Establishing a Care Plan for Your Patients

The use of rehabilitation procedures is becoming more of a mainstay within chiropractic health care. Core spinal musculature stabilizing exercises, proprioceptive training, as well as activities designed to enhance flexibility are currently being used to help support the chiropractic adjustment. Each of these methods has become a major point of interest to help a patient enhance his/her overall health and wellness. This has subsequently helped patients to be more involved in their health care by physically participating.

There are a few things that we do well, and other things we do not do so well when creating a treatment plan. Are your rehabilitation programs designed to address postural deviations, improve strength, balance, sport specific or prevent injuries?

Depending on the scopes of practice in the state you practice, the amount and types of rehabilitation the Doctor of Chiropractic is allowed to do will vary. For many doctors, the use of rehabilitative exercise, neuromuscular reeducation and therapeutic activities are of most importance. Others choose to use physical modalities to help increase healing time by improving circulation and decreasing edema. The choices you make are more than likely based on your state statute and, possibly, the chiropractic college you graduated from.

The profession’s approach to therapy maybe demonstrated as recently as 1935. When B. J. Palmer established the Rehabilitation Laboratory at the B. J. Palmer Chiropractic Clinic, all the equipment was patient driven. The only electrical piece of equipment used then was a mechanical horse. One of the rules at the clinic included, “At no time, in no way, do we use any therapeutic apparatus on any case.”

A common mistake many Doctors of Chiropractic make when developing a rehabilitation program for their patients is that they overload a joint before it has healed or full ranges of pain-free motion have been reestablished. This usually occurs by using a weight that is too heavy or of too high resistance. The difference between neuromuscular reeducation and strength training should be reviewed by many of us so that we are accurately performing therapy. Neuromuscular reeducation should be established prior to initiating strengthening protocols, especially if the patient is someone who appears to be physically fit and/or has a history of working out.

The mistake of muscle strengthening before neuromuscular reeducation usually results in the patients’ complaining that the exercise or activity you initiated aggravated their present condition or exacerbated an improving condition. Whether pain is present, either constantly or during an activity, it will prevent the body from performing normal moving patterns. To ensure this will not happen, the Doctor of Chiropractic must have a good understanding of the patient’s present-time muscle strength and his physical endurance. This must be established through initial and interim chiropractic evaluations and management.

Gait Cycle:
Another commonly overlooked patient presentation is gait cycle. Evaluation of the patient’s gait cycle can show muscle imbalances. These imbalances can occur from differences between antagonist and protagonist strength, flexibility, and the subluxation complex. One of the most frequent gait alterations that may be seen is the Trendelenburg gait. Clinically, this presents as a dropping of the hip on the unsupported leg during each step of the gait cycle. This usually results from a weakness of the gluteal musculature. Often this problem can be addressed and stabilized by reducing the subluxation complexes and initiating normal motor pattern movements, followed by strengthening exercises.

Base of Support:
Another area to observe would be the patient’s base of support: Is it too narrow or too wide? Are the abnormalities within the gait due to neurological inducement, altered biomechanical dysfunction, or antalgic due to pain? Is the patient’s posture in good alignment from head to toe? Keep in mind, postural defects and movement distortions in one area can affect seemingly unrelated distant areas, causing dysfunction and pain. Does the patient show an anterior translation of the head, rounding of the shoulders with thoracic extension, anterior pelvis translation, functional leg length inequality, and asymmetrical bilateral pronation?

One of the most frequently missed patient presentations is how a patient raises and lowers himself from a seated position. How often has a patient said to you he is having difficulty raising and lowering himself from the toilet, difficulty maneuvering stairs and getting out of bed? Quite often, this is the result of weakened musculature and altered spinal biomechanics. Are the assistive devices (walkers, canes, crutches) being used properly, or are they a contributing factor?

As the Doctor of Chiropractic, you routinely develop a plan for how you will provide the chiropractic adjustment. You do this from a correlation of your examination findings, which may include X-ray and other additional testing. It is important to have and implement a plan that may compliment the chiropractic adjustment with thorough rehabilitative techniques. Please remember, this is much more than merely handing your patients a bunch of exercises and expecting them to do them on their own.

A 1980 graduate of Palmer College of Chiropractic, Dr. Kirk Lee is a member of the Palmer College of Chiropractic Post Graduate Faculty and Parker College of Chiropractic Post Graduate Faculty. He has lectured nationwide on sports injuries and the adolescent athlete, and currently practices in Albion, Michigan. He is very active with the Michigan Chiropractic Society, serving on the legal and government affairs committees.

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