporosis is often associated with poor postural support, specifically an increase in the thoracic kyphosis.  This posture is secondary to many decades of flexed activities, and may be compounded by poor posture habits and tendencies to slump.  One important factor in chiropractic care is to correct any loss of the normal upright alignment of the pelvis and spine.  In addition to general strengthening and coordination exercises, all patients (especially the elderly) should be given corrective exercises that are specific for the postural imbalances they have developed. 

Conclusion

A well-designed exercise program can improve posture, help to reduce bone loss, and prevent fractures, while also reducing symptoms.  Exercises performed with the spine upright (standing or sitting) can specifically train and condition all the involved structures to work together smoothly.  The end result is an effective rehab component for osteoporosis and aging patients who will make a rapid response to their chiropractic care.

 

Kim D. Christensen, DC, CCSP, CSCS, DACRB, 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.  Dr. Christensen is currently a postgraduate faculty member of numerous chiropractic colleges and is the president of the American Chiropractic Association (ACA) Rehab Council.  He is a “Certified Strength and Conditioning Specialist,” certified by the National Strength and Conditioning Association.  Dr. Christensen is the author of numerous publications and texts on musculoskeletal rehabilitation and nutrition.  He can be reached at Chiropractic Rehabilitation Assoc., 18604 NW 64th Avenue, Ridgefield, WA 98642 or by email at [email protected].

References
1. Chien MY, Wu YT, Hsu AT, et al. Efficacy of a 24-week aerobic exercise program for osteopenic postmenopausal women. Calcif Tissue Int. 2000; 67:443-448.
2. Campbell AJ, Robertson MC, Gardner MM, et al. Randomised controlled trial of a general practice programme of home based exercise to prevent falls in elderly women. Br Med J. 1997; 315:1065-1069.
3. Davies GJ. A Compendium of Isokinetics in Clinical Usage. La Crosse, WI: S & S Publishers; 1984.
4. Pirnay FM. Bone mineral content and physical activity. Int J Sports Med. 1987; 8:331-335.
5. US Dept. of Health and Human Services. Physical Activity and Health: A Report of the Surgeon General. Atlanta: 1996. 
6. Hatori M, Hasegawa A, Adachi H, et al. The effects of walking at the anaerobic threshold level on vertebral bone loss in postmenopausal women. Calcif Tissue Int. 1993; 52:411-414.
7. Orwoll ES, Ferar J, Oviatt SK, et al. The relationship of swimming exercise to bone mass in men and women. Arch Intern Med. 1989; 149:2197-2200.
8. Bravo G, Gauthier P, Roy PM, et al. A weight-bearing, water-based exercise program for osteopenic women: its impact on bone, functional fitness, and well-being. Arch Phys Med Rehabil. 1997; 78:1375-1380.
9. Fiatarone MA, Marks EC, Ryan ND, et al. High-intensity strength training in nonagenarians: effects on skeletal muscle. JAMA. 1990; 263:3029-3034.
10. Nelson ME, Fiatarone MA, Morganti CM, et al. Effects of high-intensity strength training on multiple risk factors for osteoporotic fractures. JAMA. 1994; 272:1909-1914.
11. Kerr D, Ackland T, Maslen B, et al. Resistance training over 2 years increases bone mass in calcium-replete postmenopausal women. J Bone Miner Res. 2001; 16:175-181.
12. Ross PD. Clinical consequences of vertebral fractures. Am J Med. 1997; 103:30S-43S.
13. Sinaki M, Mikkelsen BA. Postmenopausal spinal osteoporosis: flexion versus extension exercises. Arch Phys Med Rehabil. 1984; 65:593-596.

Having a sport and rehab facility demands great expertise and close attention to detail in treatment protocols.  In such settings, doctors often rely on objective findings of manual testing.  Nonetheless, given the explosive level of technology available today, it is ludicrous for any doctor to rely strictly on “manual findings.”  One of the greatest sources of objective findings available, to date, to all doctors but especially in rehab and sport facility settings is the use of diagnostic radiology.  Indeed, the information that can be gathered using diagnostic radiology is very impressive. 

What is the benefit of diagnostic radiology?
After a thorough physical examination has been done and the need for the X-rays has been established, X-rays are sent to a specialized company which uses highly technical equipment and techniques to produce computerized enhancement of the radiographic plain films.  One of the enhancements is called digital radiographic mensuration.  The X-rays are scanned, and multiple landmarks are selected and stored in a location separate from the image.  The numbered data, “landmarks,” are later used to reconstruct a variety of biomechanical relationships and measurements that are useful to the doctor and the patient.  The diagnostic analyses, as well as biomechanical data, are extracted from these plain film radiographs and are then displayed on high-resolution monitors using comparative standards and technical procedures.  These visuals of radiographic imaging are used objectively to analyze the biomechanical properties of the spine.  At least fifty-nine biomechanical analyses for diagnostic purposes can be performed on such instruments.  (See Table 1 to for a list of a few examples)
Using highly technical equipment and techniques produces computerized enhancement of the radiographic plain films, that can then be used to perform at least fifty-nine biomechanical analyses for diagnostic purposes. Here are some Examples:

• Atlas Skull Line
• Stress Line 
• Skull Line Baselines 
• Thoracic Apex                          
• Baseline Atlas                         
• Stenosis
• Spinal Length 
• Occiput Angle  
• Ferguson’s Angle 
• Sacrum Angle
• Penning’s Range of Motion 
• Thoracic Kyphosis  
• Jackson’s Angle 
• Lumbar Instability  
• Motion Segment Integrity 
• Vertebral Offset 
• George’s Line 
• Atlas/Axis Angle  
• Lumbar Gravity Line 
• Vertebral Body Rotation 
• Pelvic Rotation 
• Lumbar Lordosis  
• Cobb’s Angle 
• Spondylolisthesis

It becomes medically necessary for a sports and rehab facility to fully assess the degree of injury and its effect on the patient’s health and future well-being.  Reports obtained from digital analysis include impairment ratings, per the American Medical Association (AMA) Guides to the Evaluation of Permanent Impairment. 

Defining “disability”
American Medical Association Guides evaluate Medical Disability as well as Permanent Impairment.  The term disability has historically referred to a broad category of individuals with diverse limitations and the ability to meet social or occupational demands.  However, it is more accurate to refer to the specific activity or role the “disabled” individual is unable to perform.  Several organizations are moving away from the term disability and, instead, are referring to specific activity limitations to encourage an emphasis on the specific activities the individual can perform and to identify how the environment can be altered to enable the individual to perform the activities associated with various social or occupational roles.  Nonetheless, Guides to the Evaluation of Permanent Impairment defines disability as “an alteration of an individual’s capacity to meet personal, social, or occupational demands or statutory or regulatory requirements because of an impairment”.  (American Medical Association. Guides to the Evaluation of Permanent Impairment. 5th  ed. Chicago, Ill: American Medical Association; 1993)

What are the benefits to the patients?
We live in an age when patients are particular about their health care needs and are demanding that their doctors under- u u stand not only the need for specific treatment, but also the findings of the objective testing.
Using diagnostic radiology will bring the following benefits to the patient:

• Films read by a board certified radiologist 
• Photographic reproduction of the patient’s film images, printed with complete measurements and displayed next to comparatively normal images, should be shown to the patient to explain the findings and insure patient retention.  If the healthcare practitioner has expertise and is well acquainted with the individual’s activities and needs, then he or she must express an opinion about the presence or absence of the specific disability and how this will impact the patient’s daily activities.

Benefits to a Rehab Center
Rehab centers are often made up of exercise physiologists, body trainers, physical therapists (Pt’s), Pt aids, Pt assistants, chiropractic practitioners and others.  These sports and rehabilitation oriented practitioners, although very knowledgeable in assessing a patient’s diagnosis, can greatly benefit by the highly technical, yet diversified, information which is gathered from diagnostic radiology.
Because every patient’s injury or disease is different and every patient responds differently to treatment, the information obtained from the digital analysis of radiographic images can prove or disprove the necessity for further treatment.  This information is then used to customize the most effective treatment protocol for the patient’s injury and/or disease and may cut down on or eliminate unnecessary treatment.
Biomechanical measurements are vital and are critical to the appropriate diagnosis analysis, treatment, and prognosis of the sports injury patient in a clinical environment.  With accurate measurements, a fundamental base line can be determined and can further be explored for an accurate and reliable assessment of the patient’s condition and outcome potential. 
There is also a financial benefit, since the referring doctor gets reimbursed u  u for the professional confirmatory component above and beyond the X-ray coding.

Below are a few samples of indications for diagnostic radiology.

• Sprains/ Strains
• Trauma
• Motor vehicular accidents
• Sports induced injuries
• Work related injuries

On a side note, and as a fundamental basis, DC’s often deal with the dynamics of the musculoskeletal system, whether or not the clinical neurological components exist. 
Simply stated, the science of chiropractic is founded on the premise that adequate nerve supply is of prime importance in regulating body function.  Hence, radiographic measurements obtained from diagnostic radiology and utilized in a rehab facility can:

• Increase Personal Injury referral
• Enhance reputation
• Increase patient compliance
• Support insurance claims with scientific medical proof
• Provide attorneys with professional documentation
• Increase collections 

How to implement diagnostic radiology

1. Determine need for X-rays.
2. Take flexion/extension study of cervical or lumbar area (or both, if needed).
3. Referring doctor reads films and gives brief impression to patient.
4. Films are sent for digitization and for impression by Board Certified Radiologist (licensed in the state where patient is being treated).
5. Analysis is done and returned to referring doctor.
6. Treatment protocol is established and information is given over to patient.
7. Service is billed for consultation to proper carrier.

In conclusion, other procedures (i.e., NCV, SSEP, MRI, US, Electromyography, etc.) should always be correlated to clinical history, physical examination and radiographic findings for a more comprehensive and complete picture of the patient’s status.  Digitized radiology has shown reliability, accuracy and benefit paralleled to this time in history with respect to spinal radiographic analysis.  In determining need for treatment, type of treatment to be administered, and/or monitoring of changes of treatment resulting from re-injury, for prognosis, digitized analysis for radiology is an effective outcome assessment device and methodology for chiropractic services in a rehab facility.

Aadam Quraishi, MD, was a clinical instructor at New York University Medical Center.  He is board certified in radi-ology and has additional fellowship trained qualifications.  He has seventeen years of medical practice experience.
Dr. Quraishi specializes in Vascular and Interventional Radiology MRI (Neuro and Musculosketal), MRA Mammography, Breast Localization, Nuclear Medicine CT and Ultrasound.  Dr. Quraishi has board certification in Diagnostic Radiology, and can be contacted at [email protected].  For more information and/or sample reports, go to www.aboutpdi.com.