Category: Rehabilitation

About 83 million people in the U.S. (42% of the adult population) used at least one alternative therapy in 1997.  Usage among those 35-40-years-old is even higher, at 50%.

The estimated number of visits in 1997 to providers of “unconventional therapy”  (629 million) was greater than the number of visits to all primary care medical doctors nationwide (386 million).
Americans spent $21 billion out-of-pocket on visits to alternative practitioners in 1997 (an increase of 45% over 1990’s total).  This does not include money spent on retail products, such as herbal products ($5.1 billion), books, classes and equipment ($4.7 billion).  By comparison, out-of-pocket expenditures for physician visits were $29.3 billion and for hospitalizations were $9.1 billion.

We have to ask why 42.1 percent of U.S. citizens surveyed used at least one of sixteen alternative medicine practitioners, increasing from 427 million in 1990 to 629 million in 1997, exceeding the total visits to primary care physicians.  What is of greater interest is that these statistics have continued to increase—by 3.6% between the years of 2001 and 2002. 

None of these statistics, however, come close to the billions Americans spend on exercise and fitness.  Over 50% of the American population is overweight and the number is growing.  What does this all mean for the primary healthcare provider such as a DC?  The DC, basically, has to be prepared to diversify his/her services and, most of all, create a center where exercise and rehabilitative therapy are key components.
DC’s have always looked for ways to increase their income, often by learning new techniques or buying some expensive piece of diagnostic equipment.  While these can be valuable investments, they are not as effective as knowing how to establish, manage and/or promote a rehab center.

Following are the basic protocols, which have to be put into place to establish a rehab center. (See Table 1).

Table 1. basic protocols to establish a rehab center
1. Necessary Education:  Proficiency in sports medicine.
2. Professional Staff:  Exercise physiologist, physical therapist, physical therapist aide, and/or assistant, fitness trainer, massage therapist.
3. Equipment: Minimum equipment necessary is a full body station, treadmill, enlarged physical therapy table, various weights, stationary bike, exercise mats.  Miscellaneous:  towels, theraband, cold packs, etc.
Approximate initial cost of total equipment, between $10,000 to $15,000
Certification is a must for all professionals
Ideal size room, 800 sq. ft.

Table 2. Most Common Scenario Used in Rehab Facility
1. Doctor initial exam
2. X-Ray/ancillary services
3. Treatment protocol established and started
4. Diagnostic testing
5. Rehab with PT (4 weeks)
6. Re-exam to update or change diagnosis
7. Rehab with PT (4-8 weeks)
8. Discharge

Table 3. 10 Steps to Opening Date
1. Plan out (draw out) rehab room space
2. Interview and hire professional staff
3. Design marketing plan (newspaper ads, coupons, flyers, etc.) and allocate marketing budget ($3,000 to $5,000)
4. Purchase equipment (ask accountant if leasing is better option)
5. Understand billing codes and implement rehab form (See Table 4)
6. Create appointment script for front desk
7. Train office staff
8. Send letter to all local businesses
9. Send announcement letter to all active patients
10.Have grand opening day (balloons, prizes, music…)

Expected Reimbursement in Rehab Exercise Facility
The above scenario is by far the most practical flow that will allow the highest reimbursement.  It is important to take into consideration that insurance companies do not approve “medical maintenance care”.  Insurance companies will pay for treatment, but not for exercise physiology and/or rehabilitative medicine when used to enhance a patient’s stamina or endurance.  Insurance companies are interested in treating patients and rehabilitating them, given serious practice medical diagnosis.

Table 4. reimbursements for rehab patients
Total reimbursements for rehab patients vary between $4,500 to $6,500. CPT codes most often used are as follows:
97535   Activities of Daily Living
97112   Neuromuscular Re-education of movement, balance, coordination, kinesthetic sense, Posture, and/or proprioception for sitting and/or standing activities
97110   Therapeutic procedure, each  15 min., therapeutic exercise to develop strength and endurance, range of motion and flexibility.
97530   Therapeutic activities, direct patient contact by the provider, each 15 min.
97799   Unlisted Physical Medicine/Rehab service or procedure
97139   Unlisted Therapeutic Procedure (specify)
97150   Therapeutic procedure(s), group (2 or more individuals)
97750   Physical Performance Test or Measurement w/report
97504   Orthotic(s) fitting and training, upper and lower extremities, each 15 min.
97520   Prosthetic Training, each 15 min.
97140   Manual Therapy techniques (Manual Traction), each 15 min.
97124   Massage Therapy, including effleurage, petrissage, and/or tapotement
97113   Aquatic Therapy with therapeutic exercises
97537   Community/Work Reintegration Training, direct contact, each 15 min.
97542   Wheelchair Management/Propulsion Training, each 15 min.
97703   Checkout for orthotic/prosthetic use established patient, each 15 min.
97545   Work Hardening/Conditioning (initial 2 hrs.)
97546   Each additional hour (list separately in addition to code for primary procedure).  (Use 97546 in conjunction with code 97545)
97116   Gait Training
95833   Total Evaluation of Body w/o Hands
95834   Total Evaluation of body w/ Hands
95851   ROM Measure w/Report, each extremity
95852   Hand w/ or w/o Comparison to Normal Side

Objective Testing That Can Be Used to Support Medical Necessity and Enhance Medical Records
1. X-Rays
2. Digitized Radiographic Mensurations
3. MRI
4. Neurological Diagnostic Testing

General Discussion
Overall, a rehabilitation center is a great addition for any practitioner.  Using diversified healthcare, the doctor has the ability to promote the best treatment protocol available.  The core problem in healthcare today lies in the fact that there are currently not significant entities that can provide quality care at sufficiently low prices on a large enough scale to service the overwhelming needs of the population.
By creating a rehab sport center, a clinic will provide a viable solution to the healthcare crisis, by integrating the skills of the chiropractor and various other healthcare practitioners, such as exercise physiologist, physical therapist, etc., leading to the development of a profitable venture.  This, by all means, is the wave of the future.

Dr. Daniel H. Dahan owned and operated one of the most successful clinics in Southern California.  As previous chairman of the West Coast Medical Advisory Board and writer/editor for the Sun’s Weekly Health Column, Dr. Dahan, the President of Practice Perfect, developed a successful management and consulting health care system for doctors throughout the United States.  His seminars are rated among the best and most proliferate lectures in the country.  Dr. Dahan has taught over 4700 doctors and integrated 800+ offices in 45 states.  He can be contacted at [email protected].  For more information, go to www.dahan.com.

A large percentage of patients don’t perform the home-based rehabilitative exercises that are recommended to them.¹  Even though you spend precious time deciding which exercises will be helpful and explaining them to the patient, your experience has probably been the same as most chiropractors:  Too many patients just can’t seem to do their exercises.  And yet, you know that if they would just do the exercises, they would get better faster.  Patient cooperation and satisfaction with at-home exercise programs are important for successful outcomes.²

In my opinion, each patient has several barriers or “hurdles” to get over in order to reach the goal of exercising.  The more hurdles we can lower or even eliminate, the more likely it is that the exercises will get done.  Here are some ways to lower the hurdles and help your patients get to the “‘finish line.”

Small Beginnings

Lower the first big hurdle by recommending only one (or, at most, two) exercise(s) initially.  This minimizes the start-up effort and decreases the amount of time required.  Once a patient has been doing one or two exercises regularly for a couple of weeks, additional or more complex exercises can be more easily implemented.

Consistency for Success

Consistency helps to ensure success in many areas.  When a new habit needs to be learned, frequent and regular repetition helps.³  Trying to schedule exercises into a busy schedule is difficult, especially when your patient has to decide which days to exercise and which days to rest.  Since rehabilitative exercises do not tear down muscles, daily exercising is safe, and the scheduling hurdle can be eliminated.  Instruct your patients to “do the exercises every day.”

Why, What, and How

Make sure your patient knows why the exercise needs to be done, and what benefits to expect.  Motivation improves compliance with exercise.⁴  Motivation is much better when a purpose is understood and a mutual goal has been established.  Explain that doing the exercise will help your patient better perform the activities he or she enjoys.

Simple Is Best

Keep instructions to patients clear and simple.  This is particularly important when discussing the numbers of repetitions and “sets” (groups of repetitions).  Many doctors recommend six repetitions of the exercise, followed by a brief (up to one minute) rest, done three times.  This “three sets of six” concept is quick to perform and easy to understand.  Recent research has shown that only one set of ten-to-twelve repetitions can be just as effective.  This is particularly true when patients are just starting to exercise, and especially when they are exercising daily.  Use either approach, but keep the instructions clear.

Using the “Whenever” Approach

Any time of day is the right time to exercise—what’s most important is getting the exercises done.  Even though some professionals feel that athletic activities are somewhat safer in the afternoon (when muscles and joints are warmer), encourage your patients to exercise whenever it works for their schedule (and once a day is plenty). 

Utilize Allies

A spouse or family member should accompany the patient when exercises are taught, so they can help ensure correct and regular performance of the exercise.  A second person who wants your patient to get better can be a tremendous ally,¹ one who will provide encouragement and reminders.

Focus on Function

Focus your patients on function by keeping them off the floor.  Exercising in a weight-bearing position is actually easier for 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 an exercise that clearly prepares them for better function during normal activities of daily life.  

Provide Demonstration

Demonstrate, then watch and correct your patients’ performance of the exercise.  When patients need an exercise, they usually can’t do the exercise correctly.  Diagrams, pictures, even videos can’t ensure that patients will be able to figure out the suggested exercise.  When you spend the time to show them the exercise, and then you guide them through it, they realize that you believe this is an important part of their treatment.  Patients are then much more likely to do the exercise.¹

Keep it Easy

Well-designed, easy-to-use home rehab equipment helps to ensure compliance.⁵  Home equipment should be easy to figure out and set up, and should help guide your patients through the necessary exercises.

Monitor and Praise

As an integral part of their rehab while under your care, all patients must record their exercising in some form of exercise log.  This allows them to “give themselves a pat on the back” each time they do the exercise.  And remind them to bring the exercise log with them to every adjustment, so you can see how the exercises are going.  Make sure to give them praise and recognition for the exercises they perform.

Rehab Review

At least once a week, have the patient perform their exercise in front of you.  This allows you to confirm that it’s being done properly, and you can correct any faults that creep in.  A regular review also reinforces, in the patient’s mind, the importance of the exercising and encourages them to continue.

Aim for a Rapid Response

There is nothing more motivating than the feeling that the most important exercises are being done.  Make sure that the exercise(s) you are recommending will produce a rapid response, so the patient starts to feel the benefits of the exercising immediately.  Don’t give all patients the same six exercises; instead, try to start the patient on the most important exercise for his or her condition.¹

Gradual Development

If you implement these rehab tips, your patients will be more likely to do their exercises faithfully.  Once they have established the habit of doing one or two exercises, you can use the rehab review to add other exercises.  With this method, a patient can gradually develop a good general fitness and spinal health exercise program while under your care.

Word will soon get around your community that you care enough about your patients to help them establish a regular spinal health and exercise program.  This will build your practice, and also improve the reputation of chiropractic for years to come.

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 Consulting, 18604 NW 64th Avenue, Ridgefield, WA 98642 or by email at [email protected].

References

1. Kamiya A, Ohsawa I, et al. A clinical survey on the compliance of exercise therapy for diabetic outpatients. Diabetes Res Clin Pract 1995; 27(2):141-145.
2. Chen CY, Neufeld PS, et al. Factors influencing compliance with home exercise programs among patients with upper-extremity impairment. Am J Occup Ther 1999; 53(2):171-180.
3. Rejeski WJ, Brawley LR, et al. Compliance to exercise therapy in older participants with knee osteoarthritis: implications for treating disability. Med Sci Sports Exerc 1997; 29(8):977-985.
4. Friedrich M, Gittler G, et al. Combined exercise and motivation program: effect on the compliance and level of disability of patients with chronic low back pain: a randomized controlled trial. Arch Phys Med Rehabil 1998; 79(5):475-487.
5. Stenstrom CH, Arge B, Sundbom A. Home exercise and compliance in inflammatory rheumatic diseases: a prospective clinical trial. J Rheumatol 1997; 24(3):4700-476.

Patients receiving rehab care for various chronic or acute neck problems often come across advertisements promoting special “neck support” pillows.  Cervical support pillows are recommended by many chiropractors, physiotherapists, and even surgeons.  In a 1998 comparison study of three types of bed pillows, the authors write, “From a patient’s perspective, neck support is an important part of a comprehensive physiotherapy program.”1  Most bedding stores and sleep shops have at least one special pillow (and often there are several) for people with neck pain. 
While many doctors of chiropractic have recommended cervical support pillows for years, the scientific evidence for benefit has been skimpy, at best.1-5  Empirical and anecdotal reports from patients who report “improved sleep” and “decreased pain” have often been all that is available.

Scientific Studies

Let’s review three scientific studies2-4 which have attempted to address some of the questions regarding cervical pillows.  Although each of these three took different investigative approaches and evaluated different pillows—which means that the findings are not directly comparable, and no definitive conclusions can be made—the results are still worth consideration, since they give us some guidance in selecting a support pillow for our patients.
Two-pillow comparison study.  In a study2 performed at the Johns Hopkins University School of Medicine, Drs. Lavin, Pappagallo, and Kuhlemeier recruited forty-six subjects with chronic neck pain and cervicogenic headaches.  The investigation compared the subjects’ daily pain levels, sleep quality, and medication consumption during one week on their own pillows, followed by two weeks each on two special neck support pillows.  One of the pillows was a “cervical roll” style and the other was a “water-based cervical pillow.”  A statistically significant improvement in all scores was recorded when using the water pillow.  Most subjects preferred the water pillow to their own pillow, and many had a very difficult time sleeping on the roll pillow.  In fact, the researchers reported that some of the patients had to discontinue the two-week trial of the roll pillow due to significant discomfort. 
The investigators felt that the higher satisfaction ratings of the water pillow were due to its ability to conform better to the position and shape of the subjects’ head and neck during various sleep positions.  They believed that the roll pillow was not well tolerated due to its tendency to exaggerate the extension of the neck when supine (since there was no support underneath the head).
Single-style study.  A small feasibility study3 at Canadian Memorial Chiropractic College seemed to find very different results.  After recording two weeks of baseline pain ratings in thirty subjects with chronic neck pain, the researchers supplied a roll-type cervical pillow (a soft cylinder shape).  Of those who persevered in using the pillow for four weeks (many subjects found the pillow to be very uncomfortable initially), most reported decreases in neck pain.  However, three subjects described increased neck pain during use of the pillow, and two women dropped out of the trial, saying they were unable to tolerate the discomfort they experienced while using the cylindrical pillow.  Since the data collected do not reflect these “pillow failures,” and since there was no placebo or comparison with other pillows, this study’s conclusions should be considered overly optimistic.  This demonstrates the difficulty in designing a scientifically valid and practically useful scientific investigation.
Six-pillow comparison study.  At Lund University Hospital in Sweden, researchers4 studied the responses of fifty-five subjects to three nights on each of six different pillows.  However, none of the six pillows included their own pillows, and none was the same as the two types studied in the previous experiments.  Since no “roll-type” pillows were included, we are left without a practical comparison to the other studies. 
The subjects in this experiment rated the six pillows for comfort, but were also asked about pain reduction and sleep improvement.  The six pillows varied in their designs, materials, and construction. 
One pillow stood out from the rest as the most comfortable, and also the most likely to decrease chronic pain.  Rated the “best” by both men and women, this pillow was made of soft polyurethane with two firm supports along the edges—one side high and the other side lower.  This pillow supplied an easily tolerated support for the neck, while the two different sides provided a choice of heights.  The pillow that rated the lowest was the one which most closely resembled a roll pillow.
The investigators concluded that the optimal neck pillow to reduce neck pain and improve night rest was a soft, not-too-high pillow with support for the cervical lordosis from a choice of firmer cores.  Since the participants used each pillow for only three nights, and only comfort ratings were evaluated, no conclusions can be drawn from this study regarding the long-term effect of these pillows on pain or sleep patterns.

The Search for Healthy Sleep.

When patients report chronic neck pain, cervicobrachialgia, and/or cervico-genic headaches, or when a patient has been instructed to perform rehabilitative cervical exercises, a cervical support pillow should be considered.  This is especially true when the pain is described as being worse in the morning and improving during the day.  If sleep disturbances are part of the history, or accompanied by a history of injury to the neck, a comfortable, yet supportive pillow should be a part of the chiropractic treatment recommendations. 
The right pillow will vary depending on the size of the person and on the amount of neck support that can be tolerated.  Roll-type cervical pillows are initially uncomfortable, and may worsen some patients.  A pillow which supplies a choice of sides is more likely to be helpful to a broader range of patients.  It is also important to re-evaluate your patients’ pillows, to ensure that proper cervical support continues over time.
Recommending the use of a good cervical support pillow (and supplying one that has a good track record) can be one of the most useful adjunctive procedures to rehabilitative treatment of neck pain.  Patients appreciate the doctor who goes beyond the office setting to give advice regarding supportive home activities, and even specific sleep  recommendations. TAC

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].

The body’s soft connective tissues (such as muscles and ligaments) are generally exposed to stress throughout life.  Such structures respond and adapt to the usual amount of stress exposure.  Damage occurs when soft tissues are exposed to higher-than-usual stress levels.  This can be a single, sudden, excessive stress, or it can be the result of repetitive stress to the muscle or ligament.  In either case, the doctor of chiropractic must determine how the damage occurred, and then make appropriate recommendations (rehab following rest, for example) to help the body heal the injury and to prevent a recurrence. 
Problems can also develop when these tissues are not exposed to sufficient regular stress to maintain functional health.  It’s important to recognize that the soft tissues in the body are normally used in a range of intensity, and that categorizing a patient’s level of use helps in the planning of care and exercise regimens.

The Range of Soft Tissue Use

What we usually consider to be normal use is in the middle of the usage range.  At one end is paralysis, where soft tissues are completely unused.  Close to paralysis is immobilization, such as in use of a cast or bed rest.  The difference between these is that paralysis lacks a neurological stimulus, called “tone,” which is present in immobilized (yet still neurologically intact) muscles and skeletal ligaments.¹  Next is sedentarism, when the ligaments and muscles are used only minimally.  This is also called the “disuse syndrome”.²  This condition is, unfortunately, becoming more common in all age groups in our rich, advanced society, which has so many labor-saving devices.  Normal use can vary widely, but requires the intermittent and regular exercise and use of all muscles and ligaments.  Those who are employed in active (often blue-collar) jobs and people who engage in regular, active recreational pursuits fall into the strenuous use category.  And then there are the athletes, who are always trying to improve and push their limits by specifically building and strengthening their muscular and skeletal ligament tissues.³  Athletes are at the far end of the continuum, demonstrating the body’s response to progressive overload.

Damage through Overuse

The muscles and ligaments in any of the above categories can be overused and damaged.  Less stress is needed to cause injury to tissues in the lower use end of the continuum.  After several days of immobilization, or when someone has been on bed rest or is a couch potato, even mildly strenuous effort can be too much.  Fitness protects from some injuries, especially overuse conditions of the spine.  Athletes, who are regularly pushing their muscles and ligaments, are most likely to end up with either overuse or acute injuries.  There are two major categories of excessive stress to ligaments and muscles—repetitive use (chronic, over time),⁴ and sudden injury (strain or sprain) with tissue tearing.
Repetitive overwhelm.  When muscles and ligaments are stressed, they respond by repairing and strengthening.  In some cases, however, the physical stress occurs so frequently that this process is overcome, resulting in damage.  Examples include runners who quickly increase their mileage, workers who are placed in a new position which requires repetitive movement or bending, and athletes who practice throwing to the point that they injure their shoulders.  Even someone taking up walking after years of standing on rigid flooring can quickly overwhelm the foot’s ability to strengthen, developing plastic deformation of the plantar fascia with arch collapse.
Acute injury.  Of course, trauma to a ligament or muscle is a single episode of stress which causes damage.  When a muscle or ligament is torn, there is immediate pain, followed by swelling and loss of function.  Around the spine, this is often a complex injury, since it is inevitable that several layers of both muscles and connective tissues will have been damaged (a “strain/sprain” injury).  Understanding of the healing response is necessary for good management of acute injuries to muscles and ligaments, wherever their location. 

Healing Response

Whether damaged by repetitive overuse or by acute injury, muscles and ligaments will heal most rapidly and completely when they are cared for properly.  A brief period of “relative rest” is important, the amount depending on the extent of injury.  This may require a brief period of immobilization of the damaged region, followed by gradual reintroduction of movement and activity.5  Then, reactivation is necessary; this usually requires specific exercise instruction and expert guidance.  The patient should be encouraged to return to the level of pre-injury, and then advised on preventing further injury, either by providing additional response time or by improving muscle strength and balance (or both).  Exercise tubing (with areas targeted for rehabilitation) and a wobble board are usually helpful adjuncts.
Occasionally, ligaments become damaged and deformed to the point that full repair is not possible.  In these cases modification of stress may be necessary, either through changes in activities or through the use of supports, such as knee braces or custom foot orthotics.

Conclusion

It is vitally important to understand the status of a patient’s muscle and ligament tissues prior to injury.  It is also necessary to realize how these tissues became overwhelmed.  Was it from an acute injury, or can a history of repetitive insult be uncovered?  Once the doctor of chiropractic has the information for the “start point” and an understanding of the method of stress damage, proper care can proceed rapidly.  This is what separates caring doctors of chiropractic from those providers who prescribe drugs or bed rest for ligament and muscle injuries.  TAC

 

Kim D. Christensen, D.C., C.C.S.P., D.A.C.R.B., 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.  He is currently a postgraduate faculty member of numerous chiropractic colleges and is the president of the American Chiropractic Association (ACA) Rehab Council.  Dr. Christensen is the author of numerous publications and texts on musculoskeletal rehabilitation and nutrition.  He can be reached at Chiropractic Rehabilitation Consulting, 18604 NW 64th Ave., Ridgefield, WA 98642 or by e-mail at [email protected].

Hamstring injuries and athletic running seem to go together.  The injuries also tend to reoccur and become chronic.  Often, the recovery rate becomes frustrating for the athlete as well as the practitioner.  While the etiology remains controversial, the primary causes may be considered, in order to enhance recovery and prevent reinjury.

Main Causes

Some of the most common causes of hamstring muscle strains are:

1. muscle fatigue
2. muscle strength imbalances
3. lack of hamstring flexibility
4. insufficient warm-up

Hamstring muscle strain is a non-contact injury that presents in two ways:  sudden onset with acute pain (runner pulls up and grabs his/her leg), or a more insidious onset of muscle tightness.  Typically the biceps femoris, with or without the semitendinosus, is involved.  The area most commonly inflamed is the proximal and lateral musculotendinous junction of the hamstring near the ischial tuberosity.

Acute Phase Treatment

During the acute, painful phase, the goal is to reduce inflammation.  Ice works best; don’t use heat.  As a general rule, use ice for twenty minutes, every two hours (during the hours the patient is awake), until the pain is gone.  A light towel or face cloth should be used to protect the skin, even though it will dissipate some of the cooling effect.  This treatment may be utilized from two days to two weeks.
The injured athlete should be advised to maintain a normal walking gait, even if it means walking with a cane or crutch on the opposite side (the toe of the cane or crutch should always be in line with the toe of the injured side).  Most athletes aren’t happy with this advice, but to compromise the gait into a hobble will only prolong recovery.

Rehab Protocol

Active knee extension and flexion without resistance should be performed as soon as tolerated by the patient.  Some pain may be experienced during this motion, as long as it is not increased pain.  When the athlete can perform knee extension and flexion with little to no pain it is usually safe to perform these two range-of-motion exercises against resistance with an at-home rehab system.  Be particularly aware of pain.  Initially, the range of motion and/or the amount of resistance may be limited.  Set them to patient tolerance.
Do the uninvolved side first.  An effective protocol is:

 • 1 set to fatigue of knee extension (uninvolved side)
 • 1 set to fatigue of knee extension (involved side)
 • 1 set to fatigue of knee flexion (uninvolved side)
 • 1 set to fatigue of knee flexion (involved side)

Repeat the sequence above two more times.  This protocol should be done daily at first, and then progressed to twice daily as the patient recovers.
I recommend doing one extra set of knee extension exercises, because according to the hierarchy of strength in the body, the extensor should be slightly stronger than the flexor.
If any soreness develops, follow the rehab exercises with ice.  Do not let your patients overwork themselves.  Athletes have a tendency to do too much too soon and reinjury occurs.  This type of protocol is designed to facilitate neurologic firing into the involved muscle(s) and initial strength gains.  As muscles get stronger they will naturally be able to do more.  Let pain be your guide.  This type of exercise will also build up endurance levels over time.

Proper Stretching Activity

Stretching is important, but only if done correctly.  Many people stretch their hamstrings by bending over a propped-up knee and curling their back to touch their forehead to their knee.  This will not effectively stretch the upper portion of the hamstrings where the injury site is.  Do that stretch, but arch the lower back to create anterior pelvic tilting and lean the body forward, keeping the head level.

Evaluation of Progress

To progress to activity, an athlete should be able to:

1. walk without discomfort
2. jog straight ahead without discomfort
3. run straight ahead without discomfort
4. run with change of directions without discomfort
5. perform the tasks of his/her athletic activity without discomfort

As with any condition involving the lower extremity, thoroughly evaluate the sacroiliac joints and the spine.  Subluxation complexes can create structural imbalances, and muscular imbalances may also be playing a role.

Orthotic Support

You must also look for involvement of the knee and/or foot/ankle complex.  Remember that the most common painless biomechanical fault is excessive pronation.  Excessive inward rotation of the mid-foot and rear-foot can set up a serial distortion, resulting in structural misalignment and muscle imbalances.  Without stabilizing this area with custom-made, flexible orthotics, reinjury will always be a concern, even with the best rehab program.  Consult with an established orthotics laboratory about specialized shoe inserts for athletes. TAC

Dr. John Danchik is the seventh inductee to the American Chiropractic Association Sports Hall of Fame.  He is the current chairperson of the United States Olympic Committee’s Chiropractic Selection Program.  He lectures extensively in the United States and abroad on current trends in sports chiropractic and rehabilitation.  Dr. Danchik is associate editor to the Journal of the Neuromusculoskeletal System and the Journal of Chiropractic Sports Injuries and Rehabilitation.  He has been in private practice in Massachusetts for 24 years. You may reach Dr. Danchik at (617) 489-1220 or e-mail [email protected].

When treating soft tissue injuries, especially the chronic degenerative ones, you must be well versed in the Triune of Exercise. 
I’m not just talking about athletes but about patients as well.  They all suffer from some type of soft tissue injury, as well as being subluxated.  In fact, why do you think their subluxations persist?  Because nobody ever handled the underlying soft tissue injury correctly.
Please remember this: “The nervous system controls function, but the musculoskeletal system supports the nervous system allowing it to function”.  When addressing a subluxation, it would behoove you to address the soft tissue, as well, via the Triune of Exercise.
The purpose of the Triune of Exercise is to help repair and rebuild the surrounding soft tissue to compensate for the degenerative joint; and, thus, to some degree, to remodel the soft tissue, restoring normal function to that joint, reducing exacerbations and continued degeneration.  This is done through the proper conditioning of the surrounding soft tissue.

The triune consists of:

• Progressive resistance training (weight training)
• Stretching (flexibility conditioning)
• Cardiovascular (“repetitive stamina conditioning”)

In order to condition soft tissue properly you must utilize this approach.  If you do not, you cannot treat soft tissue injuries effectively.

Why Stretching is Important

As you may be aware, damaged soft tissue, left untreated, causes the soft tissue to become fibrotic.  Fibrotic tissue (scar tissue) causes loss of joint mobility; thus, stretching is extremely important.

Why Cardiovascular Exercise is a Great Conditioner

We all know the importance of cardiovascular exercise for our heart, lung and circulatory tree; but, are you aware of the benefits to our stamina, or the ability to do things repetitively, which often decrease as a result of soft tissue injuries?  Whereas, previously, you could run for miles, you find it difficult to walk down the block, due to circulatory disturbance to soft tissue.
Progressive resistance exercises and cardiovascular exercises are extremely important in reducing muscular fatigue and enhancing muscular stamina and endurance.

Why Progressive Resistance (Weight Training) is an Important Conditioner

I saved the best for last. 
Muscles lose up to 30-40% of their strength within weeks of an injury and their strength continues to decline, as time goes on.  Soft tissue loses flexibility and stamina as well.  The best part of weight training is that you can accomplish all three:

• Increased flexibility
• Increased strength, and
• Increased stamina

Weight Training

About 1984, I began to exercise, using weights.  At that time, weight training was gaining popularity.  I started to see professionals from all fields (tennis, golf, baseball, basketball, etc.) using a specific program that included weights to enhance their performance.  Prior to this, the mentality had been (and still is, to many people) that you never wanted to exercise with weights, because you would become “muscle bound” (whatever that means).  Also, when you stop working out with weights, all that muscle turns to fat. 
In fact, I bet half the doctors reading this article still, to some degree, believe those statements to be true.  If you think I’m exaggerating, just go to any state chiropractic convention and look at the physiques of some of the doctors attending.  Your physical appearance speaks volumes about you, as a doctor.  After all, are we not the doctors that state, “STRUCTURE GOVERNS FUNCTION”?
Some of us look like “LONDON BRIDGE”.  You want to be a super success in practice?  Start looking like the healthy specimen you are capable of being.
Your body is a billboard (like free advertisement).  Your state board should make it a prerequisite that, in order to practice chiropractic, you must understand the concept, and train with weights at least three times per week.
Do you not want this very same thing for your patients?  Well, if you are not well versed in the physiological and anatomical relationships between weight training and its effect on function via its effect on structural integrity, then you are missing a big piece of the pie.
I cannot, in this short amount of space, even begin to explain the fundamentals of weight training without doing it a grave injustice, so I won’t even go there.  Just realize that weight training, like chiropractic, has a philosophy, science and art.  It requires a great deal of understanding, on your part, to be successful using this valuable tool.

 
Flexibility (Stretching)
Guidelines to Follow When Stretching

When developing a program of stretching for your patients, use stretches that stretch every major muscle group/joint through the respective ranges of motion, and follow the rules below:

1. Stretch in the morning, or evening, or both, depending on injuries or tight areas.  Each session should last 15-30 minutes.
2. Stretching daily helps create a routine (like brushing your teeth) that eventually will become a habit.  In fact, I look forward to my morning stretches, which I also use as “quiet time” to get in touch with my mind and body.  By the way, the only way to gain flexibility is to stretch daily.
3. Taking a hot shower before the stretch loosens the muscles.
4. Never perform ballistic or bouncing, hard-type stretches that are painful.  These exercises are dangerous and can cause a lot of joint damage.
5. Always use a comfortable firm surface; and, if there are low back or neck injuries, use a roll behind your neck and/or a roll behind your knees.
6. Always start your stretching in the lying position, then proceed to sitting, then to kneeling, and then into your standing stretches.
7. Always use deep, relaxed breathing when stretching.

When stretching a muscle, you must stretch as far as you can comfortably, at which point, you must focus on two things:  Breathing, and blending your mind with that muscle, with the focus on relaxing it.  When you reach the point in the stretch where the muscle starts to tighten and ache from the stretch, you use breathing and mind/muscle relaxation to gain more stretch in that muscle or joint.  Focus on deep, relaxed breathing, gaining a little more stretch on exhalation.  In other words, as you exhale, you will be able to push the stretch a little more, and then hold that position while you inhale.  Then, when you exhale, you may gain a little more, or hold that position longer.  Then, repeat the cycle one more time. 
At this point, you can hold the position for another 10-15 seconds, and then release the stretch slowly.  Your mental focus should be on consciously relaxing that muscle or joint, by visualizing the muscle relaxing. 
This process can be repeated two more times, if needed, and you will get a further stretch by the third time. 
At some point, you will notice that you hit your sticking point—you cannot stretch any further.  You may have pain or the muscle may start to cramp.  In this case, you should stop the stretch and slowly bring the muscle or joint out of the stretch.  I also recommend that you lightly massage the muscle or joint that you are working while you are stretching that muscle or joint.  Always spend more time on the tight muscle or the tighter side.

Cardiovascular Exercises

• Walking
• Jogging
• Dancing
• Swimming
• Cycling
• Skating
• Aerobic classes
• Climbing
• Cross-country skiing
• Rowing

Progress resistance performed one set after another with little or no rest (circuit training)

Guidelines to Follow When Creating an Aerobic Program for Your Patients

1. Make sure that the exercise fits the patient.  Overweight patients or patients with knee injuries, etc., should not jog, play basketball, etc.
2. Monitor and keep score of their pro-gress.  When it comes to measuring your patients’ cardiovascular performance, their pulse and respiratory rates must be determined.  This is what you should measure—not how much weight they are losing.  It is interesting to note that most people do cardiovascular exercise for weight loss, which is not the purpose when measuring cardiovascular performance.  As you condition your body properly, cardiovascular exercise will cause the weight to come off, provided you are eating right and intensifying your conditioning, using your pulse and respiratory rates as indicators.  You must be able to take the following measurements:
   · Resting heart/pulse rate.
   · Target heart/pulse rate (approximately 60-80% higher than the resting rate).
   · Resting respiratory rate.
   · Target respiratory rate (approximately 60-80% higher than the resting rate)
3. There are three phases of cardiovascular training that patients must go through.
   · Warm-Up Phase: This portion takes five-to-ten minutes, as you approach your target heart rate.
   · Maximum-Effort Phase: This takes from ten-to-twenty minutes.  When achieving higher levels of conditioning, you want to intensify your routine by using methods other than time (how long you work out).  Grueling sessions lasting hours at a time, or working out countless hours during the week lead to burnout and poor results.  
     There are other ways to intensify your cardiovascular program; wind sprints are an excellent example.  This procedure is not for the beginner, but for the athlete, or someone already in good condition.  Wind sprints are performed toward the end of maximum effort when you increase your speed to the point of labored breathing, which takes focus and perseverance.  Sustain this level for as long as you can and then slow back down to your maximum-effort level.  Once you catch your breath, you repeat the sprint two or three more times.  Please note that wind sprints will take your target heart rate over 100 percent, so be careful.  For those just starting out, the goal is to nudge the target rate up over time. 
     How much time?  That depends on your age, your condition, your diet, etc.  Just continually push the envelope and reach higher target heart rates for up to 40 minutes and then you will be ready for wind sprints.
   · Cool-Down Phase:  This takes five to 10 minutes, as you slow your pace and come to the end of your routine.
4. How often should your patient perform cardiovascular conditioning?  Three or four aerobic workouts per week are sufficient for most people.  Any more, and you are causing too much stress on the body. 
   Remember, it is not how many times or how long you exercise; it is the intensity of your exercise sessions.  And, there you have it:  An exercise program that will support and improve sports injuries, degeneration, and joint damage. TAC

Dr. James Cima has been teaching, and writing on this subject for 20 years.  Dr. Cima also teaches seminars and has created a software package for the doctors to help them assess their patients’ needs.  For more information, call toll free 1-877-627-2770 or fax 561-624-3871, or e-mail Dr. Cima at [email protected].

Children, like adults, often need to do some exercises as part of their chiropractic treatment.  But, how safe is exercise for children, especially exercise with resistance?  How much weight is appropriate for a growing body?  And which exercises are most effective?  Because of these and similar questions, doctors of chiropractic may hesitate to recommend exercises for their younger patients.  Let’s see if we can arrive at a reasoned response, based on experience and useful consensus information.

Passing Phases

Prepubescence is the phase of childhood prior to the onset of secondary sex characteristics.  Rapid, but variable growth occurs during this period, with open physes and changing muscle and ligament lengths.  Adolescence begins with the onset of secondary sex characteristics and continues until physical and skeletal maturity.  Selecting the best exercise approach for each child’s situation is important, since needs may vary during growth.¹  However, all children should be encouraged to engage in frequent and regular fitness activities.

Exercise Benefits

The benefits of physical activity in youth include fitness, weight control, and the development of habits having the potential to span a lifetime.  One study systematically determined the amount of moderate-to-vigorous physical activity students obtain during elementary and middle-school physical education classes (time spent performing moderate-to-vigorous physical activity compared to total class time).  The researchers concluded that the amount of physical activity observed (elementary schools, 8.6%; middle schools, 16.1%) was significantly less than the estimated national average of 27%, and far below the national recommendation of a minimum of 50%.² 
A review of current youth fitness data indicates that children in the United States are fatter, slower, and weaker than children in other developed nations.  Also, children in the United States appear to be developing a sedentary lifestyle at earlier ages.  A low level of exercise is a contributing factor for childhood obesity and hypertension, and predisposes the individual to premature death from coronary heart disease.³  Fortunately, through intervention in children and adolescents in the form of education and motivation, exercise levels may be increased to the recommended minimum of thirty  minutes on most days.⁴

Safety Issues

High-intensity resistance training appears to be effective in increasing strength in preadolescents.  Children make similar relative, but smaller, absolute strength gains when compared with adolescents and young adults.  Resistance training appears to have little, if any, hypertrophic effect, but, rather, has been associated with increased levels of neuromuscular activation.  Researchers have found that the risk of injury from prudently prescribed and closely supervised resistance training appears to be low during preadolescence.⁵  In 1993, Mazur, et al., reviewed the types and causes of injuries to preadolescents and adolescents resulting from weight lifting/training.  The researchers concluded that “prepubescent and older athletes who are well-trained and supervised appear to have low injury rates in strength training programs.” ⁶
A risk that must be considered in the immature skeleton is the susceptibility of the growth cartilage of the epiphyseal plates (physes).  Weight training in a submaximal controlled, supervised situation is beneficial to bone deposition.  Strength training can be a valuable and safe mode of exercise provided 1) instructors are properly educated; 2) participants are properly instructed; and 3) the absolute necessity of avoiding maximal lifts is reinforced.⁷ 
The most important factors in avoiding injury in children who are doing resistance exercises are proper performance of the exercise; avoiding overload by focusing on repetitions, not weight; enforcing rest periods during exercise; and resistance training only twice a week.  Exercise tubing is an excellent tool for strength training of children, since the risks of injury are minimized, and a spotter or expensive equipment is not needed.

Training Balance and Coordination

For many children, it is more important to learn the fine neurological control necessary for accurate spinal and full body performance than to simply build strength.  Better balance and coordination will often result in improved physical function, both in daily and in sports activities.  This may entail performing exercises while standing on one leg, with the eyes closed, while standing on a mini-tramp, or using a rocker board.  The advantage of these balance exercises is seen when children engage in sports activities and perform at advanced levels for their age group.
All exercises are most effective when done in an upright, weight-bearing position, since the entire body is in a closed chain position during the 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 in the long run, particularly for children who are interested in becoming competitive athletes.

Corrective Postural Exercises

Children’s spinal problems are often associated with poor postural support.  A spinal asymmetry, such as scoliosis and kyphosis, is invariably accompanied by neuromuscular imbalance.  This may be compounded by poor postural habits and tendencies to “slump.”  One important factor in chiropractic treatment is the correction of any loss of the normal upright alignment of the pelvis and spine.  In addition to general strengthening and coordination exercises, patients (including children) should be shown corrective exercises that are specific for the postural imbalances they have developed.  For instance, when the pelvis is carried flexed forward, a patient of any age will need to retrain with resisted pelvic extension exercises.  Likewise, when there is a forward head, posterior translation exercises for the cervical region are very important.
Whenever a child shows evidence of abnormal gait or begins to develop lower extremity complaints, a careful evaluation for the need for shoe inserts is warranted.  Custom-fitted orthotics can improve performance and spinal alignment by ensuring proper lower extremity alignment, and reduce overuse injuries by providing additional shock absorption.

Conclusion

A well-designed exercise program for children who need to strengthen, develop better coordination, and improve postural support will allow the doctor of chiropractic to provide cost-efficient pediatric spinal care.  Exercises performed with the spine upright and functional can specifically train and condition all the involved structures to work together smoothly.  In some children, orthotic support is necessary to help ensure correct alignment from the lower extremities.  The end result is a more effective rehab component and young patients who will make a rapid response to their chiropractic care.  With a few common sense precautions and careful supervision, children are capable of performing rehabilitative exercises very safely. TAC

References

1. American College of Sports Medicine. Guidelines for Exercise Testing and Prescription, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2000.
2. Simons-Morton BG, Taylor WC, et al. Observed levels of elementary and middle school children’s physical activity during physical education classes.  Prevent Med 1994; 23:437-441.
3. Cunnane SC. Childhood origins of lifestyle-related risk factors for coronary heart disease in adulthood.  Nutr Health 1993; 9:107-115.
4. US Dept. of Health and Human Services. Physical Activity and Health: a Report of the Surgeon General. Atlanta:1996. 
5. Blimke CJ. Resistance training during preadolescence: issues and controversies. Sports Med 1993; 15:389-407.
6. Mazur LJ, Etman RJ, Risser WL. Weight-training injuries: common injuries and preventative methods. Sports Med 1993; 16:57-63.
7. Schafer J. Prepubescent and adolescent weight training: is it safe?  Is it beneficial? Natl Strength Conditioning Assoc J 1991; 13:39-45..

Kim D. Christensen, D.C., C.C.S.P., D.A.C.R.B., 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.  He is currently a postgraduate faculty member of numerous chiropractic colleges and is the president of the American Chiropractic Association (ACA) Rehab Council.  Dr. Christensen is the author of numerous publications and texts on musculoskeletal rehabilitation and nutrition.  He can be reached at Chiropractic Rehabilitation Consulting, 18604 NW 64th Ave., Ridgefield, WA 98642 or by e-mail at [email protected].