The doctors that have protocols which include movements or forces that decrease disc displacement which, in turn, cause pain to decrease, disappear, or centralize with a rapid increase of lumbar ROM, see their patients get better. These types of movements should be pursued with decompression, exercises, mobilizations, and manipulations. Doctors, who fail to recognize that their protocol’s movements or forces, which increase the disc displacement and cause pain to increase, appear or peripheralize with a rapid decrease of lumbar ROM, will observe that their patients get worse or plateau. These movements should be avoided, and that can involve decompression, exercises, mobilizations, and manipulation.2
Loss of coordinative control/co-contraction and endurance of the core musculature; the Transverse Abdominis, Lumbar Multifidus, and Internal Obliques, according to research by Richardson and McGill, et al.,3 is an underlying source of low back pain and creates susceptibility to disc injury. Therefore, any exercise pattern which promotes co-contraction of the core musculature, and increases lumbar range of motion, while observing centralization, should be pursued. In our office, we do this in two ways. First is a series of seven types of exercises that strengthen and give endurance to the core muscles. While doing these exercises, we are observing the centralization phenomenon, developing core endurance, and trying to increase active lumbar range of motion. We affectionately call the seven types of exercises the “Seven from Heaven.” The seven types of exercises that we use in the office are:
• Curl Ups (Core Abs) for the Rectus Abdominis
• Side Ups (Core Abs) for the Obliques
• Bird Dogs (Spinal Extensors)
• Short Arc Extensions (Spinal Extensors)
• Squats (Gluts and Quads)
• Lunges (Gluts and Quads)
• Bridges (Gluts and Quads)
There are various ways that all of these exercises can be performed. They can be performed on the floor, exercise mat, or using a physio-ball. Just remember that, when using these exercises, we are trying to observe three things: First, centralization of pain; second, increased active lumbar range of motion; and, finally, core stabilization.
To increase centralization, lumbar range of motion (actively and passively), muscle endurance and flexibility and to increase core strength and mobility, we have added a form of flexion/extension passive motion to our lumbar disc syndrome decompression protocols. Look for a table that increases range of motion, and centralizes pain at the same time. Appropriate protocols will consider the patient’s directional movement preference, and provide measurable and positive outcomes, particularly in the management of acute and chronic, severe low back and leg pain (without a neurological deficit) patients. Directional movement preference theory uses the rule of “centralization” to evaluate and proceed into rehab using activities that “centralize” the patient’s pain and, again, restores lumbar ROM. Recently published scientific research articles have established that the presence of “Centralization” can be a strong indicator of discogenic pathology and is a highly accurate and reliable predictor of treatment outcome. Movement, activities and postures that cause the symptoms to “centralize” indicate the “preferred direction(s)” for the Doctor/Therapist to use in developing both an in-office and self-treatment strategy for each patient. Simultaneously, the Doctor/Therapist must teach the patient how to avoid those positions, activities, and movements that cause the symptoms to move “peripherally.” Many patients suffering from low back or neck pain, with or without referred pain, will unmistakably exhibit a “direction preference” when repeated movements and/or static positioning are applied to the spine. This means there will be a particular movement or position which will cause the symptoms to shift to a more central (proximal) location. Frequently, there will be other movements or positions which will cause the symptoms to shift to a more peripheral (distal) location. An example of this is the patient who, when asked to go into an extension movement (restoring normal lordosis) which, in turn, reduces the pain. This is the directional movement we want to begin exercise movements that will start their rehab.
Each smart clinician will observe the centralization phenomenon, but will also pay attention to the directional preference exercises that increases the lumbar range of motion and, subsequently, increases the lordosis of the lumbar spine. This missing link is where I see most clinicians fail in their decompression protocols. They’re very good at assessing the patient’s needs on the decompression table, but neglect to establish a clear-cut protocol to reestablish lumbar range of motion and lordosis. Their core stabilization programs are usually weak, and their patients often drop out, or plateau in their progress. Use the missing link to your advantage, and you will have more success in treating lumbar disc syndromes. Because of billing and coding issues that differ in each state, it’s best to search out an expert to assist you in collections for your services, and to keep you legal.
(For a free 15-page report on billing and coding go to www.flexionextension.com)
Randy Reed, D.C., F.I.C.C., F.A.C.C.
Dr. Randy Reed has 22 years of clinical experience as director of Reed Chiropractic Clinic in Solon, Ohio. His expertise Is; treating scoliosis, sports injuries, Intervertebral Disc Syndromes through Axial Vertebral Decompression and enhancing athletic performance through plyometric training and manipulation under anesthesia. You can contact him at 1-888-330-3627 or visit www.betterdoctorseminars.net
References
1. The Lumbar Spine: Mechanical Diagnosis and Therapy, R.A. McKenzie, F.N.Z.S.P., D.I.P., M.T., Spinal Publications 1981.
2 .M. Schneider, D.C. “Rehabilitation in a Nutshell: The Lumbar Spine Seminar (2006).
3. Richardson C, Jull G., et al: Therapeutic exercises for spinal segmental stabilization in low back pain. Churchill Livingstone NY, 1999.