Rehabilitation of the Spine: A Practitioner's Manual

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REHABILITATION OF THE SPINE A PRACTITIONER'S MANUAL

Editor

CRAIG L1EBENSON, DC Los Angeles, California

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Q) ~.J Williams & Wilkins A WAVERLY COMPANY

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II,\[T[MORE' I'H[!.\DEI.I'H[A • 1.0~DO~ • 1',1[\[$ • IIASGKOK HONG KONG. MUNICH· SYDNEY· TOKYO' WROCL\W

1996

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Contents

Seclioll I. Basic Principles

1. Guidelines for Cost-Effective Management of Spinal Pain

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CRAIG UEBENSON

2. Integrating Rehabilitation into Chiropractic Practice (Blending Active and . 13 Passive Care) . CRAIG UEBENSON

3. Training and Exercise Science

...•.•...... .45

JEAN P. BOUCHER

Sectioll ll. Assessment of Musculoskeletal Function

4. Pain and Disability Questionnaires in Chiropractic Rehabilitation

57

HOWARD VERNON

C) 5.. Outcomes Assessment in the Small Private Practice

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...................73

CRAIG UEBENSON and JEFF OSLANCE

6: Evaluation of Muscular Imbalance

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97

VLADIMIR JANDA

7. Diagnosis of Muscular Dysfunction by Inspection

............... .113

LUDMILA F VASILYEVAand KAREL LEWIT

................ 143

8. Evaluation of Lifting

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LEONARD N. MATHESON

Sec/ion 111. Patient Education

9. Back School

153

PAUL D. HOOPER

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10, Patient Education '

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Appendix IO.l How to Care/or Your B(J(:k "lid Neck: A Sec/ioll Addrc.'i.\"cd J(J the Patient __ . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. .

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CRAIG UEBENSON and JEFF OSLANCE

169

Section IV. Functional ReslOrarioll ll~

Role of Manipulation in Spinal Rehabilitation

195

KARELLEWIT

)l;iii

CONTENTS

12. 'Spinal Therapeutics Based on Responses to Loading

.225

GARY JACOB and ROBIN McKENZIE

13. -Manual Resistance Techniques and Self-Stretches for Illlproving Flexibilityl 253 Mobility CRAIG L1EBENSON

14: Spinal Stabilization Exercise Program

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. . .21.)3

JERRY HYMAN and CRAIG L1EBENSON

Appendi.\' 14.1 Ex.ercise Checklist

. ..•.....•.•......316

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15. Sensory Motor Stimulation

319

VLAOIMIR JANDA and MARIE vA vRovA

16. Postural Disorders ofthe Body Axis

329

PIERRE· MARIE GAGEY and RENE GENTAZ

17. Lumbar Spine Injury in the Athlete

341

ROBERT G. WATKINS

18.- Active Rehabilitation Protocols ..................................... 355 CRAIG LIE BEN SON

Sectioll

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Psycho.weial and Sociopolitical Aspects of Rehabifiwrioll

19. Psychosocial Factors in Chronic Pain.......

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391

GEORGE E. BECKER

20. PatientIDoctor Interaction

A05

WILLIAM H. KIRKALDY·WILLIS

21. Place of Active Care in Disability Prevention ......................... All VERT MOONEY

Index

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I BASIC PRINCIPLES

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1 GUIDELINES FOR COST-EFFECTIVE MANAGEMENT OF SPINAL PAIN CRAIG L1EBENSON

MISDIAGNOSIS AND MISMANAGEMENT OF THE PROBLEM Em'crging evidence indica(c~ the problem of low bad: pain has been mismanaged on a gr;md scale. From overprescription of bed rest to overuse of surgical intervention and advanced imaging techniques. the costs related [0 low back pain afC unccilwincd. The U.S. govcrnmcnl reccntly issued federal guidelines on .acme low back pain aimed at promoting a quoJlit)' care modeL I RC Most of these individuals recover within 6 weeks, but 5 to 15% arc unresponsive to treatment and have continued disabili ty 7-'O (Fig. 1.1). The minority of patients who do not recover within 3 months ae· count for up 75 to 90% of the total expenses related to this health care problem,1l-17 which exceed $60 billion per year in the United Slates. 11 The 7.4% of patients who arc out of work for 6 momhs account for 75.6% of the 101'11 cost lll (Fig. 1.2). The majority of these costs (60%) are attributable to indemnity. with only 40% related to treatlllcm ll . 15 (Table 1.1). Among those patients whose symptoms resolve. recurrences arc COllllllon. In some studies. recurrence rates were as low as 22 to 36%.I'}-21 Berquist·Ullman and Larsson found Ihat 620/c; of patiellls with acute back pain suffered at least one recurrence during I year of follow-up. 10 A long·term study revealed that 45% of patients had at least onc significant recurrence within 4 years. 22 The incidence rate. cost of chronicity and disability, and high recurrence ralC add up lO a problem of epidemic proportions. In his Volvo award winning paper. \VaddclJ stated. "Convcmional medical treatment for low-back pain has failed. ~md lhe role of medicine in the present epidemic musl be critic::llly eXtllnined:·~.\ The cause of this epidcmic involvcs a number of f"ctors. The reasons for this fail· ure or treatment .md potcntial solutions .are presenteu in Table 1.2.

Ovcrcmphasis on a Structural [)iclgnosis Artcr ivtixtcr and Barr's, discovery that compn::ssiol1 of a nerve root by a hcrnialc<1 disk could cause sciatica. thl' medical profession has belicved sirongly in thc pathoanatomic basis for back and leg pain.;J,::; Structur.ll cvidc;lcc of a disk hernia is present in Illore than 90% of palicnt~. with appropriate symploms.:{o-~'J Unforlunalely. even whe;n using. such .ldvanced imaging lechniques .lS mydogr
REHABILITATION OF THE SPINE: A PRACTITIONER'S MANUAL

cause of their symptoll\s.Jb For this re<\son, most such cases ;.tre classified with the label "nonspecific back pain:' According to Frymoyer. "Most commonly. diagnosis is speculative and unconfirmed by objective tesling."-Il The Quebec Ta~k force states that "before we b~coll1e I1lcsllH.:rizcd with the dcveloping diagnostk tcchnology. such lcchniques must be adjudic~\tcd rigidly ;as to their cost/bcndil. risk/hcnclit. ~md cost/cfft::cti\'t:::~~~;s r:lliOS,"11l Perhaps with diagnostiL: blocks paving the way. other h:ss expensive lests Illay bc found to compare favorably to this potcntially important "gold standard."

PERCi)H 70

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Fig. 1.1. Likelihood of injured worker:> returning to active employment as work absence increases. Quebec, 1981. (From Spitzer

WO, Le Blanc FE, Dupuis M, et al: Scientific approach to the as~ sessment and management of aclivity-related spinal disorders: A monograph for clinicians. Report of the Quebec Task Force on Spinal Disorders. Spine 12 (SuppI7):Sl. 198'/.)

PERCENi

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O\'crprescription of Bed Rest "Because of the failure to pinpoint lhe specific pain gcncr~llors in low back pain, bed rcst and analgesics have become the typical treatment. The self-limiting course of mosl low back pain episodes has given justificatio!l to this pracl ice of symptomalic lrcatm';;:nl. As it turns ouL this seemingly benign prescription of prolonged bed rest has been shown in be one of lhe most costly errors in musculoskeletal carc. Allan and \Vaddell said, "Tr'lgically. uespitc the best of imcntions to relieve pain. our whole approach 10 b'ickachc has been
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Table 1.1. Percentage of Costs by Type of Treatment and Compensation

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Back Pain Costs

Percent

Percent

Medical costs

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Physician's fees Hospital costs Diagnostic tests Physical therapy Drugs Appliances

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Oisability Temporary Permanent

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22 45 100

Tolal costs Adnplcd wilh permissIon from Pope MH, Frymoyer JW. Andersson G

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Occupational low Back Pain. New YOlk, Pracgcf. 1984. p 107"

set of clinical features (history or cX~lInin:.ltioll}.'l.\ In contrast. a study ill\"olving chronic ncek pilin patients who had suffercd whiplash revealed that double
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Table 1.2. The Low Back Pain Epidemic Thc Problem

Overemphasis on slrucu!ral

The Solulion

10 deconditioning syndrome

diagnosis Overprescription of bed res! Overuse of surgery

Early, aggresive conservative lherapy Ac!ive care lor subacute cases

Ignoring abnormal illness

Early JD of disability predictors

behavior

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FOR COST·EFFECTlVE MANAGEMENT OF SPINAL PAIN

Prolonged lx:d resl may be counleq)roduc(ivc."l~ Dcyo and colleagues p~rformcd a controlled clinical lrial comparing ] d'lys ;.lg;lin:-:l ::! weeks or bed n.::.;(. They concluded lhal nol only was 2 days of bed fC.'a as crfc.:ctivc as 2 wc.:eks. but also the negmivc effecls of prolonged immohilizatioll wcre also lil1litcd:~'~

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Overuse of Su rgcry The t)\'crus.... ()f surgery has he..... 1 perl laps tllc single lliost damaging medical intervention for b'H:k pain sufferc.:rs. Bigos and Baltic said. "Surgery seems helpful for ,It most 2~~ of patients with back problem:;. and its inappropri:'ltc IJSC can have .1 greal impact on increasing the chance of chrOllic back pain disability.··l'·ln his Volvo award rape.!'. W..lddcll said, "Such dramatic surgical successes unfortunately only ;:\pply to approximately l'lc of palit;llls with low back disorders. Ou.r failure involves the remaining 999'0 .. for wholll the problem has become progressively worse."=' Saal and Saal supervised care for a group of patiClllS referred by neurologists for surgery. They <.Htcmplcd rchabilil ..uion for these p.llients .lIld made the following obSe(valions: "Surgery should be rcser\'cd f~r tho:;e patients for whom function C,lIll\ut be s'llisfactorily improved by a physical rehabilitation progr<.tlll .. F;:tilure of passive nonopcrativc treatmCI1l is not suflicicnt for lhe decision to opcr
5

more promptly relieved by surgery, but this has a significant morbidity and rarely mortality. Surgery is not invariably successful.···11 Allen nnd \Vaddell, using the strongest possible Innguagc, blamc their colleagues. "The rnpid and enthusiastic expansion of disc surgery soon exposed its limitations and failures. It was nceused of leaving morc trngic human wreck~ 'Ige in its w'lke than any other operation in history."~5 Frymoyer describes a particularly difficult patient group on which !O pdform surgery: "One place where treatment has an adverse effect is surgical management of patien!s with COIllpensation:'H Schneider and Kahanovitz echoed these same remarks. noting that even in patients who had an apparently successful operation for sciatica. if their problem is compensable. they are still at significant risk for recurrence and disability.52

Overemphasis on a Psychogenic Diagnosis According to Dworkin.~·\ "Pain report often occurs in the absence of pathophysiology or any discernible peripheral somatic changes. This finding implies the need to reexamine our limited understanding of pain. rather than leaping to the conclusion that such p
REHABILITATION OF THE SPINE: A PRACTITIONER'S MANUAL

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Because most patients do not have a diagnosable structural cause of their symptoms, a functional disorder should bc assumed. Pain in the locomotor system should be viewed as a sign of impaired function. Nonspecific or idiopathic back pain most likely has to do with muscle or joint dysfunction with rc. sultant soft tissue irritation and pain generation. Treatments designed for injury states or disk lesions inevitably fail. thus C·ll:-.!:ig r~p:-~(,"!0rt. desp~ir. and illness bchavior.n-JI:> Abnonnal illness behavior was dehllct..i by PiI0wsk~.'Jl as a patient's inappropriate or maladaptive rcsponse to a physic
on quantilicalion of fUIll..:tional delkits. cxal."i~e. education. and psychologic intCfvcntion havc proven th~ir succcss with chronically di~3hk<1lnw-h;Kk pain sufferers or recurrelll p;tin patients (T
Because lirst-lilll~ had, pain p;l\iell(s ;m..~ likdy to sutler recurrcnces. slll,:ce~~ful primary pre"cnlion would he ut" gre;1l .'alue ill reducing this epidemic disorder. Unfortun;l!e!y. little scientific literature <1ddresscs this topic. Those eng
Primar.y Conservative Care QUALITY CARE: COST CONTAINMENT STRATEGIES FOR MANAGING SPINAL PAIN Feuerstein J~ has modeled how rehabilitation deals with assessment and multidisciplinary managcment of medical status (internal, neurologic, musculoskeletal). physical capabilities (functional capacity, work capacity). work demands (biomechanical. psychophysical), and psychosocial /behavioral resources (coping skills, job satisfaclion. family situation). A quality care .approach begins with primary prevention and thc aggressive trcatment of any acute pain cpisodes. Manipulation is a proven cost savcr in this regard. l Overutilization of expensive imaging techniques to make a structural diagnosis should be avoided. UM Strict crilcria for prc..c;cribing bed rcst or surgery should be maintained. After studying a group of patients with operable disk lesions. Blish et ai. commented thut "Even if paticms have markcd reduction of straight leg raising. positive neurologic signs. and a substantial intervertebral disc herniation (as opposed to .1 bulge).... if the pain can be controlled, nature can be allowed to run its course with the partial or complete resolution of the mechanical factor:'·'! Paticnts with subacute pain should be educated about the benign nature of p
A pro-activc disnbility managcment program '.lggn:ssi,·dy (reats acute pain t:pisodes with conservative carc. The Quebec: report Slated that. "Management strategies should be directed at maximizing lh~ number of workas rClUrning to ''''ork before I month and minimizing the number whose spinal disorder keeps them idle for longer than 6 lllomhs"""1 Most Ir.lditionally minded physicians arc still ignoram of the dangers of bed rcst and immobilil.lltion. l They are too pi.lssivc in their .11'proach to lower back p
Table 1.3. Abnormallllness'Sehavior Symptom magnification syndrome n~!~·?vo!d",O(:~ behavior Psychologic distress Calaslrophizing as a coping strategy Anxiety Treatment dependency

Table 1.4. Quality Care for low Back Pain Primary prevention Primary conservative care lor acute episodes Secondary functional restoration lor subacute and recurrent cases Tertiary multidisciplinary functional restoration for chronic. disabled patients

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CHAPTER 1 : GUIDELINES FOR COST·EFFECTIVE MANAGEMENT OF SPINAL PAIN

ulations over a I-month period. s" Certain studies excluded from the meta-analysis were those such as Meadc's, which included other therapies. the effects of which could not be disentangled from those of manipulation.&4·s5 The study by Meade and co-workers was one of a select few that suggested manipulation was beneficial for chronic low back paill. R5 Triano et at reported recently that in patients with low back pain over 7 weeh, an avemge of 10.) treatments with chiropractic manipulation resulted in improved function and significantly reduced pain.«l Erhard and Delitto demonstrated that patients receiving manipulation and exercise outpcrfonned those receiving ex.ercise alone.'u

PROBABILITY OF RETURNING TO WORK

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Fig. 1.3. The probability of recovering from low back pain. (From Frymoyer JW: Epidemiology of spinal disorders. In Mayer TG, Mooney V, Gatchel AJ (eds): Contemporary Conservative Care for Painful Spinal Disorders. Philadelphia, Lea & Febiger, 1991.)

times lower in the Early Active Intervention group than in the traditional group. Many doctors consulting in managed care situations today wrongly conclude that care should be minimized for back pain sufferers because most will get better regardless of carc.

MANIPULATIVE THERAPY RESULTS IN LESS DISABILITY AND INCREASED PATIENT SATISFACTION

Manipulative therapy has clearly established its cost cfrcc~ tivcncss in patients with acute and subacute low back pain.'·~-'~"~ Jarvis and colleagues found. in comparing medi..:al versus chiropractic treatment for identical diagnoses, that "COSI for care \Va... significantly more for medical claims. and compensation costs were lO~fold less for chiroprac~ tic claims."S(J Authors of a recent meta-analysis looked at studies comparing spinal manipul<.ltion to other conservative treatments for acute low back pain and found signific3mly bet(er rales of recovery for those individuals treated with maniplllation.~J In fact, they concluded that manipulative therapy has demonstrated a 34% better rate of recovery at Ihe 3~weck mark than other conservative . therapies. lt) Patient satisfaction is a critical aspect to reducing disability and treatment costs. Chiropractics (which offers over 90% of the spinal manipulatlons) has shown higher levels of patient satisfaction than family practitioner visits for back pain.S7~ti" This level of satisfaction may be auributable in parl to the thorough explanations that chiropractors give their patients regarding the nature of their symptoms (facct. rnyofascial. disk. etc.}.R'1 Shckellc noted that the expert Rand panel rccommcn~ dations for spinal manipulation included about 12 manip-

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EARLY RETURN TO WORK IS A KEY

Aggressive care gives the best chance for early return to work. Litigation neurosis is easy for disabled workers to acquire. Promoting bed rest and prolonged inactivity only in- . creases the likelihood of prolonged disability. Treatments that mobilize the patient and auempt to return them to work quickly are advantageous. Communication between doctor and employer is essential because certain job modifications may be necessary to ensure worker safety on return to work. Deyo and associates said, "Our data support a recent trend toward earlier mobilintion of patients with back pain .... early return to work may help to prevent the emergence of chronic back pain syndro·mes, with their enormous human and monetary costs."~s Cats-Baril and Frymoyer also said. "It would seem that people who 3re able to work through the acute phase of a low back pain episode or those who go back to work even if the pain has not disappeared after a period of rest arc unlikely (0 become disabled .... keeping people al work is vcry effective thcrapy."n Waddell succinctly stated that, "Prolonged time away from work in itself makes recovery and return to work progressively less likcly."~J

Secondary Functional Restoration Prolonged passive care in an attempt to ameliorate the suffering of back pain patients can lead to patient dependency. In the acute stages of an injury. such care is nccessary; however. when the chemical signs of innammation arc missing. a more active. patient participatory type of care is required. Oland and Tveiten said, ". . . resources from the health services should be used in the subacute stage to enhance diagnosis, treatment, and rehabilitation and to inform the public of the benign. self-limiting course of low~back pain and the positive effect of physical training."')) Secondary functional restoration care that focuses on specific functional goals and patient education should be the mode of care for subacute or recurrent pain,· paticn(s~ Comprehensive rchabilitation involves functional capacity testing. physical training. education about biomechanics and ergonomics. and identification of psychosocial predictors of disability (Table 1.5).

REHABILITATION OF THE SPINE: A PRACTITIONER'S MANUAL

Table 1.5. Functional Restoration Functional capacity evaluation Rehabilitation of the motor system Patient education Identification of psychosocial factors (disability predictors)

FUNCTIONAL CAPACITY EVALUATION

Functional reactivation requires .lsseSSll1cnt of the fUllctiom,1 status of the patient's 010101' system, EvalmHion of posture and movement or static and dynamic function is essential and should include assessmcnl of joint mobility. muscle strength. coordination. cndUl
In a comparative study of pa.<;sive physical therapy versus rc· habilitation. Mitchell and Cam1cn found. "Active exercise to provide mobility. muscle strengthening. and work condition· ing has shown superior results, , , substantial savings have been realized in the number of days absent from work and savings in the dollars expended for compensation benefits. There was an initial increase in health care costs resulting from the intensity of the treatment, but these costs were more than offset by savings in wage loss C05t.'"')(' Lindstrom et al. compared a group of patients treated with exercises and education to a control group that received more traditional trc:atment. They documented earlier return to work and decreased re-injury in the rehabilitation group.'H The notion th
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patients, including tho:,c for whtHl1 surgery is being consid· cred, Again, Saal .11ld 5;l;1l said the failure of passive nonop·' erali\'c trcmmcllt i~ 1\(1t "ufticicl1t support of the decision to opcrale.~"

In one: notahk stud~ l.'\lHLcrning thc tn:aUllcnt of unCOlllplicatcd. ,H.:utc bal.:k pain paticlHs, Fa.ls ct al. reported that exe:rcise was no hCIl\.'r (h;1I\ llSU;t! L';\l"l': hy a gcneral practitioner:" One oh\'i\\u" \.'ritiL'i~m or thi~ ~tud)' is that exercises were givcn l\l1 a "gcneric" basis r"ther than being customized to the need" of eat.:h p
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IDENTIFICATION OF PSYCHOSOCIAL FACTORS {DISABILITY PREDICTORS,

It is the responsihility of the rehabilitation specialist (0 be on the lookout for carly ..igns of :.l disability prone patient. According to Frymoycr. "if a patient is identified early in the course of thc low hack p
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CHAPTER 1 : GUIDELINES FOR COST·EFFECTIVE MANAGEMENT OF SPINAL PAIN

important than biomechanical ones.68--rn:·7-l1.75 Frymoyer said. 'There is increasing evidence from the general field of disability, and specifically low back disability, that a 'disability prone profile' can be identified and used to predict polential disability before the condition becomes truly chronic....., Job dissatisfaction is one of th~ only proven predictors of disabling back pain. m According to Cats-Baril and Frymoycr,Il6 other predictors of low back disability include work status and job satisfaction~ injury being viewed as compensable: past hospitaIi7...,tion; and the patient's educational level. Recent studies indicate that it may be possible to idcmify acute back pain patients with psychologic predispositions to

becoming chronically disabled. ll7 · m In the Minnesota Mulliphasic Personality Inventory (MMPI), responses indicating increased catastrophizing as a painMcoping strategy as well as emotional distress appear to be promising discriminator5.111-122 D~prcssion. anxiety. hypochondriasis, and hysteria arc related to poor surgical outcomc. n .1l6 The "bio-psychosocial" model has been proposed by Waddell to address the disability problem in patie",s with low back pain"(Table 1.6). Tertiary Multidisciplinary Functional Restoration

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CONCLUSION

\Vith consensus-based guidelines emerging as the best chance to cut costs associated with diagnosis and treatment of low back pain. it is incumbent on us to be aware of the direction in which new findings lead. Quality care will result in bcHer patient satisfaction and reduced costs. Manipulation and exercise both appear to be of value if our beliefs arc based on [he scicntitlc literature. Future studies will hopefully nush out which patients respond better to what type of care and what arc appropriate timelines for transfening from passive to active care.

Table 1.7. Multidisciplinary Functlonat Restoration Quantifiable, functional capacity evaluation Physical reconditioning of the impaired "weak link Work hardening Behavioral disability management Ongoing outcome assessment using objective criteria M

REFERENcr~

Tertiary treatment of the chronic. disabled patient with multidisciplinary junctional restoration has demonstrated its cost effectiveness. A combination of technically advanced functional capacity evaluation. exercise training. «iid psy.::liVsocial intervention are essential to the program's succcss. With a functional restoration approach. Mayer et al. allowed 87% of chronically disabled people to return 10 work compared to only 41 % of a comparison group.12) Hazard et al. rcported that 81 % of the treatment group returned to work compared to only 21 % of lhe conuol group.I~4 \Vhen Sachs et at. used less psychologic intervention. 73% returned to work compared with 38% in the control group. This approach was less costly than that used by Mayer or Ha7.md and their colIcagues.l~j Oland and Tvciten aUemptcd a modified program in Europe. but they had difficulty achieving similar results. 9 .' Alaranta et al. compared a multidisciplinary functional rcslOration program to a primarily passive care approach and documented improved function, pain, and disability Icvcls.I~(' In contrast to most other multidisciplinary approaches, their approach lnvalved the use of low cost. "low-tech" functional capacity measures. Multidisciplinary functional restoration includes the components described in Table 1.7.

Table 1.6. Blopsychosocial Approach to low Back Disability Restore function Promote return 10 work Decrease pain Reduce distress Reduce abnormal illness beh~'::;:::

I. Riga... S. Bowyer O. Brnen G. ct :11: Acute Low B;\ck Problems in Adults. Clinical Pmctice Guideline. Rockville. MD. U.S. Department of Hcallh and Human Services, Public Health Service. Agcoc)' for H{'allh Care Policy and Rcscl:lnza Me. cl :11: Epidemiologic studic~ of lowMback pain. Spinl:: 5:419.1980. 4. Svensson HO. Andersson GBJ: Low back p:lin in forty 10 forty·scven year old Olen. l. Frequency of occurrence and impact on mcdicOil servicC5. Scand J Rehabil Mcd 14:47, 1982. S. Valkcnburg HA. H:laneR HCl\'1: The cpidcmiolog.y of low back: pain. Clin OnhorI79:9. 19S3. 6. Bicring·Sorcnscn F: A prospective slUdy of low back pain in a general population. I. Occurrence, recurrence and actiology. S,und J Rehabil Med 15:71. 1983. 7. Denn RT. Wood PH: Pain in Ihe back: An allcmpt 10 cSlimalc Ihe size of Ihe probl~m. Rhcum:l(ol Rch:lbil 14: 121. 1975. 8. Horal J: Thc clinical appcotrancc of low back: rain disorder-: in the cily of Golhenburg. Sweden. Acta Orthor Sc"nd Suppl IS: I, 1969. 9. Rowe ML: Low back pain in indU!';[ry. J Occup Mcd II: 161. 1969. 10. Berquist·Ullman M.l.arssol1 U: Acute low hack pain in induslry. Acta Grtllop Scand Suppl 170:1.1977. II. Websler OS. Snook SH: The cost of 1989 workers' compcns31ion low back pain claims. Spine 19: 1111. 1994. 12. Snook SH: Low back pain in indu!,;lry. In While AA. Gordon SL (cd!';): Symposium on Idiopathic Low Back Pain. 51 Louis. CV Mosby. 1982. 13. Speng.ler DM, Bigos SJ. Marlin NA. cl al: Back injuric!'; in industry: A retrospectivc study. I. Overview and cost analysis. Spine 11:241, 1986. 14. Frymoycr JW. Pope MH. Clelllcnl.~ JB. C( ;II: Risk f.lctors in low~back pain: An epidemiological study. 1 Bone loinl Surg IAO\I65:213. 1983. 15. Andcr-:~on G81. Pope MH. Frymoycr J\\': Epidemiology. In Pope Mit FI)'moyer lW, Anderswn G (cds): OlX:upalional La..... Dack Pain. New York. Praegcr. 1984. pp 101-114. 16. Morris A: Idenlif)'ing workers 'II risk 10 b"ck injury is nOI guesswork. Occur HC:llth Sar 55: 16. 1985. 17. Fryll10yer lW: Epidemiology. In Frymoycr lW. Gordon SL (cd!'): Symposium on New Perspective.": on Low Baek Pilin. Park Ridge, Americ;!n AC:ldemy of Or1horaedic Sllrg'·('ll)>:. 1989. pp 19-33.

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REHABILITATION OF THE SPINE: A PRACTITIONER'S MANUAL

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18. Sri,,,, wo. Lc Oboe FE. i)urul, M." ,,, S,I,,,,llk "ppn""h IU Ih' ;\s:>cs~mcnt and man3~.:mO:IlI of :lCli\ II~ -rdalc,l spillal disort!crs: A

rtlOllognlph for diniciallS. R~pUI1 lit" llw <",luo:hcc T;ISk FIlr.:..: on Spillal Disorders. Spine 12(Suppl 7):51. IIJSj. 19. Rossignnl M. Suiss:! S. t\bcllhcim L: \\','rkillg di.":lhilily due lIHX'CUp:I' tiollal back pain: lllrc~,yc:lr follow,"l' \\! 2.3110 l'Ollll11.'IlS:11cd wurkers in Quebec. J Occup ~kd 30:502. III1'S. 20. Abcnhcim L. Suissa S. Ktlssi~mll ~l. ki,1" uf r.....:ur....=.m:l,.· (lr occur;llional b;ICk pain o\"er ;I lllre..:: )"c:lr f"lll'w up. IIr J llld ~kd 45:829,

1988. 21. Fl)'moycr JW. RtlSr.:ll Jc. Ckmenls J. Cl :11: Psydwlogil' factor.. . ill lowback-pain dis;lbility. (lin On!lllp 19:': 171'. 19S5. 22. Dillanc JB. Fry J. Kallon G: "I,.·ute h~"" ,ymirollle·;\ simly frOIll general pr:l.ctice. 0, ~'lctl J ~:S2. 1%(1. 23. Wilddell G: A new dini~';jl mudd fll' Ih~' Irc;ltmcll( of IlIw-o:v.:k Jl:lin. Spine 12:634. 19R7. 24. Mixter WJ. Barr JS: Rupture of the inll'r\l'nehral dis, with involvement of the spinal e;m:l!. ;.; Engl J Med 11':~ 10. 19;\4, 25. Allan DB, Waddell G: .-\n histNkal pcr.\jX"t:ti...l; 011 Inw back pail\ :UllJ disability. Acla Orlhup Sl.:al.ld Suppl 6U: I. 19S9. 2b. Wiesel Sr::. T~nunn:lIl~:\. Feller ilL. el :-1::\ study of cCllll,.lgr:lllhil; eomp:JrislIlI (If pOl· tients wilh and WilhoUI hack a,·he. JA\lA 152: 1610, 1953. 37. Torgeson WR. Dot!cr WE: COll1parali\'c rnel1t~elll)S:faphie study of lhc asymptomatic and symptomatic IlImb;lr spin..::. 1 Bonc Joint Surg IAml 58:850, 1976. 38. Dilbbs VM. Dabb.' LG: Correlatinn betw.:ell disk height n:lrrowing ;md low-b..ek pain. Spine 15: 1366. If)l){J. 39. Nachcmlion AL: Nc\\ '::'\ kfl(lwktl~c of l(lW b;lCk pain. Clin Or1hnp 279:8.1992. 40. Videman T. NUffilincn M, Tf
279'110,1992. 43_ Schwar.ter AC. April CN. Derby R, el .11: Clinical fe;lturcs of paticll1s wilh pain stemming frmll the IlImb'lf l.}'g:lp0physeal joillts. Spin..:: 19: 1132. 1994. 44. Bamslcy L. Lord SM. Wallis Ill. ct 011: TIll' pre\'alence of ehroni~' cervical 1.yg.apophYseal jnilll pain after Whiplash. Spine 20:20. 1995.

·t'i. $eh .....;lrJ.er AC. April eN. Bogduk N: TIle sacroiliac joint in chronic low 1l;ll'k pain. Spin 2U:.". 199). -16. Bigos. S. Baui ~1C: n;\~k disahilil)' prc\·cntion. Clin Onhop 221: 111. 19S7. -17. Frymoycr J\\': I'r... di.:till~ disahility f'om low back p3in. Clin Onh 279:HH.11J9:!. 4~. lkyo RA. Diehl AK. Rllselllh:11

M: How 01;10)' days of bed rest for a.:utc luw hack p'IlIl.'. '" EIl!;1 J ~-lcd .H5:106-t. 19~6. -It). S:ml JA, $;\,,1 JS: ~\ln')llI.:r;l1ivl: trC:Ulllelll of hcrni:l1elllumh:lT illh:rn;r· lcbraillis( wilh r:l\Ji..:ulopal.hy. Spine 1-1:-131. 1989, ~O. H:Jkclius A: Pw~no~;~ in ~iatiea. Acta Orlhop SC:lOd Suppl 129:1. 1970. 51. Weber H: LUllln:tr disc hcmiati\ll1: A controlled prospceti\'c study Wit'l Icn years \If Ilh~f\·Jlion. Spine 8:131,198;\. 5:!. Schneider PL. KahJllll\·itl. N: Clinic:tl te~ling in chronic low back pain. Surg Rounds Onhop ~:19. 1990. )J. Dworkin SF: P... r~p\.. ~·ti\'es on psychogenic \,cr.;us hioc.cnic f:lctors in orufaci:ll ,md other pain slale.~. APS Journ:J13:172, 1992. ~~. LaRo(ca H: A 1:l..\Onomy of chronic p:tin syndromcs. 1991 Presidential Address, Cervical Spine Research S()Ciety Annual Meeting. December 5. 1991. Spine 10:5344. 19'n. ~5. Slater E. Glithcfo E: A follow-up of palicnls diagnosed as suffeno£:. fmm "hysteri:l:' J Psyehosom Res 9:9. 1965. ~6. Mcr...key H: Limitations of pain t.cha\'ior. AilS Journal 2:101. 1992. '57. \lcrs\.;ey II: Rq~'l'lIal p;lill is r;lTely hy'lerical. Ar..:h Neuwl ~5:91:'. 19S5. 58. Mers\.;e)' H: nl':: import:mc.... tlf hystcria. Or J Psychiatry 149:2.;.

1986. 59. Intcrnational r\,,~ociation for the Study of Pain: Polin terms: A list with definitions and 110tcS on US:lge. P:lin 6:2-19. 1979. 60. Loescr JD. Fordyce WE: Chronic pain. In Carr Jr.:, Uendgerink fir\. (cds): 8cha\'ior;1I Sciellee ill the Pr-.lcticc of Mcdi...inc. Ncw York. Elsc\·icr.1983. 61. Philips HC. Jah:m\hahi M: 111e components of pilin hch;l\"ior report. Beh.. v Re... Ther 2~: 117. 1986. 6~. Z.arkowska E. Philips HC: Rccent onsel vs. pel':'i;steill pain: E\'idcl1~'''' fur a distinelion. Pain 25:365. 1987. 63. Waddell G: r\ ne\\ clinicalmodcl for the treatment ~lf low !l:le!.; pain. In Weinst~in IN. Wi..::scl SW (cds): TIle Lumbar Spine: The International Society for the SlUdy of Ihe Lumbar Spine_ Plliladelphi;l. \VB S:lund.:",. 19'90. pp 38-56, 64. Linton SJ: The relationship hctwccn activil),' and ...hwnic ~in. Paill 21 :289, 1985. 65. Fordyce WE. ~k:'\bholl R, Ibinw..ter G. C! ;.1: Pilll\ cOlllpl:.inl-cxcn:is-: performancc rclatioll..hip in chr~ll1ic pain. P:tin 10:311. 1981. 66. Nachemsull A: Work for "II. fOt those with low !:lad; p;lin as well. (lin Orthop 179:77. IW!3. 67. Bom~. WM: 'n1e di~u~e syndroll1t:. We~l 1 Med 141:691. 1984. 68. Engel GL: P!'>yehogcllic pain and Ihe pain prone palient. Am J ~lctl 26:899, 1959. 69. N"liboff BD. Cohen \-11. Swanson GA. Cl al: COlllprdlel1liivc ;1l'l'l·S5· ment of chronic low back pain p:llients and I;ontrols: Physical abilit!l-:-. IC\'el (If ;lcti\"itic~. p"ydHllogical "djustmenl and p,lin perception. P;.in 23:121. 1985. 7fl. SI.;ISl TS: 'nlc painf!ll Pl=t.~Ull. Lanecl S~U8. 1968. 71. W..ddelt G. Main CJ. ~to"lrris EW. el :.1: Chronit, l\lW bal;k p:l;n, psy· chologic;ll disuc\\ and illness hchavior. Spine 9:209. 19S4, 72. Wiltse U •• Rocchio I'F: Pre(lpcr;ltiVl: p\)'chol(lgi~'al leSIS ,IS predil,.·h1n; of succes.... of chelllonucleolysis in the tre..tmenl of the low hack l'yn· tlrome. J none Joint Surg IAIll157:478. 1975. 73. Fordyce WE. Brochway JA, Bergman JA. et al: Aeute b:lek p:lin: .-\ control-group comparison of behavioral \·s. traditional 1I1:ll1agelll.. . nt methods. J Bell"\" Med 9:127.1986. 74. Fordyce WE. Fowler RS. Lehl1l:mn JF. ct :11: Op..::r.lnt condlllOntnc in the treatment of chmnie pain. Arch flllys Med Rehabil 54:~99. 1973.

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FOR COST-EFFECTIVE MANAGEMENT OF SPINAL PAIN

75. Stcmh M. ct al: ManipulOltivc therapy versus educalioR programs in chronic low back pain. Spine 20:948. 1995. 91. Erhard RE. Delino A: Relative effectiveness of an extension program and a combined program of manipulalion and nexion and extension exercises in patients with acute low back syndrome:. Phys Thcr 74:1093, 1994. 92. Cats-Baril WL, Frymo)'cr JW: Identifying patients at risk of becoming disabled becausc of low·back pain. Spine 16:607. 1991. 93. Oland G, T\'cilen GT: t\ lri:ll of modem rehabilitation for chronic lowback pain and disability. Spine 16:457. 1991. 94. Alaranta H, Hurri H, Hcliovaara M.el al: Non-dynaffietric trunk per· fonm.ncc tests: Rciiability and nonnative data. Scand J Rchab Mcd 26:211,1994. 95. Rissanen A, Alaranta H, Sainio P, ct OIl: Isokinelic and non·dynametric tests in low-back pilin patients rdated to pain and disability index. Spine 19:1963, 1994. 96. Mitchell RI, Camlcn GM: Results of 3 multiccnter trial using an intensive active cxercise program for the treatment of acute soft tissue and b.:lck injuries. Spine 15:514, 1990. 97. Lindstrom A, Ohlund C. Eel. C. ct :1.1: Activation of subaCUle low back paticnts. Phys Ther 4:279.1992_ 98. Faas A, Chavannes AW, van Eijk J Th M. et OIl: A randomi1.ed, placebocontrolled trial of exercise thcr.lpy in patients with acute low back pain. Spine 18:1388, 1993. 99. Catchlove R, Cohen K: Effccts of a dircctive return to work approach in the tratmcnt of workmens' compensation patients with chronic pain. Pain 14:181. 1992. 100. Fordyce WE, Brockway JA, Bergman lA. et al: Acutc baek pain: A control group comparison of behavioural vs. lradilionallllanagement meth· ods. J Behav Med 9:127,1986.

101. Mayer TG. Gatchel RI. Kishino NO. et at: Objective :lSsessment of spine function following industrial injUl)': A prospective study with comparison group and one-ycar follow-up. Spine 10:482. 1985. 102. Linton SJ. Dndlcy LA.Jensr.n I. el al: TIlc secondary prevention of low bad: p3in: A controlled study with follow-up. Pain 36: 197, 1989. 103. Kdlct KM. Kellett DA. Nordholm LA: Effccts of an exercise program on sick Ic AT. Hilycr JC. cl 31: Cost.. d fectivene55 of a back school intervention for municipal employees. Spine 17: 1224, 1992. 107. Moffcll JAK, Chase SM, Portek I. et al: A controlled, prospective study to evaluate tlte effectiveness of a back school in the relief of chronic low back pain. Spine 11:120. 1986. 108. Versloot JM. Schilstra N, Tolen FJ. et 31: Back school in industry. A prospective longitudinal controlled study (3 YC3rs). ISSLS Meeting, Miami. FL, April 13-17.1988. 109. Nordin M. Frankel V. Spengler OM: A prc\'enti\'e back care program for industry. Presented at thc International Lumbu Spine Meeting. Paris, May 1981. llO. Rl~rwick OM. Budman S. Fddstein M: No c1inic at risk of becoming disabled because of low-back pain. Spine 16:605, 1991. 117. Waddell G. Newton M, Henderson 1, el al: A fcar-avoidance beliefs qucstionnaire and the role of fear-avoidance beliefs in chronic low back pain and diS3bility. Pain 52: 157.168, 1993. 118. 1c1.1,i A, Adams HE, Swkcs GS, ct "I: An identific
'--*'------,-------------------------I I %J

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Integrating Rehabilitation into Chiropractic Practice (Blending Active and Passive Care) CRAIG L1EBENSON

Rehabilitation and chiropractic (manual medicine) are perfect partners in the delivery of high quality neuromusculoskeietal health care. Disorders of the locomotor systc;m onen resolve spontaneously, but high recurrence rates dictate a more pC". active approach. Manipulation and exercise ·arc the two mcth~ ods that have become the standard of care, especially in the costly aren,a involving tow back pain. New treatments must prove their value against these "gold standards. Combining: passive and active care is a new art that requires certain Fun· darncnlal skills. which arc outlined in this chapter. It

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FUNCTIONAL PATHOLOGY OFTHE MOTOR SYSTEM Clinically significant structural abnonnalitics. such as disk syndromes, are present in less than 20% of patients with low back pain. In the absence of trauma or relevant pathoanaromic change. the primary goals of care should be restoration of function and prevention of disability, including the chief functions of the locomotor system; strength, endurance, flexibility. coordination. and balance. Patients should be educated about the negative effects of immobilization and deconditioning and the safetylbenefits of early mobilization and controlled activity. Rehabilitation is guided by evaluation of the functional capacity ano work demands of the individual. This evaluation also provides ideal outcome measures of quality care.

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Rehabilitation attempts to address physical. and if necessary psychologic. deconditioning that accompanies most persistcnt pain syndromes. Muscular disuse leads to weakness. incoordination. atrophy, and loss of flexibility. Joint immobilization leads to bone demineralization. capsular adhesions, and decreased ligamentous stress tolerance (including annular weakncss). Cardiovascular fitness is diminished. Deconditioning affects not only peripheral anatomic structures, but also afferent systems, such as proprioception involvcd in balance as well as ccntral neuromotor control of movemcnt and pOsture. Although a specific pain generator often is diff1eult to pin down, the deconditioning syndrome can be identified in most patients with chronic or recurrent back pain by the pres· ellce of immobility, musclc weakness. and pain-avoidance behavior. It encompasses many of the typical physical and psy· chologic signs associated with back pain patients. The various

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interconnections between Ihese clinical signs are shown in Figure 2.1. The o\'eremphasis 011 trcutmellt of ('(mjeclIIrell struclIIj"al pathologic change (disk. facct, etc.) has resulted in (l failure to identify or focus on intrinsic fwu.:tit~"(ll losses. pSydlO,'Wcial factors. and extri"."ic ellvirollmelllal streuor,'i (\1'ork de· nIa"ds). This failure to recognize the limited reach of clinical diagnosis has especially plagued the medical community. whose overconfidence in the diagnosis of disk syndromes has promoted an overly passive approach involving rest and medication. The overcmphasis of this noomanagement philosophy is typically grounded in the belief that llle natural history of most b~lck pain episodes leads to resolution. Unfortunately. by encouraging inactivity. this approach results in immobilil.3tion of tissues and leads to deconditioning of thc musculoskeletal system. Dc)'o encourages maintaining function as the mainstay of treatment when a specific diagnosis is elusive.· Chiropractors or myofascial specialists who concentrate exclusively on passive intervention (i,e.. spinal adjustments. trigger point therapy) to treat a specific pi.lin generator (joint or soft tissue) arc also placing patients at risk for dcconditioning. Unles,\" the pariefll is educated to control em'irollmental stressors and trained to recondition !ullctio1l(lj' lh:ficits. pai" recurrences and treatmefll dependency will be rhe !"IIle rather ,II('" rile exceptio". NEGATIVE EFFECTS OF IMMOBILIZATION

Prolonged immobilization results in compromise of the musculotendinous, ligamentous-articular. osseous. cardiovascular, and central nervous systcms2-~. (Figs. 2.2 and 2.3; Table 2.1). 'Prolonged immobilization after an injury can lead to scar tissuc foonation and lowered fatigue tolerance of injured tissues, Soft tissue healing has three phases: inflammation. re· pair, and remodcling. Some form of local (issue immobilization is usually advisable during thc inflammatory phase. which usually peaks around the third day after injury. Toward the end of the inflammatory phase. fibroblasts are fouild in increasing numbers in the injured area. These fibroblasts contribute to scar formation. In a study of calf contusions in rats, Lehto and colleagues found that connective tissue scar formation will persist and become fibrotic rather than be 13

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absorbed if the acute inflammatory reaction is allowed to persisl.~~ These authors suggest early. aggressive management of injuries 10 limit enlargcment of thc injurt:d arca.~~ During the repair phase. passive and active m~tion of the tissues positively affects the injured tissut:s. Classic work on knee cartilage by Salter and co-workers. showed that/after 3 weeks of immobilization. intra-articular i.ldhesions complicate the repair phase of sofltissue hcaling.l~ Either intermittcnt ae-

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Joints Shrinks joint capsules:.) Increases compressive loading' Leads to joint contracture~·G Increases synthesis rate of glycosaminoglycans"';' Increase in periarticular librosis'o-': Irreversible changes after 8 weeks immobilization')" Ligament Lowers failure or yield poinF·H> '5-" Decreased thickness of collagen libers 'l'I_~ Disk biochemistry Decreases oxygen~' Decreases glucose~l Decreases sullate 2 ' Increases lactate concentralion~.l' Decreases proleoglycan cooteot n

Bone Decreases bone density:n-3' Eburnation" Muscle Decreased thickening of collagen fibers 18 .3.l' Decreased oxidative polential1.... 3~ Decreased muscle mass::'2.3C>-3? Decreased Sarcomeres'o Decreased cross-sectional area t l -4) Decreased mitochondrial contenr" Increased connective tissue librosis"~ Type 1 muscle alroph~2.,o."T Type 2 muscle atroph~e.• ~ 20% loss of muscle strength per weekUl Cardiopulmonary Increased maximal heart rate~' Decreased va: max,"l Decreased plasma volume'"' (From liebensoo C: Pathogenesis of chronic back pain. J Manipulative Physiol Ther 15:303, 1992,)

nonnal after 8 weeks. After 5 months of reconditioning. stiffness was reduced to only 7% of nonnal levels.} Five months of reconditioning improved the tissue failure rate to 80% of normal. and after 12 months of reconditioning, the ratc was completely nonnal.}

FUNCTIONAL DEFICITS ARE PROSPECTIVELY CORRELATED WITH LOW BACK PAIN

Patients typically become inactive when they cxperience pain, and this inactivity promotes dcconditioning. \Vith deconditioning comes greater susceptibility to typical postural or occupational repetitive strains. A chronic cycle of recurring pain is easily established unless function is restorcd./lf pain relief is the only goal of treatment. and functional restoration is ignored, painful recurrences arc more likely". Spons medicine specialist Stanley Herring says, "signs and symptoms of injury abate. but these functional deficits persist. ' . , adaptive patterns develop secondary to the remaining functional dcficits,"~ Focusing on function helps patients to develop control over their symptoms and to prevent recurrences. In many retrospective studies, investigators have documented that various functional changes in musculoskeletal performance arc associated with episodes of bnck pain. al-

though tht:y C:l 11 1l0t dctcrminc if (hcse changcs are a cause or :1 rc:,uh of lhc pain. Prospcclivc studies come closer to id"'lltiryin~ clioll\gic factors. Thc goal of such research is to idctltify what factors are causally linked to low back pain epi:'Olks in a prcdictivl: manner. The following studies arc all pnlspCl:liw, i\
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Table 2.2. Intrinsic Functional Losses Correlated Prospectively with Back Pain Episodes

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Muscle strength~·~ Isometric lilting strengthlendurance~ Abdominal strength~·~7 Isometric flexion/extension strenglh~ Physical fitnessS-O· s, Job skill(,O Extension mobility!>7 Physical a,ctivily~9.6~

(fatigue) and eventunl injury arc the result (Fig. 2.4). The stress! strain curve explains the mech:Jnics of the relationship between extemalload (~aress) and lissue deformation (strain). The applied or elongming force is termed slress. The amount or percent of elongation is the strain. Stress is measured in newtons and strain in percent (%) elongation. Loadittg of biologic tissues produces a characteristic stress/slrain curve demonstrming the amount of stress (load~ iog) required to produce a set amount of strain (percent cion· gation or deformation)I"- (Fig. 2.5). Thc initial concave portion of thc curvc is lhe "toc" region, which corresponds [0 the initial tissue distraction involving a structural changc from a crimped. wavy fibril organization [Q a morc straightened, par· alleI arrangement.~ In the toe region, little force or energy is required to lake the slack out of the tisslle. but the tissue quickly becomes stiffer, resisting further dong..Hion. If greater forc\"~ arc prescnt. tissue dcform
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STRESS

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pectcdl)' applied oul'ing their vulncrable. recovcry pk,~~."M According to Andcrsson ... It is generally believed thai r~pe!i tive loading causes failure becausc of faligue of the various tissues:· I •.\ Brinckmann and Pope condudc under repetitivc loading. the yield strc~s of thesc l1lillcriilb .tIld the strength of struclllres buill from these matcrials i:-: n:duccd with respect to the stress or strength obscrved under a single load cyclc..f .... (Fig. 2.7). l?educillg ('xjJo.mre 10 high /t.\.e/.\" of load-sllch as trunk flexioll wilh eilher CO/1//u·(!.uiofl or rota-

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oO~-:-l--:2--'30'--'-4--:;;--'6:-' OEFORMATION (mm) Fig. 2.8. The strength of rested tissue deteriorates dramatically compared 10 normal tissue. In this medial collateral ligament of a rabbit knee thai rested for 9 weeks, two thirds of the strength has been lost. (From Mooney V: The subacute patient: To operate or not to operate. In Mayer TG, Mooney V, Gatchel RJ (eds):

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Neuroph)'siologic Factors

Fig. 2.6. Stress-strain curve illustrating hysteresis. When unloaded. a structure regains shape at a rate different to thai at which it deformed. Any dillerence between the initial and final shape is the ~set." (From Bogduk N. Twomey LT: Clinical Anatomy of the Lumbar Spine. 2nd Ed. Melbourne, Churchill Livingstone. 1991.)

Injury

As tbc activc component of our locomotor system. muscles arc often called on consciously or by reflex to protect othcr tissues' under stress. Compcns3lOry adaptations (facilitative ;llld inhibitory) typically follow any strain, whether or not it is painful. \Vhat may begin as a segmcntal, reflex muscular 'Idaptalion to pain may become "programmed" in the form of
Repetition Fig. 2.7. A fatigue curve illustrates the importance of repetition and load to fatigue failure. (From Andersson GBJ: Occupational biomechanics. In Weinstein IN. Wiesel SW (eds): The Lumbar Spine. Philadelphia, we Saunders. 1990.)

back pain. Similarly. frequent microbrcaks. t~lkel1 as often as every 20 minutes. C'ln help reducc thc chance of injury .Iner exposure to repetitive overloading. Frequent microbreaks can prcvclll the instability that arises after tissue creep has occurred. Such breaks can prevent repetitive strain injuries noted after prolonged stalic loading such as from sitting or repetitive overuse from sports or occupational activities. The more impaired lhe sort tissllt:. the less stress required to reach the soft tissue fatigue or f:.lilure p~int. Im/1/obilized fisslle.f; are more I'IIlllcrable t"OI/ I/orll/al (issues to similar WJl01U1ts oj/1/cc!ul1lical stress (Fi,t:. 2.8).' Pre\'elllin,~ the negative effects oj ilJl11lobilizmioll is O1W of the primary goals of relwbilil£llirm for 11I11scuioskeleUlI complaints.

Th~

existence of a pain-spasm·pain cycle has been a \vellacccpted concept of physical therapy and chiropractics. As a criteria for therapeutic decision making. it is one of the most il\lluel\tial "" priori" assumptions of many practitioners. espc· dally aillong those who lise extensive passiv~ techniques and/or soft tissue manipulation. Its validity is unproven. howcver. and currently. it is often ignored. The litemture docs show thm prolonged or intense pain can lead to both psychologic (abnormal illncss behavior) and neurologic (dorsal horn sensitization) consequences. Either or both of these behavioral and physiologic dysfunctions arc at the heart of the transition frolll :.111 .\cutc to a chronic pain syndrome. Significant external loading that exceeds intrinsic functional capacity leads to tissue fatigue and altered biomechanics. To maintain spinal stability following biomechanical changes,. such as can occur after creep and hysteresis, type I and type II affcrcllls arc stimulated to maintain accurate proprioception Crable 2.3). The initial firing from the joint mcchanoreceptors, muscle spindle affcrents. ilnd Goigi tendon organ afferCllts allows ad'lptation to occur so the fatiguing tissues can avoid failure. Because these receptors arc adaptive. they do not continue to discharge if the biol1lechanical changes :lr~

Table 2.3 Nerve Types and Functions FAST MYELINATED LARGE

SLOW UNMYELINATED SMALL

Low Threshold/Adaptive

High Thresholdl Nonadapting

II g~mma

A alpha

A beta and

Golgi tendon, primary muscle spindle, al· lerenls to skeletal muscle

Secondary muscle spindle, gamma efferent to intrafusal muscle spindle

III

IV

Adelia

C

Acute pain

Chronic pain, postganglionic autonomic, dorsal root afferents

present for a long period of time. As a result, repetitive strains eventually exhaust the adaptive capacity of the body's dc fenses and lead to painful injury. Once tissue failure occurs, inflammation, mediated by bradykinin. substance P, and prostaglandin E2, lead to stimulation of nonadaptive, types III and IV nociceptive affcrcnts. Various changes in the muscular system occur automatically when injury occurs. For instance, muscle inhibition follows acute low back pain or knee injury/inflammation. 67.(,~ Additionally, increased neuromuscular tone also results from strong nocic.:.ip;iVt .Hiiiiulation,!,9-71 Protective mechanismsnonnal illness behavior-to immobilize an injured area are usually appropriate in the acute stage. If they become memo· rized as a "pain-motor program," however, they can lead to a chronic state. Abnormal illness behavior, such as excl!ssive or prolonged stress, fear, or anxiety, will affect the neuromuscu· lar system behaviorally via canditialling alld ph.lfSiologicalJ.v from the limbic center, thus providing an ideal terrain for chronic pain. Testing with evoked potentials of patients with chronic back pain revealed lower pain thresholds and higher than normal evoked responses at thresholds than are noted in normal subjects. 72 Magnetocnccphalographic study with sub, supra, and standard intracutancous electric shock stimuli in chronic back sufferers also revealcd a higher than normal pain-evoked magnetic field. n It was concluded that this heightcncd response was attributable to central nervous system hyperresponsiveness in the primary somatosensory cortex. Acute pain involves biomcchanical insult (i.e., injury, repetitive strain), biochemical mediation (inflammation), facilitation of algesic pathways, and finally neuromuscular adaptation. If repetitive biomechanical insult is not avoided; abnormal illness behavior is present; or deconditi~ning occurs, resulting in inadequate neuromuscular adaptation, then chronic pain with central nervous system involvement (corticalization) can be expected. To prevent the transition from acute to chronic pain, three things should ocq~r once the initial acute, inflammatory phase has passed: ( 1) patietll educaricm about how to idenllfy v

and limit external SOlfl"ces of [);o/lll'chan;nt! ovcrlo(ld; (2) early idelllificatioTl of psychosocial j{zctors (~r abnormal iff· Iless behavior; and (3) idellfijicatio/l and rehabilitatioll (~ftlu' functional pathology of the motor system (i.e., dl'COlldit;ollill~ .~~vlldro/llc). This third aspect involves looking for specific joint and muscle dysfunctions so that patient reactivation can be promoted and deconditioning prevented. Figure 2.9 shows how chronic pain can arise from dccol1ditioning syndrome. , Pain is dcrived from the Latin term "poena" mcaning penalty or punishment... Unfortunately, pain docs not always serve as a good early-warning system, but/oftell arises only after damage is done,. Pain alone is just a symplOm-the COIlscious perception of nociceptive aClivity. If [Jain relilf is the 01l/Y goal of care, thell decollditiolling afld variollsfulIctiOfwl pathologies will remain as precursors to future bio/llccJ/(mical failures. Functio/lal re:"'toratio/l ill additio" to paill reliel are appropriate goals because prevellfion of recurrent or chronic pain is the ultimate goal of a cost cOlllainmelltoriellled approach. In as much as we can identify specific functional pathologies that are causally linked-trigger points or overactive muscles, weak muscles or abl1of!lIal movement patterns, and joint dysfunction-we can then not only provide symptomatic (pain) relief, but also restore function. Evcn in the absence of uncovering a clear chain of functional patllologic changes. identifying deficits in functional capacity can drive the reactivation of the patient by rcrnediating pain avoidance behavior. MUSCULAR PAIN, TENSION, AND INHIBITION

Muscles are often ignored while joints or disks receive the majority of recognition as potential pain generators. For

THE PAIN CYCLE: INJURY

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years. skCplics have enjoyed pointing out thc unproven nature of such clinically popular concepts as myofascial trigger points. RC\'it:wing the lilc:ratllrc on muscle p~lin. however. rcveals the error or this omission. Traumatic injuries overload the structural components of muscles and lead In frank lissue dis£uplion and failure. Under lhese circum~tances. incre'lscd muscle pain is predominal1lly a result ()f neurochemical events. "Tr~lumatized muscles rcIeasc various chcmi(,;;'lls capable of aCliv;'lting no..:iceptl\'e pain gcncr;nors.;J These chemicals can also activate nociceptive pathways via (HHaSsiulll. br;.ldykinin. or histamine extravasation. Increased mll~c1c (one or "spasm" has been widely used as a descriptor for palients with p;'llpable stiffness in their soft tissues. Unfortunately. viscoelastic connective tissue and neuromuscular factors arc rarely differentiated. Additionally, terms such as increased muscle tone. muscle tension. tightness. stiffllc~s. shortening. hypertonicily. spasm. fibrosis. and others arc llsed loosely and without ~dcquate definition. Scicntific work in this field has been l~cking. but researchers arc beginning to redress Ihis situation.74.7~ Although it is admiuedly unproven. muscle tension is widely believed 10 go hand in 'hand with p~in. Muscles as the active components of the locomotor system are responsible for both reflex and centnllly mediated adaptations to repclitive strain. injury. or pain. The significance and \'alidity of p~lIpable increases of soft tissue tension or stiffness have been called into question by. among other things. the poor reproducibility of electromyography (EMGI and lhe poor reliability of palpation. Nonetheless. as Paillard expl'lins. muscle tone is a key aspect of mOlar control: "Muscle tone. once widely used as a basic semiological dimension of clinical neurology. is now almost totally ignored by neurophy:-:iology. It (;'crtainly de:-:efvcs new COI1sider;,uions as a potent contextual dimension of motor pcrform;mce. "7f, The organ of muscle lOne is thought to be the muscle spindle. which sels the sensitivity of the muscle to streIch. Boyd refers to the muscle spindle <.\s " ...•1 marvel of control engi· ncering. incorporating many of the features of an engineering 'servo-control' systcm."n In theory. muscle tone is greatly influenced by the amount of gamm<.l activit>, present: the greater thc background gamma activity. the larger the intrafusalspindie response to any given change in muscle length (Fig. 2.10). The gamma syslcm is under the coolrol of descending impulses from the cX.Ir'lpyramidal motor pathways. These higher cortical centers (i.e.. the limbic lobe) arc more active under conditions of emotional stress. Many examples of increased soft tissue tension arc unequivocal. such as cases of acute lumbar strain. tonicollis, acute appendicitis. peritonitis. and whiplash. To What, degree st!ch ncuromuscular changes "lrc attributable 10 rencx, central, or other mechanisms is unclear. It is also unproven to what extent the muscle spindle or gamma system participlltes. Increased EMG
Afferent

impulse

frequency

I

High gamma

/ !/LOW

___ }

gamma

Muscle length Fig. 2.10. Inlluenee of muscle length on spindle impulse freQuency al two different levels of gamma motoneuron activity. (From Korr 1M: Proprioceplors and somatic dysfunction. J Am Osteopath Assoc 74:638, 1975.)

patients with low back disability.'" In addition. sustained EMG activity has been found in the nidus of trigger points.'9 It has also been noted that when pressure is applied to an aclive trigger point. EMG activity increases in musclcs in thc referred pain zone.l;O Static overstrain. such as from prolongcd sitting or slumping, has often been suggested as a high risk activity for individuals with a back problem. Sustained contractions of only 4% of thc maximum voluntary contraction possible have been shown to lead to negative cffccts.(,·~·111 Metabolites are produced that stimulate groups 1II and IV aUerents and increase gamma motor neuron activity. It has also been shown that increased interstitial potassium concentrations sensitize the groups III and IV muscle afferents. ,n resulting in an increase in the sensitivity to stretch of muscles with convergent afferent inpu(Sj (Figs. 2.11 and 2.12). Study of muscle fibers has shown that conditions of constant 10,1'1 affect the ability of a ltlusde to achieve efficient rclaxation.'4 As a result. tension and pressure build up in the muscle.'J The more the muscle contracts. the greater the energy expenditure. Local ischemia is another key factor involved in increased muscle tone. Under conditions of ischemia. groups III and IV muscle affcrents become more sensitive to strelchX-l (Fig. 2.13). Ischemia itself is not painful; however. if II muscle contracts under ischemic conditions. pain develops wilhin I minute.lI~ Br~ldykinin is released during ischemia and is therefore thought to be associated wilh ischemia-produced pain."lJ Under eccentric muscular conditions. mild overload may swell muscle fibers without inflammation.!((; Heavy eccentric exercise leads to swelling and necrotic inflammation. 1I7 Joint receptors. if stimulated. cause both facilitation and inhibition of muscles. Low intensity stimulation of joint afferents in the knee have been shown to influence the sensitivity to stretch of Illuscles around Ihe kncc.w.llt-91J Also. rellcx inhibition of muscles has been noted when joints and ligaments ;,ue
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Fig. 2.11. Pathophysiologic model for mechanisms possibly involved in the genesis and spread of muscular tension in occupational muscle pain and chronic musculoskeletal pain syndromes. (From Johansson H, Sokja P: Pathophysiological mechanisms involved in genesis and spread 01 muscular tension in occupational muscle pain and in chronic musculoskeletal pain syndromes. A hypothesis. Med Hypotheses 35:196,1991.)

Fig. 2.12. Increase in muscle tone with chronic irritation of the small nociceptor afferents from skeletal muscles. (From Dvorak J: Neurological and biomechanical aspects of back pain. In Buerger AA, Greenman PE (eds): Empirical Approaches to the Validation of Spinal Manipulation. Springfield, Charles C Thomas. 1985.)

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Fig. 2.13. local vicious cycles in damaged muscle as a possible peripheral mechanism for chronic muscle pain. The right-hand cycle is assumed to be started by a tissue lesion that releases vasoneuroaclive substances (path A). The centrallactor of the cycles is ischemia, which can be produced by venous congestion, local contracture. and tonic activation of muscles by descending motor pathways (path 8). (From Mense S: Nociception from skeletal muscle in relation to clinical muscle pain. Pain 54:241.1993.)

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hibition of certain muscles required for a task is a likely contributor to overload injury or pain.9.,.I1~ Hides et al. documented/unilateral wasting of the multifidus muscle in patients with acute low back pain/"~ With realtime sonography. they measured cross-sectional area (CSA) of the muscle and determined that the wasting was isolated to one vertebral segment. The wasting occurred rapidly in a 10' calized area and was thus not considered to be the result of disuse atrophy. The authors were abk to correlate the area of wasting with a dysfunctional segment identified on clinical manual examination (i.e.. motion palpation)....ln patients with chronic back pain. CT scanning demonstrated generalized atrophy but a relative increase in the CSA on the symptomatic side~~ Such a relative increase in the CSA could be explained by Ihe findings of increased paraspinal muscle activity% and hi..ologic evidence of type I fiber hypcl1rophy on the symptomatic side and type II fiber atrophy bilaterally in persons with chronic back pain.!H Bullock·Saxton et al. described gluteus maximus and medius inhibition during gait. and their subsequent facililation after a brief course of propriosensory retraining."ll Janda also reported r~ciprocal inhibition of the abdominal muscles as a result of stiff. overnctivc erector spinae musclcs.r~) He showed that the abdominals became spontaneously stronger following inhibition and stretching of the erector spinae. Headley successfully demonstrated inhibition of the 100ver trapezius muscle during shoulder Oexion or abduction when active trigger points in the upper trapezius are prescnt.lI~ Simons also reported inhibition of the deltoid muscle during shoulder flexion when infraspinatus trigger poilHs arc prescnt.!!!)

TIIP ;/lirhtl muscular reactioll to pain alld injury has trat/itional/y been as.mlllct/to be im:reased tell-fie", ami slijJ"ess. Data ill Ihe lilerlllure indicate ilihibiliull is at least as significallt. Tissue immobilization occurs secondarily. which leads to joint stiffness and disuse muscle atrophy. Such changes become a habit. mediated by central motor regulatory pathways as a new "pain-motor program" forms. The combination of trigger points. muscle inhibition, and joint dysfunction arc kcy peripheral components of the functional pathology of the motor system. If sustained over a period of time. these components 1ll.1Y outlive the elimination of what caused them in the first place. This f
According to Schaiblc and Grubb. "The major sensation th'..lt is ascribed to the joint is pain:" l ,(] The joint is involved in pain, proprioceptive. reOcx muscul~\r. renex sympathetic, and other neurobiologic events. Thcsc events arc depicted in Figure 2.14. Although joint afferenls participate in movement and position sense, proprioceplion is primarily a muscle sense.IOlJ.11J1 /fyperstmsitjvit)' (increased or abnormal paill respo/1se) ofjoints to movemellf is a key factor ill the developmellf ofthe dec:omlitioning symlrome. Groups III and IV afferCnlS can develop "long-lasting 'sensitization' to mcchanical stimuli after the onsct of joint inflammation.... many of them have been fOllnd to exhibit ongoing uisclwrgcs whcn the joint is kcpt in its resting position."II~' Mcch.mo-inscnsitivc affercO!s arc also

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prCl\ellt. These "silent nociccptors" also can become pain prodlicers when sensitized by inflammation. II.) Joints as a source of pain are ,111 too frequcntly ignored. In a study of318 consecutive patients with intractable ncck pain. examined by provocation diskography and/or zygapophyseal joint blocks. 26% of the patients had symptoms aSl\ociatcd with a joint. whereas 53<;(: had symptoms related 10 a disk.lU~ In a similar study. 56 patients with neck pain a"od no l\igns of nerve root involvement of at !C;'lst 6 months dural ion were ex· amined. The results shO\vcd 23% had a symptomatic joint. 20% had a symptomatic disk. and 41 % had symptoms rel;'ltcd 10 bOlh a disk and a facet joint. lU.\ Referred pain is often ascribed to nerve root irritation. bUl joints arc also a likely source. Activated joint affcrcnts arc C
,

in these sllldic~. hut spinal joim dysrullI,;tion has hecn com:> latcd with mll\dc \vasting in paticlIis \\ illt aL'utc low h'lck p;lin ;IS wei I.""

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SUBLUXATION. REFERRED PAIN. AND NEUROPATHIC PAIN

lllc chiropractic ··suhluxation·· involves biOl1lcdlal1ical alter;'Itions such
(Fig. 2.16) As long ago ;IS 1883. Stlll"gc suggested th"\1 an injury could trigger a dwngc in the ccntr;:11 nervous system such that lIormal inputs would evoke ~1Il ex•.lggcrated rcsponse. HI~ [n 1893. ;vbcKcllzic proposed that referred p'lin ..:ould fC· suIt after sensor)' impulse" from injured tissue IW\"l~ created

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23 Fig. ~. i 5. .suggesteo nelworK of lac· tors contributing to fixed flexion of a damaged joint. (From Young A. Stokes M. lies JF: El1ects of joint pathology on muscles. Clin Orthop 219:21.1987.)

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most exciting is lhallhcy Me attacking the notion {hat pain 1';1tienls with few objective signs have psychog.enic pain. Ncuropathic pain is considered cOlllmon in causalgia. rcOex sympathctic dystrophy. posl-herpelic ncuralgia. stroke. syrillgolll)'cli~l. syringobulbia. multiple sclerosis. and spinal cord injury. Ncurop:.lthic pain C;1l1 also result from a rcpclilive strain initiating strong affcrclll nociceplivc b
REHABILITATION OF THE SPINE: A PRACTITIONER'S MANUAL

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lUres. Stimulation of viscera docs not .tlways produce pain. btU \'isccral aftcn::nts projecting into the dorsal horn do lypiclructures. I ).I.117 COl\\'crgcm::e and (elllral neural plasticity provide the ncuroanatomic basis for pain rdefr
Fig. 2,16. Physiologic mechanism 01 the ~irritable focus in the grey maHer of the spinal cord. (From Grieve GP; Simulated visceral disease. In Grieve GP (ed): Modern Manual Therapy of the Verteberal Column. Edinburgh, Churchill Livingstone, Edinburgh, 1986.) H

Poor 1'..lotor Contro'-lncoordin~lIi{ll1()r POD( balance. Test: Incoordinatcd !novcmClH pallcrns or gait; ro~ilj\,c Rhombcrg or Hamanl tcst Referred Pain or Sccondur)" H),JlCnllgcsia-Sprc:ld of p
Test: Trigger point cvalu
Neuropathic symptoms have been shown to be rel,lted in part to convergent input in the dorsal horn from skin and/or deep somatic (visceral and nonvisccral) struc;.

- The·pr~ncc of nondcrmatomal referred pain and hyperalgesia implies thnt ccntrill changes independent of convergence arc operative. ,~~ An example is the situation in which referred pain spreads to the site of iln old injury. An angina at· wck has been shown to refer pilin directly to an old vertebml fractllre.l~1 il Iws also becn demonstrated that I wcek after dental surgery. pin prick of the nasal mucosa Ciln produce referrcd pain to the treated tceth. ,~~ Distant referral of pain to a nondermmomal arca can also occur. such as in cardiac pain referring to the ear.12~ It has also been shown that a decrease in the fkxion withdrawal reflex threshold is present in women aftcr gynecologic surgery.'l What is Sensitization? Sensitization is a change in the stimulus-response profile of dorsal hom neurons so that the)' respond to mech;:moreccptivc ilfferents as if they were nocicertors, 12f,.I~~ \Villis explains that a nociceptive barrage leads to central sensitization of dorsal horn neurons:I~(J "If these lH>ciceptivc neurons have convergent input from mcchanorc· ccptors. their responses to both innocuous and noxious mechanical stimuli will then be increased.... Sensitization then causes formerly subthreshold responses to rench threshold and trigger disehargcs."'u, According to Mayer and colleagues. "Overwhelming evidence suppons the conclusion that a change in the central processing of input from lowthreshold mcchanorcccptors is responsible for secondary hyperalgesia to light touCh."I~lI Silent nociceptors that arc mechano-insensitivc also can become mechanoscnsitive once sensitized. 1flo Table 2.4 lists the neural changes associated with sensitization and Figure 2.17 depicts the p::Hhophysiology of sensitiz'ltion.

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How Do Mechalloreceptor A[[ereflts Cause Pain? The Neurochemistry of Neuropathic Paill. The p:'lthophysiology of neuropathic pain involves peripheral ilnd central neural

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Sustained activity in types III and IV (small diameter) primary affcrcnts leads to a rclcflse of excitatory amino acids (gl~t·,;!.7 Secondary neuron hyper-responsiveness after repeated stimulation is called "wind-up" and is often short term. Inhibitory amino acids such as GAB A arc present to dampen this exaggerated response. but. over time. segmental inhibition is deactivated by the flood of cxciuttory
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CORTICALIZATION OF PAIN ANO CENTRAL MOTOR REGULATION

The locomotor system has peripheral (sensory and motor) and

central (programming) components. The peripheral components (somatosensory. vestibular. visual) pro\'ide input and feedback (afferent) as \\'ell as carry out the instructions (efferent) of [hc central motor regulatory centers (cortex, cen:bellum. basal ganglia. etc.) (Figs. 2.18 and 2.! 9). Prolonged or intense noxiolls. sensory stimulation call !e;IO lo dorsal horn sensilization. reorganization of somatotopic maps. limbic dysfunction. and ··reprogr'.lI11ming" of movcmelll patterns. Abnormal illness behavior in response to subacute pain encour<1ges ehronicilY. Poor slecp habits. high Icvels of emolional stress, and excessive fear or anxicty Illay stern from a limbic dysfunction. This condition negatively affects the mu:o;culoskclctal system by promoting physical and psychologk dcconditioning. Magnetocnccplwlographic and evoked potential studies in patients with chronic low back pain ha\'~ dcmonslralcd ccntral nervous systcm hyper-responsiveness in the primary somatosensory cortcX. n :i .1 M"lgnetoencephalogmphy has revealed a somatotopic cortic,ll nl
nc.nMOIL.llf\IIUN OF THE SPINE: A PRACTITIONER'S MANUAL

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onen enough arc learned by the cerebellum. This new central programming is called an "engram." In regard to this pro· gramming. Pail lard says. "The existence in all animals of a consolidated rcperloirc of motor capacities. either inherited or secondarily acquired. is now all incomrovcrlible fact of contempof;. central motor regularion. lind psyr;/lOsocial facto,.s.

RETICULAR fORMATION

Fig- 2.19. Pathways for cerebellar "error'" control of involuntary movements. (From Guyton A: Basic Neuroscience. Philadelphia, Saunders. 1987.)

we

Sherringtol1'S Law of Rcciproc~1I Inhibition (Fig. 2,20). Thus, if Cl TU/'ilum{ mllscle SllC" as the iliop.WlJ.\' become.\· .'ihortem·d frorfloverusc. flot olily will it lJu!(:lumically {imit Ihe rang(' motion of it,'I {Jlltllgolli.'it 'fie 81weus max;mus. bw also iT . wifl 'leurolO);ically illh.i11ir.j1S_GCI,h}!l as well. This combin:l· tion of biomcchanical and neurophysiologic influences is a Clinical Features strong stimulus to the creation and maintenance of muscular MUSCULAR IMBALANCE imbalances. \Vhen muscles reacl lo protect the body from harm or lo reElectro'myographic (EMG) data (Fig. 2.21) show th;:tt a duce pain, certain muscles become overactive while others tight erector spinae muscle will be active during its rever:,\: are inhibited. As a result. joinl stress is altered and greater :lction. trunk flexion. and thus inhibits the action of the agolIluscie fatigue results. For such prolective reactions, [he poslural or anligravity muscles arc activated most easily, Table 2.5. Postural and Phasic Muscles 13S Conversely. muscles wilh a primarily dynamic or phasic function tend to be inhibited when physical Slress is prescnt. jandll Postural (Tend to hyperactivity) Phasic (Tend 10 hypoactivily) and co-workers. who studicd thcse typical musclc rcactions in Triceps surae TIbialis anlerior both neurologic and onhopcdic patients. call this common Hamstrings Gluteus maximus clinical phenomena "muscle i111balancc,"I~~-I,I~ Adduc(ors Gluteus medius Reclus femoris Rectus abdominus Janda l11ul co/{eaglles (.'x"llIined that the basis for most Tensor fascia latae (TFL) Lower/middle trapezius t1lflscle ;ml)(llallces comes from our predicwble respot1se to Psoas Longus capitus & colli stressfttl cnvironmetltal demands (constrained pO.'iIUreS, Delloids Ereclor spinae Digaslrics Quadratus lumborum (QL) reperiiive tasks, gravity stre,'iS, inactivity). They identified PeCloralis that the pO!'itural muscles tend toward overuse and eventual Upper trapezius shortening, whereas the ph'1Sic muscles tend toward disuse Sternocleidomastoid (SCM) Suboccipital and weaknessl~-l~l (;rable 2.5). These muscles arc oftcll Masticalories grouped as paired antagonists and appear to be affected by

\/tlf

,,

)

27

CHAPTEH 2 : IN' ~l:iHAl ING REHABILITATION INTO CHIROPRACTIC PRACTICE

Sensoly ncu:uOl 1, ...,10 flelCOf muscle! spindle

\ Inhibitory

Intclnouron E.. lcnsor nlusdc

ttdeeps)

Fig. 2.20. Reciprocal inhibition 01 motor neurons to the opposing muscle. Impulses lrom ttle contracted muscle .e.xcite motor .unit:!,( the same muscle (faclhtory synaptic)nlluence designated with a plus sign) and inhibit. through an interneuron. motor units in the opposing muscle (inhibitory synaptic influence designated wilh a minus sign). (From Lehmkuhl LD. Smith LK: Brunnstrom's Clinical Kinesiology. PhilEldelphia. FA Davis. 1983.)

t)

()

htensor ~ mOloneu·on ui.l·ub'lCd

o First Recordino

N

J\)'

-. I '.1. r--r::x::;rj

rect.obd. lower left er. sp.left

loop,vL ISEC.

"'_,--

~....:

_!>

... ...... -. ... :l

1

recto abd. upper left

Second Record ing

,

""

41

JV

S

", •

~

~ I ". ~

f

~,~ _:~~....L

'....-

6

Fig. 2.21. Electromyographic activity before and alter stretching light muscles. (From Janda V: Muscles. central nervous motor regulation and back problems. In Korr 1M (ed): Neurobiologic Mechanisms in Manipulative Therapy. New York. Plenum. 1978.)

~.

An intermediale muscle type is FR::::':J~I~!_~~y.itch fatigue This typt: resists fatigue but illS0 has f,lst COlli raction nnd relaxation speeds. The FR type has both aerobic and t1naerobic metabolic e-or[rlcsE-dlff:C~~~-ttYi)esl b;l1anccs (Illusde atrophy and hypertrophy) are prescnt in

nist. the abdominals. Alkr the crector spin'Jc muscle has been strelched. not only docs it relax during trunk llexion. but ulso :'1 significant. spontaneous facilitation effect is seen in the an· dorninallllllscics. Figure 2.22 shows the typic
~sistant:'

I

yp

REHABILITATION OF THE SPINE: A PRACTITIONER'S MANUAL

1

Erector Spinae

I

,,,

Abdomlnals

I

.,

I /

Glu1eus Msxlmu$

Iliopsoas

Tight

Weak

Of

X

Weak or Inhibited

Inhibited

Tight

Fig. 2.22. The lower crossed syndrome. (From Jull G. Janda V: Muscles and Motor Control in Low Back Pain. In Twomey LT. Taylor JR (eds): Physical Therapy for the Low Back. Clinics in Physical Therapy, New York, Churchill livingstone. 1987.)

patienls with acute and chronic low back pain. Hides et af, found lUli/metal, s('gmcmal \\-'(1.<011"8 oft},c multifidus ill llclll(' back pain patients.I>~ This dumge occurred rapidly lllld thlts '·was nor considered 10 be a di.Hl.\'C arroph,,: Stokes eI al. !owuf generalize,! atrophy in paticlIIs with dmmic back pain. but (l rd(ltive increase ill the CSA was noted 011 the symplOmafic -",yide. 9J Type I Jiber hypertrophy on the symptomlJlic side and ........... tYl!!. II fiber atrophy bilarerallv have been documented in c~roTllc back pai" patients.,}7 Muscles housing trigger points have been shown to have dramatically different levels of EMG activity within the same functional muscle unit. Hubbard and Berkoff showed EMG hyperexcitability in the nidus of the trigger point in a taut band that had a characteristic pattern of reproducible referred pain. 79 Case studies. havc also revealcd that trigger points in one muscle are related to inhibition of another functionally rcImed muscle. 7l1•9 !i In particular. Simons showed thalthe deltoid muscle.can bc..inbibl~d _~Y!lc~1JlLcre· arc infr~~p)'na1Us trigger points.ll(t HC~ldley has .ghown that lower trapezius inhibitio~ is related to trigger points in the upper trapezius:;:

Muscle imbalances alter the performance of related movements. Repeated performance of abnormal movements leads incvitably to further strain, which can perpetuate muscular imbalances andjoim dysfunction. In the work place, the combination of muscle imb<'llance and performing repetitive tasks in constrained postures has contributed to 3n epidemic of ovcruse syndromes. Musch's that become overactive or tight are (~{t(!" said to be ill "spasm. .. Loose application of the term spasm lead.\· to inappropriate trearmelll selection. Clinical decision /flaking would be bella sen'ed if muscle tellsioll or stiffiless is viewed as being related to either viscoelastic, cOllnccth'e tissue. llnd/or lIeuromuscular facrors. Trigger points. acute torticollis, appendicitis, lumbar strain with anlalgic posture. and loss of the flexion-relaxation response in disabling lumbar pain syndromes arc examples of incrc<'1sed neuromuscular tcnsion. 76•77 Elevated EMG activity typically is present in such situations. C.Q.nnectivc tissue changes in a muscle or its fascia. such as adhesion or scar foonation, usuallx arise gradually after trauma whcn the acute, inflammatol)' phase is prolongcd:'5 Improper healing allows fibroblast proliferation and eventual scar fonnation. 45 Viscoelastic changes without increased neuromuscular tension also occur in the gradual muscle shortening seen with aging and scdentarincss. A central source of increased neuromuscular tension is theorized to be dysfunction of the limbic system. 1-«1 This condition is thought to be related to abnormal illness behaviorslecp disorder, depression, anxiety. fear-and is
.~

,

--- -

-----

,"

Table 2.6. Characteristics of Muscle Types"'il·l20

,,

Type FF -Fast-Twitch Characteristics

Type S "Slow-Twitch"

Fatigable" Type II

Type I Fatigability Metabolism

Energy Capillary

Resistant ""Oxidative MitochondriaJATP Extensive

network

Metabolic preference Speed 01 can·

Constant muscle length Slow

Easy Anaerobic Glycogen Minimal

(MUSCle shorteningJ Fast

traction, relaxation and force generation Metabolism al

Low

rest Function

Posture "antigravity"

Phasic "fight or

m9ht~

-.

-".'.

i

h;

~v~n~M::r:..:,.:~::n:":<--"--"::''':'''--,~:,V:'':''':"M:'''--,':..''::.U::...:....::t::'''.::'''::.::~:.:'L::'--,',-''',-'_'U:..:."_'N_' U:..:.<;:.''-H'-'H_U_P_H_A_C_T_'C:..:.P_R_A..:C'-T'-'..:C::.E=-

muscle IS p~lp.:tually plOlced in ;1 lengthened po:'\i(ion so that rhe l1lusclc...:<;pindks become dl'SCI1",itizct! 10 strctd, ~i.c .. glu(eus l1laXilllusl.I~' .:f.;,hrogt·";c W('lIkIlCS... occurs when nociceptive affcrciH barrage from a j()im or ligamcllI causes a rene" inhibilion.I~.1 Examples arc the V
""

WL l-'J. Fin;'llIy. ,,.igga ,milll !") I"'"/

1

1·

j

i€ ~ §

,

:"~

J

I""' '.J

\I"("okm'.'i.\" occurs whell a muscle

C3nnot fully .1(ti\";ilC all its conlr,Klik libers hel'allse or the presence a trigger POil1LI~\

or

Common types of ItmSCUI;\f dysfunction. like tri~c.cr points, arc bc:o;t understood in till' context of IlHISl'ubr imb:dancc. A short. tiglll po:O;\lIral !l\u:o;ck lllil)' house trigger points because or its incrcn,Scd Ilh.:t;lbolic dcm'lI1ds and lcnsion. which call produce ischelllii\ and irritilting metabolites. Also. an inhibited phasic muscle l1lay form trigger points as a restlll of its greater than normal f,ltig;tbility and thus susceptibility (0 overload and mC<.:hani<:al f:lilurt:. .

Table 2.7. Consequences of Muscular Imbalance Allercd joint mechanicsJuneven distribution of pressure Limited range of molion and compensatol)' hypermobility Change in proprioceptive input Impaired reciprocal inhibition Alle,ed programming of movemenl patterns (From Janda V: Lecturc. Los Angeles College of Chiroprnclic. Rehabilitation Ccr1lhcahon COUISC. 1993.)

The gcneral crfects or llluscular imbalance ..Irc listed in Tahle 2.7. Muscular imbalance is lypic
('-""

~~jJ

...

~-

'"

~~.... ~3'

Muscle Hypotrophy

Muscle Hypertrophy

i'i

%

1

~29

Fig. 2.23. Depiction of the layer syndrome. (From Jul1 G, Janda V: Muscles and Motor Control in Low Back Pain. In

Twomey LT. Taylor JR (eds): Physical

0' J Cervical E'ector So"'.,

Upoer Trt'lpe,iu' levator Scapul. .

Lower Stabiliters

01 the Scapula Thofaco1urnblll

Elector Splnu Lumbosacral

Erector Spinae Gluteus

Maximus

Therapy for the Low Back, Clinics in Physical Therapy. New York, Churchill liVingstone. 1987.)

•• '-.,,......... , ... , ''"''1 tUN UI-

erector spinae). Postural analysis in onc leg standing observes presence of glu'teus medius weakncss, pelvic obliquity, and other muscular compensations. Gait Clnalysis mostly addresses hip mobility (decreased hip hyperextension). increased pelvic side shift (weakness of glUlcus medius). compensalory hyperlordosis, and lack of pelvic motion attributable to a sacroiliac lesion. Muscle leugt" tests arc specific tests to identify the amount of muscle shortening prcscili. Six basic. stercotypic 1I1O\'('l1Iem [umems arc tesled to cvall1~ ate the muscle activation sequence or coordination during. performance of key hip, trunk. scapulothoracic. scapulohumeral. and cervical movements. CORRELATING MUSCULAR AND JOINT DYSFUNCTION

The most common pain generators arc likely to be those structures housing the most nociceptors (articular surfaces, joint capsules. ligaments). Regardless of whm is the eXilct . pain gencrator. the entire motor system will rcact and compensate. Long after strained soft tissues havc becn injurcd. adaptive patterns will p~rsist. Muscles arc the medium through which ccntral motor commands or renex spinal activity compenS31e for any dis~ lurbance. Certain muscles typically rcact when specific joints arc injurcd or are dysfunctional. This relationship can work in either direction in that impairment in a muscle or joint will eventually lead to some compensatory change in its func· tional partner. Clcarly. if a Illuscle is shoncned llr ovcr~lctive. increased pressure and strain develop in the joint capsule and tcndopcriosteal junction, Also. a muscle that is inhibited .md weak is associated with poorer stability for the relatcd joints, with compensatory fhations or even hypermobility resulting. As described previously. Johansson ct al. correlated nonnoxious joint afferent activity with inc~ased rerlex gamma motoneuron activity.(,',I They hypothesized that long-lasting noxious stimulation may activate the flexion \vithdrawal rt::flex.6'l Similar reflex dischargcs from the joints mediated by effcrt::nt sympathetic fibers wcrc described by Schaible and Grubb. lm Joint innammalion in the knee c.m lead (() reflcx muscle inhibitioI1.t.1,.".,,~ Hides et ai. correlated segmclliai. reflcx muscle atrophy in the low back with acute low back p;.lin in patients in whom specific lumbar joint dysfunction was manually diagnosed.('~ Bullock-Saxton et ill. showed a corre~ lation between poor ankle joint stability and inhibition of the gluteus maximus and medius during walkillg.';~ By wufersl(",dill~ the relationship between specific l/llISdes and joints, therapcllti<: shortcuts elllJ (~rf(m he f/llcO\·crt:ll. Finding a dUli!l reaction bellrcen IIruscrdar i1ll!JaI01l("(', WI allered flfOl'cment pattern, and specijic joint dysfunctions enables thl' clinician to find the k.ey factors in tile developfllf.~111 of functional pathology, and c{lfaly::.es the therapeutic program. Lewit identified spccific joint dysfunctions that arc linkcd to individual dysfunctional lllusCles (Tablc 2,8).lH,I~~

t"W,

ALTERED MOVEMENT PATIERNS

The ,ifcscnce of pain, muscular imbahmcc, trigger points. or joint dysfunction alters lhe :.Jbility of thL' p'lticHt to perform

rHE SPINE: A PRACTITIONER'S MANUAL

Table 2.8. Muscle and Joint Functional Joint CO/1 Cll2

cm C3I6

Chains'''~

Muscle Suboccipitals, SCM.· upper Irapezius. (masticatories. submandibular) SCM. levator scapulae, upper trapezius SCM, levator scapUlae. upper trapezius Upper trapezius, cervical erector spinae, ([email protected] exJ=r~l-

C5.'T3 _). SCM. upper or middle trapezius. sc::aleni (subscapularis) T3fT10 Pectoralis, thoracic erector spinae, sena-iiJsanlerior (SUbscapularis) .1.19AL._-,<~~~~!.qtus.lum.b:o.rJ.lm. psoas. abdominals. thoracolumbar erector spinae Gluteus medius L2IL3 Rectus femoris, lumbar erector spinae, adductors L3IL4 Piriformis. hamstrings. lumbar erector spinae, adductors L4/L5 Iliacus, hamstrings. lumbar erector spinae. adductors L5/S1 Gluteus maximus. piriformis, .iliacus, hamstrings, adducSI ductors. contralateral gluteus medius Levator ani, gluteus maximus. piriformis (iliacus) Coccyx Hip Adductors ·SCM. sternocleidomastoid.

certain. stcrcotypit: 1ll0vem~lH patterns. The Ilcgatin: relationship bctwct=n various individual functional p~uhologic changes and the abnormal pcrfonllanct:: of basic m(l\·t::mcllt patterns is self-perpetuating. Ahcred or f;'llIlty movemcnt patterns thcmsch'cs place new slrains 011 the locomotor systelll and lead to the spread or a local problcm beyond a single rcgion. Slid, mm'emellt paltcms ira£, ji,.st n:co}.tlli;('d clinically by Jonda. who noticed tlla! til(' do......i<: 11111.0;<:/(' testing (~r Kendall allli Kendal{ did flO' differel11iat£, !JctU'('CII normal rt!cruitmew of re!med musch,.\" and ",rick" puucms of.';IIh...ti",tirm durillK a spedjic (lc/ion. So·callcd "trick" movt::IllJ.:l1ts arc unecollomical and place unusual strJin on the joints. The)' involvc muscles in incfficient or incoordinmcd ways_ which thus are prone to fatigue. On thc c1~issic tcst for prone hip CX~ tension_ it is difficult to identify ovcractivity of the lumhar erector spinae or hamstrings as substitutc!' for '1I1 inhibited gluteus maximus. All llwt is notcd is the ovcmll slrength or quantity of OUlput. nol how it is accomplished-its qfwli!.\: Janda's tcsts arc far more sensitivc .md allow the clinician to identify these clinically pertinent musclc imbahllK·cs and faulty movement patterns by seeing "bnormul substinltion during muscle testing protocols. Whcn a movellH::nt pattern is altered. the .tcti\·~llil)ll sequcnce or firing ordcr of different muscles involved ill a specific movement is disturbed. The prime lllover lTlay be ShlW to activate while ~yncrgists or stabilii'.t::rs subslitute .\I\d bJ.:(OI1lC ovcraclivc. New joint stresses will then be encolllliered. Sometimes, thc timing sequcnce is normal but the o\'e1';.1I1 range Illay be limited bccau!'c of joint sliffness or ant
--------------

,

)'

\

\,,;n/"\I'" I en G . ,,~ ..... vn/"\. II"\): H.t:Hf't:SlLlIJ\IIVN INIU

31

<;HIHOPRACTIC PRACTICE

Table 2.9. Muscular Imbalance and Altered Movement Patterns

',.

Weak A£;onis:

Overactive Antagonist

Gluteus maxim uS Gluleus medius Abdominals Serratus anlerior

Psoas, rectus femoris Adductors Erector spinae

Deep neck llexors Lower and middle

Overactive Synergist

Movement Panero

Erector spinae. hamstrings

Hip extension Hip abduction

Pecloralis major/minor

QL. TFL. piriformis· Psoas Upper trapezius. levalor scapulae. rhomboids

Suboccipilals

SCM'

Upper trapezius. levator scapulae, rhomboids

Neck flexion Shoulder abduction or lIcxion (SC.J.;::";!':::'

Scalenes. pecloralis major

Respiration

Trunk flexion Trunk lowering from a push-up (scaptltar

fixation)

, .j

Irapezius Diaphragm

fixation)

·OL, quadraluS lumborurn; TFL. lellsor l
during thl: 1l10\~ell\C;IH. leading to ovcrm:tivity of the st
Table ",I (I. Pain motor programs. poor poslUral habils. or altered movement paHcrns arc mcmorized jusl as is normal g;'lil. skiing. or ViflUOSO lllusici'lIlship. Inefficient or uncconomical movemcnt p
lified and the individual is not rc-educmcd. This ne-ed to relearn is an important reason wilY p'-lin often outlasts lhe elimination of its cause. Janda advanced the concept that the control of mo\'ement by the cenlral nervous system can be re·educatcd, Thi$. thcory wns tested in a study in which propriosensory stimulation ex~ crcises were given to individuals in an llltel1lpl to improve the speed of recruitment of the gluteus maximus and gluteus medius muscles during gait.')!; Individuals performed balance excrcises for 15 minutes per day for 1 week. These exercises led to significant increases in the speed of HCli\'ation of the gait muscles. Such propriosensory retraining improved gluteal ;:lctivity "automatically and subconsciously. and nOI as a voluntary muscle contmction."'ls

REHABILITATION OF THE MOTOR SYSTEM Rehabililation includes functional capacity cvaluatil..... n. reha· bilitativc carc, patient education. and psychosoci~l! fJ.:tors, It is ideally suited for managcd care pr
sdf-c;:lrc,

Hchal)ilitation ,,"s. Consl:r\'ativc Tn.·atmcnt Rchabilitation is different from Heutc. conscrv;.uj,,(' carc.

Conservativc cme is ideal for acutc disorders. h l",uses on stabilization of the injured part. pain control. and pr('lllotion of soft tissue healing. Rehabilitation is concerned with restoring Illusculoskeletal function in p<Jlicnts with "ubi.lcutc. chronic. and recurrent conditions, Rchabiliwtion ~m('mpts to prevcnt or manage dis'lbilily through function
or

Table 2.10. Trealment for Altered Movement Patterns Relax/stretch overactiveftight muscles Mobilize/adjust still joints FacililaleJstrenglher: we"k ;7;:..;::;cles Rc·educate movement pallerns on reflex, subcortical basis

32

i

~

I

I I

1

i ~

I

nL..",.......

medicine model directed at rapid safe return tu work l:oupkJ with ergonomic intervention h
Historically. this approach was appropriate for physically exceptiollal (athletes) ami physically impaired (lulIIdicappt:d) individuals. To(/a...,., it is ~lCces.\'llryfo"l1lost pai" parients. The i"dicmious for rehabilitation indude the subacute Slage oj illjU0~ chronic pain, disability, or reCllrreHT pain. Tile purpo.H: of rehabilitation i.\· to trcat or prc\'ellt deconclitiolling syndrome (llld abnormal illness belUll'i01:

Blending Active and Passive Care in Practice To be a rehabilitation specialise a health care provider must identify" red /Iags. .. shift from passive to ucth'e care. lIlIder-

stmul the emerging guidelines for care. peryorm outcomes assessment and functional testing. and identify psychosocial factors re!llling to abuon/wl illness belull'inr. It i:; impol1ant

I I I

,I

to rulc out morphology, infcction, carcinoma. and Visceral, metabolic. rhcumalOlogic. or neurologic discases (red nags) before attcmpting rehabilitation.I-lS Such patients should be referred to the appropriatc specialists. Acute disk problcl1l~ and traumatic injuries require fonowing specialized conserv..tive care protocols. bUl these p.uients eventually will become candidates for rehabilitation. Current guidelines dictate Ih.u exercise .md .. ctivc care arc crucial to the management of subacute. recurrent. and chronic condilions. Bed res!, medication. passive methods, injections, surgery. and manipulation all have their proper place in trcatment planning. Being able to define (Ill apprupriate re!woili*

tafion goal depends 011 knowing !low To judge fimcfiOlllll j"!a(lfS and work. dem(/luls. If ;Ill individuat has a high \vork demand. grcatcr functional status will nced to be achieved. Injured workers should be vic\\'cd as "occupalional athletcs" racing high levels of stress/strain in their work placc for

'~,·

•• • ...... "

... ,

.,. __ .

i.vlii>:li il,,,::)· ii..::.;d ;" ~'..: propaly traincd. It is csscllli;t1 10 ;H.I. dress deconditioning ;\1lJ leach .. worker 11m\' 10 reduce Ill!.> chunk,1i strcss while :-;.illllllt:lllL:Ollsly training them Hl illlpnm,..• their functional stalU:,>. Individuals wilh "hnnrm,,1 illncss bclwvior arc lIlore likely to becomc dis;lbkd tIl' \0 th:vclop chronic p,lin syndromes. Quick shiftin;; from p:lssivc (nlllscrv;uin:l h) ;lI.:live (rehabilitative) care ,,:an prevent llllH.:l1 disability. Rd~lTal flll" nlllhidisciplin;I1"]' fUlll.·li'lllal n~Sl\lralioll. involving psyclh1logic support and hh)bt'h~l\-ioral rt.'-;.:dueation lllay also he indicated. Although treatlllent dccisions an.: oflcn llIade on the h;'lsis of a di'lgnosis. palicl1\s with spinal pain n:sist ;ILTUf;lle labcling. Painful spimll syndroml:s arc considen:d mcchanical disorders mosl of the lime. bUI many ex pens vicw the psychologic or social factors to bc prcdominant Polin-sensitivc slructures abound in th~ spinal region. :lnd pcrhaps hecausc of the ovcrlap between ~itcs rcferred pain from lllust:les. joints. ligaments. fasl·i;l. nerves. CIt.:.. a diagnosis orten is given on (he basis of lhe physician's pathoph)'siolo~icphilosophy rather than on any provable hYPOlhcsis (i.c.. dcgcncr
,

,

......

,

or

or

)

)

,

.1

) )

,.'

) Table 2.11. Primary Goals of Rehabilitation and Conservative Care Pain Reliel

Promote Tissue Healing

+

+

Rehabilitation Conservalive care

Functional Restoration

Passive Patient

+

Active Patient

+ I

(Adapted from liebonson C: Rehabilitation Ollhe chronic back pain patient Calilornia Ghiroprilctic Journal, July 1991.)

-----

-11'

33

CHAPTER 2 : IN I "GRATING REHABILITATION INTO CHIROPRACTIC PRACTICE

Table 2.12. Goals of Treatment Remobilization

Acute Intervention

Increase pain·free mobility

Reduce inflammalion No pain at rest Minimal pain with unstressed daily activities Decrease muscle ~spasm~

Minimize Clecondllioning Promote tissue repair/regeneration

Rehabilitation and Reconditioning

Lifestyle Adaptations

Increase muscle strength/endurance Improve coordination Increase flexibility' InCrease aerobic capacity Promote tissue remodeling

Improve ergonomic factors Education about biomechanics Address psychosocial lactors

PAIN RELIEF <'\: !lI{OMOTION OF SOFTTI$SUE HEALING

FUNCTIONAL RESTORATION

(Adapled Irom Triano J: Standards of care: Manipulative procedures. In While AH. Anderson A (eds): Conservative Care 01 low Back Pain. Baltimore. Williams and Wilkins. 1991. pp 159-168.)

:1,

, f'''i

-~

1

I I

~"J

"(...,~

\3

...~ §

~

, ~-

-I l

() y

Table 2.13. Treatment Strategies Acute Intervention AesVice "SupponsJbraces ,'Gentle stretching , Physical therapy : Anti·inflammatories

Remobilization

Rehabilitation and Reconditioning

Prevention and Lifestyle Factors

Chiropractic adjustments ':"Solt tissue maniputation ~ Physical therapy ..... .4Postural correction ... 5 Functional exercise ......

Functional strengthening Slretching (Cardiovascular fitness ' \ '. Balance and coordinati~9-'

Stress management Ergonomics "work stationBiomechanics ~liltingJbending OieVnutrilion

I

AcnvE CARE .'-~

i

i3

~

"j

,~ C' , I

PASSIVE CARE

~

%

I

~

,j 11

l

r'~

%2 [~

'i..#

successful. thc)' arc able 10 impart cnoml0US (~)st savings. Similarly. a trial of manipulative therapy for a chronic suf~ rerer who has not previously had such carc is also indicalcd. Rehabilitation of lhc motor system involves restoring norlllal joint mobility: inhibiting ovewctivc musculature (including trigger points): improving muscular flexibility. coordinatioll. strength. and endurance: stretching retracted soft tissues: propriosensory re-education; cardiovascular training; and poslUral rc-education, Passive and active care are both required to achieve these goals Crable 2,14), Physical training alone would fail to address specific joint dysfunctions or ll10vcment incoordination. Chiropractic adjuSlJllcnts alone would fail to address muscle imbal;.mces or faulty movemcnt patterns. A.uC"\",'iflleflf slum'd idcllfijV fIle various links ifl fIle elwin tl./imcriollal pafllOlogic processes. Often the problem is in the patient's posture or work activities, Rcgardless of what other influences exist, rehabilitating the motor system requircs that we scc the interrelationship betwcen the functional pans and between thc patient and his or her environmcnt, This approach is cmpiric in that one identifies functional deficits and seeks those interventions that can have the most

positive impact on improving functional integrity, RcslOring function by rc\'crsing thc dcconditioning syndrome is Ihe prj· mary goal. as opposed to mercly treating symptoms, Highly lcchniculmuscle function testing and training apparalll:'t's arc not nccessary to achieve this cnd, Proctit;oners ill s11/al/, pri~ l'me practice.\· who (/.\".'iCSS a1l(/ frettf .!ffflcfiollal /)((t"ologic problems while tmini"g alld educ(I{ing ,"e p(l{iellf ill hou' fo

Table 2.14. Integrating Passive and Active Care in Rehabilitation Goal: Improved posture and motor control on a reflex, semiautomatic basis Increase mobilitylllcxibility Joint mobilization/adjustment Muscle relaxation/streIch Improve coordination, strength. endurance Muscle lacilitation ·Spinal stabjfization~ or lunclional exercise training Propriosensory retraining Cardiovascular training Posturat re-education

Hl:::HAtlILI

Table 2.15. Factors that May Predict a Longer Recovery (from the Mercy Guideline) History of more than 4 episodes Longer than 1 week of symptoms before seeing a doctor Severe pain Pre-existing structural pathology or skeletal anomaly (i.e .. spondylolisthesis) directly related to new injury or condition (From Haldem.:.n S, Ch<\pman·Smith 0, Petersen OM: Frequency and dura; lion of care. In Guidelines for Chiropractic Quality Assurance and Practice Parameters. Gaithersburg, Aspen, 1993, pp. 115-130.)

preve1lt reoccurrenccs rC'present the ('osH:ll<'uin' FOllt /ille against roda.v:\· soaring costs for caring ./f)r illdividuals with low back pain.

Case Management and Standards of Care PROGNOSIS

The natural history of uncomplicated spinal disorders is toward resolution within 6 weeks,I.JS.I
Table 2.16. Risk Factors for Chronicity History/Consultation Previous history of low back pain T9.tal work loss in past 12 months

v+i"e-avysmoKffig'

Personal problems-afCohol, marital, financial Adversaria! medicolegalprOblems Low education attainment· Heavy physical occupation' Questionnaires/Pain Drawings or Scales Radiating leg pain--":· Low job satisfaction -~ Psychologic distress and depressive symptoms-BMG Examination Reduced straight leg raising Signs of nerve root involvement Reduced trunk strength and endurance (dynametric, nondynametric) Poor physical fitness (aerobic capacity) Disproportionate illness behavior (Waddell's signs) 'Only slightly incre
j

A IIUI'l VI- I Ht: <::>1"""11'01:.: A I""" HAl,... 1lllVI'Icn 0 IVI .... I'IU .... L

Patil.'lHS ha\"l.' traditionally been categorized as having anHe. subacute. dtn\llic. or recurrent disease. depending on tilL' sta\.?e or soft tissuL' healill!.!. or timc course of their recov~ cry.;" l'~, The aClltc .j.!!lhlD.!!!!';~.!~,!E}~l}llase of soft tissue healing 1;1~1> het\~.~11 2-l __~!llLZLh()lIr~ The subacutc phase. in which rl'l~ai"r and regeller;lllnil occur, !:lst.. . from 24 hours to 6.wecks. Till' linal phasl' in\\ll\"~ . . relllodc\ing. which pro(~eds from the third week !\l 12 l1lonths after injury. These phases or soft ti . . slt~--llc~\iTi\g--ill:"II~~~il."e for 1~~lli~I-1IS sulTering traumatic injuries. hut for illlli\"iduab expl'rietH:lng. pain syndromes related to cumulati\'e l1liewtrallllla. such a framcwork is not appropriate. Ikca/fsc of rht' pl"csC/lce of a!JJ/ormal illncss hdw\'io/, dis/ll"Ollol'ti(lJlatl' to illlpail"lllel1~ or strtlctura! parI/()logic .lindillgs. Ihl' chl"OlIic slap,e is (~tieil eJ/te!'l'd as S(J()/UIS] \1"('eKS ({tier paill ollse(. 1511 ~ccording to \VaddClI. cases in~ \'ol\"ing back pain should he regarded as aellte. recurrent. or

-

-

chr()nic.!~S

The individual suffering an episode or pain an~r injury or trauma should be better in 7 to I() WCCks.'~·J The
- - - - - - - - ~-

-_.,-

Simple Backache or Nerve Root Complaint Yes

Yes

+

+

Timeline: 1-3 Days LI_R_e_,_e..,rr_a_'-J Reassurance: - No serious pathology /C- P~ive prognosis. but possibifity 01 recurrence ( Symptom Control: • Analgesics. NSAIOs

+

- Heat or lee

Activity Modillcatlon: \. Bed resl 1·3 days (<. 7 days lor nerve roOI pain) i .. Avoid aggravation

Is pain settling within Ihe first 1·3 days (2 weeks if nerve root pain), even if still present?

Yes

--1

Increase Activity

I

I

No

Time/ine: First 4·6 weeks Pain Relief: Goal -to facilitate active rehabilitation • Adjust analgesics

Yes - - - + -

• Manipulation (avoid if severe or progressive neurological deficit)" - Active exercise, "hurt does not equal harm" (gradually increasing)

No

t

• Physical agents (gradually decreasing) . - Increase activity - Early 10 o! distress or depression

"Red Flags" (See Table 18.1) ~

Non-mechanical pain (constant, progressive, no relief wiJh ...

bed.r~

- PH: carcinoma. steroids, HIV. drug abuse • Weighlloss i ' V

yes......

• Malaise"":""\.oo-' - Unremitting flexion restriction • Fever _. • Violent trauma

Return to Normal Activity

No

+

• Widespread neurology

Timeline: 6 weeks Reassessment: • Review diagnostic triage - Consider imaging & lab work - Psychosocial & vocational assessment (see table 18.4)

No

~

• Leg pain> back pai - Radiales to lower leg - Dermatomal numbness . & paraslhesia

• posilive SLR - Localised motor, sensory, reflex changes

Timeline: 6-12 weeks Continued Primary Management: - Active Rehabilitation (active care> passive care) - Id of factors which may predict a longer recovery (table 2.15) or risk factors of chronicity (table 2.16) - Alternative symptomatic measures (muscle relaxants . antidepressant, injections. supports) - Objective outcomes utilized·'

No

~

• Low back. buttocks. Ihigh pain • ·Mechanicar pain (varies with posture & movement)

A

PH • past medical history SLR • straighlleg raise tesl Lap· low back pain

Yes-+-I Simple Backache

f--

Is function improving within 12 weeks. even if still with some pain?

Yes

+-I

Return to Normal Activity

No

Continued next column.

Time1ine: 3-6 months Consider Second Opinion: - Active Rehabilitation Specialist (reconditioning, functional outcomes, behavioral principles)

Ves

+-I

Return to Normal Activity

No

+

Time/ine: by the 6th monlh Secondary Referral to MUltidisciplinary Rehabilitation Center - lnc[emental exercise - Behavioral medicine principles with functional objectives • Close liaison with the work place

Fig. 2.24. (A) Diagnostic triage algorithm. (8) Treatment guidelines algorithm.

• Type of manipulation should change if no progress after 2 weeks (t84).

B

•• Treatment beyond 6 weeks must be tracked by acceptable, outcome assessment measurements. Failure to show significant progress by the 8th week of an uncomplicated case or the 16th week of a complica1ed case or nerve root complaint should resuft in

......... .'\.

ncnMoll.. IIJ"\IIVI'l ur- I nt: ",..11'1.1::: A .... HAl,;

Table 2.J7 ~ulnmarizcs the pnlglHl~i~ for tll~ \'ari(lll~ g~n~ral typ~s of cases, Th~ algorithm in Fi.surc 2.24 is llsd'ul for UIldcrst;:lIldin!.! the indicati()n~ for bed rest, m
ment. and ~disability in patients with inappropri3h~ signs

or

symptoms of illness behavior. nil An individual who is ullwilling (0 move from being a pain avoider to becoming a pain m;n.llgcr is such a patienl. Exccssi\"l";: dependenc)' on medk:ltion or passive forms or thempy. along with an unwillingness to develop internal control ovcr symptoms hy Ic'lming ~clf treatment skills. ;lrc clear signs of a potcmial chronic pain patient. The treatment plan for spinal disorders focuses on aggressive. conservative care for promotion of soft tissue hcaling after an injury, When p.llin is a result of a repetitive strain. conservative care may be approprialc for p:lin relief. but treatment goals must quickly change to rehabilit:Jlion or rcstor;,,· tion of function. Intervention involving manipulative therapy has demonstrated a clear advantage over other methods (reduced disability) in the initial care of the patients with pain. 17J Early. active intervention: preventative education: and rehabilitation approaches have all shown their positive imp'lct on

Table 2,17.

prog~o(Musculoskeletal

Syndromes'5!J

Pain

'/

Syndromes

Mild-moderate injury Moderate, severe injury Repetitive strain Nerve root compression

Acute

Subacute

2-3 days

6-8 weeks

<1 week

8-16 weeks

2-3 days

6-8 weeks

<1 week

8-16 weeks

Chronic

4-12 months

Table 2,19. Guidelines for Management of Uncomplicated Soft Tissue Musculoskeletal Pain Syndromes \. Bed rest should nOI exceed 2 days and passive methods 6 to 8 weeks. 2. Treatment frequency IS. 210 5XJweek for the first 2 weeks (pas· sive care with manlpulalive therapy appropriate). 3 From week 3 to weeks 6 to 8, treatment frequency should be decreasing, 4. Functional capacIty evaluation is recommended when patient is subacute (week 2 10 4) and mandatory.'3t 6 to 8 weeks. 5. Progressive exerCIse prescription and sell-care advice recom· mended within 1 10 2 weeks and mandatory at 6 to 8 weeks, 6. Evaluation by a rehabilitation specialist may be appropriale at 6 to .--. 8 weeks, ( i· Advancgq ima9!,:l.9.~r,tqu_~§_2rc appropriate only when n~ur_o V .{og;c.function is deteriora1ing or progressive exerCise therapy has r:"- failed. ',8. Evaluation by a palo behavioral specialist may be appropriate at 6

months. r~dllcing futur~ recurrcnces and prcVl'nting the emcrgence of duonic pain SYOl.lrolll~S,~'I.r,(un.r:.' Bush showed that
often .mfJiciCl/t to idelltif.), !!!l!. keY/I,mc.r.~'.!.!!~lJp.~~t!I(!{~!£~~ problef,-i7i-lizatwlf[ cmlble{7;~-il(.'lliik(:llrc_pmvid{.',. to indi\'iduali:'t' a .'ielf-trc~,;,~;~,~~,-~-';~-teJi.\~-Collii;Ule(J ~~;;e-;~:i;/~ (/~~~e(i.~~lg frt'qllency for approximately another 4 Il'eeh is I;sually llppn l !,riate. Additional care is often required in ca~cs or Jnodcrm(' to .,,>c"cre trauma, di'do-; prolapse with nerve root compression. or chronic pain, or when significant complic.iting factors or abnormal illness behavior arc present. The disability-prone patient often requires intcrdisciplinJry rcferr"l. Table 2.19 provides an ovcr\"iew of these guidelines. which arc also discussed in Chapter 21, REPORT OF FINDINGS

4-12 months

Although it is sometimes considered speculative to assert that a specific tissue is the primary pain generator, it is not nccc::-s;jry 10 burden the patient wilh the diagnosis of nonspecilk back pain,lf.1 Kirkaldy-Willis discussed the cardinal signs of difrerent sources of nonspecilic pain. such as facct. sacroiliaL~. and myori.lsciul.l!'~ Cherkin and MacCornack noted that offering
Table 2.16. Profile of the Disability Prone Patient Symplom magnification Pain avoidance behavior Psychologic distress Job dissatisfaction Anxiety Treatment dependenc'r Catastrophizing as a coping strategy Pending liligation

- - - - - --

IIIIUNI::H'S MANUAL

ter 18),'~'

----

)

, I

i

After the patient has been given the working diagnosis. ii is important to explain that although most {Xoplc gel bcltcr within 6 weeks. recurrences nrc the rule rather than the cxceptionY' For this reason, it is prud.:nl to spend some time

tcaching paticnrs how to reduce further strain on their back and how to increase their intrinsic capacity to handle extemal

demands. If a patient is "disability prone:' psychosocial as well as biomcchunical issues will need to be
ing technique. or repetitive manual handling activities. The simplest way to avoid fwure problems is to reduce the external stress. III as Ilmdr as this change is IIot a!l\fllYs possible, intrinsic fiU/ctiol/al capacity call be iI/creased. Various intrin-

J_:,·. 1~ ,'~

".J

I

37

vnM.rlt:r14!; 11\1 I tUN1\1 INu Ht::HAl::.iIUIAIIUN INTO CHIROPRACTIC PRACTICE

sic factors such as muscular imbalances of strength or f1e~d bility. postural faults (i.e.. slumpcd posture). structural asymmctry (i.e.. shon leg). impaired coordination or balance. or poor cardiovascular fitncss also predisposc to recurrent pain episodes. TIle dangers of even low level repetitive strains should be made clear (refer to Fig. 2.7). InstnIction should stress taking frcquent "microbrcaks" from either prolonged slatic loading (i.e.. desk \\"ork) or repctitl\'c activities (i.e.. 1Il<1IIW,!i m;,ucri;,li handling). Whalcver the pain complainl, proper managcmelH hinges on reducing strain so .IS to promote healing and to prevent recurrences. In the acule stage, especially with disk syndromes or trauma, reducing load on the injured structures is called "relative rcst:' This measure, along with chiropractic, physic.11 therapy. and exercise. may be used to reduce tissue swelling or irritability and to prOlllote a good environment for healing of soft lissue injuries. PatielHs C;1n be cdUC;'ltcd about the dangers of recurrences as pain subsides and [he need to increase intrinsic back fItncss and decrease exposurc to harmfUl. extrinsic sources of back struin. Comparing the patient's treatment w that of an alhlete will help to motivate Ihe patient tow;.1rd seeking m,ore than just symptom
fUllctiuilai restoration .......ays to rl.:ducc eXIHlsure to h;:lfmful extcrnal stress :lOd how to increase functi()n~ll Glp;'lCity arc thc focus of carc. Rmhcr than adhcring to the philosophy or "no pain-no gain," thc patient is taught how to "handlc" pain, The difference between "hun and harm" is cxpl>lincd. Strelching exercises may hun slightly because stiff ..;tnlclures arc heing stretched. but strcngthcning cxercises should he painkss in lheir symptomalic arcas. They may feel ;\ "hum" in thl.: lllLlScle being trained. bLH thcy should not cxpaicnce pain ill tlh:ir symptomatic area. Manipulatioll alld OIher thcrapie,\· may be used to acldrcss key trig.~cr poillts or)oillr dyJjillictiolls \\'itll the' goal (~frl'iax ing and IIwIJili;:';lrg t(-'lI.'it· or sriff tis,\"fIc'\" (.H't! Chal'tt'l' II'.

Then. IUlJiems Icum abOlll strellgt!tL'lling and sIahlli:i".!: III(' "wea~

link" b)' training Ihe "l1ig:'.,l,IJUsr!t..'s (,!I/adri~·{'l"'i. (lb~~.~) to do 1~IOSl oj the \\"ork and to m'uid o~·!!I~!8..Jhe "s/1~~ll1e!~·__ p.!!.:g!~rt.tI II1IlJdl'S alld clapa ,~P..!.I!!!UJrJ((t!tres.This training may lead to sOllle postexercise soreness, but this discomfor:L~hQ~].I~UrlY,o(yc_a[ea.'i_quiil:distinf.!Jrom their primary area of complaint (sec Chapter 14). \Vhile training these "big". muscles. the patient is taug.ht to pers...~~~.-!.~~~af~~~~~T.p~~_~~lrc.With repetition. lhey ICi.lrn to cOlllral their posture bClIer. by dcvcloping improved kine~_tic.l\..~a~~ness.and to lise the "big"' muscles to pCI'· formJJ1Q.S!9f.the work, \~:.~ic.~Jakcs strain off all the structur~s oLl.hc_l)p.inc.._W.isk~..ligaIJ1ent,j oint. etc.). Uhil11alcly. their improved motOr conlrol should become automatic, r~qlliring no conscious effort. (S() long ns the patient's case is uncomplicated. recovery c:.H~e expected within 6 If r~lclors are pre:.;cnt that complicate the cast.:. these should be explained to lhe pmient. Such a paticnr should be apprised of lheir poorer prognosis. It call bc mentioned lhat approximmely 15Cj( of p~Hielll!' with low back pain develop chronic pain syndromes. and at least 33% of illl paliellls suffer recurrence5 at :,;ollle time. Complicated cases require pro-active management to dCftlsc tllese "ticking time bombs." It is bCHcr (0 inform such p.ltients of their risk for chronicity lhan ((l allow them to build up anger and rcsentment when they arc fnJstratcd by lheir unsutisf'lctory progress. A brief course of manipulati\·e therapy, rollowcd by aggressive rehabilitation efforts with an active care focus, arc cssential for thcse patients. If thi~ :.;cqucncc is unsuccessful. a biobehavioml approach incorporating multidisciplinary SUppOrl is necessary.

gluteal.

wcc0

REPORT TO THIRD PARTY PAYOR

It is imponanr to be able to communicate lhc rationale for rehabilitation to the group responsible for financial reimbursement. With musculoskeletal injury or pain. changes will occur in_.t1!c ;,trcas of strength, mobility/Ilexibility. balance. coordination. and c;.Ifdiovascular litncss.~" These functional losses arc a result o(immobilil.ation
g b. ·i,-.::::---~--------------_. __._._-.. _.

nc.n..... OIL.I.I'\IIUN Ut- I He tiPINE: A PRACTITIONER'S MANUAL

faCIal's ill the 1)(Ilicm:,· hi.\"/Ory and c'xami"atiolf: (2) Use outcOllies a......cJslJleJl( /(wlx /0 doC/mlc'lIl (Illy fimcliOlwl changes Of

subjeclive illlpml'(.'l1wllf:

(3) IJUr"1'(Jllfi(lf('

'0

ch'od.\' betwl'eJl

passin: a/ld aClin! can: tre(ll/lll'1/T lIPIJI'oac!/{'.\': lind (4) Quote I-J/lblislted gtfidclil/cJ (Quebec. Mclt·y. AHCI'U and CSAG) /0 (/('IJ/OIlJlrare the op/,mpriate!lCJS (/1/(1 pIcK{' of llulIlipu/mioll alld eXl'rc:ise (oClil:l' ('til'£'). US.l'1.11.l~:

It might he hdpflll lO explain the phases of care
In C;'lses iJl\'olt'ill.~ moderme 10 Jc\'er(' i"jury. Ihe acute stage may last up to I \veck and the subacute stage up to 16 weeks. A chronic phase follows in which the goal of Ireallnent is to promote reillodeling of the s·;)n tissues and rehabilitate any lostl11usculoskclctal function. Rel110deling after a moderate to severe injury can 1:.1St up to 12 months. Treatment is inclusive of muscle siretching. strengthening. cardiovascular filness, coordination exercises. and decreasing applicmion of physical ther;'lp), techniques and chiropraclic joint manipulation. The goal is rehabilitation of the patient to their preinjury level of functioning. Measuremcnt of specific outcomes becomes essenlial to prevent patients from developing chronic pain syndromes. Outcomes evaluotcd include mobility. activities of daily living. and muscle strcngth. For patients who suffer pain without any acute trauma. a repetiti\'e stra;n is the likely cxphmalion. Repelitive "l1\icro~

Date

trauma" from prolonged overuse and/or constrained postures I~ads gradual dcconditioning o( the strained soft tissues. This deconditioning weakens the various musculoskelct3.1 stnJcturc..~ to the extent that painful injury can result without any trauma. Such pain ean occur without the innaml1l
INCREASING PATiENT ADHERENCE, COMPLIANCE. AND MOTIVATION

".'

Converting a pain patient from f.l passive recipient of c;,m: to an active panner in their own rehabilit::llioll involves beha\'ioral psychology::'(l,lll.l specifically. making. the shift fwm being a pain avoider to a pain manager (Fig. 2.25). A key 10 Ihis process is convincing lhe patient that their pain is not a stop light warning them away from all activily. Reassuring an individual that we do not advocate a no pain - no gain approach, and instead teaching them how to differcnti,\tc !:'I,,> tween hurt and harm. helps Ihem become re;,\ctiv<.lled. Chronil· pain requires a different coping strategy than is used for aCllt~ pain.III.l·ls~ Increased activity is Ihe goal. because gre;'I(Cr stiff-

,

")

Trunk Flexion and ---;: SLR (degree) ---:7' VAS (low back) (%)-:7 Extension ROM ----7 Oswestry (°/0)

219/94 2/16/94 3/1194 3/16/94

30

85

60

50 26 1.3

75 85

20/60 40/60 50/60 60/60

and and and and

5125 15/25 20125 22/25

78 54

30 04

'SLR, str;lighllcg r;lise; VAS, visual analog scale; ROM, rango 01 motion,

,

, i

l'HAI-' I t:H ~ : IN I t:t:iHAIING REHABILITATION INTO CHIROPRACTIC PRACTICE

)

Injury

+

Nociceptor activity

+

Fear of pain

Acute pain

~

Psycho3ocial context: Stresslullife-events Personality Familial influence Medical influence Personal pain history Pain-coping strategies

/

39

plained that this tightness or weakness is what leads to irrilUtion and pain with activity. They must learn that rchabilitation Of restor,ilion of function will prevent pain from arising in the first place. and although such rehabilitation Illay be more painful in the shon term, improving function is the key to long-tenn pain relief. Always seeking tcmpormy pain relief will do nothing to prevent the problem from sHIrting again. \Patients can be re
">

.!2~jJ.hY. __<JQ~s. _nm~W_t..9-c.h~on i~ . .~j!L.~~.h!l~.i.!.Hat i(l~l})

Exercises afe performed untBthe point of muscle fatigue only 'so long as proper coordination is maintained. The only pain should be in the muscle being worked (~l ·'burn"). If :.1 symptom.alic area (spinal muscles) is activated during the exercise_ the movement is stopped. When we can achicve an illlcnsity of training that leads to postexercise soreness in dccondiPain-confrontalion Pain-avoidance tioned tissues without exacerbating the original symptoms. we arc well on our way to a successful outcome. Fear of pain Motivation Objectification of function is a key tool in mOli\'ating increased Calibration of patients. Helping patients focus on function rather th,m on Exaggerated pain-stimulus with pain·perceptic pain experienced pain is an important first step. Then. baseline levels of funcSecondary gain Rehabilitalion tional impairment. pain distribution and intensity. and levcl Chronic Full recovery of disability should be qU<:lmified. These quantifiable base· invalidism lines can be used to track the patient's progress objcctively. Fig, 2.25. Fear of pain and the generation of exaggerated pain Treatmcnt should be guided by the results of thc objecperception. (From JOG Troup: The perception of musculoskeletal tive. functional capacity cvalu;nion. Progress can be monipain and incapacity for work; prevention and early treatment (Qred at regular intervals (every 2 to 4 weeks) to give the Physiotherapy 74:435. 1968.) patient :'lccurate feedback on how thcy arc improving. Se~· ing an increase in their walking and sitting tolerance as wdl as in the number of trunk curls serves as positive reinforceness :.md wcakness will othcrw'ise dcvelop. which will only ment. Pre- and posHre
I

REHAtilLllAllUN UI"" I HI:: :::it"INt:: A I""tiAl;IIIIUNl::H-:::; MANUAL

4U

S. Akcson WHo WOO SLY, Amici D. ct al: Biomcch:lIIical and biochemical changes in the periarticular conllective tissue during contracture development in the immobilized rabbit knee. COllnect Tissue Res 2:315.

1974. 6. WOO SLY, l>'1athcws JV, Akcsoll WH, ct "I: Connective tissue respollse to immobility: Correlative study of hiomcch:mical and biochemical measurements of normal and imlilobilized "lbhi! knees. Arthritis

Rhc\llll 18:257, 1975. 7. Vidcman T. MidH~lss(1l1 JE, Rauh:lIl1aki R, ct al: Changes in 355-5UIph:llC uptake in differ"111 tissues in the knee :md hip regions of rabbits during irnllwbilizalion. rClllOhilizalion and the development of os" teoarthritis. Acta Orthop ScamI47::!90. 1976. 8. Eronen I, Videman T, Frimon e. et al: Glycosaminoglycan metabolism in experimental osteo;Jrlhrosis c
52:11. 1981. 10. Lloyd-Roberts GC The role of capsular changes in os!coarthritis of the hip joillt. J Bone Joint 5urg [Brl 35:627, 1953.

II. Akeson WH, Amiel D. Mcchanic GL, et ill: Collagen cross-linking al-

12.

13. 14.

15. 16. 17.

18.

19.

ter
20. Tipton CM, Tcheng T. Mergncr W: Ligamentous strenglh me;lsurellIents from hypophysectomized mls. Am J Physiol 221: 1144. 1971. 21. Holm S. Nachernson A: Nutritional changes in the canine intervertebral disc after spinal fusion. Clin Orlhop 169:243.1982. 22. Eyre D. BenY:l P. Buckw;llter J. et al: Intervertehral Disc: Basic Scicnce Perspectives. In Fryrnoyer JW, Gordon SL (cds): New Perspectives on Low Back Pain. Park Ridge, American AC:ldem)' of Orthopaedic Surgeons. 1989. p 167.. 23. Hansson TH. Roos BO. N
27. Whedon GO. Shorr E: Met:lbolic studies in paralytic acute unterior poliomyclitis. J Clin invest 36:941.1957. 28. Walton IN. Warrick CK: Osseous changes in myopathy. Br J Radiol 27:1.1954. 29. Abramson AS: Bone disturbances in injuries to the spinal cord and cauda equina. J Bonc Joint Surg lAm} 30:982,1948. ~O. Gilkspie JA: 111C n:lturc of bone changes :Issociated with nerve injurics and disuse. J Bone Joint Surg IBrl 36:464. 1954. 31. Geiser M. Truct;1 J: Muscle action. bone rarefaction and bone f\lrm;\· tion. J lbne Joint Surg (Brj40:2&::. 1958. 32. Nakagawa Y. Totsuka M, S:lto T. ct :II: Effect of disuse of the ultrastructure of the achillcs tendon in rats. Eur J Appl Physio! 59:239. 1989. 33. Saltin B, Gollnick PO: Skeletal muscle adaptability: Significance for metabolism and pcrfonnance. In Peachey LD, Adrian RH, Geiger SR (cds): Handbook of Physiology: Section 10. Skeletal Muscle. Bethesda. American Physiologic:ll Society. 1983, pr 555-631. 34. Henriksson J. Reitman JS: 1ime course of ch:lOge.'i. in human skektal muscle succinate dehydrogenase and cytochrome oxidase activities and maximal oxygen uptake with physic:J1 activity and inactivity. Acta Physiol Scand 99:91, 1977. 35. Saltin B, B10mqvisl G, Michell JH. et al: Rcsponse to excrcise after bed res! and aftcr training. Circul
o3;i3o. in7. 40. Goldspink G: Alter;ltions illlllyofibril sile and structure during growth. exercise, and changes in environment;11 tcmpcr.lture. In Pcacht:y LD, Adrian RH. Geiger SR (cds): Handbook of Physiology: Scction In. Skelelal Muscle. Bethe~da. AnH::ric:lII Physiologic
539-554. 41. Sargeant AJ. Davies CT, Edwards RH. et al: Functional ,md strut'lUral changes after disuse (Jf human muscle. C1in Sci 52:337. 1977. 42. Gihson JNA. Smith K, Rennie MJ: Prevention of di~usc muscle :ltwphy by me:lns of electrical ~tilllul;Jlion: Maintl,.·!\:lnce of protein ~ynthcsis. LanceI861-l-:767.1988. 43. Selr.l G. Tugnoli V. Eleopra R. et al: Neurophysiological eV;llu;ltion of thc muscular hypotHlphy
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51. Katz DR. Kumar VN: Effects of prolonGed bed rCSl ,'n l·;.rdiojlul. monary condilioning. Onhop Rc\' 11:89.1982. 52. Chaffin DR. Park KS: A longiludinal sludy of lo.....-b3d I\,~in;\s ;\ssod::Ited wilh occupalion31 weighl liflin~ beloo>. Am Iml Hy~ t\~soc J

34:513.1973. 53. Chaffin DB. Herrin GD. Keyscrling WM: Preemploymcnl "tn:ngth lCst· ing: An upd::l!ed position. J Occup Moo 20:403. 1978. 54. Cady LO. Bischoff LP. O'Conncl ER. et 31: SlrclI1;th and litness ;Jnd suhsequcnt b.:Id: injuries in firefighters. J Occup ~kd 21:269.

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55. Rowe ML: Low hack pain in induslry. J Occup Med 11:1!ll. 1969. 56. Bicring-Sorcnscn F: Physical mC3surcmcnts :1... risk indicators for low. back trouhle ovcr a ollc-year period. Spine 9: 106. 1984. 57. Troup JOO. M::lrtin JW. Lloyd DCEr: Bnek p:lin in indust!'}·: A prospective slud)·. Spine 6:61. 1981. 58. Dehlin O. Berg S. Andersson GB1. ct ;1.1: Effcct of physical training and ergonomic counseling on the psychological perception of work and on the subjectivc assessmenl of low-back insufficiency. Scand J Rehahil

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s)'mploms :lIld 3bsence from work. Spine 18:587. 1993. ~kilL back injuries. and back pain. Spine 14:148. 1989. 61. B3t1ie MC. Bigos SJ. Fisher LO. et "I: The role of spinal ncxibility in back p;'lin complaints within industr)': A prospeclive slUdy. Spine

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15:768. 1990. 62. Dcyo RA. B:lSS JE: Lifcstyle and low baek p;lin: -nlC influencc ofsmokin~, cxcrcisc nnd obesity. Clin Rcs ~5:577A. 1987. 63. Frymo)'er JW: Epidcmiolo~y. In F!'}'moyer JW, Gordon SL (cds): Symposium on New Perspective... on Low Back P;!in. Park Ridge. American Academy of Onhopaedic Surgcons. 1989. pp 19-:U. 64. Bogduk N. Twomey LT: Clinical Analomy of the LUllln:tr Spine. 2nd Eel. C'hurdlill Livlllgslone. Mdbounll.:. 1991. 65. Anderssoll GBJ: Occupmion;11 biOnll.:chanics. In Weinstein J:-;. Wicsel SW (cds): The Lumbar Spinc: the Imem:llional Society fur the Study of the Lumb;lr Spine. Philadelphia. W8 Saunders, 1990. p 213. 66. Brinckll1ann p. Pope MH: Effects of repeated loads and ,'ibratioll. In Weinstein IN. Wiesel SW (cds): the Lumbar Spinc: the Im.:mation:L1 Society f()r the Study of the Lumbilr Spine. Phil:ldclphhl. WB Saunders.

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1990. p 171. 67. OcAndrad..: JR. G ... nt C. Dixon ASJ: Joinl dislension and rdkx muscle inhibition in lhc knce. J Bone Joint Sur£ ,17:313.1965. 68. Hides J,'. Slokes ~H. Saide M. CI al: Evidence of lumhar mullilit.lus mu.''Cks waslinl; ip\ilatcrallo symplolll!i- in p:llicnts wilh :Kutdsub:lCUIC low back pain. Spine 19: 165. 1994. ()9. Johanssl1Jl H. Sjolander p. Sojk;J P: RCCeplOT'S in thc knee joill1 lig.nmcnts ;tndlh.:ir role in the biomechanics of the joint. Crit RCl' "iollled Eng UU41. 1991. 70. Woolf CJ: Long tcnn aller.llions in the cxcitabilil)" of lhe fk~ion reflex produced hy pcripherallissuc injury in lhe chronic decerebratc r.lt. l'ilill 18;3'25. 1%4. 71. D
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if. Pai;;.II,1 J: ;','Shll": .m.i i,.....IIl.. li,ul. ;:;;,; j'r,'hkllb aud new l·OIIlYPh. In Amhlanl B. IkrlllOl A. C1::lr.ll· F (cd!>,: P.. ~IUfl· anI! ('ail: Ikn'lt'plllent. :\dapt:flinn :U1d ~hxlulalioll. Anbh:nbm. Ehe\'iI;r SCi<:lIl·... l'ullh,h...' C". I<JS~. pp V-XII. 71. Boyd 11\: 111e isu!all'd m3mmalian mu'ck ,pimlk. In EV:trh IS. Wi,... SP. Buuslidd D (~d:.l: 11,C Mowr Sysll'l1110 Selln'hilllil~Y. :\l1hlcrll:lIl1. Else,·icr. I ~)X~. is Tri;mn J. Sdlllil/. AU: Currelaliun or ollJ";, II·. ..: llIea!>lIrl.' Ilf lrunl. m"lill1\ JmJ IlIllSCIe hllll:li(\n \\illi luw·h;I\:1. ,!I,:::":hty rollin}:... Spill'· I~ :'61. !tJS7. 7't Huhh:ml DR. Bef(,:nifG~1: Myur:L\l:ial tn~;er pnillb :.h~l\l "fk'nl:l11l'UU" needle EMG :'l·ti\"il~. Spill": IR:IKUJ. IlJtl~. SO. Simons DG: Referred phentllncna of 1O~C1f. In Veechict I.. i\llx:-Fc....:lrJ D. Lilldlonl l': S..:w Tr..:nds ill Ikkrr..:J P~lin and Hyperalge.~;:l. AlIhtenl:ull. Elsevier. IlfJ."I. 81. Sato H. Ohashi 1. IW:lllaga K, el ;II: Er.dur:ll1ec timc and Llti:;lI': ill stntic contr:lctitltls. 1 HUlll Ergol (Tokyo! ~: IJ7. IIJX4. 81. RylJicki KJ. Waldrop TG. Kaufman 1\11': In;.;r~'a,ing gr;lcili ... rnu'l.:k interstitial pol;lsslum conccntr.ltions slimu!:'le' gruups III ;1Il1i IV ;lff.:r· ents. J App! Ph)'l>iol 58:936. 1995. 8~. Johansson H. Sokj3 P: P:llhophysi(llogli::.1 fIle..:halli:.lll" in.. nh.:d in genesis ilnd spread of muscular tcnsion HI /)ecup:ltinnal muw!.: pain and in chronic rnu$Culoskclcl31 pain l~ndtcJmes. A hyp, ~·:,d; p;,ill. £:ur Spine J I :1X. 19<)2. IJ() Cooper RG. Stoke.s \lJ. Jayson MIV: Ek:~ '~'" :lI\d acou...ti;.; m:'t>~r"rhil.: dlangcs (luring faligue of Ihl: human p:::;;:;llll
163:182.llJl J:!. 9:0;. Blllloc}.;-SaXltlll lE. hnda V. Bullock.\11 f":::I!cx. :lctiv;stion of ~fulcal mu~cks in walking. Spine IS:7U4. 11)l)} 99. Jand;l V: r-.·1usclc.~. ccnlr.tl n..:rVUllS lIli)t'): :';:';Ul:ltillll, :md l1;.d: probo. lcms. 111 Kurr 11\,1 led): Ncumhit)lo~jt: .'.l';:.h:lni"lm in ~'1<1njpulati\'c Ther.,py. New )',,1(,:. PlenulII. 1978.

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100. Sch
105. 106. 107.

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109.

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11:425. 1952. 113. Cohen ML. Champion GO. Shcalerh·Rcid R: Comments on Gf:.I~·cl)' CI al.. "Painful neuropath)': altered celllral processing l1lailllained u)"tl
I n t >;)"'1I~r::.: 1\ t"HAl.,; IllIUNl::.H·S MANUAL

126. Willis WD: ~lcehallic'l: :ll:,... lyni~l-'i\ f(.:~, rOI '~IISii;/ ... ,: ,," ... ;... .:1':;-.,,; tr.Kl ecll~ with I,:nl\\"crgcnt inpul fflllll lIl~'\·h:Ulor\,,:,,:plOr:o. alld l1\1\'i\'\'p, tors? APS J-lUm,,1 I :2~. 199;t. 117. La~1011c RH: Suhpnpulaliuns of "nnciSCnl'tlr ncurons" "'nnlrihulin~ It, p:liJl and aJllxlynia. ileh :ll1d allllkinesi~. :\I'S JOllrJl;ll 2: 115. It}l)2. 121'- r-.-1:l)'cr RA. Tre.:d RD. Srinh'as l"\R. el al: Peripheral I"Cf:o.lh ,'cnlroll m"'l.:h:ll\i"llls fllr S\..... tlllliary hYI'ICr:ll~e:o.i ... AI'S JUllfllal 2: 127. I<J'.l~. 12t). Perl ER: ~Iullire\'ellli"c ncurnns :llul lIIcl.:hani..::,1 allll..lyllia. :\I'S Jn1l0l;11 I:.';. 1992. PO. Dt!!m~'r R.: ;"··.:timp;llhi..· rain. ,\I'S llllll'llal l:s. IlJIJ.'. 131. WiIIil' WD: Mechanil"al all\ldylli,,: A rule fm lltl\'ire\'epli\'e Ira\·t \·ell... wilh cOn\'ergcnl inpul from lIleCh'llltlrct:cpwr... and tltK'icepturs'~ AI'S 10UOI:11 2:23. 199:'. 1_'2. Duhner R. Shara\' Y, Graccly RH. el ;11: Idi\lpalhic lrig<':l1Iin:l!lIeural!!la: Sel\Sor}' fe:l1ures and pain I1Il:ehallisllls. Pain 31:2;\.11):\7. 133. Sugimoto T. Benneu GJ. Kajallder KC: Tran.. ~yn'lfltic degcner.1tion in the supcrlicial dor,;:ll hom after ~d:1tic ncrw injury: ElTccts df:l chruni..: con~triclion injur}', tr:msl:ction. anti stryd.lnine. I\lin 42:205. 1~)lJO. IJ4. Moglincr A. Gms.\l1la1\ JA. Kih:lry U. el :l!: SOIll:Lluseu:-:tlry \'tlrti,'al plasticity in adult hUIll'l1l.' revealed lly lIl;lgnel(letll.:cph:lll1~rap).. l'me NaIl Acad Sci USt\ 90:3593. 199:\. 135. lull G, Janda V: Mu~de~ ami 1l10[or colllrol ill lo\\' h:K'k pain. In Twomey LT. T'lylor JR (cd.. ): Physic'll Therap)' fur the Low Bold:: Clinics in Physi"·:lllllcrapy. New Yurl.:. Churl'hill Li\'in~slune. 1'}S7. 136. J:lIlda V: Some :ISPCCI." Ill' extr'lerani:ll ~·;Ill:o.C'" \If t":H;i;11 p:lin. J Prn... thet Dent 56:4S4. 19~6. 137. Sahrll\. Uou~licld D (cd... I: 111e t1·tlltur System in Neurobiology. Amslcrdam. Elsc\'ier. 1<)85. 139. $:limons S: Functional adaptation ill skektal Illuscle. In Evan.. [v. Wisc SP. Bouslicld D Icd'l: Thc Mowr Sy... IClll in Neumhiolo~~'. Am~lcrdaOl. Elsc\·ier. 1985. 140. Janda V: Mu,c1e spasm·a proposcd pnx:cdurc for differcll\ial diagnmis. J M:mual Med 6:IJ6. 1991. 141. Sarno J: Psycho~olllalic baek:!l.::le. J F:nll Pract 5:J53. 1l)77. 142. Gibson S. Granges G.. LinJcji)hn GO. el ;11: IntTc:l... cd thermal pain !>eJl .. sili\'ity in palients with tillromyalgla syndromc. In Bromm B. I)c\lllcdt J (etl~J: I':Lin and thc Brain: N\l\:icepliml 10 Cognition. New Yurko Raven Pre...s. 1(1)4. 14.'. J:ll1da V; Mu..cle ...lren:':lh in rcl"ltlt>n \tllllu...dc knclh. p:lin anl! mu.~~·lc illlb:\lance. In Harms·Rindahl K (ell): Mu'o.(,;1c Slren~th" New Yurko Churchill Living:;lollc. 1<)<)3. 14~. Lewit K: ~bnipul;lli\'c tht:r;lpy in rehahilit"uon til' th..· lIl11lnr sy..tem. 2nd Et.!. London. BUller\\clnh... ]991. 1·1';_ Lewi! K: Chain re;lCtioll' in di:o.turhed hlllr.:llUll of the lllotor ~ystelll. M;mucllc Med 3:27. 19l;i7. 146. Kmr I: The spln.,1 cord a\ org:mi7.cr uf dl"'C:ISC proce~sl.'s: SUIlIC preliminar)' pcr"f>I.~tives. J Am Ostcopalh AS\(lC 76:35. 1976. J·17. Feuerslein M: A multidi...ciplinIud)·. Ilhy.. Ther 7-':216. 1~t}3_ 152. Schwar1.er AC ,\pril CN. Bogduk N: '1111.: :o.'lcrllili;I': joilll il1chmnic low back pain. Sjlille 2(1::\ I. ]lJIJS.

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REHABILITATION INTO CHIROPRACTIC PRACTICE

153. B:lmslc)' L. Lord SM, Wallis 61, et al: The prevalence of chronic cer· vic,; zyt:arophyseal joinl p:,in :Ifter whip!a~h. Spine 2n:20, 1')95, 15..\. Nordin }.·I: E:..!r1y lilldinfs of NIOSH/CDC model b:ld clinic n:n.'al surprising obser\'ations Oil work-related low h:lck p:lin prcdicl\\r:-. Spinc Lettcr 1:5,6. 1994. 155. Kellett J: Acute soft tissue injurks-a rC\'iew of the litcralull:. Ml'O Sd Sports Excre 18:489, 191\6. 156. ():Ikes U: AculC SOflli.~suc injuries: Nalull: and managcment. AUSlr p,lIn Physici:lII Suppl 10::'1. 19S2. 157. Va:: Dcr~ktllill HIC: !'~I.'::;:": :i,:;:(' ,If kmlwkJgc Oli p;a;;cs~., .,:. :i':;1\' ing in col:agl.:'11 stnlClures. Ill! 1 Sports ~kd 3(Suppl 1):9, 1982, ISS. Waddell G: to. new c1inic:ll model for Ihe lrt::lllnent of low-h:ICk pain. Spine 12:634, IllS7. 159. Tarola GA: Whiplash: COnlCl1IrXWJry considerations in asS('ssmelll, In:lnagemell1. trcallllelll :md prognosis, JNMS 4:156, 1993. 160. M:lycrT, Galchel R, Maycr H, et oJ: A prospective r:llldomized two year study of functional restoration in industri:ll low back injury utilizing objeclh'c :L~se~Sll1enl. JAMA 258: 176:'1, 1987. 161. Reis S, Borkiln J. Hcnnoni 0: Low back p3in: More Ih:m an:\tom)'. Film Pmct 35:509, 1992. 162. Kirkaldy-Willis W: Managing Low Oack Pain. New York: Churchill Livingstone, 1983. pp 75-128. 1(13. Bosh K. Cowan NK. Kml, DE, et :II: Thc nalur;)1 history of sd::llica :'.~. s()ci:llcd wilh di~l' n:llhnln~y: r\ pros['lCclive study with clinical and indepcndclll T:ldiologic follOW-Up. Spine 17: 120S. 1992. I(H, FT)·tl1o)'cr JW: Prediclinf disahility from low hack p:lin, Clin Onhop 221:121. 1987. 1M, C:tI.\-E3:1ril WI. FrY11lo}'cr lW: Idelllifying p:l\iCnl.~ 011 ri~k of I:Jccomin!! disabled because of low h:td: ~in. Spine 16:605. 1991. Waddell G, Ne\~1on M. Henderson L ct al. A fear-amidance t>clicfs questionnaire and lhe role of fCaT-
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170. W:uJddl G, Bin:her }'1. FilllaY~llll 1>•

.:1 :11: SYIlI(lhllIlS :.lIld si~m:: PhYl\ieal disease or illn.:ss bchavin(~ Br }.kJ 1 ~HI):7W. 11)1\4. 171. Shckclk PG. l\d:UllS AH. Chassin MR. ct :11: Srill:11 m:tiIipulalinn I'm 100r·~ack pain, Ann Inlcm i\-lcd 117:590. 1992. 172. t.inum 51. Iidising AL. Andersson 0: ,\ cOlllrolled study Ilf lhe dfecls of an e;lrly inter\'ention on ;Jcute lllu.~cutoskl·1clal pain ]1roh1cIl\~. I':,in ~":J5.'. 19tH. J 7.l. Lindslrolll A. Ohlund C. Eck C. (,'1 al: Aeli\':llitlll Ill' sllh;\I:1I1 ... 1(1\\' h:ll'J.: p:niclils. Phys -Iller 72:29.'. 1(1)2. ll.. I,:lrJ RG. FCllwick H\\'. Kaliseh S~·l ....1 :,1: FIIlK'lilln:lI r.: ..lnr.lliull with hch:l\'ior:t1 suppon. Spine 14: I H. II)S9. 175. S:lchs BL, Da\'id IF. Okimpio D. et :11: Spinal rehahililalillil by \\'lll'k lokr:lnce hased on ohjecti\'e ph)'skal c:lp:lcity assessment uf dysli.t1K· lion. Spine 15:1.'25. 1990. 176. t\lar:lnt:t Ii. Hy\tl1:osld U. Riss:ulcn A. el :I1~ Inlensive physic:l! :1l1d psychosocial tr:\ininJ; pmj:ram for paliellls wilh chronic low back j1:lin. Spine 19:1.'39. 19')4. 177. Milchell RI. C:lfInen G~I: Results \11' a l1\l1l1in;nter Irial u~ill~ :111 illlellshe active e,'(erci.~c program for the lreatment of anile SlIt'! li."SlIC :11\<1 back injuries, Spine 15:514. 1990. 178. Saal JA, Saal JS: Nonopcr.llh·c lTt:almel\! of herniated ll11n~.,r il1t.:r\,\,r· lcbr;l! disc with radictllopathy. Spine IJ:431. 1989. 179. Chcrkin DC: Family phy~icians :Ind chiropraclors: Wlla!'s bcSl for lhe p:uienl? 1 FoHn Pr,lcl 3~:505, 1(l92. 180. Cherkin DC. MacComack FA: Palienl e\'alu:ilions (\f ](.w h:H:J.: p:lin care from fami)' physicians :md chiropracwrs. WCS-l J ~lcd 150;3~ I. 1989. lSI. Bo£duk N. Simons DG: Neck pain: loint p;lin \)r trigger points? In Vocroy H. Mcrskey H (I.:ds): Progress in pihrllrnyalg.i:l :lIld Myofascial Pain_ Am..to,:rdalll. Elscvier Science. 199,1. pp "2(,7.:!73. 1~2. Haldeman S. Ch"pm:Ill·Smith D. Pelcr~o.:l1 D:-'I: Fr.:quellcy ;Itld duration of care, In Guidelines for Chiropr-Jctie Quality J\sSUr,lIK'c and I'ractil,;e Paramcter..:. Gaithcrsburg. Aspen. 19')3. pp 115, IJlI. IS3. Turk DC. Rudy TE: NcglcCll:d 1i\pks in lhe lrCal1l1..:nl of chnl\lic p:lin paticllts-rebpsc, nnncnmpli:mce. and :Idherencc enham:elllcni. I~ilin ..\....1:5. 1991. Linton SJ: 11)e rel:'lion..hip between ;leti\·jty :Illd dmlllk hack pain. Pain 21:2X9, 19S5.

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3 Training and Exercises Science

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JEAN P. BOUCHER

Human behaviors ;Ire dictated by many laws. constr.lims, and dcgrees of freedom. In other words, (hI: human s)'stcm has ·limilalions. Many IimjtJlions in rcgartllo mOlar bcha\·iors. or movcments. are wcll dOCUl11cnL~d in the field of excrcise science or kinesiology. defined as the science of movement in biologic syslcms. Such limilations liS the muscle dynamics lind the fundamental facLors of performance arc discusscd in this

including the feet. legs: and thighs. l Any measurable discrcp;lucie,., in the measuremcnt.s from olle side to the other ~,re wken ~,~ an asymmetry. Tr'lditionally. an
elI,j!)(cr.

THE LOCOMOTOR SYSTEM The locomotor system. which is responsible for all motor behaviors involved in locomotion. is composed of fundamcntal \lnits that must be controlled to achieve complex movcments. such as walking or runni~g. Understanding the locomotor systcm rcquires then a knowledge of the fundamcntal units composing il (e.g.. boncs. joints. and musc.:les); of the qualities characterizing these units: and of the operations im'olving them. Concentr
The "n.Homic components represent lhe Slnlctufal units of the system. They dictale the status of lhe internal environment that must be controlled. These units, the bOlles or rigid segments, represent thc baseline informalion requircd by the control system to producc fluid. well-coordinated movements, FOf the lower limb asymmetry model. the ~matomic factor is defined by the lengths of the scgmenls in the lower limbs.

MECHANICAL (STATIC COMPONENT OF POSTURE) COMPONENTS

The mech'lllkal factor represcllls the static mechanics Of positioning or the joints. The mechanical components arc described as the st~ltic postural units of the system. lllcse units. the joilll~ and soft tissue holding lhe bones together. dictate thc passi\'c mcchanical alignJ1ll:nt of the l11ultiscgl11clllal links. such as thc 10\\'l:f limbs. the trunk, and the upper limbs. These unit~ ~lrc then responsible for the passive basclinc meeh'lIlies that thc system must t.lke ..s a starting point when executing and cOlltrolling 1ll0\'cmCllts. The mechanical factor is measurcd through thc honc-bone rel:ltionship. or joint ~mglcs. A lllcchanic<J1 asymmetry can then be operationally defined as a difference from one side to the other in the lower limb joint ilngles, or as <111 above-nor~ mal amplitude in a specific joint ;:lIlgle. It is important to rnC:lw sure lhe<;_~ ;:ll1glcs in a normal wcight-bearing situation to apprcciaLc fully the implications of the mechallic~11 factor. With this in mind, the lower limb lengths ilnd pelvic till mcasured in a weight-bcaring position art:: ;lIso considered mechanical variables. FUNCTIONAL COMPONENTS

The fUl1Clional components, llluscleS and motor units. are rc~ spol1siblc for moving the bones around the joints. In other words. lhe functional units make it possible fOf movement of the structural units to occur. st'1l1ing from the posture dictated by the mechanical or posturalullits. The functional f
45

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to mutually exclusive sets of struct\m::s. Anatomic factor!" reveal the staWS of the hones. the mechanical factors

CENTRAL CONTROL IFEEDFORI'IARD)

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and joints. Using this three-component approach. Desmarais and Boucher~ and Zarow ct all> demonstrated that functional components and not anatomic or mechanical components arc the major contributor to sacroiliuc joint dysfunction

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and chronic low back pain. Systematic evaluation of the human system according to its fundamental components will allow a better undcr!'i1anding of specific factors underlying any dysfunctions. and a wcater chance of efficient treatment,

Motor Control Following the siudy of the units composing the human system, a greater challenge is to understand how this system can produce and comrol voluntal')' movements, In general. movement comrol C;;1Il be divided into two mechanisms: (I) fecdforward conlrvl and (2) feedback control. These modes of

TRACTS

Ihe different I1ll'l'hanis1H:", hm abu how Ihe:-=c l11edl;ll1i:"I1IS interact 10 ;Khicn: hKOIlHlli\\n or any oth..,!" i.:oordillal~d movemenlS.

The fccdforwarJ conlrol ml"l'h:llli'Ill, also n:fCITl'd ((1 ;1-. Cl'lltral or supras~gmenlal control. i... d~:"nihcd ,I:" Ihe dir~l'l L'()lltrol {)f effector" by the cel\tral na\'Olls sy:"h:m withOlIl ill{craClion with thl.': information fwm Ihe I..':llvironlHclH. i.~ .. Ihl..': moving limb or segmel\t. UnJ~r this type of control. movemel1ls arc carried oul by the excnl\ion of 11lotor COmll1alKls or programs whik the :-;ystem is nol concerned by the feed hack coming from the afferencc:-; ;lCli";'llcd during the mOWIHCtlb. The motor commands arc sent d\)WJ1 dilTerell! ~lru(llIr~" ;md through pathways or tracls rl."prescl1lcd :"Chclll;lticall~ in Figure 3.1. Such a I11cdwnislll j, useful for underslanding Ih~ execution and control of fasl. hallistic movements that arl' :"0 rapid thaI fcedbck contraction, cannot modify the llHl\'C~ ment. Learning or modification or (hi:" type of 1Il0VCllh:1H {':Hl occur only by modifying the motor commallds after thl" fact. by using the knowlcdge of response inform;,nion. InfoflU:llion

about the error committed can be incorpor~ted through ~Xle roceptors or proprioceptors and the ccntral (ol1l1nand elll be modified as to reduce lhe alTIOUIl1 of error detccted. Thi:-; lype of learning or plasticity is then (arricd out in ;,ttl 01Jt:n loop

STRUCTURES

Fig. 3.1. Neuromuscular slruc-

tures and pathways or tracts implicated in motor control.

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- - - - Cerebral Cortex Conicospinal-------'.\

1------ Thalamus

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f\.iANUAL

..:onifO! ;.11\: .Il"~' ii·.,J;t;~,il;d:~, .~fI.':IT~Ll to a:" {lpJ:H hhlp ;llId dosed loop cClntn,ll. Till..' (halkllg~ is to umkr:-;t:IlHI not only

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as any discrepancies revealed between the paltcms of the uut~ put parameters (c.g., forces. muscle aCii\'ity) from onc side to the other. Such discrep.mcics arc quantilicd by determining the difference between the pilucrns. or by establishing sidc-[{)side ratios on specific discrete variablc~. According to these definitions. all three f;Jctors penain

reveal the status of the Iig.aments hulding the bones together, and the functioll<.ll factors revcal lhe status of the muscles producing Ihe funclion or .mo\'cmcm of the bones

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Cerebellum RubrospiJlal-------~==='1Ioi

Reticulospinal-------_.I' Vestiblllospinal--------Itt-

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'-----,'---- Red Nucleus

-+----- Reticular Fonllation 01

.f4------ Spinal Cord

Muscle Fibers

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anti knowk't!gl' of response ;11'(" modify fnlUrt' 1ll00'L'llll'nIS. The cxc.:c.:t1litlll-l!c!l.'C· lioll-inILgr;lt;on-n.'('\l'l.'l!lillll loop is S:I;(\ ttl hL' Ilpl.'ll hl't'au:>:!.' the <.it.'tC(titlll anti intcgration arc lUll I'l.::lii/cd IHl·line whill: the Illovement is \)Ilgoing. hut rather :1t'1I.:!" thl' I\hl\'L'llh,'nl is Icrmi n:ltctl. FUl1hcrl11orc. it j, illlll\ll"t,IlH to 1l01l' that the motor (""Illl1I:lIld rl"ponsihk rill' I Itt' cxcnJlion {If :1 1Il0\"l,'mCllI under I'ccdltl\\;lrd COlllnll i, rc"pol\sihk IhH (lilly for the ,lew;!1 1ll0\TIllClit. but :t1su for the pllslllr:1I :IJjusllllCllts needed to maintain Ihe equilihrium. H~l1t.:L·. Ihe pO~lural ;ldjustlllellt j~ not only a rdlcx fl'aClion to ,I pCl1urh~lIiol1 c;luscd hy thl.' lllO\Tllll.'llt: it is pn1l!r'111111l1.;d within the movClll~'llt C0111manus .md pre<.:cdc~ the aeW,,1 1ll00·cm~nt. Pr;,\ctIGilly. this fact is imp0l1
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i\'1an)' movemcnts :lJ\: corrcl:led as tht::y arc produ('cd. If lhe object wc arc picking up i~ displaced immediately before wc \\,;,lIlt to grab it. mo;;t of the timc we will be able 10 change the trajectory or (lur hand in order to m
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I HAININlj AND EXERCISES SCIENCE

n.::huivc positions. etc. R~ceptors play an important role in the COIuwlof movement ;,IS well as in lhe learning ~r modification of motor behavior. The status of the locomotor system, and of the IllllSdcs. al any given time is influcnced greatly by the dist.:hargL· of reL:eptors. Their role must then be well understood. especially for functional rclmbilitmion. which is often based 011 heha\ ioml approaches. Relwrioral Systems and lipproaeh. Ajoinl adjustment or lIlllhilizalions basica;iy it funclional stimulus applied to the bouy. Th~ body. in lurn. can be seen as ;,1 behavioral system in lhat it hehavcs ill a stimulus-response mode. In other won.b. all heh:lviors of lhe human system are Ihe result of a stimulus that is perceivcd ..md integrated. and then a response i~ org;'lnized ;'lnd carried out through lhe effeclors (e.g.• musclesi. Therefore. for a practitioner to be successful. he or she must understand well the stimulus-response relationship associated with any given functional or behaviorallcchniquc. A successful practitioner will be able to prescrihe and administer the proper treatment because he or she is able to predict. with acceptable accuracy. the outcome of the treatment in the specillc case. Naturally. lhe receptors represent lhe first line of COIll:tct between the environment and Ihe human system. In fact. a qimulus-responsc reaction will be obtained only if the rce(;ptor~ mc simulated and'l response is triggered. Therefore. the efficiency of any behavioral approach depends immensely on the ability of slimulating specific receptors. The mechanism triggered th~lt will ultimately produce the desired re~ sponsc is no longer under the control of the slimulus. il is oc~ curring Iwwrally. This explains why several researchers are now intcreSlcd in the role of different receptors in (he rnodu· I~llion of neuromuscular information. From our study of joint receptors especially. some data stlgge~t IhiJt sacroiliac joint adjustments and direct sacroiliuc pressure arc responsible for a significant modulation of reOex respon"c ... ::"~ Such results conflnned that sr:inal infonnation or commands call be modulated as a result of a joint :ldjustmcl1t. ami th;'lt the pressure component especially could be the triggering mechanism. Such a reaclion could be medialed through joint receptors. Further. joillt receptors. more so than muscle or tendon receptors. are interesting becausc some me slowly adaptive and nonad<tptive receptors. Thus. Iheir effects ;'Irt.: longl
T()

Fundamental Physiologic Qualities of Pcrrornwncc The physiologic qualities of the human or locomotor system arc divided into thret.: categories: organic. muscular. and perceptivomotor.

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ORGANIC QUALITIES

The organic qualities can be presented on a cUlHinuulll based on the type of metabolic processes underlying lhe production of energy needed. These qualities ;Irc: C/UlltrtlIlCC, rcsiSf(l/lcc. and POWCI: The aerobic processes. underlying the cnduf,ancc quality, are those realized in the presence of (l,Xygl:ll. On till.: otlter hand, resistance and power arc based on the (///(/('fof,ic Q

processes available when the oxygen is not presenl. MUSCULAR QUALITIES

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TIle muscular qualities of force. <.'Iu/ural/Ce, resi.'lUlJlcc. and fJowerarc best understood using the concept of the strength continuum. This continuum ranks the strength production capabilities from the production of a movement requiring vel)' little force (e.g., moving a limb without an cxtCnl31 loading). to the production of tile maximal force output. On
OF THE SPINE: A PRACTITIONER'S MANUAL

v()llIm~). Thercr\lr~. w!ll'n p:"escrihillg rc!wbilil,ltion excr~ cis..:s. on~ should k~l'p in mind the l~lrl!...·t quality. th~ nature of the Ill11SCIt.: cOlHr;It.:(ioll r...· quircd in a real-life sitU'lIioll. and thc spct.:ilic nature 01" ll111SI,:k training. The prescript1tlll of exerl';:-;e is disl"lISSed rurth~r in sllb."~qlll·nl se('liol1. Trainiu/.: COl/sid{'rtlt;tH/s. Til...· !HO\( important cOllsideration for the prcscriplillll of Ir:lillill~ cx......ciscs ;tntl pmgr:uns is the: Iraining InaiJ Ill' O\"l'r!O
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As the name suggests. the pl:rccptivomotor qualitit:s represcllt the interaction between perception skills ;lI1U l1lotor output. qualities specific 10 the ncurollluscul.lr SystClll. The differellt

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49

CHAPTER 3 : TRAINING AND EXERCISES SCIENCE

pcr.;:cptjQ 1t11l1!Of qll
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unJinah::u ;lI1d how perception is imponanl in the control .1Ild I.:Xl.:l'Ulillll

of any

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.) Musdc Dynmnics Muscle dynamics focus on the mechanisms underlying muscle fU1Iction. First. the smalkst functional unit of the neuro-

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llluscular sY;";'Clll lllust be addressed: the motor unit. Then. the basic mechanisms arc di~l:u.sscd in light of the strength continuum. which facilit:IICS the prescnt;,uion of lhe contraction

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MOTOR UN!TS

The motor unit i~ defined as the alpha motor neuron. its axon. and the Illusclc libel'S it innervates. 10 The motor unit and IllU5ck libt:r types call be catcgorized in lllany different ways. The Illost objcl:livc ways arc',IC(;ording to electrophysiology. fatiguc resistance. ~izc. and histologic classifications. In all of thesc quantitativc motor unit classifications are three types of units: [<.1st fatigable. f<.lst fatigue resistant (imemlediate motor unit). and slow motor units. Edington and Edgerton ll prcsented one of the 1110re comprehensive descriptions of the mo101' unit types (Fig. 3.1). To fully apprcdalc thc mcchanisms underlying the muscle dynamics. the cnc;rgy sources that fuclthe contraction must be discussed (Fig. 3.3). The first source of energy available to the

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muscle is the immediate source stored in the muscle
Fig. 3.2. Summary of the motor unit types and char~

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Fig. 3.3. Energy sources available for muscle con-

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A PRACTITIONER'S MANUAL

Oxidati ve i\l eta boliSIll

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---',

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should be considen:J can::flllly when cXl:n:iscs or training :Irc prescribed. Finally,
CONTRACTION TYPES

Simply stated, muscle contractions C<1I1 occur under only three functional conditions: (I) the external force (F) is equal to the contraction or muscular forcc (F,) or F,. = F",: (2) the external force is smaller lhan the muscular force or F.: < F",: and 0) the external force is greater than the muscular force or F > F . The lirst condition. vielding contractions while no "rnov;;ncnt occurs. produces i,~olllelri;' contractions. The second condition. usu;,tlly the desired ('on· dition. makes it possible for the expected movement to occur because of shortening of the lIlusck producing a displacement in the expected direction .It a given ~pccd. This type is known as cOllcell/ric contraction. The third condition is the exact opposite of the second. Eccentric: con· tractions afe produced while the muscle is aClUaliy being stretched and movement is going in Ihe dircclion opposite to the one the muscle would normally produce. For that reason. cccentric contraclions
- -- --_.----------

FORCE-VELOCITY RELATIONSHIP

A schematic representation of a typical force· ...elocity curvc is shown in figure 3A. This curve shows clearly that the grt:atcst amount of force is produced in the eccentric condition. Thb faCl could he explained by t\\to distim.:t mechanisms activc simultancou .. ly during muscle lcngthening ecccntric contractions. One mechanism is lht: \tretching of the clastic COI11poncl\ls in the muscle. In fact. the muscle acts panly OIS an clastic: it is able to si(lre energy while being stretched. This storage of energy automaticillly increases the force output monitored. The \ccono mcclw.ni\1l1 is based 011 the ncuromllscul;'lr control jJvail~lblc to Ihe muscle, Receptors. the muscle spindle specilically. arc sensitivc to stretch. When the mu:.dc is being stretched. the spindle is excited. the Ia afferent libel'S thai connect directly on lhe alpha motoneuron respollsiblt.: for the ongoing contraction ,Ife soliciled. and thc nerve output to the muscle is increased. producing gre;'ltcr force. These (wo mechanisms arc speed dependent. Accordingly. the forccvelocily curve Ic\·cb off at greater levels of negative velocity. As soon as movement starts in the desircd direction (Le.. concentric contraction). the capacily of the muscle to produce force is drastic<.llly reduced. At greal speeds. force production goes down to 30 to 40% of the isometric force levcl. This rt:'1liwtioll is disconcerting. because usually the object of muscle contraction is to produce a given 1ll00'Cl11cnt and in that vcry condition the muscle is less efliciem Onc can ask: so what? Wlwi is the relevance of the forc~ velocity curve? Outside of acknowledging our limitations in producing force during voluntary movements. it is important to consider the force-velocity curve for two rc'lson:'.: (I) training spccificity and (2) recognizing naturally occurring eccentric contr
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I HAININ\j ANU EXERCI::iES SCIENCE

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Figure 3.5 presents an idcaliz.ed force-angle curve. The importance of this relationship is the dcmonstration that .1I1Y muscle. or muscle <'IffillP and jQint system hilS an~()ptjlllai \".q!ki_~£..p..Qs.it.ion. Joint position or angle, related to the Icngth of the n~1s._~nfluenc~~Jh<:...f9J:ce p~oduc~i.9~ E.~P~~.!.!J' of the m~le.~ the knee extensor muscle group. for example. the maximum forcc output is measured at between 80 and 90° of Jn~c flexion, Again. this relationship is important to consider because of its implication in training effects specificity.

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TRAINING SPECIFICITY

As suggested previously. training effects are known to be ve· locitt~·'·l and position (i.e., joint angle) spccilk.I~.I~ Training with neg.llive work. for example. increases force output of eccentric contractions without affecting. thc muscle capacit)' during concentric contractions. !':urther, training at a specific joint angle (full joint flexion. for example) will not or may not influence the force omput of the muscle group when the joint is nenr full extension. This fact suggests {hat a rehabilitation program ~hould be specifically adapted to the muscle. the joint. and the task t<.Irgclcd. Accordingly, a person expected to do static work requiring isometric comractions in a specilic joint angle should not be traincd or rehabilitated in the san~c way as
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Professionab dealing to ~ grc:1l extent with functional problems (e.g.. pathologic or traumatic) or dysfunctions are often calkd on to evaluate. treat. and rehabilitate Illuscular functions. Exercise and/or tr;'lining prc~l:ripti()n is then a common demand. The basic training in exercise science or kinesiology is often limitcd. however. In that respect. lhe information rel .. ative (0 the force-velocity and force-angle relationships and training specificity arc fundalllcntal to the practice of exercise prescriplion. More specifically., when confronted with exercise or train .. ing prcscription. I always consider lhe following: (I) the objectives or goals pursued by the exercise program and the concerned individual (c.g.. rehabililation, well-being. compe.. tition); (2) lraining specificity (e.g.. velocity and position): (3)

Full Flexion

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USE. OVERUSE. MISUSE. AND IMMOBILIZATION

Dysfunctions are often associated with usc. overuse. misus('. or immobilization. It appears that too much or too little move.. ment brings aboul a functional problem. Movement in men and women is neither accidental nor in.. cidental. Movement is cenainly csselltialto heahhy life. if not its essence. Realizing that both use and immobilization. two opposites. can or will cause functional problems leading to discomfon. dysfunction. or dys..e'lse. highlights the need to define what can be called a u'ilU/ou' of ol'lima/ a<"li1'il.\: On .1 !1(.',!ormlllKe COIII;IIuum (Fig. 3.6). this window should bt:' placed in a functional zone between rcactivation and activa .. tion. This concept of performance continuum. including tilt:' levels of intervention (i.e.. rehabilitation. reactiv:.Hion. and ac .. tivation). the types of intervention increasing performance. and the eve illS leading to decreasing perfornlance (see Fig. 3.6). should help to organize the research needed to under· stand the complexity of functional health or pathologic change to organize the inlervention needed to mainwin an in· dividual in an optimal position along thal continuulll. ,lI1d to reveal the imponancc of overuse and immobilization. Such a conceptual framework is the bal·;js for the re .. search. in chiropractic, kinesiology. and SpOrts medicine. produced in our laboralory. Our focus is on imbalances. knee dysfunctions, ,lOd lhe relationship existing between the mechanical and neuromuscular cOl1lponellls of function. This research program should help 10 understand this win .. dow of optimnl activity and the consequences of being oul .. side of it.

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53

CHAPTER 3 : TRAINING AND EXERCISES SCIENCE

LEVELS of h'lTERVENTION

REACTIVATiON

REUADIUTATION

ACfIVATION

TYPES of II\TERVENTION Incrensing Pcrformun(:c

.. "NORMAL" Performanu

DECREASED Pcrfornlance

EVENTS

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LEVELS of PERFORMANCE

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INCREASED

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.,

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Fig. 3.6. Performance continuum including the relalive position of the levels of intervention (rehabilitation. reactivation, and activation) and the different phenomena responsible for increasing and decreasing performance.

CONCLUSION

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disciplin
REFERENCES I. OcSI1l,lr:tis F, Boucher lP: t\ Illwer limh a'YlIlIll..:lry modd: /\nal
litional work) The normal work r;lllge of motiull (i.e., angle specificity) The luad required for the specific development targeted (i.e.. Spt> ci(ic muscular qLl,ilit}', endurance. rcsist:lllce, force, power, or articu!ol1lUscular
Only when all these "spects arc considered carefully <m~ the reactivation and activation goals reached systematically. Therapists lacking background in the exercise scicnces which is needed to appreciate aHlhe important details underlying the reactivation and activation techniques, should seck a lIluhi-

VA. It}tn. I'l' 52-53. ..1. Hcrwg. W, NiJJg OM. Read JL: Quallljl"~'illt,: 111..: df..:t:b of ~pill:11 Illanipll!:tt;olls (Ill JJ:lil, llsil1g p;It;cnb with low h;lCk pain. J ~hniJ1l1"'li\'·e

PhpiolThcl' 11:151.

(I.

chronic lC'w b
7. Ch,Hh(lnn{':1U M. Boucher JP: Scgrncnl<.J1 nw
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5. Roy SH. Dc Luc;1 CJ, C'Isa\,:llll DA: Ltllll!>;lf mu!>dc f:lIiguc :lml

llcxcs and ,....1 \'I:I\'C lollnwill,!C

;1

chiropr;lcllc :ldjuslIllCIlI: A pilot sllldy.

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REHABILITATION OF THE SPINE: A PRACTITIONER'S MANUAL

III I'ml..'l;cdin!:s of the 1990 Intcrn:ll;on:,t CmlfcrCIICC on Spinal f\h· Ilipublioll. FeER. Arlingl
S Ldchwc S, Ch:lrlwnlll:all M. Ihllldlcr JP: :...1odllbtioll of scgmcllIal ~pin:ll c ....cilahilily hy mC'l.:hanicll :-Ifl'"'' l'l)tl11 Ihe s;\cf(l-ili;tc joint: Prdimin;ll)' rcpt'rI. In l'rt>l'ccdill~S IIC tll..- 191).1 llllcm:llional Conferc:nc..: on Spin;\l l\1;1I1iplll;tliulI. feEK :\r1in~lOn. VA. 1993. pp %-57. 9. ..\slr'lIld PO. Rodah! K: Texthook (I( \\'prk Physiology. New York. !'-IcGraw HilL 197i, 10. Ba:'lI1ajbn JV. n.,.. I..U~·.1 CJ: ~l11"l;k Ali, ..... 5lh co. Baltimore. WilIi:nns & Wi\kills. IlJS:\. II. Edington D\\'. Ed~~'rion VI{; Th~' Bit'],l';:~ of I'hysical ACli,·ily. Bo:-lull. IhlUghwlI ;"lifllin. 1',17(1. 12. !\lotTried MT. Whipple lUI: Sp.. . l·ilkiry of spL:ed e:'tercise. Phys Ther

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50:1693. \970. 13. C:liz...o VJ. I'erille. JJ. Edgerlt1u VR: Tr;tinin~·induccdalteralions of Ihe in "jvo fllrce-vcllx-:ilY rdalinnship of human muscle. J Aprl Physiul 51:75n.1981.

14. Bcnder JA. K:lplan HM: 111e llluhipic anglc test ill£. rnelhod for lhe evalualion of muscle stren~th. J Bone Joint Surf: lAm) 45,\: I 35.

1963. I~. ~k)'C;rs

C: Effects of 2 isometric roulincs on sln=nglh. size and endur:llIce uf excr~'i~ed :md lion-exercised anns. Res Q JSA30. 1967. 16. Boucher JI'. Cyr A. King MA. el "I. )ltOUlClnc t(:linin/; ll\"er!ltlw: Dc· lerlllin;l\ioll of :1 ll(lIl':"I~ciliciIY winuow. ML:d Sci SPllriS EXL:n.:. 2:': SD4.19<)J. 17. EllOk:t R~'1: ;-':curumech:lIlic;11 Ibsis til' Kiuc..il,lugy. Ch;ullllaij!ll. 1L. Human Killclin BI1lOlks. 1985. JR. S::tle D. ~hcD(lugall (); Spccili..:it)' III ltlrellglh lraining: A re,·ie\\· f{lr Ihe coach ;L1111 :Ilhlele. C:m J Sport Sci 6:87. 19S l. \9. RUIIII.:rford O~'l: Muscular comdin:lliml and strength lr;lining. implications for injury rehabilitation. Spuns Med 5:196. )9SS.

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II ASSESSMENT OF MUSCULOSKELETAL FUNCTION

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4 Pain and Disability Questionnaires in

Chiropractic Rehabilitation HOWARD VERNON

"An old joke: \Vhich is better to have. a watch that's slOpped. or a watch that's always five minutes fast? Answer: T.!!c wmch that's slOpped-because m Icast it's dght twice a day!" [[valuation is the cornerstone of clinical mcdicin,flNo diagnosis can be reached and no effective treatment can be rendered without conducting a clinical evaluation. which allows for the identification. of salient signs and symptoms 9f lhe presenting disorder. This fOfm of clinical assessment is conducled by using a time-honored system comprising a patient intervic\\' or history. obscrv~Hion. and clinical examination

procedures. These procedures often include established and traditional "tests" 10. for eX
~~~cd_condition. each may have diffcrc:~t_a!.t~!.:l.~~~~.~~~unc 11011. CSPCC1
dcfinitions ,Ife helpful. a com:eptual model .Iids greatly in clarifying the c.:omplcxities in\'olved. Locser's modd depicts pain as a multidimensional hicrarc.:hy. hc~inl1illg ill its lowest level with nocic.:eption. which leads to p.lin. which h,.'ads to pain beha\'ior and ultimately to suffering,I,I'Each of thcst.: dimensions lends itsclf to particular kinds of ;lsseSSlllcnts. On the other hane!. the further \.... c asccnd in the multidimcnsional hiermchy. the more it is that uny p:.lrticular phcnomcnon is a product of e~cll of thc dimensions subscrving it. For examplc. tcndcrnes!' levels measured in the somatic tissucs may reveal something abollt nociceptive activity and its interprctation
CONCEI'TUAL BACKGROUND It is useful for this discussion to st.lrl with a definition of pain. as originally ..dopted by the International Association for the SWdy of Pain: ':,Pain is Ih.'1l associ
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As a preface to a discussion of lests for pain and dis'lbiiily. the HAlder should .'pprcciate ~cvcral axes alUund which tests such as these arc configured (subjectivc \'s. objeclive. qualil;.ltivc vs. quantitativc). l..,lcasurcments arc idcally designed to mini·

57

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Table 4.1. Attributes of Tests in Clinical Rehabilitation • Reliability • Validity • Sensilivily

• Specilicity • Responsivity

mize error and 10 reduce variability. In the clinical selling. the involvemcnl of the patient in the process of measuremcnt of pain creates a great dC
i"leasurcment Scales

All instrulllents usc a scak to measure a specific para mcter.!(I,:1 Typically. the scale is only representative of the phenomenon itsdr. For example. the increase of temperature is really measured in lineaf)lnits of increase in a column of mercury-a thermometcr,@milarly. the visual analog scale (VAS) uses a 100-mm line [0 represent pain intensit . In this ins-iilllcC:-the anchors or ell poll1ts of the scale arc both absolute and arbilrary. They are absolute because they are intended to measure the phenomenon from its lowest to its highest level. On the other hand, they are arbitrary because the numbers assigned to these and any intennediate states arc purely a miHter of the choice of the designer of the scale. In fact. many pain sC
OF THE SPINE: A PRACTITIONER'S MANUAL

other words, whether 2 really represents twice as much of the value as one. or, on a scale from I to 5. whether each interval really represents 25% of the tOlal value is. at best. uncertain. Nonetheless, this relationship of ::In ordinal scale to the value measured is often assumed by users, prompting some inappropriate conciusions. In the ;ll1en'al scllic. numbers do not merely n:prcsellt units of value. they constitute the units of \'aIUl~, Thi.;. ,;,c;lk j..; synonymous with a type of data known as "continuous daw.·· On the interval scale. data points arc true numeric rcprcsenla~ tions of the value of tht.: parameter in questiollUI,ese data (X?i nts c::ar~..~~~~l~~~51.{~t J<:.<}~t ~1).t?~!e~i~al!y.l1IJ1Qinfinitely smaller uni~s. each of which would still repreSCIlL3 true unit .of~ea-~u!~·!l,lc-l1tof~h~,p'.ax~_mS:,~r.'Forcxamp-I~.·tempcratureis measured on a continuous scale, whereby a measurement of 10Q is hotter than 9::1. and colder (han 11 0 , and the diffcr~nc~ between 10° and 10.5 0 is real. On an interval scale. however. there may not be a true zero point: there arc three different temperature scales. each with their own zero poinl. As such .. at least on the Fahrenheit and Celsius scales. there may not ~ ..In absolute representation of the measured vnluc by the scale. in thm 20° may not be twice as hot as 10°. The laner aspect is the feature of scales known as ralio scales. When measuring the angle of the straight \('g raising test, the angular scale from 0° to (typically) 90 to I (Xl~ is used. Data are continuous. and ratios can be formed such that 20° of angle is. indeed. twice as I~,uch as 100. This scale allows the observer to make true comparisons l:letween measured results of a test under a variety of conditions. As an example of appropriately ratio scale comparisons. consider a patient with low b~ck pain who scores 30 oul of 50 on an ordinally scaled disability questionnaire...Hld whosc straight leg raising signs. bilatenilly. arc limited to 45<:. If. after a course of treatment and rehabilitation. the dis
Table 4.2. Scaling in Pain and Disability Questionnaires Nominal Scale: ~Do you have painT

Yes/No

1

2

Ordinal Scale: wHow severe is your painT

o2

4 6 8 10

none Testing

awful

Interval Scale: Determine Ihe thermal pain threshold in a pain patient (Range: 40 to 55°) Ratio Scale: Determine the pressure pain threshold in a pain patient

(Range: 0 to 10 kg,'cm l )

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CHAPTER 4 : PAIN AND DISABILITY QUESTIONNAIRES IN CHIROPRACTIC REHABILITATION

Sources of Bias

SP~llbl'

One funuallleiHal premise tllltkrlying dinil.::d lllC;lSllrl.'l11t.:nl is Ihe notion Ihall'lTOr and bias Ill.,)' l..'.\i,q at :lll len::ls and from .111 sources throughoUl Ihe measun::mcnt pnH;ess.: I :: Thcsc sources include lhe subject. the instrullh.'IIt. ;Iud till..' l..'.\alllincr. THE SUBJECT

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Emotional. f'."ycIJ%gic. ami pl'rsollalily jt'C!o"x illl..',·ilahly pl;t)' a p;U1 in lhl' :-uhjel:I's n,:spOllSl' hI lllcaSlirCIllCIll.:; bc it sclf-r.tting qucslionnaires or physi":<.ll paforlll.ult.:e lcsls. Such fal.:lors as p'lin IOkram::c, sdf-image. beliefs ;ll1d ;l\titudes , and pain Ie\'c!s may all influence testing. Cogllitil'cj(ICIOf!i playa crucial role. especially in the .lrea of instructions for test activities. Language and cullural and cdUl.:.uional lal:turs all impact the subject's comprehcnsion of the ovcmll purpose of .IIlY tesl. as ,\:ell as the manner in whit.:h it is to be conducted. Fin.lily, In.tditioll:.ll sources of IH.n.:/wl/Il!lric bias oist.:! such as in the tendency of subjects to choose responses in the mid-range or at the extremes of a scale; the crfccls of the order of different responses, itcllls. and, indeed. of different tests when using a battery of tests: and Ihe tendency of subjects to ovcr- or underestimate depending 011 their pcn:cplion of the responses expected in the lest. THE INSTRUMENT

The coll1elll domaill of sclf-reponing instrul11ents Jll~IY be insurllcicllt to capture all necessary chLlrac((;rislit.:s of the parameter to be mC.lsurcd. The [On/1ll1 of qllc.'ifiOIlS eilll ilHroduce errors or response bi.L<.;cs. by providing too Illuch or tOo little prompting information. If
The cmlf£'.W (lthe cli"ical .'lellillg is an important aspect of the mcasurcment. Questionnaires may be filled Ollt differently before relative to after seeing a health practitioncr. The quality of the ovcrall health care experience of Ihe patient may influencc their responses. The IJI"('scm:e or ab.\"(!/l(:e ofall examiner while the piiticl1t is completing various lests may influence their responses. Response expectations 1ll.IY be operative. such as the Hawthorne ctTect,:1.2S in which the patient's responses may be inl1ucnccd by the knowledge that the)' arc being tested, or the Pygmalion crfect.: 1.2S in which thc patient Ill:"y erroneously assume th.u the practitioner or examiner has .1 ccrtnin rc-

----,.,'..... ,..... ,." ..... ".

expectation that the patient merely fulhlls. The dellh::.IIHll· of lhe examiner and the cucs and instructions they gi,·l' af(' all iIl\POI1~1I\t in minimizing lhis sort of error. Rdiahilily Rdi"hilily m.ty he ddlned most technically as the degree to which random I..'rmr in a tc~t is reduced. More colloquially, re~ liability is charaClaii'.ed by the degree of l:onsistcl~cy in the rl..'sulb oht;lined wilh repeated lesting. The d'lI01 obtained rron~ only nne 'Ipplicalion of a lest can reOcct results from any~ wht::r(' ill the typical range of the tt::st. With repeated 'Ipplication~ of the test. the.: results tend to Ilarrow ill their variation. In fact. in c1assiL:-mcasliremcllltheory. the reliability of a statistic increases ill proportion to the squ.tre root of the number of additional data (or test applit.:atiol1s). The mean of 16 data points is four times morc rcliable lhan that of a single data patll!. In rcgard to pain and disability questionnaires, the mos( important fonn of reliability is test-retest reliabilit)~ which mcasurcs stability ovcr time in repeated applications of th~ Icst. Some assumptions must be made when considering lhis form of reliability. In delCfmining if thc tcst itself is i.1 source of error, all other factors th:lt c:.tIl contribute to variability in the I('st result must remain constant. In c1inic.ll settings, the natur;.1! histQry of the condition under invcMigation is .1 variable. Changes in the course of the condition will n.llurally introduce variability \\lith repcated applications of the test. making it dinicuit to determine the reliability of the test itself. Typit.:ally, two applicmions of the test are made in an inten·al of time that is suitable for the n.ltllral history of the condition itself (typit.:ally within hours to I or 2 days). The results 01" these tests arc t.:ompareu using some form of reliability statistic, such as Pearson's R or the Intraclass Coefficient. Acceptable levels of n::liability range from 0.70 to 0.90 and up. Olher mcalls of determining lhe reliability of questionnaires for pain and disability include the "split-half' method. in which the responses of one h.t1f of the test ar(' comp
may be placed upon the test; what do the results mean !"21 This definition also L
Face validity, or content validity. refers to the dcgrcc to \vhich the questions or procedures incorporated within a tcst make scnse to its users. Typically, a group of experts is asked to review a test and come to a consensus on the overall sensibility of its components. CONSTRUCT VALIDITY

This term refers to the degree to which a test and its result fit with accepted theory. As an cxample, lift strength testing has a high degree of construct validity when used in assessing an injured worker with low back pain whose job involves significant manual handling and carrying. Assessing small differences in the length of the legs in such a worker has poor construct validity given that no evidence suggests that a small leg length difference equates with work impairment. CONCURRENT VALIDITY

One way of determinir..; th;.::: ·.. ~lidity of one test is to correlate it with another test done at the same time. In some cases. dif~ ferent tests have been designed to measure similar attributes. For example, a VAS for pain intensity can be validated by comparison to a verbal rating scale for pain severity. In this context, relatively higher correlations are expected between tests of similar attributes. On the other hand, a test of one attribute can be correlated with tests of another attribute that is related. at least theoretically if not empirically; for example. reduction in levels of activities of daily living with levels of pain severity. In such a circumstance. the levels of expected correlation are usually lower. CRITERION VALIDITY

One form of concurrent validity that is particularly robust is to compare the results of one test with the best test available at the time-known as the gold standard. If the new tcst performs in a relatively similar fashion. then it can be said to have good criterion validity. DISCRIMINANT VALlDtTY

This attribute of a tcst refers to its ability to discriminate between major categories of test findings, often referring to categories such as "normal or abnormal," positive or neg~ ative, symptomatic or asymptomatic. S'ellsirivilY is the at~ tribute of a test whereby a positive test result is highly correlated with the true diseased or abnormal state; i.e .. high true-f.'(\~!tive rmellow false-negative rate. S[Jecijicily is the

opposite. wherein test r:cgativc:~ C\.ji.i'HC :lig:,l::; .,';;::; :ruc negatives (with low false positives). Respolls;l';ty. One form of discriminant validity involves the perfonnance of a test ovcr time. It is reasonable to determinc if the test accurately measures the amount of change in a condition or attributc when such change truly occurs. In the development or the Neck Disability Index (NDI)..'s we studied 10 subjects with neck pain who had undergone chiropractic treatment for 3 to 4 \vceks. All 10 individuals reported improvement. They were asked to complete two instruments-the NOI and a visual analog pain scale (VAS)-at the beginning of treatment and again at the cnd of the treatment period. We correlated the change in VAS scores (as a percentage) with the change in the NDI scores. The average change in VAS scores was approximately 757c, whereas the change in NOI scores avcraged only ,\bOUl 50%. These data correlated at 0.62, which is a relativcly good level of correlation. \Vhich test result reflectcd the true level of impro\'ement'? \Vhieh was the more responsive? Only fUl:ther research using statistical techniqucs dcsigned specifically to study responsivity~(J-:lI will provide answers to these questions. MEASUREMENTS FOR PAIN AND DISABILITY Each instrument discussed subsequently is representative of a greater number in each category. This section provides a SUlllmary of the content and description of each instrument and then a discussion of its reliability and validity.

Location Pain may be localized by using the pain diagram.1>·t 7 (Fig. 4.1). a standardized self-report measurement of the location. extent, and, to some degree, the quality of pain. As well as these descriptive features, the manner in which a patient de~ piets his or her pain has been shown to reveal a grei.1t deal about interpretations of the pain experience, mood, and psychologic state and behavior while in pain. In this respect. tilling out the pain diagram becomes a pain behavior, and it can demonstrate an appropriate as opposed to an inappropriate manner on the pan of the patient..1~ Outcomes are derived from the pain diagram in a number of ways. First. subjective ratings by trained observers Gill be made from the appearance of the diagrams. These ratings. in facL can be system~tized, using rankings from more 01'g:'ll1ic/more realistic to less organiclless realistic and, perhaps. psychogenic or inorganic."'" Second, scores from a checklist of penalty points, which rate the anatomic fidelity, the prescncc of cxtraneous markings within and outside the body. etc., arc compiled. The higher the score, the more likely it is to reflect inappropriate pain behavior:''<'··l(, Third. body area charts can be used to quantify the size of the painful area so a single mcasure can be derived from the pain diagram:l1 High reliability of the pain diagram has been reported. Murgolis et aI" reported test/retest correlations for body area to range between 0.83 and 0.93; for pain locatio:•. they found

,

V.,.... ,.. I r:n .. : r-'f\Il'l AI\lU UI::>At::HLlTY QUESTIONNAIRES IN CHIROPRACTIC REHABILITATION

PAIN DIAGRAM

PAIN DIAGRAM

INSTRUCTIONS

INSTRUCTIONS

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8 Fig. 4.1. Pain diagram. A, Example of a well-delinealed, analomically correcl depiction. B, Example of a poorly delineated. anatomically incorrect. exaggerated depiction.

lest/retest .lgreeJ11elll to be 7(IVr. These authors rCluno no .lge or gender differences in the degree of reliability. With regard to validity, high pain orawing scores h;'lve been correlated Wilh elevated hysleria .lno hypochnndri;'lsis scores 011 the l\;1inncsota l\·1ultiph;'lsic Personality Index (MMPI): greater chronit:ilY of low back pain iJnd higher 110spiWliz
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Concurrent validity among these scales and with mher measures of p.tin ;md loss of function is reponedly high. SCOlt and Huskisson~7 reponed comparisons of the VAS and the VDS-t)'pl' sc.alcs that correlated at 0.75, where:'ls a coefficient or 0.63 was reponed betwecn the VAS scores and MPQ scores.~7 The VAS tli.lS been shown time and again to be sen· sitivl' 10 treatment cffccts.~s although Scott ;,md Huskisson t::.Iutioned that providing lhe original scorc or using a VAS for relief or improvement may be more appropriate.~oj Other authors disagree with this stf
In 1975. Melzack introduced the McGill Pain Questionnaire it has since been llsed in numerous studies musculoskeletal and other pain syndromes. It has undergone a great de;'ll of rcplicmion ,,1I1d is acknowledged :ls onl' of the gold standards in the field of pain assessment. Tht: MPQ consists of 20 category scales of vcrbal descriptors of pain.,'I.l5~ ranked in order of severity and clustered into four ~ubscales: st::nsory. affective. evaluative. and misccllaneol1:-i scales. us well as a five-poinl "present p;'Iin rating index." Scores can be obtained on the rank scores added for the total instrument or for each of the subscales. or grealest inlerest to researchers has been the ability to distinguish the scn~ory and the affeclive domains of the pain experience. Test/retest reliability had been confirmed as high from the outset. with Melzack's lirst report indicating .1 70% consistency of responses of three trials over a 3-day period.~1 Aikll

(MPQ).~1 "lIId

or

Ht:.NAt'ILIIAIIUN UI" IHt:. ~I""INt:.: A

Make a mark (I) along the line which you think rGprese;,~:; y~.;; CUi;en~ :l;:ve; vi IJdill in youl major area of injury, somewhere between ~No Pain At AII~ and ~Pain As Bad As It Could Be",

Fig. 4.2. Visual analog scales for rating pain (A) and visual analog scale for rating improvement (B).

:1

PRACTITIONER'S MANUAL

No Pain

I

Pain As Bad

A AtAIi

As It Could Be

ABF YOU RETTER SI~CE YOUR EIRST IREATMENIl

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Please try to remember back to the first day when you started these treatments and tell us how much you have improved since that first day. Please do this page before today's treat~ent begins.

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relief

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2.

ACTIVITY INCREASE (walking, standing, working, exercising, etc)

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2

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7

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) and Weinmann~·~ reportcd similar results over four tri.tls within I week. Phillips and HUlllcr~(o studied tcst/retest rcli'lbilily of the MPQ in patients with headache and reponed correlation coefficicilts as follows: for the Presclll Pain Index. which is the total scorc. an R of 0,94; for tbe sensory scale. 0.83; and for the affective scale, 0.95. These findings indicate thut people can, wilhin a rel.ltively short period of timc. remember their pain state from one measuremcnt intcrval to

anothcr. Thc greatest imcrest with the MPQ has bcen in the area of validity, Numerous factorial analysc~ have confirmed the fac~

torial structure, especially of the sensory and the affective scales.:>1'{,(J The concurrent validity has been confirmed be(ween the MPQ and the MMPI and many other instrumcnts that measure pain intensity. mood state in pain. and psychosocial disturbance. Phillips and Hunter reported an interesting and significant correlation between MPQ scores and the pain diary in headache subjects.~ With regard to discriminant validity. Dubuisson and Melzack!>-l found that 77% of 95 pain p;.nients could be correctly classil1cd into diagnostic groups on Ihe basis of their MPQ score alone. Reading~7 studied patients with acute ilild

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IIUNNAIRES IN l,;HIHUI-'HAL; IlL; Ht:.HABILlTATIQN

63

Fig. 4.3. Borg verbal rating pain scale (A) and verbal pain rating scale (6) (from the Roland-Morris scale).

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chronic disorders and found that the fomler 'used morc sensory words whereas the laner. as predicted by the theory. used more affe<.:tive and c"i.llu;nivc words. Finally. the MPQ has been used in a many treatment trials (lnd h.ls been found to be sensitive to treatment effects.f'l Its usefulness lies ill its relative case of administration. Also, it is casy to score and rich in data, particularly with regard to the sllbsc;llcs and how their scores may apply to the thc(Hetie <.:Ollcerns mentioned previously. Because of its strengths. it has taken on the status of a gold standard in pain

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K\::HAt:SILIIAIION OF THE SPINE: A PRACTITIONER'S MANUAL

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Fig. 4.4. Pain diary.

PAIN BEHAVIOR This section addresses five instruments. the purposes of which .Ire less to describe the p'lin complaint itself than to as-

sess the behavior of the individual in pain
10

an un-

derstanding of the motivational components Oflha! pain state. Le.. to assess the illness/disability component of the disorder. The foclis of this discussion is on systematic behavioral observation. and then four scales that m~asurc activities of daily living: Oswcstry.;'-' Roland-ivlorris. fol Neck Disabilily.:Ji and Pain Disability.('S

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S)'slcmic Behavioral Obscn·alion Keefe ct all,(· devised a method of observing a patient's pain behavior in order to provide qUilnlifi~lble data regarding lhe patient's dis~lbility that would be directly relcvant to functioning. Thcy identified a group of overt behaviors thut appeared to be unique for the pain cxperience: grimacing. bracing. guarded movcments, rubbing.•md sighing. Thc protocol of Keefe et al consists of a IO·minutc video of the patient undergoing a standardized series of movements. They walk. sit. recline. and stand lip :.tgain, and lhe frequency of various pain behaviors is recorded by trained obscrvers. With regard 10 reliability, Keefe ct al reported interexamincr agreement levels as high ~lS 88%.(,(> Findings from a study of patients with chlonic low back pain by Jensen el al1>7 COtl-

firmed the high dcgn:e of reliability of th(; prolOeo!. They reported inter-rater agreement Kappa c(xflicicl1ts betwecn O.SO and 0.93. Test/retest correlations over I ~ days were al O.7};. \\lilh regard 10 validity. Kecl"c c! al'''' n.:portcd scnsili\'ily 1.0 treatment changes
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,~n

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rM."" M.liV UI;::.1\t:SILII Y

UUESTfONNAIRES IN CHIROPRACTIC REHABILITATION

Nonctheless. lhe link between pain behaviors and pain sevcrily i~ not lirlllly estahlished. evcn at the thcorctil:al levcl. Observers haw noted a grcal dcal of pain behavior in (he absence of high lc\'cl~ of pain severity ilsclf. ns well as diminished pOlin beh~l\'i()r
Thi~

scored from 0 to 5, so a total score of 50 can be compiled. The lirst section is a pain-rating s~ale. Thc other sections deal with various daily activities deemed relevant to low back disability by the consensus tcam, in lheir original report. Fairbank el al included a test/retest reliability coefficient of 0.99 and a spli!:!l~Jf.£..~f.fici~.OLr~ poric(f·~~rg·ood:· Regarding validity, Fairbank et al rcported only th,lt O~wcstry scores lowered after ~l 3-wcek rest pcriod. which is presumed to indicatc sensitivity to trcalment effcels. Triano ct al f " provided a much necded study of concurrent validity. They compared Oswestry scorcs to measures of mus~ cle dysfunction and reponed a good correlation between higher O~\\vcstry scores and the prcsence of signs of abnormal muscle function. with the conversc correlation existing as well. This finding speaks, if only implicitly. to the sensilivity and specilicily of this instrument

Roland Morris Scale" (Fig. 4.6) This scale consists of a sct of 24 questions pert
65

Neck Disability Index (NOI)'" (Fig. 4.7) This index. a re\'ision of the Oswestry Index. W.1S developed at thc Canadian Memorial Chiropractic College by Vernon and Mior to address the nced for an instrument specific'llly designed to measure reduced activities of daily-..Jiving in l?~lents \rilh....n~1in.Q.·he lcst/retest reliability was found. in a suitable sample of subjccts. to be 0.89. The total Crol1~ b:1Ch's alpha. which is :.\ measure o~lal reproducibililY. was 0.80. and all of lhe itcms acilic\'cd aip1la·lc-\~els above 0.75. Regarding lhe construct validity. scores were nonnally distributed and clustered al the moderate severity level. which was approprialc for an ambulatory clinical population. \Vith regard to concurrent validity. wc compared NOI to MPQ scores at an R value of 0.73. and sensitivity to change was measured by comparing changcs on the NOI to visual analog scale rating changes. This correlation wns 0.60.

Pain

Disabilit~· Index

(POI)

The PDI was first reponed by Pollard in 1984. 65 It is a ~cven item scale using VAS to rate illlensity of disturbances to a variety of psychosocial variables and activities of daily life. Tait Cl apo reported a Cronbach's alpha value of 0.87. As for \'alidity. POI scores for inpatient groups were higher lh,lIt those for outp.ltient groups. and more recently. Tait et ai' I found tllat high PDI scores correlated well with higher psychologic distress Slates. higher dis:.lbilil)' 1C\·cls. high pain dcscriplion scorcs (from the MPQ). <Jlld higher pain behavior scores frum the protocol of Kcefe and colleagucs.f~' The adv'Ultage of the PDI as opposed to the other indices is tll.1t it is nOl specific for one type of pain and Ihe seven categories can be applied 10 virtll
Leavitt and Garron !ina published this scale in 1979.': It is a subscalc of a larger check list of symptoms .Ipplicablc 10 back pain. Of the 1,Irge list. 13 words werc found to discrimin
HtHAt::lILIIA1IUN Of THE

uu

~PINI:::

A PRACTITIONER'S MANUAL

r:aase late (he st:vt:1iiy 0: yvv,' :ow back pain by circling a number below:

No pain

Unbearablo pain

Date

Name

_ _-"-_ _1-_ _ '

File #

lnstruclions: Please mark lho ONE BOX in each section which most closely describes your problem.

I 1 I~ ~,

"

.~

I j

Section 1 • Pain Intensity

$eclion 6· Standing

0 0 0 0 0 0

2. Th p",in is mild and doos not vary much.

o o

2. I h;)vo somo pain on Sl.1.nding bUI It doos nol incroa!iC with timo.

3. The p<)in comos ill'ld 900S and is moder:lIO.

D

3. I caMol SI3nd lor longor l!\Jn ono hovrw1thout il"lCfoasing pain.

'.

o o o

1. Tho pain comos and g005 and is vory mild.

The pain is moder
S. The p.,in comes and goos and is SOVetG.

,

Tha pain is sovors and doos not vary mIlCh.

o

I would not havo to chango my way of washing or dressing in ardor to avoid polin.

2. I do not normally dlntlgo my way of washing or dressing (lvon though it causes some pain. 3. Washing and dressing increase the pain but I manage not to

change my way 01 doing il.

4

Washing and dressing increase the pain and llind it nacossOiry to ch
S Because of tho pain I am unable 10 do some washing and drossing

without help. 6. ~cause 01 tho POlin I am unable to do any washing

Section 3 - Lifting

o

I can lilt hoavy weights without extra pain.

02 03.

I can lif! heavy weighls but it givos ex'lra pain.

Pain prevents me biting heavy weights off the lloor.

I

o

II I

1~ ,fi ~

~

I

I

or dressing

Without help.

Section 4 • Walking

~

6. I avoid SI<1ndlng

o o o o o o

~

.~ ;j

5. I cannot stand lor longer than 10 minutos wilhout inaoasing pain.

Section 7 • Sleeping

I I

4. I cannol stand tOf longor than 112 hour without incro
Section 2 - Personal Care (Washing, Dressing, etc.)

o

~

1. I can stand ~ long as I want without pain.

4, Pain provents me filling heavy weights otllhe Roor, but t Cin manage if they are conveniently positioned. o.g .• on a table.

£:] S. Pilin prevents me from ~Iting hoavy weights but I can manage lighl to modium weights ;t thoy are conveniently positioned.

o

6 I can only lift very lights wflights at the most.

3. I CMnot walk more than ono milo without incr
5. I cannol walk mote than "4 milo without inC/easing pain. 6

I cannot walk al all without increasing pain.

1. I can sit in any chair

2 1 c.Jn

2 I got patn in bod but it does not prevenl me Irom sleeping well. 3. Becauso 01 pain my normnl nights stoep is reduced by less than 114

4. Becnvso oJ pain my normOll nighlS skwp is reduced by leSs than tft

o

G. P.:r.in prevonts me from slooping :1t all. "':>1

Section 8 - Social Life

):

01 02. 03.

My soaal hie IS normal ;lnd gives me no pain.

0,.

Pain has rC5lricled my social hie .ilnd I do nolgo out very olten.

05. 06.

PaIn has toslllcted my SOCI.il1 hie 10 my homo.

My soci<'lllife is norm
I have hard1-, any socinillfe because of the polin.

Section 9 - Traveling

01. 02.

no p.ilin when 1r::Jvehn\J

gel SO'TlC pnin when It;lvehng bUI none at my usuallorms of travel m.,kc II any worse

I

3_ I gCl cl(tra pain while lr.ilvcl
04 0

I get

gOI Olllra pain while travu!lng which compels me 10 seek altern;)tive forms aflrnvol

I

5 . Pain tCSfticlS

mq

10 shorl flUCP.ssary journeys under

30 minutes

06.

P.ilin ICSttictS alllollTls 01 It.ilvel

01.

Pain prevent!;. all fOlms of lr,wel

~I(Cepllh.il1 dono

lying down

o

as long ilS llike.

~il only in my fOlVorl!O chair as long as I like

3. Pain prevonts me sitting.mom than 1 hour. P"in prevents me lrom sil!lng mora than 1/2 hour.

5 P.1in pmvents mo Irom ::oitting lor moro than 10 minutes 6 I avoid silting because it incr03ses pain immodlately.

t. Myp;un is rapIdly 901l
02.

My pnin fluclualos

o o

My rmin is nr:ilhN gr:llin!)

2 My p,lin SCorllS 10 be gell
0·1

o

)

bUl overall is definitely gening hetter.

h(!ll<:!f

nor worse

My pilln I;' gr;ldually 'watsonlng

5_ My pain is rapidly Vlorsemng

Fig. 4.5. Oswestry Low Back Pain Scale.

<

I 11

i-f;

,!_----~---------------------------------- N -

)

Section 10· Changing Degree of Pnin

Seclion 5· Sitting

0 0 0 0 0 0

1 I got no pain in bed

£:] S. Bocavso of pain my oarmi1l nlghLS stoep IS reduced by less than 3/4

D

1. I havo no pain on walking.

£:] 2 I hi1VO some pain on w
o o o o

D

o o

boc,luse 1\ lI'IOO
... _._ . . .

o o o ()

........ ,u~ ..... n~.;:J

11" ..,. "nurn/'\"" I I"" t1t:.NAI:HLlTATION

1. I stlly home most of the time because of my back. 2. I change position frequently to try and get my back comfortable. 3. I walk more slowly than usual because of my back.

I:}

4. Because of my back, I am not doing any of the jobs that I usually do around the house.

o o

5. Because of my back, I use a handrail to get upstairs.

o

7. Because of my back, I have to hold on to something to get out of an easy chair.

o

8. Because of my back, I try to get other people to do things for me.

o o o o o

9. I get dressed more slowly because of my back.

6. Because of my back, I lie down to rest more.

10. I only stand up for short periods of time because of my back. 11. Because of my back, I try not to bend or kneel. 12. I find it difficult to get out of a chair because of my back. 13. My back is painful almost all of the time.

o

14. I find it difficult to turn over in bed because of my back.

o o

15. My appetite is not very good because of my back.

0

17. I only walk short distances because of my back pain.

0

18. I sleep less well because of my back pain.

0

19. Because of my back pain, I get dressed with help from someone else.

0

20. I sit down for most of the day because of my back.

0

21. I avoid heavy jobs around the house because of my back..

0

22. Because of my back pain, I am more irritable and bad tempered with people than usual.

0

23. Because of my back, I go upstairs more slowly than usual.

0

24. I stay in bed most of the time because of my back.

16. I have trouble putting on my socks {stockings} because of my back.

Fig. 4.6. Roland·Morris Back Pain Scale.

67

. . . • . _ ••

~

••• '

"

~

, I ,

"

' .. '

vr .

NECK DISABILITY INDEX

, ,

Section 1 - Pain Intensity [=::J I have no pain at the moment. c:J The pain is very mild.at the moment. c=:J The pain is mode:rateat the moment. c::J The pain is fairly $CVere at the moment. [=::J The pain is very severe at the moment. c:::::J The pain is the .....orst imaginable at the moment. S«tion 2 - Personal Care (W.ashing.. DK'5SinS dc.) (=:J I can look after myscl£ nonnally without causing ~ra pain. I can look after myself normally but it caUSl'S extra pain. It is painful to look after myself and I am slow and careful. J need some help but manage most of my personal care J need help every day in most aspects of sclf cat"C.. J do not get dressed, I wash with difficulty and stay in bcd,

= = = = =

Section 3 - Lifting (=:J 1can lift hC:lVy weights without extra pain. c=:J I can lUt heavy wcighls but it gives extra pain. c:::J pajn prevents me from lifting heavy weights off the floor, but I can manage if they a.rc conveniently posi tioned, forcxample on a table.. Pain prevents me from lifting heavy weights,but I can manage light to medium weights if they arc convcn icntly positioned. ( can lift very light weights. J cannot lift arcany anything at illi.

= = =

S«1ion 4 - Re.ading [::=J J can read as much as I want to with no pain in my

I

I I II }I

1\ 11

I• ~

I

= = = = =

neck.

I am read as much as I ""'ant to with slight pain in my ncd<.

r can read as much as I want with moderate pain in my neck. 1can't read as much as 1want lxxausc of moderate pain in my neck. ( can hardly read at aU because of severe pain in myncck. I cannot read at all.

S«1ion 5 - Headach~s ~ I have no hC<1dachc:s at all. [=:J J have slight hcadachc:s which come in.frequently. c=:J I have moderate: headaches which come in-frequently. ~ I have moderate headaches which comc frequently. [=:J I have $Cvere headaches which come frequently. ~ r have headaches
Section 6· Conccntr3Lion I can concentrate fully when J want to with no difficulty. I can concentrate fully when I want to with slight difliculty. I Mve a fair dcgroc of difficult,y in concentrating when I want to. J have a lot of difficulty in concentrating when 1 W,1ntto. I have a great dC3.l of dimculty in concentrating when I w;mt to. 1cannot concentratc at all.

= = = = = =

,

0

Section 1 • Work c::::J I can do as much work as I want to. C=:J I can only do my wual work,. but no mot"C.. c::J I can do most of my ust.J.a.l work,. but no more. c::::J I cannot do my usual work. c:::J I can hardly do any 'work at all. c::J J can't do any work at all. Section 8 - Driving c::J I can drive my car without any neck pain. c:::J I can drive my car as long as I want with slight pain in my neck. I can drive my car as long as I want with moderate pain in my neck. I can't drive my car as tong as I -want because of moderate pain in my nock. I can hardly drive at all bcc:auscaf severe pain in my neck. J can't drive my car at aU.

= = = =

S«tion 9 • Siuping c::J I have no troublesJccping. c::::J My sleep is slightlydisturbOO (less than 1 hr. sleepless). c::J My Sleep is mildly disturbed (\-2 hrs. sl~less). My sleep is mooCr.ttcly disturbed (2-3 hI'S. slc:cplcss). c:::::l My sleep is greatly disturbed (3-5 hrs. sleepless), c::J My sleep is completely disturbed (5-7 hrs. sleepless).

=

Section 10 ~ R~.1;tion c::J I am able to engage in all my f'CCl'C4ltion activities ....;th no neck pain at all. J am able to engage in all my I"CO'C.1tion ;]ctivitic:s, ....; lh some pain in my f\CCk.. I am able to engage in most, but not all of my usual recreation activities bocausc of pain in my neck. I am able to engage in a few of my usual recreation activities because of pain in my neck. I ca.n hardly do any recreation activities because of pain in l-:ly neck. I can'l do any rccreJtion activities
=

) )

-J

= = = =

Fig. 4,7. Neck Disability Index.

11

~

"~--------:-----------------------------------------------------------~i

~

_f

i

l

"

.J

69

<;HAPTER 4 : PAIN AND DISABILITY QUESTIONNAIRES IN CHIROPRACTIC REHABILITATION

ILLNESS UEHAVIOR QUESTIO,,"-:AIRE (IBQI First reported by Pilow~ky ilnd SPCl1(~ ill 1<J76.;~'-· the IBQ \Va!\. dcsignctllO aSSlOSS fundamclu;11 altitudes (Owanl "i...· kncss. the role of doctors. ~lIld a VariL:ly of ~Hha psychnst\\..'ial v
\

., .

abies considered imponal1\ in explaining abnormal illlll;SS bchJ.\'ior. It consists of 62 items ;\n:'i\\'crcd in ;\ yc"/no 1';\" shion and comprises sevell factor seaks. The no'liability of

;\"")

ano

"

J

I

thc:-.c scales

)

o () tl

I

I

I~) I ")

I ~

~"'!-t

'1

I,) .J

,£

i

test/retest correlations has been

hel\\ l"L"n

0.(17

The following !"oK!S h;\\,c hccn rcpl~rlcd ;lhllUI the IBQ. II has good correlation belween patient .IItU spulIs,,1 ~\'aIUaliuns. so it seems to be consistent. Factor ;'\Ilalyses have L'01111nnc<.l the seven scuk structure and. in fact. other scales ha\'c been found by Main and W"lddell. 1h Compar;.ltivc and L'olltrol stlld~ ics demonstrated dirfcr~lIces bc(wCCIl symplOIHatiL' and control subjects, be(wc~n various clinical groups, and be· twecn responders and nonrcspondcrs. Concurrcnt v.llidity has heen established bctwcen the IBQ and the ZUllg depression scalc;7 as well as other IllCi.lsurcs of anxiety. Waddell. Pilowsky, and BOlld;~ correlated the IBQ to previollsly deter· mined <'lbnorll1i.l1 illncss behavior. which incluth:d thc non· organic signs of WaddcIL 1 ') One of the strongest findings in tlwt study is the impon<1llcc of the disease conviction scale of the IBQ in distinguishing p.uienls with low buck pain who demonstrate abnormal illncss behavior. In other words. they belicvc strongly that Ihey havc il serious problem. even though they may not.

Sickness Imp"cl Profile (SIP)

1

I

011

(1.~7.

The SIP~o",~~ consists of 136 statements clustered into 12 catc· gorics thm involve issues ranging from those from the simpler ADL scales as \\.'cll as Ihose from the abnormal illness be· havior rc.lIm. To address the n:liubility of the SIP. Pollilrd cl <.II'" rcp0l1cd (estlretest coefficients between 0.88 and 0.92. with an intcrvicwcr·~ldministcrcd
".--~

I: 1 . "}

1'.

~

10 I

',1, ,~1

~

I~

Nonorganic Signs The 1l00IfJI".!.lllllic siglls of Waddell and colle"lgllcsl'J arc lISCful in dislill~lIishing those Ixuicll1s who manifest abnorm'll dines" bdl
LSES OF PAIN AND IJISAIIII.ITY QlESTIONNAIRES IN C\SE YL\\A(;E\IENT ITahl,' ~..\l Timin~

/;0.\,'1"11", TtH:d s\..·ores I'm each lest help to darify and qualltif~ Ih\..' \..'\Ielll of

p;lill :l1ld disability. Tlll~sc scores l:all be eOIllparl'd lt1l'XPCl:tcd \';lIuc... in thl..' literature or within Illle·s uwn dillll"al p\lplIl;uit\ll. Indi\'idu;lI ilellh I..·:in [ll"\lyide IllL':1I1ingful inrtlrlll:lli\lli (,n \\t)r'I-~':h~' i~~lle~. rtlr cxalllpk. Illl thc Chwestry llr NDI ~c;lk,. any itl..'lll sl"orillg -l or :' rcprcscllts a key issue in Illl.' paticnt"s lire. Id\..'llIifying tllal ilCIll (i.e., driving or lifting. ctl.',) as imponant and 11101'\..' highly i1\lj'h.lircd allows for indiddualizcd ~oal sClting ill Ihl' l'l'hahilit;lliOIl pl;lll of managcmcnt. St'qt/('It/;al re,\·rin,::. SL'rial tt:,,,aing. at appropriate illlt:rv.lb (i.e .. weekly for acutc l·OIHlitioIlS. biweekly for chronil' cases) allo\\"~ for ongoing evaluation or progress. Puwiding feedhack to the patient C
Mode of Applic'Jtioll Douor-ollly. Patients Illay lill out a \";lriet)' of forms. the r~ sulh of which may neva he disdo...cd to thelll. This pnlL'licl". is suiwble Ii-x l'ohort rcsl'..m.:h. ill which some level of palicill blinding is useful to reduce bias ill sclf-n:p~,rling. DoC/or plus PllI;CI/{ .I(>clllwd.:. Ongoing n.:suhs_ especially in the form of simple !\crial C()lllP~ll"isons (i.e .. "Your pain level is 50% reduce,!"·'. arc provided 10 the patil'llt for,lllotivation
Patient Care Timing

Application

• MeasufCs of post-treatment

• Doctor-only • Doctor plus patient feedback • Doctor plus palienl plus staff

outcome • Measures 01 ongoing

improvement

m----....- --,---------------------------------------'ri

Iv ~ I,'

.P

"

I ' , ...... ~- 1I'lIt::.

CONCLUSION As r~habilitalion pro~rams develop and expand within chirojlmctk. a corresponding need ~lriscs 10 document both the

progress of the pmit.:JH and the outcome of the care pro\'idcd,t'~·S6

regardless of its spccilic components. The instruments discussed in this c1mptcr will hdp lhe modem chiropraclor meet the chalk'ngcs of outcome ;lSSCSSl11cnt. REFEHEi'I'CE.."i I.

Valli.~ "DiC

I\kHugh

s: Jllrl~'''''s

hehavior: C'h:dkllgin,!; Ihl.: lIlcdiC;lllllOOCI.

HUlllan.: ~·h:d . \::~. !Y:\'7

2.

En~d

GL: The need f(l(;l new medic;,1 nltl(kl: r\ Ch;lllclll;C for biomedi-

cine. Sdcllcl'

l ~

-iJ

~

I

~~

i , ~

~

I, !

i~

I

I

I

I

iI

I, I ~

i

196:1~'J.

!y77.

3. Wadddl G: A neW dini\:JI llltldd for the tr,;-;lIl1lcn\ of low hack p;lin. Spine 12:632. 19X7. 4. Frc)' WD: FUnCli(ln;l! :t~"'e~~l1lenl in lhc 'SOs: A conccplU:l1 cnigm'l, 01 technic:11 chalkll!;c. In lhlflCm liS, Fuhrer ~'1J (cd!'): FUI1I:tion:t1 As· SC~SmC111 in Rl'h:ltJililalit'll. lbhimorc. !';lUl Brooks, 1984. .'i. Forer SK: Flln~li{lnal :t~~C"'Sl1lCIll inslnullclII" in nH:dical rch<Jhilil<Jlioll. J Or~ani1.Olti()Il:l1 Rchahil [vOlluOltOrs 2:29, 1982. (l. Willi:llll.~ RCA. JOhll~101l ~1. Willi." l.A, CI al: Disahility: A model :md lIlCa~UrClllclll h:chniqul:. Br J lin.;" S(lC ~'kd JO:71, 1916. 7. Gallin RS. GiwlI C\\': The COllCo:jll :lIld dassilicatiOIl of disability in hC'lllh inlcrvJcw sun'cy", Inquiry D:J95, 1976. S. Harfl\:r A<;. H;u1lCr [),\. L:1l11l1cn U. ct al: Symptolllsof illlpainllcm. dis· ability and llilndic:lp in low h:Jck p;lin: A taxonomy. Pain 50:189.1992. 9. r..1 cchanic D. Volkhan EH: Illness behavior and medic:!1 di:lgllO.~i~. J Health HUlll Beh:!\' 1:86. 1960. 10. Pilowsky I: Anllorma! iIlne,." bchavior. Br J ~lcd PsychoI42:3J7. 1969. II. Vcmon H: Chiropr.lctic: .-\ model of incorporaling the iIIncss heh;wior mooel in thc management of l\lW back pain p:lllenl.... J Manipulativc Physiol Thcr 1..1:.'19. 1991. 12. Vcrnon HT: Applying re~carch·b'l~d ;)"SC~!iments Qr pain :md lo.. ~ of function 10 tht.' i!'~tJe of developing s1:Indards of COlrc in chiropractic. J ChiroTt.'<"h 2:1~1. 1990. I .1. Loeser J(): COIKCptS of pOlin. In Stanton HM. Bo.. . !' RA (cds): Chronic Low (hick POlin. New York. Raven Press, 198~. I.... Mclzack R: The I'uzzk of Pain. New York. Basic Books. 197:\. 15. Koran LM: Reliahility of clinical mcthods, data. and judglllcnt~. N Engl J Meil 293:(,.;2. 1975. 16. Waddell G. ~hin CJ. Morris E.w, ct al: Nonnality and rcliabilil)' in clinical asse...sTllcn! of backache. Br r-.led J 284: 1519. 1982. 17. Nelson MA. Alkn P. C1:HllP SE, el al: Rdiabilil)' ami reprtxIudbililY of clinical finuinp ill low back pain. Spine 4:(J7. 1971). IS. H.lIlsol1 DT. Ayres JR: Chiropr.lclit· t1utcomc mea.~ures. J Chiro Tech 3:53, 1991. J 9. [kyo RA: i\k:lsuring l!le funCli(lnal stalu~ of p:llieuts with low back pain. Arch Ph)'s Mcd Rchabil 69: IO.J4. 198~. 20. Torgerson WS: Theo(\- and Methods of Scalill2. Ncw York. ~kGra\\'-Hill. 19;'iS. . ~ 21. McDowcll!. Ncwell C: ~kasuring Health: a Guide In ROllin!;. Scale... and Qllcstionnairl's. New Y(lrk: O.dord Press. 1987. ~2. Bennell AE. Rilchie K: Qucslionll;lin,:.~ in i\lcdkillC: A Guidc 10 Their Dcsign .lIld Usc. London. Oxford Univcrsit)' Press. 1975. 2.1. Fordycc WE: Beha\'ioral ~lclhods in Chronic Pain and Illness. 51. Louis, CV Mosby. 1976. 24. Bradhurn NM. Sudman S. Blair E. Cl .11: Que~li(lll lhrt=at and rt=sp<m"c hias. Public Opiniun Q .J2:221. 1978. 25. Philips RB: 111e challenge of proving lhe cfficacy of chiropraclie: Plat:coo. Hawlhorlle and Pygmalioll effccts in rcscarch. ACA J Chiro 20:30, 19S~. 26. Cronbaeh U: E!iOSCllli'lls of Ps)'cho!Ufic,11 ·lCsling. 3rd Ed, New Yt)rk. Harper, 1970. 27. Keating J. Ikrg:llI:lIln T. Jacoh.~ G: Inlcr-~xailliner rdiabilily of cighl cvaluati\'c dimensions (If lumbar scgmcntal :lbnormality. J M:tnipubti,·c Ph)'.~iol Th~r 1.1:-163. 19~)(J.

M

rNA"" 1IIIUNt:H'::;

MANUAL

28. Vemon HT. Mior 5: 1llc neck disabilil), indc),: A slody of rcli:lhility and \·ali,Iity. J J\.'lanipul'l\i\'c Physiol TIlcr 14:409, 1991. 29. Guyal! G. Walt..:r S, Nunllan G: Mca...uring changc ovcr lim..:: Ass:.=.ssing u.~dulne ...s of cV:llu'llion inslrul1lCnl.". J Chronic Di$ .JO: 171. 19X7. 30. Bombardier C, Tugwell P: McdlOdologica! considerations in fum:lion:ll assessment. J Rhcumatol 14(Suppl 15):(1. 1981. 31. Kirsdmer H, Guy:m G: A IlIclhndologic:lI fralllcwnrk fm ils~cssing hcalth indices. J Olronic Dis 38:27. 1985. .12. Kl'-dc K1>: 'nlc pain chan. L... ncet 2:(1, 194M. JJ. 1\!.lrgl)lis RH. Chihn:llt IT. T;dr RC: ·I\.. st·rl'l";~;l n:!i::bilil}" Ill' lh~' p;d;, drawing. inslfUlllcnt. Pain n:49, 19Htt :,\-I. Marg.olis Ril. Tail RC. Krause SJ: R'l1ing !'ysh~m for usc with p:ttielll p:lin drawings. Pain 2·+:57, 1%6. ;\5. Tail RC. Chibn'lll n. Margolis RB: P'lin C:(lcnt: RelaliOlll' Wilh psycho· It1gic:!1 stme. polin sc\'crity, pain histnry anu uisability. Pain 41 :295. 1990. 36. R:lIl.~fmd BV, Caims D. Mooney V: 'n,C pain umwing :1S .m aid 10 PS)·· dlUlugical c\'aluation of paliellts with low hack pain. Spine I: 127, ItJ76. ;\7. Uden A. Hstrom M. Bcrgcnudd H: P.lin dr:!wings in chronie hack pain. Spinc 13:389, 1988. J8. I-luskisson cC: r-,·1t.'asurelllClll "fpain. LUlcc, 2:127, 197..1. 39. RC:lding Ac: CompOlrison (If pain ralill~ scales. J Psychosolll Re... 2J: 1/9. 1980. .JO. Ohllhaus EE. Adter R: Melhouologkal prohkms inlhc lI1e'l... urcIllClll.~)r pain: A c(Jl\lparisol1 between the vcrp:l1 r.ltil1t: scale and the visual 'lIla· loguc scale. I);lin 1:379. 1975. 41. Duncan Gil. Bu.shndl MC, Lwignc GJ: CornpOlri:.:on of verbal ;llid ,·i· !'ua1 analog.ue scales (or mcasuring. lhe il1lCllSity and unp!c;\s:tlllncss {)f cxperimental pain. Pain 37:295. 191'19. 42. Jensen MP. Kamly p. Bravcr S: 11,c meOlsurC1\lcnl (If "lini":11 pain inlen· ~ity: A comparison o( six methods. fl"in 21: 117. 19$6. .J3. Downie WW. Leatham PA, Rhim.l VM. ct .11: StuJies with pOlin r:ltin;; scales. Ann Rheum Dis ~1::n8. 197X. 44 Huskisson EC: Mea....urement Ilf pOlin. J Rhcum:11(I1 9:7(lloi. 19X2. .J5. Husldsson EC: Visual :lIlalll~ue sl·a!c!'. In Md/.al.:k R (cd): P'lin Mea~uremcnt :HIlI A~sc'"melll. New York. 'Raven Prcs!'. 1910. 4(1. Dixon JS. Bird tit\: ReprodUl...ihiliIY ailing" Ilh'nt \-....nkal visual ana· logue »Calc. Alln Rheullll)i.~ .JfI:R7. 19HI. 47. Scott J. Huskisson EC: Verticalm 1I\)ri7.(1I1I;11 \'i~ual ;mall1gue scales. Ann Rheum Dis J8:560. 1979. 48. Ma.'( .....ctl C: Scn...iti\'it)' and a1.:curm:y of Ihe \'isual all;JlllplC s{·a!c. Br J Clin Pharlllaeol (d5. 197R. 49. Seem J. Huski!'s(lll EC: Accur
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CHAPTER 4

PAIN AND DISABILITY QUESTIDNNAIRES IN CHIROPRACTIC REHABILITATION

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:IS lho.: s...nSUf)· comjlnno.:nl of hcad;l.:h~· pain. 1k;lIl:ldl': : I'~ IS. IIJS I. <:1 al: 111.... OS\W~lI~ I.,\W Had, 1';lil1

63. Fairh;l1lk JCT. Couper J. Davio.:s JB. ludcx. I'hysiotho.:r:apy 66:271. 1%0.

Ruland t-.'" Morris R: A study of th..: nJllIr.11 hiSln Ill' r;l1n h.... ha\'il)r in low b:u.:k p:lin palicol\ls durin~ phy:-kal cX:lIuinatiun. 1';1111 ~n:~'it). It)X4.

:-.1. Pil"w:-"~ 1. SI'..·IKC NO: 1';lil1 ;lml 1I1tl':~~ hdl;,,·i,lr: ..\ t.:umpaf;lli\·c slUd\". J 1'.~ydll''''lIIlk~ ~O:IJI. 1<)76. . -::.. l'illl'\.~"~ I. Sl'l·n..:.... Nt>: ,\I:lIllltd f"1 lh' Illtt~'" l\,,:h:I\·ltlr Q\lco~ti(1l1n;\irc OBC)). :ull Ell. Addaitk. AIISlra!l;I: L·nn .... r:-ll}· uf :\ddaitk. 19S.~. t.:1l111l'ari~(ln ,'Il")~l\ili\'c lll~':hllrcs ill Inw 1':I..:k p:lin: SI:IIl~II~·.11 ,trtKlllrC ;tnt! dinicli \:=Iidil\' ;11 initial ;1':-CSSlllCIll. I'':lin .1(,:~:n. !,JIlI

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l'ilo\\":-k~ I. Ch:q'l1l;1ll CR. lh'lli c';1 JJ !':Iill. do.:Pl\·~~itl!l :lI\d illl\\.'~'; b..:· 11;\l"i"r ill ;I P:\l1l dini.: p'lplllatillil. I',llll -l: I:-\:;-. l'n7. W;lddcll (i.I'lllll\,ky I. BlInd t'.... IR: CI:lli,·:tl a~"~',~~I1\':111 :Illd illl ...ql1.:t:llillll abnpl'l1l:11 illll"" h.:ha\'illr in 101, 1'.,.. " paill. 1':lill ,,1):-11, IIlX'J. W;ultkll G. \J..:Cull~lCh J:\. KUtIlm.-l E. ~'I al: N'lnnr~:mil· phy... il·al .. i~ns inltlw had.. p:nn. Spinc 5:117. I'JSU. Ikr~ll..:r:-'1. n,'hhill RA. I'o((:lfd WE..:I al: The Sidn..:"" 11111':1\.'1 !'r(llil..: \'alill:uillll ,,1';( he:lhh sial us 1ll :I~lIr..: \1.:11 Clr.... 1J::'I7. 197(1. Ikr~IKr t\1. llllbbilt R,\, Kr.... s.~ ·h. ~'l .11: '111": Sickll~· ...s.iill[1act I'rnlik: :\ etlllc....lllll:l1 t"llfllllllalillll ;\mllllcolh(lt.!llh,::y for Ih~' d':l'dupmclIlllf a hcoahh ~1altlS tlll~·'II\llln;li,~·. lin J I kalth Sa, h:}I)Y. I InCl.

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(17. JcIl~CIlIU. llr:.Jdk)· LA. Linton 5J: \'alidatioll (If:1II \lh:-.:n;ltiuII m,,:thtld of pain a:"s.....~slIlcnl in non·chrunil' h:ld: pain. Pain .31J::to'!. 19S1). £IS. Triano JJ. SchultJ. A[J: Corrd:nion or" ohjeclh''': 1Il":':I.~ur.... ~ "I' trunk lIIutinll and muscle funClion wilh low h:ld disahility r:llil\~~. Spino.: 12:5C,1. 1987.

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69. Hsieh CJ. Phillips RB. Adams AU. ct al: FlIllclilln:lI ("IUI;:OI1\CS of low b':lck pain; COlllp"rison of four treatment ~roIlP,~ in a r;ml!ol1\ll.o.:d cun· trolled lrial. J Manipulative Ph}'siol Ther 15:4. 199~. 70, Tait Rc' I'tlilard CA. ~·targolis Ril . ..:t al: ·IllC Pain Di,ability Imk... : Psychometric and v,didil)' data. Arch Phy~ Med Rch:lbiI6S:-l3S. 1987. 71. Tail RC, Chibnall JT. Kr:1USC s: 'nK' P':lin Di.~:lhi1iIY Illd~": P~ych(llll~'lrk properties. Pain 40:171. 1990. 72, Lcavin F. Garron DC: Validil)" (If:l Bal'k P;lin C1a~...iliC.lIl(ln St.:;lk ;UlIilll¥ p
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IIcrgn.:r ;\1. B\ll-ohiu R,\. Clrt..:r WH, ~·t :11: 111...• Sickn.......s Illlp;lt.:1 Pwlik: Lkvcloplll.... llt ;>lld tin;ll r...."isillllt'l a h'::lhh sl:II11S HlC:I.~uro.:. tkallh Car...• PJ:7R7, [l)S l.

S3. Pollard WE. Bobbill RA. B':I'::nt::T \1. \.'1 :11: Tho.: Skkl\c~s 11lIP:II:t I'wlik: Reliability of a h'::llih sl;\l\1S l1lC;',lIr,', \1..:d ell\: 1-1: 14(1. 1')7(1. R-l, D"'yl\ J{,\: C(ll1lp:lI':lti\"~' \":Ilidity 1'1' th.: Sidll~'SS llllp;ltt Prolik :\I1d shmlcor ~c:lk, fur fllll...·li,lll:11 a...:-...·."m.::1l in It.\\, "a~·k pain. Spin..: II :'J." 1. 19X6. S5. Mill,lrd RW: ..\ crillt:al r~" i.... w Ill' qll·:~tlolln;lir...." f1lr ;I"e... ~ill~ p;lin-I''''lat....d disahility, J Genlp lh·!I:lh 1:~S\J. 1991. S6. Bomb:lnlkr C. TlI~wdl P: 1\klhlltl"I,,~jclll·\,Il~i\kr:lliun' ill rtlll~·li,'nal as~ .... ~!'m..:nl. J RhcullI:lllJ! 1.I(Suppl !:":Il. 11J:'\7.

Outcomes Assessment in the Small Private Practice CRAIG LIE BENSON and JEFF OSLANCE

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0 Determining. th~ most cosl-clTcCliw IrC.llmclll {kp~nds on appropriate lllcasur~-!.!l~L~).r tr.catlll~lli resulls. Sut.'h measurcment is called ouTcomes lIS.H'SSllll'lIf. The dcvc!()pnlcni·o-r outCOIllC "ssessmcnt tools for -objccti vc measurement of a p: Although quantification of functional deficits is the goal. this attempt is only in its infancy. Many physiologic paramctcrs or thc musculoskeletal system C~lJlnol be realislically measured quantifi'lbly. Intersegmental
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MEASUREMENT OF PAIN, DISABILITY, AND PSYCHOSOCIAL STATUS Rchabiliti.llion begins with a Ihorough history from the p;;Jliclll. The history should identify various features about thc pain. occupation. lifestyle, and psychosocial status or Ihe in~ divid\lal. Cerlain objeclive lools that complemcnt the traditional history.taking process arc shown in Table 5.1. \Vaddclrs signs of abnormal illness bcha\'ior arc important in paticnt evaluation. The presence of three of five of Ihese signs is signifk:antly correlated with dis~lbility.l~ Supcrlicial or l1ollal1atomic tenderness: WiJL':;pr~;\d sensitivity to ligll1 low.:h in Ih~ lumb"r region and pain rckm:d 10 olher ~rcas. "ud~l..Qr..x. ~;U;fllnl. or pclvi~. Silllllilltior;: ;\.xial ](~jing (ligi"lt prc.\surc 10 tilL' ::kull) ~h(lllld lHH ~i~lljtic;llllly incrca~c low h;lI.:k paill~ Passive Hlt:l1i~)l) of lhe shou!· ders and pelvis together in a slallding--paticllt ~hl1llld not rc:prodllCl~ low b:lck pain.:/Oistractions: Differencc of 40 tort5'" between th~ ~~JpillC and seal<.:d straight leg raising Icst~. ncgional dislurlmnct.'s: SCll~ory or m(llm t1i:'lurhancc ("giving way") th'll is not ncurologically correlated. Ovcrrc~lc.lion: 11l~lprropri~llt: ovcrrcaelion. such a:, ~uartji!lg. limping. rubbing the affcclcd .In;a. bradng (lllc~c1f. !=ril\l:\cing. or sigh. ing. arc all sigll~ of illncs:-; hehavior.

Wernecke el al found thallhesc bchavioml signs could be il11· proved in individuals in a phy:-ic:.i1 retwbilitation progr:,ull.1.l Measuring pain intensity and flll1ctionalloss as a result of pain
73

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Psychosocial Beck.~·

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LifestylclOisability Osweslry\~'

Neck Disability Index'(.·

MiVion" Vermonl'~

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Dallas Pain OueSlionnaire:;>Q' Sickness Impact Prolile~' n Pain Disability Index;~ Job Dissatistaclion

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ferred pain). Finally. it helps to identify signs of neuropathic pail1 (hyperalgesia 10 non-noxious.stimuli).

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FUNCTIONAL CAPACITY EVALUATION

A key to successful rehabilitation of the musculoskeletal systcm is funclional assessment. In contrast to the clinical examination. this cvaluation is not important until thc patient is "out" of thc acute episodc. As soon ;IS a paticnt cmcrges from lhe :Jcute st<1ges of an injury. objective mcasurement of functional Olj{comes is nccessarj. 111is infonnation gives the daclor. patient. and third pany payor means by which to communicatc the status of the patient and to identify the goals of c'lrc. The chief purpose of the functional capacity evaluation (FeE) is 10 demonstrate objectively an individual's level of impairment as it relates (0 both pain and disability.)'·.l~ This cViJluation gives objective infonnation to the health care provider who can then rationally prescribe treatment aild then monitor its results. In addition. it provides (he patient with ohjectivc feedback on how their injury and/or pain aff~cts their ability to perform normal activities. as well a.c; an objectivc way to see their progress. Finally. the FeE provides the third party payor with objective. quantifiable evidence of imp
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Table.~

Tissue Tenderness Grading

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Grade Grade Grade Grade Grade

o-no tenderness I-tenderness with no physical response It-tenderness with grimace and/or flinch III-tenderness with withdrawal (+Jump sign) IV-wilhdrawallo non-noxious stimuli (i.e.. super1icial palpation. pin prick. gentle percussion)'

'Adapted from Wolfe cl OIl...• and Hubbard el at:>'> lin noninjurod lissue, a sign of neuropathic pain.

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The "~pons medicinc" appro;lt..-h. which l1lcaSUfe~ fulH.:tion;1! impairmcll\ and lI:'\CS active cx..:rdsc to rdl:lbilit:lte in· jured ti'slIcs. is rCl,"ognizcd as the "sl:llldanJ of c;lrc" for :'\ofl tisslIl' injuries.:· t:.;,. This ,Klive approach is bel1er suit..:d 10 ;ll~ Ic\'i;ltill~ p:lill, (ulllpkiing sofl tissll~ he:lling. and pn:\"l:llIing

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Thc FeE shoultl be m.lI1datory for any patient slill ..:xpericlI(ill); p,lin after 6 to 7 weeks (st:c Chapter 21).1 Thc FCE is (,;ompo~cJ of me;,tsurable functional tests and compk'ments previollsly described questionnain.:.s iscc ClmpICl" -l). The fUlIctional tests mcasure nexibility. strcngth .. ·.mortlinmioll. cntlm'lll(c. ;'lcrobic capacity, posture, and balance. The FeE idclHifies intrinsic jmpairmenls in the individual. Oflell. the extrinsic dClTl.and~ of the work environillent arc thl: o\'l:r\oadin.g or injurious f..tctor. A work capacity e\'alua~ lioll (WeE) or job i.lllulysis Illay be required to identify such potl:llli,11 sources of repclitive overload or injury. The combination of an F"CE, a job "lll,i1ysis. and a WCE will help to idcl1~ lify rctunHo-work outcomes and spccilic crgollomic and excn.'ise instructions for safe sining. lifting. or other repetitive tasks in lhe workpl
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i Table 5.3. Critical Factors for Functional Tests Valid/relevant

Normative database

Reliable/reproducible Safe

Cost! practicality

75

Table 5.4. Key Aspects of Musculoskeletal Function Static (Maintenance 01 Posture)

Posture Balance Dynamic (Production and Control of Movement)

Mobility.1lexibilily Strength Coordination Endurance Cardiovascul~r

lilness

normal fum:tion,"" Using elcctromyogmphic (EMG) evaluation during isometric trunk extension, they demonstrated dccoupling or asymmelric lumbar paraspinaf muscular activity in pmients with low back pain who were considered nonnal on dynamomelric tcsts. This dccoupling was also useful in differentiating pain and noupain subjects. The study by Grabiner and colleagues points out th"11 musculoskeletal function involves coordination as wcll as strength during performance of a specific task. Simply because u patient passes a battcry of technologically advanced tests docs not necessarily mcan their spinal funclion is normal. The EMG tcst not only points out the limitations of hightechnology dynamomctric testing of muscle strength and endurance. but suggests that overl}' harsh criticism of 100.,.'er technology evaluations of coordination may be unjustified. As Lcwit puts it ..... in many fields of medicine the importance of changes in function is now well recognized. whereas in (he motor system.. where function is paramount. this fundamental aspect is rarely considered. However, the functioning of the locomotor system is extremely complex, ... and diagnosis of disturbed function is a highly sophisticated proceeding carried out. ns it wcre. in a clinical no mall's I:.lnd..... l In the Presidential Address to (he Cervical Spine Research Society Annu.i1 Meeting in Decembcr of 1991. LaRocca criticized his colleagues for jumping to a psychologic dingnosis when they cannot Hod a structUl:.11 C<\llse for a patient's persistent pain: ..... The error here is the autornmic leap to psychology. It assumes that all organic factors have been considcredo when in reality the clinician's npprcciation or the complexity of such factors in often severely limited.'·~~ Newton and \Vaddell said, "There is no convincing evidence Ih;,1t isokinetic or any other iso-measure has greate::r clinicnl utility in the paticnt with low back pain than either clinical evnluation of physical imp
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In 1987. the NIOSH Low Back Alias idclltilicd 19 tests with signilic.79 cocflicicnts for interclass corn.:latioll cocf1iciCllt [ICCI j.W.I,(, ;vloffroid and colleagues round 111;11 ~3 or 53 NIOSH tests could discriminate between subjt.'cls with and without ]0\\" back pain."'.(Thcy also found that the SC\'l;l1 .str~lngcsUe.s.1::i.to

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Fig. 5.2. Dorsolumbar extension.

eluded. "The non-(I\"namomctric tests arestillJJsel"td ineJinical practice in ~Jih~~i~·;~h;I;·I~~~;·of aecur;!tc ll~~';~ ell' ~lrcllgth cyaluatil)1l lllcthods,""s In allother stlld~, i-brdillg and l.'llllcaguc\ found a battery oLll)\\' tcchllolog~ lc"ts safe. rl.'li;lblc. and valid I'll[' as"c""ing physical funetil lllin.:;. in patient..; with chronic pain,li! Alaranla and co-workl..'r.; ~hnwed t"eli;lbilily and cswhli;-;hcd a normtltin.; databaSL' fllt" h\\\ lcch-

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Fig. 5.1 Dorso·lumQar flexion. "Inclinometer used is the Duater from JTectl (324 West 1120, North American Fork, UT 84003).

110h'S)" les!'> on more than 500 indiYiduals,7! ."\"sessing impairmcnt i.., crucial to rating t11'..' k\ ~'1 \.'r per\.'1..'111 Ill" illlp;!innclIl ~\ patient !J,IS surfered. II is al.;,' lill: ollly

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\)hjc,.:II\ ..· way 10 ~Il()w pro~r~ss and 10 dOl'lIlllCnl the Ilt.:'cd for (unhl'r
:lbsolulcly l'ssl.'lltial ill cases il\\'oh"ing Illl'di\"('k'~al challL'llfc. hut it is also IlSL'fuIIO doculllent ;i11 in,mall,,';.' ,:Jaillls. whit'lt arc c:oming umkr greater and grc:.Hcr SLTllllll~ :\s standards af\,,' e1ucidatcd. these industries will rdy till 1111l\;':[";;l1 OUICOlllL'S ;lssCssmcnl tl!L';\,.U: ..'UlC:llt

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• Sensors arc 7.crocd and paticlH is requested to ncx maximally. the new angle is recorded ..::. If hanlstrings afC t"ight. patient may b~nd knccs"'~ _ Note: if lesser of wai~glaisc._:.!.1J:&~Sexceeds trunk ncx.ioll, thell test is invalid:q •

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77

(Fig. 5,:!)

Starting position is the Silme as for tlexioll P.uicJ11 is requested to extcnd maxim'llly. and the angle is rCL'ordt.:d

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Lumbar Spine Ral/ge oj ~/otiol/ .,,/lil/etc jh'xihi!ity) (Fig. 5. I)

P~lticllt

st:lnds with knccs straight ,lIld feet slightly apan S;.'n~ors arc pl~lL'cd on thc sacral apex and TI 2 spinous proct:ss (lise skin marking pencil) -':\ \ hk,,:.. ~·: ,"''''llI,:n.

~:-:

~,]{I

ul',I.,I...,I"'\:""lrl,llillrl r,.rll" un lit... hmcliunal C:lpKily C\':.h/:lliun h~' S.

,,'o>ll:Ihk fr'"11 xon""'}.'-72fi.'>.

Starting position is lhe Same ;,IS for flexion Palienl is requested to side bend maximally to the right/left To minimize rotation. patient is inslructed to slide fingers along the side of their'leg Angle is recorded QI/lIllt ificat iOIl

Ohjf.'l:ti\l·. Quantifiable Tests '

I-'I('X;(lI; / erector

Lateral flexio/l (Fig. 5.3)

Final angles arc recorded Normal vaILlcs~·1 Trunk nexion, 60° v'" Trunk extension. 25°""--Trunk lateral flexion. 25"

v

PIIl/)OSe

Screening tests for erector spin.ac (ncxiotl) or quadratus lumborum (Iateml flexion) tightness Screcning tcst for lumbar joint stiffness

Fig. 5.3. Dorsolumbar lateral flexion.

Ht:HAtjILIIAIIUN Ur I HI:.

TllOradc Spine Range of J\1otioll (Flcx;Ol1IExtcllsitm) (Fig. 5.4) • Patient swnds with knees straight and li..'t:l slightly apan .:...-Scnsors
l

i 1

1 I

~~INl:.:

A PRACTITIONER'S MANUAL

QuwHijinlli(In The 1\\'0 ;lngh::s im: l'lllllbinl'd for t\lI;t1 lllC;lSlln":1l1l'lll Norll1;l1 ,";l!ue. (l!J"~:

SEATED

Trunk Rotatioll Rauge oj IHotitm (Fig. 5.5) Patit.'01 is sCOIh::d slfOlddling the tahle Paticnt \Urns shoulders and torso as far as possihle while avoiding trunk lkxioll or cXlCnsion (l11ay lise Slid.; 11('~ hind back 10 hdp \'isllali~c asymmetry)

If asymllletry of trunk rotation is present If less Ihan 9ft' of trunk rotation is possible

II

Qlf(llltUic'{lrhJlI

Possihle ill st"l1dill~ position \vith tfunk Ocxcd as tiL" scribed in A,M.A. Guic.1l::lines~~

QlIal UiCllliOJI • Pasvfail (:::'.Fail if less tll'lll 90° of (ruJl_~ rotation is possihk • If asymmetry is prcsc·,li· ... -,._, -.-..-~ PlII'I1('Sl'

I

Pku.::c one sensor aL!:.L and the olher on the {)('..:ipUI (or strap to head with" Velcro slntp) Patient sits creel Patient i'i requested to flex neck maximally and ;lIlglc is recorded Patient is requested to extend neck m,lximally and angle is recorded

I

Il

IAI/enl! Flexio/l (Fig, 5.7)

Patient and scn~t1r po~ition :->.II1lC as'ncxionfcX1L'IlS1t1!l Patient i~ instructeJ to side-bend nmximally to the IdI and right: angles arc recorded

1 I

Rotatioll (Fig. 5.R)

0'"fn A.M.A. tests. paticnLis_-supilll;;

g~'!Vily_ indin~lIllL'h:r

i~~15!-=.d~

Fig. 5.4. Thoracic lIexionfextension.

• P..l1iCIll TOWles hl.:'ad flllly and angle is rccordl.:'d

t, 'd

~

~--------------------------,~i

~

I

)

"

To itlcntify if ,Isylmnctrk tfUllk rot:Ltioll lllol1ilily is presellt. indicating probable thontcolumbar joint dys~ function een-leal Spine Rauge of /\!o!iou ~V,!.f,.\ F!ex;oIlIExJ('II.\ir", (Fig. 5.6)

I

I

j

Note

1

1

,,.

111;\:\-

if1lally. the new an~k is n:cordcd SCIl:,orS an.:: zeroed :!gain after patient r::lt1rns to upri~h: poswrc
I

.......

J

""AP i ER 5 : OUTCOMES ASSESSMENT IN THE SMALL PRIVATE PRACTICE

79

I.atcr:ll Ikx ion 45' Rotatioll ~S·'

I

i

Fig. 5.5. Trunk rotation.

Quail/ /fica! it)1/

Final angles me rcconkd Norll1:d

\'altlc~"~

Fkxioll 51l" Extension 7(1"' Fig. 5.6. Cer.ical fJexion/eXlen$ion.

---_ ...__._-_.-...

uv REHAt;llIIAi ION OF THE SPINE: A PRACTITIONER'S M .., \NU ..\ L ~-----------==---=._----_._--

Sl'lI"',>, \.. ,.I.....lh.:d 01:\ tahk :llId tlll'n pl,II.:~d (Ill prll,illl:d d>t.d l.·lId Il( II,,: fl'lIll1l'

(If

Wll11,'

h(lldill~

Ill'",.! knee toward ch.:st. dOC!llr :ll'plil,,''-

pa""'l\l' t1n:qm,,''-''tlr\..' Itllhc IC~ll'd lhigh... I\dlll\.: ;11l~k i, I\·l't'i',l...:d \\,jlh i~li~h p;l .... i\l·l~ l'~ll'1Hk·d,

Ihi::h di ... t.d

,\!ld IlIl'1\ h'l'tlll! klll'l'

,'lid

or libi:t

r':·'.t'l'o int:lilltlllll..'I,·r till .. ,·Ihtll' 1111

"ll~k h~ pl:Kill~

)

Fig. 5.7, Cervical laleral flexion,

') SUPINE

flip Flexor (PSOfiS [Fig. 5.9j,Recllts FemQris lFiA. 5.101> Flexibilit), Test .,I1.H.-I~_"I_"7.(,CJ.(..."",

>,)

ModUi<'c/

,"

71101110...

Tc,\"!

table is r~qtlircd for accurate 11l~
IJ

firm

P~ltic01 sils at edge of

Fig. 5,6, Cervical rotalion,

CHAPTER 5: OUTCOMES ASSESSMENT IN THE SMALL PRIVATE PRACTICE

81

Norll1 .. t1,II, II,"

Hip cXh:n,iOll - lO e Knct' lk.\i.ioll Y()'"

, Identify Identify

/,\

pSO;I'- ... horlcnillg

rlTIU, fcmori~

shnrlL'lling {lltlrln:d i:-

till

kill'\.'

lkxinnl

,,

If hip llcxcs without klll'L' extensioll

i 0 ! !: 0 I," () !

I, n "

lhi~h ahdlll.:lipll

If hip Hexes wilh kllL"c cXh:nsiull (reCIll-> femoris) Ir hip flext . . with thigh ahthlt:lioll (TFL I No(('

1

\Vang ct al~~ (est th..: p:,oas hy ~xll.'I1(.Iing thL' hip \\"lJih.. kL'l'pill g the knec cXlcmled. They lllcasurc the 1\':C!U:, fCllloris hy e'xlending the hip with the knl,.'l,.' bent al a 90' angle. For hOlh tests, they pl,lce Ihe inclinollll.'tL'r jll~t supcril1r 10 the p;lldlaL'. Straiglrt l.eg Rai.'(;' (flam.\"i,-iIlJ,: Flexibility J 'Fe..:t (Fig. 5,11 )JJ.J~.~I.~J.;
I, 0 i~

! iJ

Iq

Fig. 5.9. Hip extension and psoas.

I Ci '<""';>'

;~

1.11"

(psoas)

Patient lies supine on a linn tahle: Sl.'ll:'>llr is pl
rockill~ j,

apparent

QU(/l/lIjicm i{ J!I

Record angle of hip llcxiol\

Normal is 70 to 900J':."!.<" FlI!'f)().\'('

• Establish hamstring nl,.'xibility

Fig. 5.10. Reclus femoris. Q/({llrtijic(tl;(1/,

,', 'ii

(J

I {) ]1

':'".'

1;-

i

(~

i 'J" J

:"

i

,,

Hip ;Illgk is recorded
Fig. 5.11. Straight leg raise and hamstring.

REt'U;,~illlAl ION

OF - ... :: SfJIN!:.: A PRACTITIONEH"S MANUAL

PRONE

Knee Flexio/l «(}{ladrin'/ls) Flexibility (Nach/a,\ Tcsf)

(Fig.5.12)-I55li Patient i:-. 11]"(111':

\111

lahk

Doctor pla('l'~ ~\.'l1~or on mid·"l1in and .l-I.'n}l'~ 1\ I ~tl!LT nate position i..; Pil ankrior "hill ;lftcl' hl'ill~ II.'i"<'l'd 1(1 bottom of whk Dr dcsk) Patient's Klll..'l' i.. passin.:ly lk\l'd Angle is I1\C;l"url.'d at poinl .ill..,! herm\..' lumbar '1111ll' hl.'· gins to extend ur hip r;\iscs up Quail! ijicafioll

Angle of knee lkxioll is recorded Normal is 140 to 150"'~

Purpose • Measure flexibility of quadricl'ps lllusCleS flip Rotation Range of AJ()(i()fI~I•. I~',f,I, (Figs. .5.IJ and

5.14) Patient lies prone with IHllltl''-.tcd kg in and tested leg at ry' abduction Doctor firmly stabilizes pelvis

~()

abduL'liull

Patient's knee is placed in 90';> flexion so that sok faces the ceiling Sensor is placed midtibia (laterally for measuring external rotation and medially for internal rotation) and zeroed Doctor passively internally/externally rotates kg until opposite pelvis starts to move Angle is recorded

Quantification Angle of hip internal/external rotation is measured Nonnal~I,.Ol

38 to 4Y' internal rotation 35 to 45" external rotation

Purpose • To quantify hip internal/external rotation mobilit~ Fig. 5.13. Hip internal rotation.

Note

Fig. 5.12. Quadriceps.

A.I'v1.A. guidelincs test hip rotation whik patient i~ supinc. with kn;::e extell~ion and no pelvic stabilization"l May also be tC"lcd with patient scated~(,",q Supine test with hip and knee at 90" may be used to estimate mobility. Also allows for testing of hip capsule integrity (capwlar dysfunction manifests with pain in internal rotation in this posilion) Gastrocnemius Flexibility Test-1-1,-1~ (Fig. 5.15) Paticnt is supine \vith feet olT edge of tabk Sensor is zc!"o-.::d io vC'l"lical planc and lhl'n placed {)11 sok (11" !"pol

VI IM"- I

en

:J : UU II...oUMt:."

Foot is maximally dorsincxcJ. 11~;lking. :~i.lfC ~;,~ Pl::~ ~::: hcel fully (knl'l' is kcpt in eXlension)

Angle

!,

,

i~ Illea:-illfetl

~'lay a!:-ill hl'

• QUi.lnliry gaslrncl1cmius flexibility

I! I,

I I

Oil

011

Angle or dorsilkxiOIl is n.x:onkd

Normal is 25 to 30"

~ I

pmllc

QfltlUfijinl1 it"l

'I

I

(\1'

Palil..'nl is prone wilh kilt;\,: ht.'1ll hl 90" Sellsor is I.el'nl'u to horizontal pblll.: alld tlll'lI pl:ll"l'd sule of ('oot FooL is lllaxil\l;dly dmsilkxL'd. Ill
Qfu,t/riJkClt;t",

,I l

ll' .. h.:tl Wiih patll'IH "l;llldill~

Soleus Flexibility "['cst H.J~ (Fig. 3.1 (1)

Angle of dorsilkxion is recorded ~orl1lal is IOlt\ 15° .• 1

~

83

A::i::it:.::;::;Mt:.N I IN THE SMALL PRIVATE PRACTICE

II

Purpo,\'t.' '"'~'" <....J

• Quantify soleus nexibilily

Notc i~"

May also bc lcs[cd with paliclH 'tanding

-~.J

!I

Qualifiablc Functional Tcsts STANDING

I

One Leg Standing Te.~t~~·(II.t." (Fig. 5.11) P,aticl1t stands on Oll~ root with eyes opl'n Foot on raised leg is .al knct.: Ie\TI Arms arc relaxed al the side Patient n~5_galc on a point on wall P"ticl1t lhcn closes eyes and ;,Hlcmpts t\) m:tinlain hal-

D

am::c for 10 seconds QIUlfitijiC:lIIiOll

Record seconds until patient

lo~cs

hal;\Ill'('

Reaches out for stahility Touches foot 10 floor Slides supporling foot With forcl: rlatforl1l~" Pwpo.'iC

•.....0 entify need for proprioscnsory rc-education ·........--Scrccning test for gluteus medius weakn\.'ss Stand to Kneel (Lunge Coordillation) Test (Fig. 5.t8) Paticnt st:lnds with fect abOll! ~houldcr width apart Patient is instruclcd to perform a lunge Itl kneeling position One foot steps forward with knee lkxinf. to <,)C)o and back knee just touches nom Back should remain straight wilh ,Iflns a! Ihe side Qua1ltificatioll • NOlle. except wilh Chattanooga lumhar 1I1t1tion 11l0niIOf Fig. 5.14. Hip external rotation.

__..~

,

:-':.:'-,,'_.'_"_.-_'-_.'_'_'_"_'-=~:-":,,:~_.'.::.:'_.' :.:'":..:0:-'_.'_...:.:":.:,_.n.::.:c:.:n:-n:.:::v:.:,.:,:-,:.:,v~,,:.:~:.:n v:.:.::":-'M.::.:":.:U::M.::L

Fig. 5.15. Gastrocnemius.

QI(ll / ification

Patient should do a deep knee bend with their back straight to about 90"' of knee llcxion

Pass/fail

Positive tcst if patient flexes trunk while performing tcst Also note: Balance of forward fOOl Strength of quadriceps

QWl!lrijica tlon 71

Record number of repetitions patient can fX.'rform Alaranta ct al has published normative dm,llxlsc for different ages and genders. ~ I

Mobility of hip joint and flexibility of hip flexor" of back leg

Quolijicwioll Purpose

Pass/fail

Positive test if patient flexed their trunk or ..:annot reach 90'''> knee flexion

• Qualifiable tcst for balance, coordinmion. hip extension mobility, and quadriceps strength

Squat Strength/Coordination Test Mt •71 (Fig. 5.19) Patient stands with fcel about shoulder width apan and is instructed to perform a squat

No!e

If heels raise off floor (sokus tightness)

I I

I ,

!'lIr.!'! ":' ()U;tlili;thk l~·~t fllr h:l!:IlIL"\'. ,,','rdin;tlilili.• ;L!.!dn..: ql'" 'Irl·I\~lh. :'(Ik'Il'"

IkxihililY

SEATED .~

.J

l'a"/bil

S !loll!dcr .'\ htlll('riIJII Coordiuotio/l "/('Sl ~ I.'," \ Fi g. :'. ~111 Palil.,.'lll i, "l';l\...-d willi I..-'Ibm\ lh"l'd 1090 11' 1111lil llll-

1\I,ili\\' 11."1 if 'clpubr \.'k\;liil>1l or ftilalilill 11;lll'r:lllyt PIXllr... 111 lir,! .~(l !ll (lO"

W;Lllh.:d f\1\;llillll

P"lil-'lll

i", iU"lnh:h:d In

:-J{l\\"I~ :,hdlH,,:t :trll1

hh:lllify 1\1,,,,

llf

normal glcrll1hullh:r,d rhythm
;I!lk III \I\\'!"acliviIY or lIPP\.·r trilpl.:/.iu:- andlor k\':l1Or "\..';lpU\;1I': 111\1 ... d~"

Fig. 5.16. Soleus.

•••• "., ....... I , ..... ,~L..,l .... ''''MI'lVhL.

QIIlUltijin'titm • NOlle Quu/Uicarioll

'-"

Cir'lde I "hie to p;.·rforlll A. B. and C Grade II able to rL"rfOnll A ,l11d B Grade III abk 10 p..:rfOrill nnly A Gr'ltk IV unahlt.' iO perform A. B. or C

! I

Purpose

1

!

Evnlu..ltc lumbopt.'hic coordill~ltion and control Lower abdomin
i

I f;

I I $

I

II I~

I

~ --f~--~~!~~~~ -~~~ -.~~~

II ~

.~

) .i• ~

I i ·v

,

~

Ii x

?

.1 ~

t

}

Fig. 5.17. q4leg balance test.

..,'

I

iI

,

~~.~~~

SUPINE

\

'

Peb'ic Tilt (Supine '/look LyillJ:) (Figs. 5.21 and 5.22) Palicm is supine with kn~("s bellt I)(lt:ter plact.:s hand under lumbar Spill~ ,1111.1 instrut:ts patit.:nt to lirst arch. then llallen low back without r;lising bUllocks off the lable (A) Doc~or l1l:.ty cue movement ur offer counter resistancc to facilitatc coordination P.llicnt then asked 10 hold had l1:.lt (posterior pelvic tilt) while sliding legs to c:Hcnt!cd position (8)·\7 Pa\ielll then asked to mise bUlh legs while holding hack 1l;1l
Fig.

~,.18.

Lunge lest.

_

CHAPTER 5 : OUTCOMES ASSESSMENT IN THE SMALL PRIVATE PRACTICE

87

(]tutt/ ti li(·( I t i (11/ Alaranta lh:tcnnined a normative l1awbase for both genders and most age groups," Test is performed holding duwn both feet _md recording llumber of repctilions ulIlil f:lilurc.

QU(1I (tina ;(111

~

J

I I;

Pass/f;\il F;.til if unable [0 perform 10 repetitions without h~~b or )umh;\r spine rising off t'lble

~)

0

Pilr/u}se

• QU;'lI1tify rcctus 'lbdominus slrength/cndurancc and coordination

f)

i 0

Head/Neck Flexioll Strength/Coordination Test Jl:rA.7: (Fig, 5,24) Patient is supine and is instructed to bring chin to ctH~st

~" ~,

1

i

Back of head should be only I to 2 em off of table Overpressure may be added at end point

1)

I

()

Note·

<)

If chin juts forward during movement

I II

If shaking occurs during movement If chin jutting. or shaking occurs with ovcrpr6:,urc

'y

added

Ii f,

jJ

Qualllijicmion'll,n

,

! ~

,0

Strain gauge mny be used':: Record time p.uicnt can hold a position wilh head I em off the table and maintaining constant force of the h~ad into a pressure eufrll

() ~')

Fig. 5.19. Squat test.

Q lUll ijj("(ll io"

0

i

Pass/fail

()

I

Trunk Flexiun Coordinlltio/l (II/(/ Strength JI,f,ll.(,!(,I"',lI (Fig, 5,23) P;.lticnt is supine with knees bent. arms forward, across chest or behind neck (without pulling) DoclOr may cont_l<:1 palicrIl's hcels or pl
I .~

~

0

~~: ','

II

,

the palicm·s lumbar spine Paticl\l is instructed 10 perform posterior pdvic tilt and to raise trunk. up until scapulae ;.Jre off table and thCll hold for 2 seconcJs Paticlll shoulcJ hold pelvic lilt while lo\\:cring back lO (
'"

() "j

i fJ

.~

.~

i

0

~

0

';j

k

I ::J ~

.,<

~

!

To identify if nel:k nc,'(or weakness or incoordin:llil..'l1

If hecls rise orf tablc (posilive test) If Cimnnt maintain pelvic tilt (positive ICSt) If excessivc shaking m:curs If IK';1l1 i~ fonvaHlllt' trunk

Cl

L

i~

present

In particular. to identify if deep neck flexors art' weak ;'lIld sternocleidomastoid (SCM) muscle is overa('lj"c

Ste,.,wcleidomastoid Strength Test (Fig. 5.25) Patient is supine and is asked to wHite head to one side

Then to raise head lip while mainwining rotatif1n and

Note

II 0 ~i'i

Purpose

hold for 2 to 3 seconds

0

~ (J

"'t

Fail if chin juts forw;.srd during mo\'cmcnt Fail if cannot hold head just I to :2 elll ofT of tai,"lk but wiscs up further

NON!

If can reach full rotation If cannot maiI1lain rotation \vhih: lifting head if t.:;lOnot lift Ih.';I{!

' n... ' , ....... , .. , ' ..... , 'V'''( VI""

I Me ~t"INt:: A

PRACTITIONER'S MANUAL

A

B

'")

.,,

-,.'

i

)

c

Fig. 5.20. Shoulder abduction test. Correct (A and S, and

incorrect (C).

Qualltijintfioll

• None

• To idcntify wcakn.:-ss of SCt\'1 Illtlscks

Respiration Coordination Test ~l (Fig. 5.26) Supine patient is asked to take in a deep brc~lth

QlUlJjJicmion

Pass/fail Fail if cannot lift head or rnaiIHain head rotation Grading I-Normal I1~Hcad

i.. lifted. but without full rotation or il canl10t be mainwincd for 3 seconds

III~Hcad cannol

be lifted

) Note Doctor ob"ervcs for excessive chcSI breathing Also n(Jh~') hHeral chest excursion Note jf ~c:alel1c muscles arc visibly ~\l,:tivc durillf rt'spi· r;ltion

J

. . . . "1\,.... I tH

~ : UU Il,;UMES

ASSESSMENT IN THE SMALL PRIVATE PRACTICE

89

Gmcemric Tc.'i( •

NOlll'

(jlluIUi('(u;()/l Pa~~/f;lil

Fail

irdl~~t r;li . . c~

more [h;lll abdomen

1'111"/10.\'1'

'I'll idcntify bn:;tthing

prc~t:ncc

of paradoxic breathing (chest diaphragm)

predomillatc~ (I\'cr

SIDE LYING

(lOll

Hip t1bduc(ilm (Gluteus Medius, TFI.., QL) CoordillaTest ~l,(.(, (Fig. 5.27) Patiem side lying with lower knee nexcd and upper leg extcnded Pelvis placed in slightly umucked position

A

B Fig. 5.21. Pelvic tilt (hook lying). Posterior (A) and anterior (B).

A

Upper leg is raised into abduction and held for 2 seconds Note • If patient can raise leg :.. Shaking or twisting .~·......A~lX hin..flcxion or hip external rotation • Excessivc hip hiking • Posterior rotation of upper ilium Quantification • Only with dynamic electromyography Qualification Posslfoil Fail if cannot abduct leg without hip flexion. if foot mises less lhon 6 inches. if hip externally rolates. pelvis rotates. or hip hiking occurs

Isometric Te.'il Pre-position leg in abduction without flexion and ask pOlienl 10 hold leg for 5 seconds NOle If shaking occurs • Hip flexion, external rotation. pelvic rotation. or hip hiking (positive les!) Quantification • None Qualification • Passlfoil Purpose To identify coor~ination of hip abduction To identify tightncssJovcractivity of quadratus lurnborum (I;ip hiking)Cfe-D~9r fascia latae•..an~L_p_~O~l~ (hip flexion and external rotationj~ thigh adducwfS ~Iimitcd abduclion range). and pii-1fonnis (extemal rotation) To idenlify poor hip join( mobility (decreased cxtension) To identify weakness of gluteus medius

j Fig. 5,22. Double leg raise with posterior pelvic tilt. Correct (A) and incorrect (B).

.. ~

REHABILITATION OF THE SPINE: A PRACTITIONER·S MANUAL

Note If patient (all raise trunk If patit'nt twists b;l\:b\;mJ (recruiting. obliqul.': ahdollli-

I

nills ) Sh"lkin,:: QuaIlIUh'(/[/II/i

j

I

•

I;

NOJ1t.'

>

I!

."i

!i

Fig. 5.23. Trunk flexion tesl.

i

II

I

-"j

I ~

I

.";

Fig. 5.25. Sternocleidomastoid lest.

) A

) -,

1

I

}

...?

•

tl ,V

A

B

j

,

) Fig. 5.24. Neck flexion lest. Correct (A) and incorrect (B).

Truuk Side Raising Strength Test6~ (Fig. 5.28) Patient is side lying with knees bellt and upper arm fully adduclcd while hand of lower arm rests on upper shoulder

l ,

DOt.:1Or anchors bOlh feel

P;llicnt ~lrIns

~lltcmp[S to

)

wise trunk ofr wblc witholll using

B

for assistance

Paticl1l i~ askl.:d lU hold for 10 s('('omJ!;

Fig. 5.26. Respiration lest. Correct (A) and incorrect (B).

CHAPTER 5 : OUTCOMES ASSESSMENT IN THE SMALL PRIVATE PRACTICE

II

A

i

•

91

•• •• j

i

•Ii

B

Fig. 5.27. Hip abduction test. Correct (A) and incorrect (B).

A

B Fig. 5.:8. Trunk side raising test.

Qual Uica ri Oil

• Pass/fail Purpose To id('lllify ~trcnglhf:.aabilily of trunk side bending JIlUSek:,- (qu~ldr;ttus lumboflllll) PRONE

Hip Extension Coordin(lt;(}IlIStrellgth~1(Fig. 5.29) Patient prone Patient attempts to raisc Icg into cxtension with knee held in extcnded position Positive lesl ifercctor spinae musculature contracts before gluteus maximus ,:.) Doctor should observe activation sequence of (I} harn~ ~rings
r.

~

(A) and incorrect (8).

Qlwntijicalio/l

• \Vith dynamic ck<':lromyography Ql/{/lificaliol/ Pass/fail Fail if erector spina~ comracls before gluleal max.imu:, Record activation sequence Of liring order of gluh:al maxil1lll."'. hamstrings. lumbar erector spinae. thora· columbar crcctuf spinae (ipsilateral ~\1H.l contralatcr:ll) Note if contralah:ral shoulder/neck Illusculature contr~lC(s Purpm;('

idcntify incoordination of hip ~x[el1sion determine if gluteal rnaximus is weak or inhibited determine if l.'rL'ClO( spinae is oYL'rac!ivc detcrmine if hamstring is ovcral,.'livc To dctermine if hip joilll h.IS rcd\1l't.~d extension l11ohil~ ily or if psoas is :,hnncncd

• To To To To

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, Trullk Extension Strength Test .. .M1·1l (Fig. 5.30) Patient is piOne with hands bt:hind head and elbows held horizontally Patient is instructed 10 Ii n chest off table (about 2 inches) 15 times (with 1- to 2-sccond pause) nod hold 15th repetition for 30 seconds

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OF THE SPINE: A PRACTITIONER'S MANUAL

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QlluliJinltiOtI Pass/fail Pass if p:lli~nt can perform 15 repetitions and position lor :~() seconds

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Purpose To cst~lbli:o'h baseline mcasurclllclH of trunk cxt~nsion

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Quantification Strain gauge tcstingl3.7~ Alaranta et al described repetltIve and isometric endurance tests. " In the fonner, patient nssumes slightly flexed position and raises trunk to neutral position until no more repetitions are possible. 'l A normative database has been established. The isometric test is a predictor of recurrences..!1 Alaranta ct 31 reported both reliability and a nonnative database for this timed endurance test.

OTHER TESTS Simple tests that identify whether a certain movement provokes symptoms have been found useful c1inicnlly. Morc :ltlvnnccd upproachcs have proven valuable for cstablishil1~ trunk flexor/extensor nllios. lifting capacity, neck tkxor strength and cndur<1nce, mld cardiovi.1scular litncss. Provocative Testing Movements that provoke. relieve, or are staWs quo with respect to presenting symptoms represent .1 reliable WilY to tcst paticnts.15 These tests have been used clinically to classify patients into different treatment groups.,n This cvidence \"~lli dates the McKenzie system of prescribing exercises based on the response of pain to various loading strategies (sec Chapler 12). The specific tests adjudicated nre discusscd in Chapter 18. Being able to provoke pain with active trunk movem~nts in more than one direction has been found to be a predictor of chronicity." Strain Gauge Testing of 1hmk Flc.xionlF..'1cnsion Strength A simple. low-cost protocol exists for quantifiably measuring isometric trunk flexion and extension strength. A ratio of

1.3: 1.0 extension: flexion is normal for this lhough reliabilily is questionable.

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A simple. low-cost protocol following the NIOSH guidelines exists for quantifiably measuring lifting strength.5~

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CHAPTER 5 : OUTCOMES ASSESSMENT IN THE SMALL PRIVATE PRACTICE

ISOTONIC TESTING OF LIFTING STRENGTH

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could differentiate headache from nonhcadachc sufferers.1! Trcleaven and colleagues described the same distinguishing features of poslconcussional headache patients. Xl Trcleaven and co-workers showed that observation of supine. neck flexion. as just discussed. was as reliable as thc strain gauge for identifying neck flexor weakness. Cardiovascular Fitness

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Simple protocols exist for measuring aerobic capacity using treadmills, bicycles. and other ergometric instruments. sa.1I1 High Technology Tests High technologic quantification of functional deficits can cost from S10.000 10 Sloo.ooo. Usc of equipment from Dynatron· ics. Lido. Cybex, MedX. etc. can isolate specific movcments and results arc highly -!'I.:pl.:at:!b!~ and reliablc. Costs makc these units prohibitive for most small private practitioners. Elcctromyographic units arc also cost prohibitive for the average field practitioner. although in medicolegal practices or re~ search settings. such equipment can be beneficial.

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Work Capacity Evaluation

It is the duty of the occupational physician to rate impairment. determine functional limitations, and establish the patient'S work capacity.8~.8) Translating functional capacity into work capacity has been a great challenge. Fishbain et al outlined the reasons for this difficulty: (I) normal values for functional capacity arc needed for the individual (for age and sex and type of worker): (2) many functional capacities arc diflicult to translate into job skills or trailS (i.e., isokinctic abdominal strength): and (3) it is hard to translme functional capacity inlo a "demand minimum functional capacity" for a specific job or job category.~·\·14 To correlate functional c:'lpacity with work cap<.lcity, the Dictionary of Occupation:'ll Tille (DOT) may bc used as the standard of physical demands of a specific job or job factor.K~.K~.K(. Twenty job factors detailed: standing, balancing walking, sitting, carrying, climbing. squatting, lifting, kneeling, stooping, crouching, crawling, reaching, handling, fingering, feeling. pushing. pulling, talking, seeing. and hearing. A sl:'Hldard WCE delineates a worker's readiness to return to work based on their ability to perform job factors. lll The DOT lists the job factors lhat arc important for most jobs in the United Statc~s.s~.Il(. According to Fishbain et ai, "the

93

DOT thus, has defined the demand minimum functional ca~acity of most jobs in the U.S."l\·\ Jobs arc funha categoriz.ed as scdcntaI)', light, mediuIll, heavy. or very heavy according to Ihe maximum weight lifted during lifting or ci.lrrying.I'~·Il(· Unfortunately, strength factors have not been defined for any other job factors. An additional problem with WCE is thm a one-time test docs not reflect an indiviclu'll's ability to perform a task O\'l:'r the course of an 8·hour day.s,1 These problems aside, tiS many job factors us possible should be included in the FCE. Silting tolcrancc can be tracked as an outcome. \Valking can be evaluated for pain provocation (sensitivity) and ex.amined qualitativcly. Lining can be evaluated as described by Matheson (sec Chapter 8). Squatting can be assessed using Alaranta's lcst or ns shown in this chaptcr." Standing can be evaluated for pain provocation and qualitativcly with postural analysis (sec Chapter 6). Stooping can be assessed with trunk flexion range of motion tests and by pain provocation (see Chapter 12). Balancing can be ~valuatcd quantitatively with the one-leg standing test.(,<} Kneeling Ciln be assessed with the lunge test. and rC2ching with the shoulder abduction test. Carrying can be ex.amined with specific protocols.8S.S9 Pushing. pulling, and other job factors can be evaluated as well.u.s<} During functional testing and exercise training. it is im· portant to evaluate an individual's performance potential for activities of daily living (AOL). athletic activities. and demands of employment. Many of the lraits just described should be objects of rehabilitation that can guide the functional training of patients. An individual who can sit. stand, balance, walk, squat, climb. carry, reach, grasp. kneel. etc, with minimum discomfort and adequate strength, endurance. nexibility. and coordination is an individual who is not im· paired. He or she therefore has little or no limitation in ADL or work capacity. Functional restoration should strive to promote the development of these functional traits as the final goal of a successful rehabilitation program. CONCLUSI07> Functional restoration addresses the deconditioning syndrome. It docs not require expensive testing or training equipment. Small practitioners in private practice C'lI1 begin to tr.lin patients with customized exercises progr:.lms lIsing simple equipment. Measurable functional outcomes are of growing importance both for patient motivation and reimbur.;cment. Directing the focus of"thc patient toward functional outcomes rather than pain relief is essential to this process. This approach is appropriatc in the subacute phase of care as well as with patients with rccurrent or chronic pain. REFERENCES I. Spitzer WOo Le Bl:mc FE. Dupuis M, et :II: Scienlific :lppro:lch 10 the asscssmCI\\ :lI\d managcmenl of ;Iclivi\y-rclated spin,11 disordcrs: A mOllO1;r.lllh for cliniei;llls. Repon of the Qucbct,' T;lSk force on Spinal Disorders. Spine 1:::!(Suppl 7):,51, 1987. 2. Maycr TG. G:llchd RJ. Mayer 1-1. CI al: A prospccli,·c Iwo-year siudy of function,,1 rC~IOr.lI;O" ;n indu.~trial low b:lck injury. JAMA ~5S:1763. 19R1

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bch'\\'ior.ll support. Spine ,·U5i. 191\11. 4, Sachs BL. D:l\'id JF, Olilllflitl D. C( :11: Spillal rdl:lhililalinll hy WIlT\.. h·l· er-mec b.Jscd on objective physic:!! l:ap;u:ity ;1~l'c~'l1lt:nl Ill" dyshIlIClh'll.

.-n.

3. Hazard RG. Fenwick jW.

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Spine 15:1325. 1990. Rcadin~ AE: A cOlllparis('n ()( I~lin r.llin~ s..:ak.... J I'sydn'snm tho, 24:119.1979. 6. Moone)' V. Clin1.~ D, Rohcrt'(lll J: A syslcl1\ t"llr ~'\aJllaling alld lr~'al:ll~ chronic bad, dis,lilility. West J .\kd 12·1::nO. 197(1, 7. ~'lcll:Kk R: The shurl-for1L1 .\kGill Pain Quc'li\lllll:lirc. Pain .1U:l\)1. 1987. 8. Beck t\: Ikpro:ssion: eliai...a!' b:pcrillh':lllal ,,1111 lhcllrcli"::ll Asp..·..· I'. New York. Baf"Jk:r & Row. 1967. 9. Zung W\VK: .-\ !'elf-rated. lkprcssion sC;lk. Arch GCll PSYl,:hi;ttr J:=:(•.~. 1965. 10, Main CJ. Wood PLR. Hollis S, el al: 'nle dislres~ and risk ;ISSCS!>lIl.. . 1Il melhod. Spin.. . 17:42. 1991. II. Lea\·in F. Garron DC. Whiskr WW. et al: ,\ "l,llllparisnn of r:lli~'ll"'. tre;tlcd. by chymopapain and lalllilh:C(Olll)' (ur low l'l:lCk pain usin~ a IIll1l, titlimcllsion:11 pain scale. Clin Onhop 146:136. 1%0. 12. Bt:rnslt:inlH, Jaremko r..'IE. Hinkley BS: On Ih" IJlilily of tht: SCl.-l)O.R Wilh [ow-l'lack pain patiellls. Spine 19:42. 199·l, 13. W'll.klcll G. Newloll M, Henderson I. ct al: A (e;lr-:l"oit!ann: hdi"fs tllll."titlllllairc (FABQ) and the rok of fear-;lvuit!:\IH.:C h\:1il'fs in dlrl11lil· h~·.\' back p:lin and disahility. i':lin 52:157. 199J. 14. \Verne!':c ~·1\\'. Harris DE. Lidllcr RL: Clinic.. 1cffecli'·elless (If 0.:11:1\ ii" rial signs for screening chronic low-back pain patients in a work-oriellted physic:II rehabilitation pro£r.lm. Spine 18:2412. 1993, 15, Fairb.lnk JC, DJ,vies JD. Coupcr J, ct at: The Oswcstry low back pain di.o;, ability questionnaire. Physiolherapy 66:271. 19&0. 16. Vernon H. ~tior S.: Neck Disability Indl,':X. j M:tnipul;llin: PhY$iol Th....r 14;..HJ9. 1991. 17. ~. tjllion R. Nilsen K. Ja)'~on MIV. ct al: Evaluation of low back pain and assess men I of lumbar co~elS with and wilhoul back suppol1s. Ann Rheum Dis 40:449. 1981. 18. Vermont Rehabilitation Engineering Centcr: Low Back Paill Questionnaire. Universit), of Vermont. 1988. 19. Roland M. ~·1orris R: A ~tudy of the natural hislol')' of back pain. Spine 8:141.1%3. 20. Lawlis OF. Cuenca... R. Sclb~· D. el al: TIle dC"elopmcnl of Ihe Dalla.' Pain QueMionn3irc for illness bch3\'ior. Spine 14:5 !I. 1989. 21. Deyo RA. Diehl AK: Measuring physical and ,",ychosocial funclion in patientll wilh low-back p:lin. Spine 8:635. 1983. 22. E\·;ms JH. Kagan A II: Dc\·clopmt::nt of functional rating scale to mea· sur.: IrC:ltmcnt OtllComes of chronic spinal paticnb, Spine II :2.77. 1986. 23. Tail RC, Pollard CA. ~brl:olis RH, ct al: Pain disabilitv im!c.'(: Psychometric .tnd validity d:II;. Arch Phys 1I.·1cd Rehabil 12:56i, 1987. 24. Bigo.~ $ .. Banie. Spenglerc OM, et al: A prospective study of work pl,':r"t:ptimls and psychosocial factors :Iffecting the report of b:lck injury. Spine 16:1, 199L 25. \'011 Korff M. Oe)'o RA. Chcrkin D, et ;tl: Back pain in primar)' care: Ou((.'ollles at I year. Spine 18:855. 1993. ~6. D\\\'rkin SF. Von Korff. Whittlcy we..... t al: Mea<"url.'lltl.'lIt of chJractcr· iqi,... pain intcn~ity in lit:ld n:~earch. POlin 5uppl ;:5290, 1990. 27. \i,lll Korff M. Onncl J, Kecfe F. et al: Gr:n.ling lhc ...t:vcrilY of ehruniL; pain. POliti 50:1:33.1992. 28_ W;lldorf T, Devlin L. N,tlI<"ct 00: -nle cOlllpar,tti\'c ;)!'!'.... sslllent of par;lspin:.! tissu.... compliance in a..<;Yllljllolllalic female and male subject... in both prone and slanding positions. J ~'hlnipulati\"e Physiol Thcr 14:-l57.1991. 29, \\\ll(c F. Smythe HA. Yunnus MH, et :II: 'nlc American College of Rhcum:lI(llogy 1990 Criteria for ClassilieatiOIl of Fihromyalgi;l. Arthriti .. Rh,,:ull1 J3: 160. 1990. 30. Hubbard OR, Berkoff GM: ~·1Y(lfascial trigger points show spontilncous 1t~·l.'dlc EMG activity. Spine 18:180J. 1993. 31. \\":!dddl G. M;lin CJ: Assessment of sl'\'crity in low-had.. dison.lcr,. Spine 9:20J. 19~.

5.

1 1 i

...:R~E::.H:.::-:A::B::.IL::IT:.:A.:;T.:;IO=N...:O:::F~T:.:H-=E~SOINE; A PRACTITIONER·S MANUAL

\\·:t,lddl I;: .-\ 11\."\\ dUll,.: 1:10 ...1.'1 !tlr Ih~' tf,·:llllk·llI ,II h.\\ .j-.".I. paill. Spill" I: t'.~.l. IIlS7, II'Hl DI.. 1,.... mhagl·1l SJ. '\L:h.·.Ptl L:\: (juiddlll~" lor fUI1,1:"Il.,] ,':IP:Il'ity l'\ :,!LI.IIIIIII "t" P':"I'!.' ,,:::, lIl\'lli~';\1 l·ll1ldili'Ill'. J Orlh"r SP"II' I'ily' ·nll'r IS I'S~. JlN:>. .q_ ;\lil\'hdl 1{1. C;lrUl"nl;~l J..i~·'llih •• f ,I Illullk.·ll!.·" In;cllhlll:-' .Ill \1l,,'n· ,i\,' ·.1,11\,: .... \~·Il·i"l.· 1'11';.:1 .. ';: :",'r Ibl' lll':lllll~'lll ,.1 :Il'U'" .. '11 ,l"n,' aud b,,\'I, Inlur,,:~, Spill" 15:::'1,~. l'"lI1 .':' ...\ndl·I~"'I\ GB.I. I'I'p': .\Ill. h~:llnY"r J\\": EP1dl:llliplll,-~:- 11: l\,p" .\IIL hyllh':l'r )\\'. And,'I,,"I: (; ,,',hl: (J..'n11';lli"ll:d I.n\\ 1I,I,k 1'.:1:1. \,,·w '·llrl... Pr.\.:~"r. 19S·l. pp 11';-II.t. .'11. Fr~·lIl\':,·r JW: Ejlid,·ll\h,i,,;:-. hI Fr:lllu:o:r j\\" Gnrd"H SI. ll'd,): Sylllp'hlUllI lin NI.'\\ I"'r·r.,:,tl\·~'s I'll Low Ba....k 1';liIL 1',Itl.. ({id~~~. AIlI~·ri,·:m .-\....:llkllly ,.!" Ou!:.·r.ll·l!k Sur;:.... '.lh. I'JSlJ. pp I<)-.~.:. .n. (julI~kl\;11I IL Lilj..:q\i'l .\1. Ibtl'~"ll T: "tilll"ry pre\"l'lllll'n "f h:ld. .~YIllPhlll\' ;ll1d ah!i"Ilt:l· IrPIll ·,\url.. Spilll' IS:5S7. ItJ9.'. .'X. Vilk'm.m T. R:lUh"I,l S. :\'r K..... I al: Pali.. . IIl·11:11111lil\~ skill. P:l.·l.. lll.lllri,·s. :Ull! h:u.:l.. P:lill. Spin.... 1·1: I":'. IIJS9. .N. M:tth.... ,,'ll l.: Ib!ii~· r"'lui/"::I"nh fur ulililY ill Illl' a"'·.. ."nwll! "i ph: ,il'al di.,ahilit:. :\I'S j(luru:ll .'. !').". 111'14. 40. Grabill..'! .\ID. Kolt TJ. GI1.:/.,'.,i l\f:: D,·.. . uuplin:: of hibt..':·.d i,.\I",I~pm;ll ..:xl'ilalilln in suhj.. . ClS wilh 1"\1 h;ll'k pain. Spilll' li:1211J. Ici,'il\iiic e\·ilkn....e. Spin.... 18:801. 1~N .:. 44. W:lnf: S. Whilncy Sl. OurJ::n RG. CI al: Lower cxnelllil: IIlU"I:!.\( Ik,,· ibility in long distan........ n.llln;:r,. J Orllwp Spt.'rt.' Ph)'s Thl'( :. HI':. I'N.~. 45. Ekstrilnd J. Wiklorsson \1. Oh-..::rg n. ~'I ;\1: Lt..wer CXlrcmil: ;':"lIl"Ill..:lric lllC;lsurcments: A study IQ determine Iheir reliahility, :\r..-l\ Ph:, \ktl Rehabil63:171. 1982, ..\6. M,lycr T. Gatchel R.. Ki",hinll N..... 1 al: Ohjl.'cti\" ;ISS .... S... llh.'lll ,'.1' spilll~ fun . . tion following illdu"lri::i injury::\ prtlspel'li\" 'lUd: \\illl ,"'lilpariSllll J;WuP and ollt:-ye>lr follo\\ -up. Spillt: I o:·1~2. IIJX;i. 47. Bicring-Surenscn I:: I'hY'I.::::l lIle:lSlU~'Ill\'llts :1' ri,k illllk,lh~r~ f,'r Itl\\"h:li:k lrouble o\,er;1 un~'-ye:lr (lC'ri{ll,1. Spine I): 106. I<)S4. .Is. TrnupJDG. Manin JW. L1(1~d DCEF: llal'k 11:,ill in illdu'lr;o: ..\ P""'P~'.: li\'e stuuy. Spine 6:61. 1'}1i1. 49. Vcmlln H. Aka P. ,'\t"Jrth::nKu M. 1.'1 :,1: Evalualioll PI" n.."·~ 11Illsl'k strl,':llglh wilh a nnxlilied 'phygn\l\l\lan\tm"k'r dyn:.IIIIlIll,'I"r: Rl'liabilily ;lIld \·alidity. J M:mipul;sli'c Phy"iol1l1l,'r 15:343. 1992. :'0. Ct..."idy JO. Lopc.:s :\A. Yvn::·Uing K: Tlt\· inllllcdi:lt.... dk.. l "f lll:llllpU· lalion \"l:rw... llltlhili/,;:lion IOn pain ,lllli r:IIl';;~ of motiol\ in ll,,· 'l'nl,';ll spine: A randomized c(,nHolled trial. J Maniplilati\'l' l'h~ "'1,,1 Thl'!" 15:570.1992. :'1. Toppenhcrg R1\·1, Bullod-. ~II: Th.... inll.'rrdalion of .~pitl:11 <"111"\.· ..... I'l'I\'il.' lilt anu !l\u'cllo.' lengths inlhl.' :Jdn!c.Wl,'nl kl1\:Lk. A\I... I J Ph:-'ll'lhl'r .~~:6. 1t)~6. 5~.

Knill. S: :..:iIOSH lifling ;:uid::lille..... Am Ind Hy~ .'\"u~:.1 ..l_~.,l.: I. I'J~~. 5 .. , :-.-I:tycr T. Barnes U. Ki:-Iuno .". 1.'\ al: I'r\':;f,·."i\·e i,uin.. . rti.l! htllll:: ,'\ :11ualiorl. I. A st:llltl;lrtli/.cd rrtlil ....lll a11l1 1I\'rm;lli\'I.' datal1a.'l'. ~!,llll' 1.~:'J9.'. 19H5. 5.t. Guide<" 10 the E\·;llu:llion III i'o:rm:lIll,'nl !ll1p:lirllll·1I1. :>rd E,:. Chll·a:;ll. American ~kdic;tl Assodo:llfm, 1l)~K 55. N.Ulscl D. Jans..:n R. CrCfIlo:la E. 1.'1 :II; Elk~·ts of l..'erviL·,,1 :IJ.llhlll\l·llb un lateral-flexion pa...si\"c cnd.r~lllge asyrlllllt:tr)' and un hllll,ld l'r..'~~llfl·. h....arl rate and plasma cateeholhys 'Oler 70:SJ7. 199U. 57. Reid DC. Bumhalll RS. S;JhllC LA. cl ;11: Luwcr eXlrelllil~ Ik\lI'i1il: 11;11terns in c1:l..."i....:,1 h:lllci d:ltlcef\, :lt1d lhl'ir ....nrrel:lliun It.' 1.It.·f.ll hil' :lml knec injuries~ Alii J Spc)n, .\ktl 15: ....17. 1t)~7.

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58. B;SIr:lnd J. Gillquisl J: The (r.:quenc)' of mu~l(' ligll1ncss ,lOll iiljuri~'s in socc..:r 1l1;1~·crs. Am 1 Sj'I('"S ~kd 10:75. 19$2. 59. Inamur.t K: Rc·'lsscssmcnl of Ihe Illclhod of an:dysis of ch,.'(;(cogmviw· I;.r::Iph and Ihe one fool les!. Aggn:ssologic 24: 107. 1983. 60. Nelson RM: NIOSH Low Back AlIa... of SlandJrilcd Tcslsll1lo:asun:s. U.S. IXpanmcnt of Health ;md HUlllan Ser\'ices. Nationnl Ins[i[Uh: for (kcup:lIional Safe I)' :llld H...allh, December 19$8. 61. Hir.Is..J\\'J Y: l...efl fOUl to suppon hum;l1l stand in:; and \\'alking. Sci :\m (Japan) 6:~~. 19S;1. 62. M;lycr T. thad)' S. Ihw:lSMI E. CI ..I: Nunillvasi\'c ntcasurcmcnl of ccrdc:lllri-pbnar llIUliull in nomla) suhj\.'Cls. Srin.: IS::!191. 1994. 63. Youdas J, CLre)' J. Garrel T: Rc:liahilil)' t,f me3.!'ourcmcnts of cervil:al spinc range l)f mOlioll-comparison of Ihree methods. Phys 11ler 71 :98. 1991. 64. Gajdosik RL. Rieck MA. Sullivan DK, Cl :\1: Comparison of four c1ini· cal tests for :lssessing halllqring muscle length. JOSPT 18:614, 1993. 65. Gricc A: l.umbar cxercises for kinesiological harmony and stability. JCCA. Del:. 1976. 66. Nelson RoM. NcslOr DE: Standardized asscssment of indu:miallow·b:lck injurks: DeveloJllllcnt of the NIOSH low-hack atlas. Top Trauma Acutc Care RehabiI2:16. 1988. (17. ~'hlffroid MT. Ihugh LO, Henry SM. et :II: Distinguishable groups of llIusculoskdetal low back pain pilticnts and a.<;ymptomalic control sub· ject:. based on physical m~;'i$UrCS of the NIOSH low back alias. Spine 19:1350.1994. 61'. Riss::mcn A. A1J.r.mta H. S3.inio P, et 011: Isokinctic and non-dynamomet. ric teSls in low back pain patients related to pain and disability index. Spinc 19:1963, 1994. 69. Harding YR. de C Williams AC. Richardson PH_ et al: The developmcnt of ;1 b:mcry of Illca.<;urcs for assessint; physical functioning of chronic p;lin palienlS. Pain 58:367. 199~. 70. Trdea\'en 1. Jull G, Atkinson L: Ccrvi(':lllllu~culo;ke1ctaldysfunction in post-concussional headache. Cephalgia 14:273. 199~. 71. Alaranta Ii. Hurri H. Hc1io\"aara M. ct :11: Non-dynamclric trunk perform:lllcc tcst~: Reliability and nonnati\'c data. Scand J Rehab Med 26:211. 1994. n. W'ltson DH. Trott PH: Cervic;11 headache: An ill\'estigntion of natural hC:ld po~ture and upper cervical lkxor muscle p.:rformancc. Cephalgia 13:272. 1993. n. Tri;mo JJ. Sko£sth:rgh DR. Kow;alski fl.UI: The u:,c of inslrumenlation ;and Iaboralol)' ex.:uuinalion procedures hy Ihe chiropractor. Inlialdeman S h..-d): Principles and Pr.3.clice of Chiropr:lCtic. ::!nd Ed. Norwalk. CT. Appleton & l..lnge. 1992.

95

7-t Sill:lkl \1. (inl"'''':, N: Bad :-lfl'n;:lh..-nin;: n.l....:i,,:s: Quanlil;lli\-..- c\'·1()tTi.~scy 1l1C: A review or the Iitenlturc related to trunk muscle r..:rt"orlllallc,,:. SpillL' 1.1:655, I t.l8!\. 79. Trelca\cn.l. Jull G. Alkinsoll L: Ccrvicalilltlsl:uluskckwl dysfunction ill po-sl-concussi(Jn:r1 h..:adachc. Ccphalgia 1.1:27\ IC)94. 80. Parker DC: A l\l':W suhmaxilll;ll trc;ll!lllill ror prcdil·tillg V02 ma~: Ratiomllc mId Y~llidalion. I\nn Spnrls l\'k~l. Sllhtlliltc~t fill' puhH· cation. 81. Aslr.md P·O. Rooahl K: T..:~thook of W,lrk I'.hysiulogy..\nl E\J. New York. ~lcGraw-Hill. 19S(J. 82. Sp.:=klor S: Chronic p:lin .md p:lill.rdatcd disabilitks. J Disaoility 1:98.

1990. 33. Fishb:i.i" DA. Khalil TM. Abdcl-~'lol)'A. el al: Physici;ln limitatioll when assessing work cap:lCity: A review. J Back MIl~culoske1ct Rchat:oil 5: 107. 1995. 84. Batistol \1E: Dis.lbility cvaluations: EXpecl:llions of insurers and payor!'. J Dis,lbilily 1:168. 1990. 85. U.S. Department of Labor, EmploYlUent and Tr.lining Admillistr,llion: Dictionary of OCI.'up'ltional Titles. 4th Ed.. Supplcflll:llt. Washinglon. DC_ CS GO\'crnmcnt Printing Office. 1986. 86. U.S. Do:partmcnt of whor. Emplnymell! and Training Administration: Selected Characlcristics of Occupations dcfin..:d in the Dictionary of Occupation:ll Tilles. W;I.~hingtol\. DC. U.S. Go\'ermcnt Printing Office. 1981. 87. Isemhagen SJ: Phy... ic:lltherapy and ol.:eup;lIiol\;1l rehahilitation. J Oceur Rchabil 1:71. 1991. 88. Fishbain DA. t\bJcI-Moty A. CUller R. et ;,1: t\ lIlethod ror 111":;lSIII'11Ig residual funelional capacilY in duoni<: low back pain palil:nts l>ased on Ihc diclionary of Ol:Cululional tilles. Spicn 19:972, 1994. 89_ Moonc~ v. ~(athssol\ LN: Objecti\'e Measure!llent of Soft Tis'::'u..: Injury: Fca..<;ibility Sludy Examiner's Manual. Industri~ll Medic", C(\llllLil, 51"le ofC.1iifornia, 1994.

6 Evaluation of Muscular Imbalance VLADIMIR JANDA

I I

I, I

I

10

I

I I

I I ,AA

~

~

!

1

I I ~

I

Muscle imbalance describes the situation in which some muscles b~come inhibited and wsak, while others become light. losing their ex.te~sibililY. M.~crat.cly tight muscles arc usually..str.OllgGOh!.1.IJ.JJQDP~L although in the case of pronounced tightness. some decrease of muscle strength occurs. This is

called "lighlncss weakness:' I The trealment of tightness is not in strengthening. which would increase tightness and possibly resuh in morc pronounced weakness, but in stretching. oriented toward influencing the po.nconlractile bUl retractile connective tissue of the tnuscld-.§.trctching of tight muscles also results in improved strength of inhibited ant
mu~s, probab'iiii~ediated via t~~~~herring!.Q~~s-.I~~~:.~ e

ciprocal hmcrvatioih The terms muscle tightness (stiffness, tautness, loss of ncxibility) and muscle spasm should not be confused. A de· tailed differential diagnosis is necessary because each condi· tion requires a different type of treatrnent. 1 Unfortunately, a precise and adcquate analysis is often neglectcd. The tcndcncy for somc muscles to develop weakness or tightness docs not occur randomly; rather, typical "muscle imbalance paucrns" can be described. Further, the develop· ment of these pauems can be predicted clinically and. there· forc. preventative measures may be taken. Muscle imbalance docs not rcmain limited to a certain part of the body. but gradually involves the whole striated muscular systcm. Because thc muscle imbalance usually precedes the nppcarance of pain syndromes, a thorough evalua· tion can help in introducing preventive measures. Muscle imbalance develops mainly between muscles prQ& (0 develoP..!J.g!!t'I
pelvic or distal crossed syndrome.
I

i

"---'-,---.

."~."

-,-~,

REHA81l1TATION OF

~o

,-= SPINE: A PRACTITIONER'S MANUAL

IJn'll l'O.\-/tT/t.,. ,;,. ~ lI1use/ex "::1Il h~ lested only hy thor-

U,'/)('/" rra{)(,':.ills (Fig. (\.1) i... h:"ll..'d with thl:

P;l\lt'lll

"-upille.

the head p:lssivcly tk\yd ;.tOt! illl'lillcd 10 Ihcl."lllllralatcl':t1

sid~: Fr-oin Ihi";Z-j;-u:..ilit;n. II~c- ... iullll-d~i-ill~(Ik· i;-ri~;hl..~T.~~;lall y. N(fnh~l1y. a soft b:uTil."r i... at tilL' I..'nd or tile pnsh: \\hl'll the 1ll0VCIl1('ut i:- rcstricll'd. il is hard. L(·\wo,.S("OIJll!ac lFi:::. (l,:!1 i......· ,aulillt:d in:1 silllil:lr man· lll'r. only (hL~ had is ill ;lddili\~J,~,r{.1,1_;11.\':~!I,~lq.1_l,'~.~,!n~r:ll;l!c{alside. Peclomli.\' 11/0)0" I Fi~. (1.:\) i... \J..'stt.:d with thl' patient supine. the ;lrIll I1U~\ctl p;'l:-.si\'dy inlo abdm:liull. The tnlltk must be s(;Jbili".cd hcf(ITI..' the :mll i... pl'lced into ;lhdllL'tion hc· cause a possihle (\Vbl of lilt.: trunk might mimic 11k' normal range of 1ll0VCllH:nl. Thc arm should reach the Iwril.Ontill level. To estimate Ill!,; d,l\icul"r jJllrtion. the ilnll is alll1\\Td to hang down loosely :1I1J the ex'lminer pushes Ihe :-.houh.kr downward. 1 ormally. {lIlly;'1 slight soft barrier is felt.

P'\!p;ltioll. L\ .:i~:,!ii\lll or till' .\IO'lIo('/CitlOIl/c1S/oiti is 1I0l rdi;lhk hCi:;WSl' it ~'r\'''l'S loom;lllY ~l'.:;rnellts {I;·ig. (lAl. lIil'110pl"." lilt".:, .. ,:.... lhg. 6.:'1. n'!'wsll'llloris (Fig, ()J)) ;lrl' !L·~lt.·d with thl' ",:::..'l1t in:\ llHldilil.'d Thomas position. Till.'

\l\1:;h

prl"l"IlI,:d llIodilic:lh':1 ,11"'0 allows l'\,llnin:ltioll or till: ....hon f'"::); addrw/ors ,lIh: ::::.' [I'llsor fiISf';" !:if{/(" Till' p:lIil'llt i... 'll;~:tll' with thc tm~(l on the plinth ,1I1d till.' ll'"ll'd k~ h)\\sl'l~ h_::,~ill~. The 110111l>,te(l leg is 1ll:lxilllally Ikxl,.'d to sl"hilit:I,.' Ill;: ;'l.'h·is and tlall~n Ih~ IlImb;II' spine. TIl(' Ikxion pllsitioll in (h~' hip joint indicatt:~ the tightness or thl.' iliop,oa", th~ nhliqu;.: position of th~ lower kg indicates Ihe tigh\lh:~S of the IS:'lU'. ThL: inability' 10 ;lchicvc passively thl.' hYPL:I\~.\tcll.'iioll ill Ill:.: hip joint .111\.1 thl.' in<.lbility 10 a<.:hicvc full llexil)ILOf the kncl.' I i.~5~) conlirms the lightncss of thc iliop."Ilas

anJ tilL:

n.:etlJ~.

r;:-,pcctivc!y. Limil:Hion of a passive hip

)

.'.l" Fig, 6.1.

Upper trapezius.

Fig, 6.2.

Levator scapulae.

" .oJ

Fig, 6.3,

Pectoralis major.

CHAPTER 6 : EVALUATION OF MUSCULAR IMBALANCE

99

1

!

Fig. 6.4. Screening test for sternocleidomastoid tightness.

Fig. 6.5.

adduction to 15<J or less indic.ltcs the tightness of the tensor fascia lata (Fig. 6.7); abduction less than 25° indicates shortness of the short one-joint thigh ..lddllctors. This lest can be innucnccd by the stretch of the joint capsule. however. and thus the more specific (cst should be used to confirm lhe tightness

of the adductors (Fig. 6.8). Confirm.nion of tightness is clear when excessive soft lisSllt.: rcsis,!al1cc and decreased range of motion arc encountered on applici.ltion of pressure in the following directions:

Hip flexion-less than 10 [() 15°-iliopsoas. A simultaneous extension of the knee joint points out the shortening of the rectus femoris. Knee flexion-less than 100 to 105°-reCLus femoris. Compensatory hip flex.ion Jll~\Y occur during the tcst. Hip adduction-less than 15 to 20°-tensor fascia lata and tht: iliotibial ballc!. An associated deepening

Iliopsoas.

of the groove on the outside of the thigh is noted. Hip abduction-less than 15 to 20o-shon hip adductors. The tendency toward compensatory hip flexion should be controlled during the ICst. J-!wrlJlrillgs (Fig. 6.9) tightness is evaluated by the leg raising test. To avoid the inllucnce tht: eventually light iliopsoas on the position of the pelvis and thus 011 the range of hip ncxion. the nomested leg should be in l1exion. Under these circumstances. the noonal range of mOlion is 90"". , Thigh adductor,,· .Ire tested with lhe patient lying supine

or

_.

at 'O:C edge of the plinth (Fic. 6.10). The passive abduction in the hip joint should be at least 45.... Iight.._~~~~lgs 1l13y__c_onLribulc..JQ,.J~.~_ mngc limitation. If this situation occurs, bending lhe k;~~-·-Siloufd-ilU.:·rease tht: range of movement.

lUU

REHABILITATION OF THE SPINE: A PRACTITIONER'S MANUAL

M. !);rUilJ'llli,1 i, !~"\L'd willi tlw paliL'lll ~llpill"'. TilL' Icst~d h:~ i~ pla~(.;d willI Ilk' hip.~\lilllll\ 11,'\1\1l1IHJl tl\,Cr(,()". Il1m;!X-

imal adductioll. and 1!1;.' pl'h-i" j" ,,!;thili/.l'd by jlushing 11lL' knee in lhe loll~ :l:-.i .. \\f lhe fl.'lIl11!" lFi~. (1.11 K ThL'll. lh~ iUh.:r. ~ Ilal rotation in thl..' hi;' I ' jlcrfornh:d. :'\onn;lIly. soft gr:l<.lually illlTca~in.:; rl..'SiSI;llh:~· i ... llOh:d ;li ti ...: clld of IhL' rangL' of molion. Iflh\.: llIuSl.'k I' il~llI. lhl' l"lhl.I\:dillg is h;m.l ;\Ild Illay hI.' assoCi;th;d wilh p:llll ,h.·cll in tlh: hUH\II.:b. QuctrintfUS [limi ·,Wl i~ diflil"uh to L',x;lI11inc because ((10 many :-:pilh: "'1':;1Il~·1l1 . . I..'llh:r tht' play. III prinl'iplc. passive

-

t

/ · ..

Fig. 6.6.

trunk side bending i~ (csted while the patient assumes a sidclying position (Fig. 6.12). The refcI~J),S:_~""p.pin.t.is (IJ~.Jcvel of tilt..' inferior angle of thc scnpula. which should.be q~~~S(~ frolll IhJ...· HOOf 1~'.!_~)Ollt ~ inches. .')/);1101 at·(·tl1l·.~ ~Irc again diflkult 10 examine. As a ~cfl..· ':lIing h:sl. fllf\'~lrtj

hending

ill ;'1

short sit ;'Illows obscr·

\'~lIi'll1

of th.: ~r;'IJu;)1 (.·Ufvallln: of the spine (Fig. (l.I.'). ).,ll>re rdi:lhk. 110\\1.."·':r. is Schober's test. AllY incrCilSC of distance 1I11i.kr :' elll should he considered as limiti.ltiull of the range of motion.

)

Rectus femoris.

,

J

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.J J

Fig. 6.7. A screening lest for tensor fascia lata tightness.

.

C;HAPTER 6 : EVALUATION OF MUSCULAR IMBALANCE

101

Fig. 6.8.

Screening test for the short hip adductors.

iog of activation of the most important muscles that take part in a particular movement and in the degree of activation of the primc movers and their synergists. In this respect. the beginning of thc movcment is more impm:tant than the cnd of the movemcnt. Poor quality and control of movcment can be of major importancc in either the production or perpclUation of advcrse stresses on the spine. Although the movement pattcrns arc individualized, the typical abnormal patterns can be observed. _ In principle. six basic movement paltcrns give o\"eral1 in- ! formation about the movel. lalitv of the articular sub- ; ject: l~ip ~hyper)e)(tcnsion. hip a~duction, curl'tfi>. pu:-> 1 up. j neck flexIOn, and shouldcr :.tbductlon" "_J Hip extension (Fig. 6.16) is examined in order to analyze onc of the most important phascs (related to low back p'lin) 9f the gait cycle-l!Y..percxtcnsi~l of the hie. The patient is prone. During straight leg lifting. the relution bClwecn the activation \?.!..~l~~ gl.~teuSJ:na~ill!.l.ls. ha!n~lri_!lgs. spin_aJ" extensors--:-ancrstlOulder gird!~__ "~n~"s"c1~_~js observed. The first sign of altered pattcrn"in"g' is when the hamstrings and erector spinae arc readily activated during the movement and contraction of the gluleus maximus is. delayed. The poor~sl pattern occurs when the erector spin'lc 011 the ipsilateral side or even the shoulder girdle muscles initiale lhe mO\'~mt:1l1 and activation of the gluteus maxillllls is weak and substantially delayed. In this situation, the entire molor performance is changed. lillie if any extcnsion in the hip joint is noted and the Icg lifl is achieved through pelvic forward lilt and hyperlordosis of the lumbar spinc. which undoubtedly o,'crstrcsscs

~ ,)

'!.:.

'''1;

Fig. 6.9.

V

'C.

~

,''\

<~

7i·ice".~

Hamstrings.

surae
ion of the fool. Normally, Ihe thcmpisl should be able to achieve passive t1or7'>illcxion to 900 (Figs. 6.14 and 6.15). More detailed description of the tests is available e1sewhere.:\

EVALUATION OF,INHIBITED MUSCLES To examine tht.: inhibited muscles is difficult, because the classic.1i muscle strength testing docs nOI give sufficient ,lnd reliable information. The focus of this evaluation is less on the strength of the p
_~

Ihis~gion.

Hip abdltC:rio!l (Fig. 6.17) gives information about the quality of the laleral muscular pelvic brace and tlHls indirectly

£J

j\

io t-----------

_

102

REHABILlIAIIUN Ut- I Ht: ::»1"'11\11:::';

Fig. 6,10.

M

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,

,~

Thigh adduClors (A): tesl if hamstrings are

tight (B).

I A -~

B

ahOUI thr..; stabilization of the pch'i~ in walking. II is tested with the patir..;nt in the si(lc~lying position. The gluteus medius and minimus together with the ten~or fasciae latac act· as prime l1lover~ while the quadrmus lumborum stabilizes the pelvis, The lirst sign of an altered abduction pattern is a ten~ sor mechanism of hip abduction: in~tcad of pure abduction, thc,.movc}llcn( is combined a~ abduction. lateral rotation, and ,Jl{xiun..:The poorest paUern of hiIJ al)uucllOll occurs when the quadratus lumborum acts not only to stabilizc the pelvis. but also to initiatc the movement through a lateral pelvic tilt)This pattern again can cause excessive stress to the lumbilr and lumbosacnll segments during walking. Trunk cll!'lup (Fig. 6.1 S) is tested to estimate the interplay between the lIsu
movement is thus performed mostly in the hip joint rathl..'r than by kyphosis of the trunk. P/lsh /II' (Fig. 6.19) from the prone position gives iJlrl'r~ mation about lhe quality of st
.,

=

CHi,?TER 6 : EVALU,UION OF MUSCULAR IMBALANCE

103 Fig. 6.11. Screening test lor piriformis tightness (A); palpation tesl for piriforrnis tension or irritability (B).

A

Fig. 6.12. Screening lest for QllZldratus lumbo· rum tightness.

104

REHAIjILlI AIIUN UI"" I Ht ::::'1"'11"'1:::

Fig. 6.13. lightness.

f'\

t"hAIv

1illUI'H:n .... IV'''''''....... '"' ....

Screening test lor ereclor spinae

"',

')

Fig_ 6.14.

Gastrocnemius.

-,

)

Fig. 6.15.

Soleus.

()

,

.• ii'

,

.•. J>

, ....i

CHAPTER 6 : EVALUATION OF MUSCULAR IMBALANCE

105 Fig. 6.15.

Hip extension.

Fig. 6.17.

Hip abduction.

Fig. 6.18.

Trunk curl up.

Fig. 6.19.

Push up.

,vv

lion of the scapula, and elevation of the shoulder girJk. Tlte ; decisive movement is identifying im:oordil1;11ion is lhe devalion (hm normally starts to occur at ..thou! 6()" l}f . lbdtKliml. 'Ill

6 I .111 individual with shoulcJcr dysfunction. e1c\'aliOl~ 51.u'ts C~lr \.Jic:r or may even inilialc the movemenl. ANALYSIS OF MUSCULAR IMIIALANCE IN STANDING

In "Ul an.dysis or sl:.Illuing. all ;ltlcmj1t is maue to diffcrcn~ tialc bc(,,,,'cclI possihk provOL:
by weakness and inhibition. The role of deeper muscles

may lleed

10

be

l".'Olllli

:::;.'l! Ill' lh:~;lh,:d III ,uh~-=qtll:lll l\llIS~'k

Icll~th

lesls. Tht' Il/lric-III is .lin; ·hH'lTed .fi'(l1Jl behind ilnd ;1Il oYl'r;dl Impression of posture ;... dCh:rmined. Allcnlion i" 111\.."11 dir~l."(I".·d IowaI'd Ihe 1")P~i;:,)ll or Ih(' pelvis. l'\,.·\,:ausc ;Ibnnrlll;lii· lies of other slrueIUf\,'''' "w:h ;IS Ihe 11l1ll1';lr spine. ~;li".Toili:ll': joinls. and lower lind", .:r;,'. ;IS ;\ rule. rl.'tll".'\,'!\,'d in p;:h"il' po:-.ilion. An il1cre;lse or lk·....... "sl." in :-agillallill. a lah.:r;t! :-.hifl. :111 oblique position, rol;tih'll, and lorsioll :-houl<.l bl..' \,lbsl.'rwd.

The peh-ic crossed s: nJi\ll11l."

Illay

.. ~

01.' rc:-pollsible for tht.: in-

In.. .

creased anterior tilt of pelvis. This condition is usually associated with il1l:rca~l'J lumbar lonJosis. The pch'ic (wist is usually associated wilh . . hortness of the piriformis amI/or iliopsoas: an oblique pthHion or (h~ J1d\"i~ i.. i.ISSlleialcd mostly with leg length asyml1l~lry. Shortness or thigh :'H.lc.lu... tms and liglllI1CS.S. of the 411aur:..:llIs 11II\\borlllll and of 'th~ . iliopsoas

Fig. 6.20, Head flexion "correcr (A) and, "incc"cct" (B).

)

A

., ..J

,

- . . ...J

--",

CHAPTER 6 : EVALUATION OF MUSCULAR IMBALANCE

--_..

A

107 ~._--------------

B

Fig. 6.21.

Shoulder abduction "correcr (A) and

"incorrect~

(B).

,

I:

Fig. 6.22.

Soleus lightness on the right.

- - - - - - - " ..

""

Fig. 6.23.

_

..... ....•.

_....__..-

..•••..

_

RighI thoracolumbar ercctcr spinae hypertrophy.

.......•...

i I

I I ,

j

~

I

I

I 1 .

I i

108 shonen the leg, whereas ligllll1CSS of th~ piriformis makes 1111..' leg longer. Next, the shape. size. and IOlle or the hutto!":k ;[t'l: observed. Usually, thc gluteus is hypotonic and inhibited 011 thl' side where the sacroiliac joint is hlocked. The hamstrings arc usually well de\'e1opcd. hUI it is important to look at their bulk relativc to lhat of thl.: glutei. b~· C,lUSt: wh"':Ji i.b,,; ::lttcr is inhihited, lite hamslrings (ln~lI be· c.:ome prcdomin;'lllL This (hangc is rc'ldily cvkklH if the impairmcllt is unilatcr.l!.

..,,

Tlll' ,hal'l.." III IIll· lin,' ,II" 1111.: llll'tli;t! ;"pect \11' tilt.' Ihi~1t ~i\y, impllrl;lIU inl"llflll..::"1l :lhtlUI Iill' lhi~h ad,.hl\·lof~. III indi,·idll;l!, wilh addul,,·h'; \l~hllll''''S. the llllC-joilll :lddllclor" hll'l11 :1 di'lilll.'1 hlllk ill ;:1,' lIppl'r (lIW lhird 01" thl' 111i~11. Thl' ollc-.il\iul ;ldduetol"s al\'. ;!..; a ruk'. shun ill p:lti~'llb wilh painful hi·p j()inl anlit.·lll':l .... ()11 I he (;11 r. difkl\'ll; :.;(1\ HI lllll:-ol hI.: 111:1dt: IWl \\ ~'l'l1 1111: ~;l";' IrnellL'mill" allli th~ :-\lk"... _ If Ihl' whok tric...· j" i... ,I!(Irt. Ihl,,: Adlille..; tendon Sl'l,:Ill' l"';-,'adl'r. ;md if the SOklh j, li~lll. III addition. Ih.: lower k~ k:,·\lll1l'S l'ylindrk (I'-ig. (l.~~).

Fig. 6.24. Abduction and winging
I ~

1

I

)

I

()

:;

~

I

'~

) Fig. 6.25. scapulae.

Tightness of the levator

) ,)

.... " .... VM.

IVI~ Vt<

--------_ ..__._._---_... _...• -

109

MU::i(.;ULAH IMBALANCE

Fig. 6.26.

C::

:~ie

;lb(lornmal dorni·

:lancc.

Fig, 6.27.

High arm cross.

Cart..'!"ul cX;lIninatioll or the back llluscle.. . is warranted. The bulk or the ae<.:lor spin;lc \hould he compared from side to side a:-; well iI" from the lumbar to the thoracolumbar n:gioll. TI1\:n.: should ht.' no c\'idcllt dilTcrcncc bct\\lCCll sides and regions. PreVaIClll.:c of thc thoracolumbar portions or the rector i:-; ;t poor ~ign. It may be indicative or poor muscle stabilization ill the lumbosacral region (Fig. 6.23). Tht..' illh:rs<.:apular span: and the position or the shoulder blade=, give infornl,ltiotl ;lhoUI the quality of the lower stahilizcrs 111l..: scapu!;,!. If these muscles ,Ire weak and/or inhibited, slight 'lhdlH.:tioll. ekvation, and winging of the slwull.lcr blade
or

Fig. 6.28.

Touching the hands behind the neck.

Tightncs ... of lhe upper trapcl.iu\ ,llId kv"tol' s<.:'lpulat..' (Fig. 6.25) <.:;111 be "'Cell 011 the llc~k ,houlder lim;. III ;m;'IS of tigllt ness. the c.;5~nt(Jur sU·;liglllens. If tightnl..'.';o;"of the !l;valOr prt:dominalcs. the' COn(~Hlr ur the 11i.:<.:k line 4lppl::lrs as it duul\k w;lve in the.: <':fl,;";J of insl..'nioJl 01 thl.: lIIH~t..·k Oil th~ Sl:;lpUlJ. This straightening uf the ned: . . houldt..'f lille is sOlllctilllt.'S lkw

110

sl:ribcd ;IS "Gothic ~holllth:r" ill tll;ll H i... rl:lll1l11:-~'~'Il\ llf the form or Gothic chull:h l(l\~'CC Vie\\'illg rhe pmi('/I! FOI/1 ,!lc' /""111, lhe q\l:llil~ pf Ihe ahdominals is obscrn.:d lir:·a. Id\'·:lll~. 11h..' :thdoillilla! \\:111 i" nal. A sagging and pn,lIrudcd ahdoll1l'l1 may 1"I.'I\""l'1 '::l'lh.:'r:dilcd weakllc~s of thl..' ahdomill:lb. \\'!il'll Ihe ohliqul" .n...· dllllli-

lli:-lilll..:1 ~11"'\ " .~

dpparCll\ t)11 thc l,tlCra] "idl' or the a pll.. . sibk 1.!t'I.:rca'L' ill the slahihllil;': i HIll'! ion Ilf Ihl' r,', u in Ihe allll.'rop{lsh.:rior din:l'l iOll. ;1Il illl!".n.tll\ r:ll'ltlr hlr 'i.>til/alioll oflhc "pine (Fig.. (1.2(1). nh' l\\p :lll\,.:rilll ;:',:;:lllHlsCk's Ihal (:Ill inlluCllCl.' lllc llllllbll:~~·1', I,' pu.. . ltl.l· ;11~' :::: lel..... llr fa~\.:i:lL bl;IC alld the rcclus

11,111',.

1\'1,',; iili ...

lilldin~ 01-;: ..,,\.',,-

h'l!!\,n,. :--';tlnJl;dl~. lh,' "~df,.

III' Ih..: h:II... "r is nlll dislilH.:1. lis \ I'olhhi~. nlllpkd \\ i::: :hl' ;IPlh.':lr;t1l(~' of a ~nlO\'e 011 the bll'r;l! . . ill... 01" lhl' Ill:;:: usually indk;lll.'S that this 11I11s(k i~ ,l\l'l"ll"'l'd and ...htll":. Wlh.'n thl.' rcctus feilloris is tight. Ih,: pn.. itioll uf Ihl' p.!i:.:lb 1ll00\.'S slightly upward and ;.Ilso l;tlt.'rally ill Ih,: l·ot ...\.· ..1 -.:,Illl..·un\:nl lighinl:Ss of the ilimibbl 1r;h:1.

Tightness (lr 111\;

i·..·,:luralis

IIh Ir..:- pftllllinClI1 lllu ... (k'

Fig. 6.29.

Extension of [he elbows.

llIiLJor is charactl.'ri"l.cd hy :t rodly and thil:kncss or the ~1I1tcrinr ;'IX-

illar f{lld. \lll(,:11 information ,:~ln he uhtaill!.:d from observation or th..:- ;lIlt":-fior asp.x:t of lh;.: necK ;uH.lthroitl. Nunnally, th~ SICl"1lI l ckil!llm;lstoid 1I1l1 ....:!;? i.. just visibk, ~!-qm!n~.I!.~"'\;_9rtl\~ ill...,.:nitlll of tht: IllUS(.:It:, f':~rtil'ularly its davicular purtion. is a ~i~n (If tightlless, A ~l"(\(\\e alon~ thi:- musdc is an carly sign of \·.:.::tKm:s:- of the d:.::;..'p necK llc;'\ors. Straightening of Ih~ throat lin!.: is usually ~ ~ign of increased tone of the suprahy· oid muscles, .\ddition:lIly. hc,Jd posturt:' should be observcd, prom a Ilw"cular poim of \'ic\\. ~I forward head posture is attribulahk 10 \\"caKllt:ss of the lkcp neck Ilcxors .mtl dominance or e\"t:11 lightness of the slcrno~:kidomastoid, From this brief lh::--criptioll. it i evidcnl tlmt Ilcglect~ ing the analysis of lb~ musl.'ular sy tcm in standing leads to a lo:"ls of a suhq,.tnti:d am~)lllll of information. Only Ihl.' m;cin t:hangcs or mo,! frc«ul.'lH lindings an.: melltioned in thi . . dt:lpll.'r: IHl\\'c\"er. other kss common signs bring addiliOlWI daw.

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Hyperextension of the thumb.

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() \111,,1.:1..-;0.

\";Ill

h\.' iun)I\".'d

!i1 llIany

(lfhL'!' ;lfIL·'!\lI1S. One

{If

Ill:..'

:-.ilU:llilllb I ' ...· 'lllSlil11li()ll;t1 h~ ;',-'n1Hlhilily. Till' va~llt.:. IHHlpn1gn:ssi \ l" \'lilli..:;l1 :o..yndnlllll'. It. 'I rl':llly a dis,:;.,\". i.\ lit' 1l1lKllll\\1I (lrigill. 11 i_, ,:haral"tcfi'l.cd j\~ .: '::l·Il.:r:lll;l.\il~ ,II

lll\lSI (\Hllllhlll

li"'SIlC:'. 111 p:lnintlar ill' li~;lIl1l,,'ll\:'. l\'lust.:k <;-~'1l~11l ill ;L!"k\'h:d illdi\'idll:d ... u"llally i.. ltm. ;llld e\"en II \'i~\":"'H' "'1n.~ll~lhl'llIll~

C)

-~ 0 I I, 3,.

,

hypCflWphy. The

muscle

EllOV!..'l1h:1lt ::: lnillb is l.:ompari.llivdy iuncascd. In Spill,,' of

joinl illst;l('il::~. it has llot h~~ll conlirmco that "hypamobilc" 'UhjlTh

arlO ,,,,,r\.·

pr(Jll~ 10

t!c\'c!0P

musl.:lllo~kdclal

pain syll-

dn 11lll·S. ('llll,lllt,i:"Il;1! hypl:fI1Hlbility involves [hl: l:rHir~ hody. <11thuuglf ;111 .:~~":, may llol hl' ;llTcClcd 10 Ihc ";lIn~ cxlCnl and :-.Iiglll a:-.~ Illi,':;:lry l:<1Il he oh,crvcd. This . . yndml·l~ is nuted more frl·qlh.·ii!l~ in women ;lIltl it typically involves the upper part of thl' ~\'\I~. With ;tging. hypcrmobilily decreases. Paticl1h \\ Ilh cOllstitutional hypcnnobility Illay develop II1USCIe lighl!l(,';s as wdl. although it is never so evident. i\,tostly, Ihi, li"i"hlllcss is cOll"idered ..I I.:olllpensatory l1ledlanistll to . . t;lbilil.e:. in panicular. the: weight-bearing joints. Thcn.::forl', 'lrctl.:hing. if necessary. should be performed gelllly unu lllliy in key lllu . . t:Ic . . 1hal ..lfe: supposed [0 be dcci· sive in ;1 p:mh:ul;lr syndrome. Because the IllllSCIe:; gcncri.llly afe wC
or

i 0

i0 ~

10 t'\ llknt

points in mu:-d~s ~nd ligamems develop c;:lsily. Assessment hypermobility is in principle bas~d on estimation of muscle [one by palpation ;md range of motion of the joints. in clinical practice. orientation tests usually ;lre suflicicnLln the upper pan of the body. the most useful tests
~ ~. ') ~,

I

k
Illl!

hlllL' is \k... rl·.:~;:d when a:,sc:.scd hy palp;ltion and the range of

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.

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R

SUMMARY Fig. 6.31.

The lorward bending test.

j\'hl.""h.:: illlb;:lJn,c is an c . . 'cmial comp0J)cnt of dysfunction or' thl' lllUS'lllo_~kcletal syslem. Important ap-

synorume:~

Fig. 6.32.

Dorsiflexion of the fool.

proach~~

ill Ihe o\'crall therapL'lIli . .· progralll lie in lh~ recognition of factors that p.:rp.:lll
HEFEREfI;CES bnda V: ~l11~dt' ~lrt'n;:lh in rdalimll\lll1U~ch: Ienglh. pain and mll~ck i111halalll.:~. III H;tr1Jh·Rindahl K (cd): M\lSck Slr~llglh, Ncw York. Chur..:hill Li\'inpllllh.'. 199,1. bnda V: r..1 usck ~P;I'lll-;l pmpl1scJ 11n~c\lurc for diffcrclIlkLl di:lI~no· ,j,. J i\1;1Il1l:11 i\1.:,1 (,: 1.::(" 1991. ~

lUllla V: i\tusd..: Fun,lion

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-

ulagnosis of Muscular Dysfunction by Inspection

I --:,

LUDMILA F. VASILYEVA and KAREL LEWIT

,

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•

This chapter is devoted to the art of iDspcction. On thc basis of work by Janda concerning 11l0VCIllcnt patterns and that of Travcll and Simons dealing with the musculature. the authors show how much can be g~lincd by inspection. It is no coincidence that findings prim:triiy concern muscles, for [hey .Ire most in;portanr for the shape of (he hum:tn body. Their hyperactivity ;:md shortening rcsllhs in visible hypcnonus. their weakness in flabbiness. These clmngcs not only arc patent but also significantly change posture. Le.. body statics. and. of course. move me III paucrns_ The aim of this chapler is to show that changes in body shape or statics (Le.. body contours) arc so specific and relcV:\nt thm often it is possible by mere inspection to identify the single muscle involved. movements affected. and related joint dysfunction. This proficiency speeds up the difficult and laborious diagnosis of dysfunction of the motor system. The importance of diagrammatic sketches and photographs is emphasized. The focus of this discussion is on inspection. i.e.. with visual charactcristics. If used judiciously. inspection allows us to assess changes in individual muscles. thcir relative weakness or hypemctivity. and/or shortness. This }nfomlation is important for the a~$essment of not only muscle function as sllch. but also body "t;.Hics. kinematics. and joint function.

DIAGNOSIS BY VISUAL INSI'ECTION: AIMS AND I'OSSilllLITlES Main concerns when assessing the motor system arc as follows: I. Identifying dysfunction

By analysis of body contours; first. bony prominences .1Ild their relative position examined from in front. from the side. from the back, .and from .above b. By comparison of findings with "the norm" (or a model) c. By identifying the arcH of the most important asymmetry d. By drawing horizonlal and vertical lines through the most important points to locate maximum distonion (see Figs. 7.1 to 7.4) 2. Visual criteria of dysfunction of individual muscles :t. Attachmcnt points arc closer togethcr if the muscle is shortened or hypcractive. or further
b. Of particular importance if these points are connected by a single joint or belong to the same motor segment (Inspection alonc, howevcr, is not sufficient to make a complete diagnosis of dysfunction, e.g., joint move~ ment restriction)l 3. Inspection is ncvertheless most important in directing our attention to the most relevant lesion Thc dysfunction that is most important tends to dctennine the asymmetry. I.e., deviation from midline. and should be distinguished from compensatory excursions.

Normal Body Statics The main criterion of normal body statics is to maintain balance with minimum expenditure of energy.2 The visual critCri
The Spille The plumb line from the occipilal protuberance passes through the spinous processes (at the ccrvicothoracic. thoracolumbar, and .Iumbosacral junctions) to the coccyx between the feel. The most important horizontal lines arc: b. between the ear lobes (tips of the mastoid processes) (2) c. between thc acromia (3) d. between the lower margin of the 12th (last) ribs (4) c. between lhe iliac crests (5) r. between the posterior superior iliac spines (6) g. between the isehial tuberosities (7)

3.

The Upper Extremity h. The plumb line from the greater tubercle to the humerus passing through the olecranon and the middle of the wrist (8) I. The horizontal line between the major tubercles (the lateral angles of the scapula (9) j. between the oleerani (10) k. between the styloid processes of the radius and ulna (II) 113

2

9 6

3

3

9

§l4 .10

~~m~~

iW~--jf\-\-lH-6

._1.3 7

14

.~5:=-

7

t~

J.!L.

~

Fig. 7.1. Important reference lines for the assessment of body statics (back view).

The Lower Extremity I. The plumb linc from the lower scapular angle through the midpoint of the iliac crest between the femoral condyles to the midpoint of the calcaneal tuberosity (12) TIl. The horizontal line between the greater trochantcfs of

6

Fig. 7.2.

b,

c.

SIDE VIEW (FIG. 7.2)

a.

The plumb line from the external auditory canal to the acromion. following the axillar line to the midpoint of the iliac crest, the greater trochanter to the lateral

condyle of the femur, (he. tibia down to a point a linger's breadth in front of the lateral ankle (I) The horizontal between the occipital protubcr;ulI..'e and the lower margin of the zygomatic arch (2) The line between the medial cnd of the spina :,c;'lpulae through the head of the hUlllerus to the medial end the clavicula (3) The horizontal lines connccting two poilH:' in the course of each rib: one 011 thc vcrtical below Ihe midpoint of the clavicle. the other on the vertical trl)\l1 the lower angle of the scapula (4) The line from a point just bellm: the anterior :,uperior iliac spine to the prominence of the posterior :,up,,'rior iliac spine (5) The line from the upper edge of Ihe palella I" the I,>"er edge of the lateral femoral condyle (6)

or

the femora (13) 11. between the femoral condyles (14) o. between the condyles of the tibia (15) p. between the malleoli of the tibia and fibula (16)

Important reference lines for the assessment of body

statics (side view).

d.

e,

f.

b

\.-HAY I "H I ; UIA(jNU~IS

115

OF MUSCULAR DYSFUNCTION BY INSPECTION

2

4 3

5

4

6

5

6 Fig. 7.3. Important reference lines for the assessment of body statics (front view).

A

B

Fig. 7.4. Important reference lines for the assessment of body statics (view from above).

Fig. 7.5. Normal body ies (diagrams).

stat~

116

REHABILITATION OF THE SPINE: A PRACTITIONER'S MANUAL

g. The linc from the upper edge of the tubcrosit
tion (Fig. 7.5). Typical changes from normal body stillics are illuslrntcd in Figure 7.6.

or

h. From the lower edge the outer malleolus to the aiI;lchment point of the Achilles tendon (8) I. The plumb line from the external ~ludilory canal through the hC
The plumb line from the center of the forehead passes through the jugular notch of the sternum. the xiphoid. the navel. the pubic symphysis. to midpoint between the feet (I): b. The first horizontal line passes through the lower edge of the auricles (or the lower edge of the zygomatic

c. d. c. f.

arches) (2) The second line through the acromia (3) The third through the lower margin of Ihe last rib~; {Ill The founh through the anterior superior ili<1c spines (5) The plumb line [rom 'he midpoint o[ 'he c1"vieul
VIEW FROM ABOVE (ASSESSMENT OF ROTATION) (FIG. 7.4)

u. The line connecting both auricles (I) b. The line connecting both acromia (2) c. The line connecting the anterior ends of the ribs (3) d. The line connecting both greater trochanters (4) e. The line connecting Ihe outer condyles of the fcmora (5)

DisturIJcd [lady Sta'ics The main criterion of static function is that muscles maintain bal~tIlcc with minimum activity. Therefore. vbual ~vidcnce of increased tcnsion or hypcrtonus is of !lrc~H importance. NOiieei.lblc signs of IllUscul;'lr ilnbaiance also imply aSYlllllletry. and thcrdorc vism!} signs of hypotonus and
f. The line connecting the midpoint of the heel with the second toe (which ought 'he midline) (6)

lO

Disturbed Statics in Dysfunction of Individm\1 Muscles or Muscle Group~

be symmetric in relation to

These criteria in a shorleJwd tII11xde include allachrncl1l points that arc closer togcther than norm
Drawn on the basis of the data and illu~trations described in lhis chapler. the diagram in Figure 7.5 represents normal conditioll~ and is used for registration of muscular dysfullc-

-~

;;

Fig. 7.6. Abnormal body statics (diagrams). a,b: Muscle dysfunction. Dotted lines stand for dysfunctional muscles. c-f: Disturbed body stalies. Black, devialion from the vertical; gray. divergence 01 horizontal lines; angle 0". open in the direction of body deviation. g. h: Joint dysfunction. Black. restriction; gray. hypermobility (see also Fig. 7.36).

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CHAPTER 7 : DIAGNOSIS OF MUSCULAR DYSFUNCTION BY INSPECTION

.< <

:.Iltachmcnt points and flattening of its contours owing to hypotonus.

The imbalance just described results in the
attach. It

\

.1150

goes hand in h:md with articular dysfunction. I

Those cases in which the attachment points were closer tog.ether were ..ssoci;ucd with a preponderance of movement restriction. Hypcrmobility was found in neighboring segments of joints where movement restriction was fountl.

Diagnostic Criteria of Body Statics These criteria include the following: The direction in which the body deviates from the nann

,,~

Diagnosis of the region (muscles) primarily affected Diagnosis of the individual muscles affected Dirlgnosis of the individual joint dysfunction in the re-

I,

gion of affecled muscles and attachment points Diagnosis of hypcrmobilily. in pal1icular in lhe vidnil)' of movemclH rcstriction

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r} Assessment of Disturbcd Motor Pattcrns ~

.J

NORMAL LOCAL MOTOR PATIERNS'

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The crilcria for normal local patlcrns, such as in onc exlrcmity joinl or concerning one section of lhe spinal column. are as follows: Movement Movement Movement Movement

:)

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~

is carried out exactly ill lhe. u(;",;!"(;J direction is smooth and of a constam speed follows the shortcst possible path is carried out in its full range

117

Dircclion of movcment is dctermined maiotty by Ihe
The shortened muscle is also hyperactive
shortened, the relationship to the synergists, neutralizers, fixalars, and antagonists. is. out of balance and the local paUenl, I.e., Ihe direction, smoolhness. speed. and range of motion. are disturbed in a charnclcrislic way. (See subsequent section for discussion cC'ncerning visual assessment of individual muscles.) If Ihe synergists. neutralizers. and fixators arc shortcned. it is again the short synergists. neutralizer. or fixators that conlract first and distort the pattern. If the antagonist is shortened, the entire pattern is altered and substitution occurs (see discussion concerning weak musclcs in subsequent section). DISTURBED LDCAL MOTOR PATIERNS BECAUSE OF A WEAKENED MUSCLE

The threshold of irritation in Ihe weakened muscle is

raised and therefore. as a rule. the muscle contracts I:.Her

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Normal movement patterns (diagrams).

Fig. 7.7.

U t.':\

~~---,-----~-------------------------------'<~J

REHAtilLlIAllUN OF THE SPINE: A PRACTITIONER'S MANUAL

110

than normal or, in some cases. not at all. Hence. the order in which muscles contract is nltered. :.IS is coordination. The

dr;'lwn by a dott~d lin~. Agalll. 1m tile s<.lkl: III \.:iarity. tht: changes havc purposefully bcen exaggerated.

most characteristic feature, however. is substitution, altering the entire' pattern. This change is weak muscle is the agonist. If. and/or the fixators 3rc weak. the there is ;:\cccssory mOlion~ if the range of movement is increased.

particularly evident if the however. the nClItr;i1ii'-cr:-: bi.lSic pattern persists but antagonists arc weak. lhe

Gluteus Maximus GENERAL CHARACTERISTICS

.

This l1H1sdt' h,l~ a It:ndcncy 10 he inhibitcd or weak.

'.'

j

COMPLEX MOTOR PATTERNS'

FUNCTIONAL ANATOMY

The criteria for complex motor patterns arc as follows:

Points of

Typical synkinesis in distam regions with primary

:JUachmcnl:

movement in other parts of the motor system

Smooth propagation of motion from one region to other

;

Origin

Inserlion

I. Upper part of the innominatc 2. Lower pari of thc

I. Tbe supcrlicial tillers cross over Ihe gre:lter lro-

sacrum

part' of the body A constant (optim4J!) rcl;'llionship between lhe speed of 1t100ion initialed in one region with the speed of synki~ ncsis in other regions If local pmlcrns arc changed. synkinetic patterns rCIll
.,

3. Cocc)'x-I
2. The lower pari (\1 Ihe lihers atlach

6. The fascia or the glu-

(he gluteal tuher-

DISTURBED STATICS BECAUSE OF WEAKNESS (FIG. 7.8)

1. Upper p:Jrt of the innominate dOTSOl1lcdioc;.sudall)'

:Ht:lchIllCllt

VISUAL CRITERIA OF DYSFUNCTION OF INDlVIIJUAL MUSCLES A key c1emcnt in diagnosis is a sct of tcsts that show wcak~ ness on the one hand and tightness on Ihe otheLf ' In this sc<"~ lion, we show how both sho;tcncd lTluscies Hnd wC~lk lTluscles call change body posture and in particular the contours of the human body. \Vc also provide the visual criteria of somc musc1cs prollc [0 such change that arc noted frequently in clinical practice. In this chap[cr. ccnain key muscles th
poill1s on ("(llltr.lctil1ll:

2. Sacrum: 1(I\\,cr p,lri mediodorsoc;l\Idally

3. Coccyx: mcdiodor...C1caudally

Possible change ill position ,...(

I. Innominillc: i1ntcn;r-

ana{(lInie

2. Sacrum: '\lHc\'cr~i(.rn. ipsilatcml flexion. and

MTLIClllres (owing tll

..ion. cXlcTIlal rotaliun

rot;.stion 10 the same \ide

wcakncss"l:

3. Lumbar spine: hyperlordosis with SCOIII)\;", toward the ipsil:lIcral ...ide .:I

Lower p;lrl of Ihe ...acrum ;.md cocc)'x:

contrJI"tcr.a1 devi;llioll

Joilll mohility:

Sacroiliac joint: IpsilalCr;tl movement

;!l

osit)' of the 1i..'lllUf

given in Figure 7.7. Deviation from the normal patterns can be registered on the diagrams. For the sake of clarity. the findings in the flgurcs to follow

pull at the

~

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10 the i1iutibial (ract.

). Sacrolubcnlll"; li~;lInclH

(eus medius

Direction of

,..

challlcr ,Ind atl:lI.:h

The results of assessment of local molor patlcrns arc

arc cxaggcr.Hcd. The most important ~)robablc objection to such CXi.lggcralion is that it is farc under clinical conditions that only one muscle is dysfunctional. although one muscle is usually the most affected and relevant. Hence. the results arc artificial, in a way. We believe. however, that it is itllpog~ sible to understand the complex clinical picture without knowledge of the significance of a single shortened or wcak~ cned muscle.

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119

UIAt.,;iNU1;iI1;i OF MUSCULAR DYSFUNCTION BY INSPECTION

Fig. 7.8. Disturbed statics in a weakened gluteus maximus. Front view (a) side view (b), back view (c) view from above (d); 1, pelvis; 2, femur; 3, gluteus maximus.

B

c

;r

D

,

120

REHABILITATION OF THE

DI~

CHANGES IN BODY OUTLINE BECAUSE OF WEAKNESS (FIG. 7.9)

Front vicw:

1. Increase in

tf'-lllSVCrSC

diameter of pelvis,

mainly in c
is lowered. anterior suo

pcrior ilia,=, is depressed 3. Ramus sup. as pubis is lowered and protrudes

anteriorly Side view:

bar

verse diameter of

1. Buttocks protrude postcriorly and pel ....is is naucncd anteriorly 2. Increased lumbosacral lordosis

I uR~eD MOTOR PATIERNS BECAUSE OF WEAKNESS

cxten~or~

become

m(\fC activ~

(see Pig. 7.12).

Biceps Fl'Oloris GENERAL CHARACTERISTICS

hip.

2. Upper margin of iliullI

t-'HAc..;lllIUNI::H~ MJ-l.I~U"""L

1. Increase in truns-

2. Gre.lIer trochmucr

portion

A

If there i~ wcakness of lhi~ IllUSCIe. Ihe halll'\trings and hlln-

In!'cnioll

Qrigin

~I-'INI:::

is displ:lccd

This musclc has a Icndcn.. . y III bc(.;olllc shoflcncd and ovcr.1ctivc.

upward and protrudes 3. Valgosity 'It knee; patella is shined medially

FUNCTIONAL ANATOMY

Puints of attachment:

1. Anterior shift

I. Long head: poslerit1!' aspcct of i~thial

mainly of distal "J

pan of thigh. fOfward protrusion of knee 2. Slight flexion of all major joints of

tuberosity

f!ethcr form

Short head: lataal lip

mOll

it CUIll-

tendon lhal rum:

of linea aspcra of

along latc"ll condyle:

femur

:lIld eSlablishes

partite

;l

lri-

'lIlchor It) bl·

era! aspect of libular head

extremity Back vicw:

I. Long head is joined hy short hcad and \ll-

1. Increase in vertical dinmClcr of ipsilateral

buttock

2. Gluteal line is lowered 3. P.S.I.S. is closer

10

sacrum IMPAIRED BODY STATICS BECAUSE OF SHORTENING (FIG. 7.10)

Changes at the ipsilateral side:

(

Direction of pull al lhc attachment

Qrigin

Insertion

I. Ischial tuberosity is pulled in caudal-Imcr;:ll·

I. Fibular head is pulled in craniu· dors.1! direction

dorsal direction

points on contraction:

Possible changes in position of analomic 'L

B

Fig. 7.9. Changes in body outline because 01 weakness of the gluteus maximus. Front view (a), side view (b), back view (c).

J. Flc;r;ion adduction and eXlernal rt1I;I(ion of leg bdow

knee (vcnlrof1h.~· dial shift of di:H.1I end of thigh)

structures:

Joint mobility:

A

I. Innomini.lte retrol1cxion adduction and imcrnal rolation

I. Hip c;r;tcnsion (Iighteniog of sacrotuberous ligament)

I. Knee. joint: Hex· ion. exlernal rola· lion. anutorsiOIl in relation Iu Ihigh. (i;r;alinn of tihiofibular juilll: valgosity

\",n",t"

. Util::i It: H I '. UIAl.,;iN

OF MU SCULAR DYSFUNCTION BY INSPECTION

121

\

1\

r .'

O"'.J•Ii, l"._

1/

fM

B

Disturbed body

Fig. 7.10. e of a short~ statics becaU~emoriS. Front e ned biceps . (b) back side view . . view (a). . m above (d), fro view (c) view r" 3 tibia; 4• . . 2 femu, . 1. pelvIs, .' ps femoris. libula; 5. blce

,j

I

1 <:<:

REHABILITATION OF THE SPINE: A PRACTITIONER'S MANUAL

CHANGES IN BODY OUTLINE BECAUSE OF SHORTENING (FIG. 7.11)

From Vic\\':

Ori~in

!lI'l'rtioll

I. Decreased transvcrsc diameter of tlppt.·r pan of bcmipdvis , [nnolllin;lh: is hl\\"crcd and com:a\"e: antcrior

I. Increased tr;llls\'c,":'e di;ullelcr (If lllwer pan of

:mpcrior ili:lc spinc raised: upper edgc of pubic bOlle is r..lised and less prmninen!

j

1

I1 1

I, ~

Side View:

%1

I. Pelvis is drawn forward ;md its dorsal outlinc flattened

i !

~

,.

hemipdvis L:lleral cOlltour (If thigh at lcvel (II' trnchalller is more prolllincill Knec lics morc medial and su dnes patella: medial

-'1

condyle protrudes

{,.

I

,

Bilek

I. Increased concavity of pelvic outline above buttocks and increased prominence of buttock ami g.rc.lIcr tuberosity

View:

I j Ig

I. Distal end of thigh is thrust forw;ml and patella protrudcs

I. Protrusitlll of IlH> dial fClmw.l1 condyle 2. Dor.-;a[ protrusioll of libul;lr head Jild of biceps muscle Icndon

~ !l

I

A

B

Fig. 7.12. Hip eXlension in a patient with a shortened biceps femoris. Back view (a). side view (b). DISTURBED MOTOR PATIERNS BECAUSE OF SHORTENING AND OVERACTIVITY

This paucrn may include an altered activation sequence of muscles during extension or the hip joint (Fig. 7.12). The order of muscle contraction during hip extension is I. Hamstrings Glutcu~ muxillllls J. COlltr~l
2.

"

\)

DcI
, f

Tcn.wr Fasciae Latac GENERAL CHARACTERISTICS

This muscle has a tendcncy to becomc shortened and over· nctivc. FUNCTIONAL ANATOMY

Points of att:ldllllent:

A Changes in body outlines because of a shortened biceps femoris. Back view (a). side view (b).

Fig. 7.11.

I. From ,Interior part of OUler lip of iliac crest to ;,mtcrior ~upcrior iliac spine

I. Antcromedinl h:lldimlus fibers lerminate in I~teral palcll:lr retinaculum

2. Posterolateral half of musclc tcndon :11taches below knee onlo later.lliubcrclc uf tibia via iliolihial truet

-"'( ,oj

,

I '

123

CHAPTER 7 : DIAGNOSIS OF MUSCULAR DYSFUNCTION BY INSPECTION

I 1 ~

Fig. 7.13. Disturbed body statics because of a short~ ened tensor fasciae latae.

1

Fronl view (a), side view (b), back view (c). view from

above

(d);

1.

pelvis;

2.

femur; 3, tibia; 4, tensor fas-

ciae lalae.

!. i1

I

(~

',,",,

'

\J ''''

p~Ai

B

124

REHABILITATION OF THE SPINe.: A PRACTITlQNt:H"::; MANUAL

IMPAIRED BOOY STATICS BECAUSE OF SHORTENING (FIG. 7.13)

DISTURBED HIP FLEXION MOTOR PAITERN BECAUSE OF SHORTENING (FIG. 7.15)

Changes at lhe ipsilateral sith.::

Din:Clioll (If

Origin

Direction of pull at the attachment "

I

I, 8

points

I. Caudolah:nHlnrsal Pill! at ;llltcrillr :'\lp~rior

I. Cralliolalcro-t1ursal

spine '"'I

Oil

pull ,il proximal end of tibia VClllroll1<:di;d dc\'i:lresull

or muscle's

tendency 10 approx.· illl.lIe tibia toward

pelvis

Possihlc changes in

J. Innominate- ahductioll. ;mld1cxi(lll. ami cxlcr-

J. Vcntronicdi.11 dcvia·

position of

nal rotation 2. Flexion. uddllctiotl. and internal rotation of proximal end of thigh

thigh: abduction. l1cxion. and eXler·

structures:

Joiu! mobililY:

I. Hip j\lint: Ilcxiull. ;lhductiUl\. internal

J. I-fip joint: abduction.

ncxioll. intern:ll rotation

l"(ltaliol1 2. Knce joint: l1exion. abduction

GENERAL CHARACTERISTICS

This muscle active.

Poinls of

lmal end of tibia

attachment:

I. Knl;C joint: stabi·

lii'.:ltion. Ilc:-.:ion. rot:ltilln

I. Increased trJnsverse diametcr of upper part of

I. Increased transverse diameter in hemipclvis 2. Lateral contour of thigh fonns straight line: tensc fibers nf iliotibial band visible 3. Lateral (emordl condyle protrudes: p.neHa deviates laterally.

protntdcs anteriorly 3. In addition. tense muscle belly of tensor fasciae latae fonns round

protrusion

Side view:

I. Pelvis dc"i.nes posteri-

a

tendency

to become shortened and over-

FUNCTIONAL ANATOMY

llal rotation of pmx-

In
hcmipclvis

hits

liun uf disl;tl end uf

Origin

2. Iliac crcst is raised and

rnt;lIes: pelvis shifts toward ipsiJmcroll sidc , Lumbar spine extends and side bends 3. Hip flexion and :lbduction ~. Lateral deviation of paldla and toes

Piriformis

CHANGES IN BODY OUTlINE BECAUSE OF SHORTENING (FIG. 7.14)

Front vic\v:

I. Ipsil;lter31 innominate is lowered ;lIld

lion of thigh is

contraction:

;lIl:ltomic

~"lovC1llelH

nexed ;lIld pro-

at level of hip joilll and

trudes anteriorl)'

J~rtiQn

I. Anterior lateral surface of sacrum between first and founh sacral for:lmen 2. Pall of fibers aHach to margin of greater sciatic foramen at cap!'ule of sacroiliac joint and sacrospin:tl ligament

I. Fibers run through grc;ltcr sciatic for.mh~n

to

and alt;leh

grc;lt~r

1

trochanter of femur on medhll side of its superior surface

)

, .J

)

.'

I. Knee slightly

orly; relative concavity

Ori<1in

,

i

_.~

f

increased convexity at

level of coccyx

')

'.J

2. Increased lumbar lordosis Back view:

I. Superior deviation of posterior superior iliuc spine appears deeper

and at greater distance from sacrum 2. Ischiill tuberosity. however. approaches sacrum

I. Protnlsion at level of contr;\cted mus-

de: pelvis is inc..'-lined to the

Si.lnle

side 2. V':llgo:-ity at knee omd abduction of tibia

A

B

c

.j

Fig. 7.14. Changes in body oulline because 01 a shortened tensor fasciae lalae. Front view (a). side view (b). back view (C).

L <..

>

CHAPTER 7 : DIAGNOSIS OF MUSCULAR DYSFUNCTION BY INSPECTION

125

1

I ~:

I

10

i I ~, \1

:j

Fig. 7.15.

I

fasciae latae. Side view

i

B

A

!i () 10

I

,)

I

I

(al,

front view (b).

IMPAIRMENT OF BODY STATICS BECAUSE OF SHORTENING (FIG. 7.16)

Changes at the ipsilateral side: Qtigjn Direction of pull at attachmcni

I. Latcrocaudo·\'cntral pull at lower part of sacrum

I. CraniulIlcdio-

CHANGES IN BODY OUTLINE BECAUSE OF SHORTENING (FIG. 7.17)

dorsi.ll pull
greater troch:.lOtcr

poim on

producing approxi-

contraction:

Illation of ~acrum

Fronl Vic\\':

and greater trocharlil.:r. causing

i f,

Hip flexion in a pa-

tient with a shor1ened tensor

Q.tigin

Inscrtion

I. Anterior superior iliac spine lies higher and is less prominellt 2. Upper edgc pubic bone devi,llcS craniamedially

I. Latcral cOntour of gre.ucr trochanter is nallcncd 2. Leg is in abduction and external wt,Hian 3. PatcH,••Uld {()C$ arc dcvi. ated laterally 4. On changing weighl 10ward ipsil.ltcral leg. position of loes rcmains unchanged. but \'algosily at knee bcnmlcs cvidellt

I. Pelvis is thrust b.\(;kward and both sacr:d

I. Knee .\flO ta\ocrunll joilll

ur

laicrovclllral deviation of caudal part of pelvis

Possible

changes in position of anatomic structures:

1. Sacrum is tilted hack

ion of sacrum 2. Pelvis is thrust back: tendency to "f:lll" compcIlS~l1C,

tient

slall(.I~

the pa-

on COIl-

tralatcrallcg.

Joint

mobility:

OUI\vard roWtiOll

and flexion; leg and knee deviate 10

side and for-

witrd with ten-

Side Vicw:

dency to varosity

backward 3. To

I. Thigh: abduction.

I. Hip joint: Olll\vard rota-

tion, abduCli\lII 2. Sacroili
al

arc slighlly ncxed

kyphosis amI lumbar

knee

lordosis arc reduced Back View:

I. Trans\'cr.;e diamch.::r of hcmipclvis is reduced: poslCrior superior iliac spine lies ne,lrer to S.lcrum ,Hld is more prolllinclll

I. Knee deviate!' I:llerally: laleral cdge of popliteal rossa in a lllorC dorsal and mcdi'll in more vl.:ntr:.ll posilil\l\

RI:.HAIjILlIAIIUN VI- I HI:. :;)t-'INt:: A PHAG

126

1IIIUNI:.H~

MANUAL

B

Fig. 7.16. Disturbed body statics because of a shortened piriformis. Front view (a), side view (b), back view (c), view from above (d); 1, pelvis; 2, femur; 3, piriformis.

c

"

D

h

...

_~~_~

... , .... , ...'

V'~"'"

.v,.. u, " ........

&;; ......

,V,,,

127

," ",

A

I \)

c

B

B

Fig. 7.17. Changes in body outline because of a shortened piriformis. Front view (a), side view (b). back view (c).

Fig. 7.16. Hip flexion in a patient with a shortened piriformis. Back view (a), side view (b).

~ ~-::

l.} .

it

~~)

~ I,"_..:::.--oL-__-,'J

10

_

DISTURBED HIP FLEXION MOTOR PATIERN BECAUSE OF SHORTENING-HIP FLEXION (FIG. 7.18)

Din:Clion of Mm"Clllcnl

Visual Crill'ria

Shcarill~ force at s
I. I)l1r;ll~ ~;1it. P~llil.;l\l raises ipsilateral

I.

abduction. Ocxioll at

Insertion

inrwmin;ltL' wilh intcfIlal rotation .., FI:llICIK'd lateral outline at hip 3. Leg is fined. abducted. and in olllward wlalion with (Onl and loes de-

Front View:

I. Tr;.lIlsn:rsc diameter of ipsihlterallowt:r part of thorax is diminbhed 2. Waist is narrower

I, Increased transversc diamcter of ht.:lllipeivis . mainly lower part

2. Antt.:rior superior ili"c spine deviates latt.:rally and is more promincllt 3. p.lticnt puts weight mainly on ipsil:ltcral leg: contralateral leg is ab-

viated l:llcrally

hip joint

Quad~atlls

CHANGES IN BODY OUTLINE BECAUSE OF SHORTENING (FIG. 7.20)

Lumhorum

ductcd flexed

GENERAL CHARACTERISTICS

The qu.tdr..ltus lumborum ll;ls "l lendency to become shorlcncd and overactive.

Side

I. Increased lumbosacral

View:

lordosis

FUNCTIONAL ANATOMY

P(lims of au~chlllcn[:

I. Vertical iliocostal fibers: medial half of

12th rib 2. Diagonal iliolumbar fibers: End of fina three of rOUT lumbar tmllsverse processes 3. Di3gonallumbocostal llbcrs: 12th rih

1. Posterior part of iliac crest llnd iliolumbar ligament 2. Iliac crcst and. frequently. iliolumbar ligament 3. All lumbar transverse processes

Decreased sagittal diameter of pelvis 2. Sacrum with coccyx tiled dors
---..

- J

is nattened Back View:

I. Lumbar spine deviutes to side. resulting in scoliosis 2. 12th rib and innomi-

,_ IMPAIRED BODY STATICS BECAUSE OF SHORTENING (FIG. 7.19)

.md slightly

nate approach lumbar spine: transverse diametcr of trunk at waist diminished on that side: lateral contour more concavt.: Frequent compen· satory thoracic scolio$is to opposite side

I. Apex of sacrum with coccyx and ischi.l1 tuberosity approach thigh 2. Transverse diameter of buttock is diminished Gluteal foid is r.tiscd 4. Posterior superior iliac spine closer to the sacrum

,.

)

Changes at the ipsilateral side:

il

'I

I 1 I .~ '~!

Ii i :~

t!

Dirct:\iOll

Q.rigin

of pull

I. 12th rib caudolllcdially: \riln~Vcrsc processes later;.lly

I. Iliac crest: craniotllediodorsally

I. Lowering of 12th rib.

I. R
at attachmcnts on contraction: Possible changes in posi\ion of anatomic strUctures:

Joint mobility:

increa~cd

hunbm lordosis and thor:lt:ic kyphosis: IUlllbar scoliosis to Samc and thoracic scoliosis to oppositc side

DISTURBED HIP EXTENSION MOTOR PATIERNS BECAUSE OF SHORTENING (FIG. 7.21)

i. Fixation of the 12th rib.

increased pressure on intcrvcrtcbr.tl .md lum· bosacr.tl joints 2. Thoracolumhar hypermobility

I. Flexion and adduction posilion of hipjoillt

---~

'-J

The quadratus lumborum contracts before the hamstrings and lhe gluteus maximus. Direction pf Movement

Visllal Criteri,j

I. L.umbar spine: extension.

I. When
side bending 2. Pelvis: laterol1cxion and antcnexiol1

~

~ ~

I• .~

,~ '1' :li

,B ~

,,",

1

b

~

'nu' v.;:).;:) ur- MU::;iI",;ULAH UYSFUNCTION BY INSPECTION

129

,

.> "

,

i 1"')

~ ....... I

,

\. .J

\

()

.,e

i

~

In ,,~ i n I ,

j

~

! ~

I i!

••

0 ~J

1 ,

•i~ ~.

i

'"'!t

,J

B

.,;,),

.7

~

j

!

t

r} 1

] i

~

•i

2

4~~r::;-

-"'~

v

,

< ~i

§ m

•

~

)

2-~'£ 4

c

D

Fig. 7.19. Disturbed body statics because of a shortened quadratus lumborum. Front view (a). side view (b). back view (c), view from above (d): 1, pelvis; 2, lower rib; 3. lumbar spine: 4. quadratus lumborum.

nl,;;, ,,, ... ,,-,."1 ,v,,. v r Inc .;) ... 11'\1(:; f'I t"'N""'l,..; 1IIIUNt:N;:;:' MANUAL

I

I ,;

@

~

~

> ,; o

~

I

A

I

B

,

c

•.ff

Fig. 7.20. Changes in body outline because of a shortened quadratus lumborum. Front view (a), side view (b) back view (C).

,

~)

:d '<;

~

~

i )

1 ~

t< ~1

l i ~

i

II

)

·I

,

?i

j ~;

~

II

Fig. 7.21. Hip extension in a patient with a shortened quadratus lumborum. Back view (a), side view (b).

A

B

I ~

~"

'"

---.,,.--

,

U

al..._

~

,•• _ ,,,>,,;>,.. Vv•.,:) vr

DISTURBED TRUNK FLEXIDN MOTOR PATTERN (IN THE STANDING POSITION) BECAUSE OF S: :ORTENING OR OVER· ACTIVITY (FIG. 7.22)

The. quadratus lumborum contracts before the iliopsoas and rectus femoris. Dirl'ctiun of r-.·1Q\'cment

Visual Crileria

I. Lumbar spine: extension. side bending (s;,unc side)

I. On trunk anteflexion. lumbar spine goes into extension and bends to same side; thorJcic

2. 111Or;lcic spine: flexion. side bending (opposite side) 3. Hip joim: nexioo

131

MU~VULAH uytil-UNCTtON BY IN::iPECTION

spine goes into flexion and bends to opposite side 2. Flexion lakes place mainly in hip joint; enlire body shifts forward

IMPAIRED BODY STATICS BECAUSE OF WEAKNESS (FIG. 7.23j

Changes at the ipsilateral side:

Qris.in Direction of

force at atlac1ullent points of contraclion: Possible change in position of anatomic

structures:

I. Ctrlil;tginous end of 5th-7th ribs :lIld xiphuid caudally

I. Pubic bone

I. Rib" and canilages with xiphoid deviate crani;,lIly and contralal-

I. Caudal shirt of

crally, resulting in ex· tcnsion and side bend·

pubic bone pro-

duces anteflexion of innominate 2. Pelvis deviatcs

ing of thoracic spine in Opposile direction 2. Compensatory scolio· sis and increased kypho;;is in upper thoracic spine

dorsally and con· tralatcrally result· ing in incrc:tscd lordosis of lumbar spine and in scoli· osis Iowards ip:'ii· liltcrul !'ide

Rectus abdominus GENERAL CHARACTERISTICS

The rectus abdominus has a tendency to become weak.

Joint mobility:

l. HypcmlobililY at thoracolumbar and lumbosacral junctions

Cr;,l-

nially

t. Hypennobility:lt symphysis: pelvic obliquity

Fig. 7.22. Trunk flexion in a patient with a shortened quad· ratus lumborum. Side view (a),

back view (b).

I§._(}_.... -~

4... _ _"""'7'"

~

•• _

_._

Inl:: .::Ir-ll'o1l::.

J\

t"MP,\,jIIIIUNt:.H":;j MANUAL

) A

B

----~

. .1

)

.,

-)

Fig. 7.23. Disturbed body statics because of a weakened reclus abdominis. Front view (a). side view (b). back view (c).

..

__

.~------------

c

_,,, ....... "

, ..... ,,...~ .... v.::U;;;)

MU~I.;ULAH UYSFUNCTION BY INSPECTION

ur-

CHANGES IN BODY OUTLINE BECAUSE OF WEAKNESS (FIG. 7.24)

Front Vic\\':

I

CJ

Side View:

Back View:

Qrigin

Insertion

I. Increase in vertical di.lmcter of abdomen 2. Trunk deviates (0 contralatemi side

I. Increase in tran~\'cr~c diamcter of lower part of

I. Increased protrusion of abdominal wall; sternum is lifted and xiphoid is close to skin surface I. Scoliosis toward ipsilateral side mainly in

lumbar region

pelvis 2. Pubic bone dcvi,lIcs down ano w sidl: I. Incrcased lumbar lordosis and prominence of end of sacrum

I. Innominatc is lowcrcd

and waist is flattcncd; deeper on oppositc side

DISTURBED MOTOR PATIERNS BECAUSE OF WEAKNESS

As a rule. the psoas substitutes for a weak rcctus abdominis. The iliopsoas. erector spinae. quadratus lumborum. and rcctus femoris may all become overactive when the rcctus abdominus is weak or inhibited. Directinn of Movement

Vi... ual Critcrin

I. Lumbar spine: eXICIlSio!l ,,;i;", ;Ji~I"'Jn~.\ioll iO

I. While stooping, the paticn(s lumbar spine remains lordotic as the patient side bends 10 the SClme side: flexes thoracic spinc. and side bends to the opposite

same side Thoracic spine: flexion wilh side bending to opposite side 2. Pelvis: l:lleroflcxion to opposite side 3. Hip joint: flexion

GENERAL CHARACTERISTICS

---

This muscle has a lcndcncy to becomc short..:n..:d and over"clive. IMPAIRED BODY STATICS BECAUSE OF SHORTENING (FIG. 7.25)

Changes.H the

Direction of pull at attachment points on contraction:

ipsilater~1l side:

Qrig!ll

Insertion

1. Occipital bOlle: cmllJovcntrally and slightly lat-

I. Acromion: in eraniollwJial direc-

ti(ln

er'llIy

2. Uppcr ccrvic:il spinc: mainly Iater.lIly ,1Il0

slightly caudoforw'lro Possible changes in position of anatomic structures:

1. Head deviates to side, forward. and into rClroflcxion wi.h rotation to opposite side resulting in increased cranioccrvical lordosis

2. uter.ll pull at spinous processes results in lateroflexion on upper cervical spine coupled with rOl
I. Clavicle with acromion deviate CfaniOllledially 2. i\·lcdia: pull produces compression of clavicle against sl~mum

3.

compens:lIc. some side benJin,g. ;\1 shoulder girdle hl opposite side Wilh r\Jt,ltiull (() ipsilataal side

T(l

3. To compensate, some scoliosis at cervicothomcic junction (0 ipsilatcr.11 side with incre'lscd kyphosis

sidc. 2. Also flexes hip and entire body is shifted back

Joint mobility:

A

133

c

I. Fixation at cervical and upper thoracic spine; hypcrmobilily at cr:lntocervical and cCfvicothoracic junction

I. f-ix;uion a[ s[erno-

c1a\"icular: hypt:rmobilil)' at acf<.\mioclaviculm joint

Fig. 7.24. Changes in body outlines because of a weakened reclus abdominis. Front view (a). side view (b). back view (c).

REHABILITATION OF THE SPINE: A PRACTITIONER'S MANUAL

134

A -",

Fig. 7.25. Disturbed body statics because of a shortened upper

()

trapezIus. Front view (a), side view

(b), back view (c).

) )

) ,

~) -

-"

.J

0 ~J

l

~.-,'

Fig. 7.26.

Changes in body

outline because of a shortened upper trapezius. Front view (a), side view (b). back view (c).

)

,J

C

'~_A' ·1

CHAPTER 7 : DIAGNOSIS OF MUSCULAR DYSFUNCTION BY INSPECTION

135

CHANGES IN BODY OUTLINE BECAUSE Of- SHO,HENING (FIG. 7.26)

f-rolll View:

I. Hc.u.l inclined to ipsi· lateral and rotatcd 10

opposite side; car is

"

1!

It ~

t

.. ' ...". U

Side Vic\\':

0

~

j;

;~~

verse diametcr 2. Acwmion dcviale:-; mediocnuli:llly 3. Prominent upper contour of shoulder; fi:1Ucncd outline of latcr.J1 part of dnvicula

I. Head is thrust forward

I. Acromi<;m dc"iah::s em-

.lIld benl back; ipsilater;1I car points anteroinferiorly

I1

II ~ ,• ~

0

~

\,

Back Vic\\':

")

t

;1

n t1

l]

I

""',

,~)

I. Shoulder girdle is raised; decrca<;ed transverse diameler 2. Raucncd latcr.JI contour of neck and shoulder 3. Lateml outline protrudes at level of acromion

contralatcr..tl in cervical ;)nd ipsilatcwl cer\·icothor.lcic region

)

~

DISTURBED MOTOR PATTERNS BECAUSE OF SHORTENING ON SHOULDER ABDUCTION (FIG. 7.27)

'>

i,;

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The upper

Jj Ii

i

I. Head and neck indined to ipsilateral side 2. Contralateral car is raised and more visible 3. Horizontal fold (sign of cx:tension) .It emniocervieal junction 4. "S" scoliosis noted-

J

I

nially 2. Increased dislance between acromion and

dosis and prominent cervicolhoracic junction

{)

I

tr~lpczius

~)
Direction of Movcl1lelll

Visual Criteria

I. Acromioclavicular joint: move men1 of shear between clavicle .1Ild shoulder blade 2. Head: extension. ipsi-

I. Elevation and oUlward rolation of shoulder and arm 2. Head is inclined to ipsilaler.11 .tnd rotated to contralateral side: head is thrust forward and in ex-

I , i

Fig. 7.27. Arm abduction in a patient with a shortened upper trapezius. View from above (a). back view (b).

DISTURBED MOTOR PATTERN DURING CERVICAL EXTENSION (FIG. 7.28)

The upper trapezius bilaterally contmcls before the spinal extensors.

contracts before the deltoid (clavicular

portion) or the supraspimltus. creating a dysfunctional scapu~ lohumcr:lI rhythm.

~

A

humeral he'lt! 3. Flattened cervical lor-

:<1

i)

ipsilalcml sidc and is r;liscd: decrcased Irans-

seen ,lI1d lowered; other car IS partly hiddell
() ,) '-.

I. Shoulder girdk rt)lah;S 10

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,ff 0 i$ ()

lateronexion.

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c(lntralat~

eral rot4ltioll 3. Cervical spine: forward shift. ipsil,Her:tl flexion. contralateral mlation 4 Shoulder girdle: upward dispiacemcill

L

tension 3. "C" scoliosis of cervical and upper Ihomeic spine

Direction of Movement

Visual Criteria

). Head eXlension: ipsilatefonex:ion. contralateral rotation 2. Cervical spine: forward shirt. latcronexion to the same. rotation to OPPOsile side 3. Shoulder girdlt.:: clcv,ttion

l. On back bending the head. pilticnt side bends it 10 same side and rotates it (0 Opposile side 2. Cervical spine drawn forward. inclined to ~'lI11e side and rolated to opposite side 3. "C" scoliosis of ccrvicolhoraci-.: SPIIlC

4. Shoulder rai~cd and rotated with ann and sC~lpula to same side

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Stcrncoclcidomastoid 1'\l.v,ihl,;

GENERAL CHARACTERISTICS

c!l;lIlg,;, III

The sternocleidomastoid 11l11~dc has a (l:IlUCIlCY 10

l1C(OmC

pnsili1ln hll Clllllr;IlII' III'

shortened and ovcracti\°t::.

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posilc siul'

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1~1l,.lk I', ';rlle sid~;

FUNCTIONAL ANATOMY

lordosis limited ttl craniocel"vic,d junc-

lllWI'IJI'~' 'If lal!.:ral

Points of

\'1111

allachm~nt:

1. Cl:\\"iclilar division: sternal end of clavi-

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to lateral

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I. Rcstriction al cranioccrvical ,md cervi-

cnlhnr.lc;c junction

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IMPAIRED BODY STATICS BECAUSE OF SHORTENING

1"'··Ik .

(FIG. 7.29)

Changes

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1

t-'HACTITIONER'S MANUAL

al

the ipsilateral side: Q.tigjn I. Sternal eno of ckl\'icle: craniodorsolat-

Direction of pull at

I. :\'taslOid

rnl{:c!>~:

cau-

dovcl1lrolllcdially

crally

points of attachment:

or

2. Medial surfJcc manubriurn slcmi: cran i odorso I ate rally

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Fig. 7.29.

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Disturbed body statics because of a shortened slernoc1fwlf'llIrltllnhlllllli I

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I,

II / '1/ •

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shoulder blade has been left out on purpose).

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l;HAPTER 7 : DIAGNOSiS OF MUSCULAR DYSFUNCTION BY INSPECTION

137

I, ,

Fig. 7.30. Changed body oul· lines because of a shortened sternocleidomastoideus. Front view (a). side view (b). back view (c).

B

CHANGES IN BODY OUTLINE BECAUSE OF SHORTENING (FIG. 7.30)

.!.illWiill.l Front

1. Decrease in transverse

Vicw:

diameter of shoulder

ginJk. less prominent shoulder outline

2. Both heads of shortened muscle and upper and lower clavicular

fossa clearly seen under skin 3. Shoulder £irdlc wim thorax slightly rotated

I. Head deviates to ~idc and rolales 10 oppo~i(c side 2. Ear on thai side i~ lowercd. turned forward. well visualized 3. Lateral conl<.ll!f of neck on ipsilatcml side flattcned and at right angles with shoulders

to same !oldc Side Vicw:

I. Sternal end of clavicle wilh manubrium slcrni r:liscd :md tilted back. xiphoid process on olher hand prolmdcs 2. Acromion with shoulder and ilrm lowered and thnlst back

I. HCild thrust forward. chin r.. iscd. occiput

I. Luer.Il angle of

sC;lpula lowered. inferior ;lI\glc raised. arm

close to trunk

~

sion at cranioccfYlcal I. Occiput

dcvialc~

to op-

posite !'ide; ipsilateral mastoid process lower and anterior. contral;.tteraJ raised and poslcrior 2. "C" scoliosis of cervical and \lppCr thoracic spine

DISTURBED CERVICAL FLEXION MOTOR PATTERNS BECAUSE OF SHORTENING (FIG. 7.31)

The slernocleidomastoid and

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..•• _

_._

will

sllb~titu(c

for the

Directiun of Movement

Visual Criteria

I. Ell;tcnsion at COil and CII2 ipsilatcnd inclination wilh rotation to <:011tralatcr.tl side 2. Allie· and JatcruOexion of neck

I. HC;ld of patient is lowered. chin

..,

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~calcnc~

longus colli.

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ster~

lowered

2. Ipsil:.slcral cur rOlated forward and lo\\-ercd 3. Reduced cervical lordo~ sis. but increased c:'(tenjunction

B'lek View:

Fig.7.31. Head anteflexion in a patient with a shortened nocleidomastoideus. Front view (a). side view (b).

.

thrust fOr\vard and to opposite side 2. Ipsilalcrnl car lowcred and dcviates (0 opposite side J. EXlension of upper cervical and llcx.ioll of low~r cervical spine

REHABILITATION OF THE SPINE: A PRACTITiONER'S MANUAL

PRACTICAL APPLICATION

Case History Patient K., male. cOlllpl:\ill~d of gnawing p:lin in his h:ft shoulder that I.Idialcd O\T!" lhl' ;1I11crior Surl"KC of the thor'lx.

!

ANAMNESIS

Six months prcdously. \vhcn paticllt K was Iihing frigerator. puin started in Ihe right bUllock and mdiated down the posterior surface of his [high. Pain disappeared within a fortnight without treatment. He then began to complain of shoulder pain. mainly while standing. which grddually worsened. Standing with feel apart lessened the paui. but pain intensified when he held his feet close together. Pain disappeared when lying on thc llonpainfu1 sidc. ANALYSIS OF BODY STATICS (PAIN-PROVOKING POSITION)

FrQut View The changes in body staLics an: illusLrated in the diagrams in Figures 7.31b to 7.32b by vcnieal'lfld hori1.ontallincs. Figure 7.32c illustrates muscle dysfunction. The vertical line 0) d~-

viatcs frol1l1h~ (ideal) midline to the left, with maximum dc~ viatio[1 at the level of the navel. the point at which the (zll· leTed) vertical line between the legs and thaI from the head intersect. 111e horizontal line diverges toward the left to the right} with maximum divergence between the lower margin of the rih cage (4) and the greater trochantcrs (6). Note, hOWC\'CT. the divergence to the right of the line between the acromia and the lower margin of the rib cage. As dcvi.uion from tlie plumb line is dearly to the left and divergence of the mentioned lines is grealer to the left than to the riglll (sec angles ex and {3), it can be inferred that deviation of lhe pelvis 10 the left is primary and deviation of the shoulder girdle Lo the right is secondary (compensatory). Side View Pigurc 7.J3b shows forward deviation of the patient's body from the plumb line. particularly noticeable at the legs. Note lillie deviation of the trunk, but, again, forward deviation of the neck. The horizontal lines diverge mainly in front, mostly between the lower margin of the rib cage and the crista iliaca (4,5). The horizontal lines between the spina scapulae and c1;wiclc and the lowcr margin of the rib cage (3,4), cor· responding to the mainly straight thoracolumbar spine.

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B

c

Front view of Patient K. in the pain-provoking position: photograph (a). diagram (b). and diagram of dysfunctional

muscles (e).

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MUSCULAR DYSFUNCTION BY INSPECTION

139

11

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12

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14

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A

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c

Fig. 7.33. Side view of Patient K. in the pain-provoking position: photograph (a). diagram (b), diagram of dysfunctional muscles (c). and (d) photograph of upper part of profile.

14U

REHAtjlLllAllUN Ur 1 Ht: tWINt:: A !'JHAG

converge dorsally. It can be inferred thaI body statics (balance) arc disturbed. with a tendellcy to fall forward. The angle between the lower margin of the rib cage and tilt:: crisla iliaca is therefore primary ,md the :-;houldcr is the secondary compensation. Back Vicw In Figure 7.34b. lhe paliclll stands with his legs apan. i.e.. in the relief position. Lillie dc\'j;'lIion from the vertical is seen between the legs; deviation is limited llluinly 10 the cervi·

cothoracic spine. with ;,\ maximum

:.11

the lc"c::1 of the lower

angles of the scapulae. Maximum divergence of the horizontal lines is between the biacrumial line and the line connecting the. klwcr margins of the rib cage (3,4). The line between the troclwnters is now almost parallel lO the lowcr margin of the rib cage (4.5) (compare Fig. 7.32b).

ANALYSIS OF MUSCLE FUNCTION (pAIN·PROVOKING POSITION)

Vie ... (Figs. 7.32c

7.34c) What can he secn on thc body outlincs is in keeping wilh the disturbance of stati~s (sec Figs. 7.32b to 7.34b). The pelvis deviates to the left and tlte spina iliaca antcrior superior appears highcr; the trunk devialcs to the right and the shoulder is lowered. The head is slightly inclined to the right with left rotation. Closer inspection reveals outward rotation of the left leg. which is adducted; the right leg is flexed at the knee. Note the tension of the sartorius on the right and protrusion of the shon adducrors on the left,..The shoulder is closer to the pelvis on the right and the thorax to rhe left, which is in keeping with increased tension of the obliquus externus on the right where its attachments to Poupan's ligament and the iliac crest arc seen. The abdof,TIcn protrudes more on the left and hypertonus of the pectoral muscles is visible on the right side. Also 011 the right side.-ffic mpple I~ lowered, the outline of the pectoralis m.illQr ~.l.Jhe. axilla is sharper. the shoulder is drawn lorward and protrudes anteriorly. the supraclaVlCUiaf fossa is deeper. .and the outline of the sternocleidomastoid and trapezius mus~ c1es is clearer. The acromial end of the clavicle is raised on the right side. and there is a step between the acromion and (he head of lhe humerus. On (he left side. the contours of both the trapezius and sternocleidornastoideus arc vaguc. The head is not only inclined. but deviates to the right. The transverse diameter of the .shoulder girdle appears smaller on the right. The head is rotated to the left, the right ear more visible on the right. The right ann is slightly flexed and the hand is pronated; the contour of the biceps is more prominent. Side View (sec diagram in Fig. 7.33c) The main feature is the forward drawn position. particularly of the lower extremities and the neck. This posture results in tension in the triceps smae and the hamstrings. in the muscle belly of the tensor fasciae latae. and. to the lesser degree. in Frolll

10

1IIIU!'lt:H'~ MANUAL

the lower iliotibial band. This tension contrasts with the hypotonus in the gluteus maxim us. producing flattening of the buttocks and lowered gluteal lines. Also noted are lumbosacral hyperlordosis and increased thoracic kyphosis with some tension (prominence) of the erector spinae and a protruding. flabby contour of the upper pan of the abdomen. The head ;md neck arc thrust fOf\vard and tension is evident in the right stcrnocleidomaslOideus and upper trapezius. Lordosis is prescnt at the craniocervical junction. In Figure 7.33d. the contour of the acromion is clearly outlined when the arms are hanging down, and, again. note the step-like prominence of the acromion in relation to thc head of the humerus. \\'e also see better the cervicothoracic kyphosis with a raised lower angle of the shoulder blade. The lower cervical spinous processes are clearly visible (also a sign of low cervical kyphosis). The forward thrust position of the head of the humerus is also obvious. The elbow is nexed and deviates dorsally. and there is visible tension in the biceps brachii. The relative flattening of the thorax with a prominent xiphoid process is also clear. Back Vie.. (sec diagram in Fig. 7.34c) The patient stands with his legs apan in the relief position. Outward rotation of lhe foot is more pronounced on the Icft and tension is greater at the Achilles tendon on lhe left. On the left side. prominence of the triceps surae is greater and the dcpression below the knee on the medial surface is dcCIXf. The popliteal fossa is deeper on the right (with th< knee flexed) and the patella: is rotateo inward. The lateral outline of the biceps femoris is more prominent on the right, the contour of the semimembranosus and semitendinosus is more prominent on the left, and there is a concavily on the medial surface above the knee. Above this concavity is the prominence of the short adductors; the gluteal lines arc lowered on both sides. The pelvis deviates only slightly to the left. but rotation to the left is apparent. The transverse diameter of the hemipelvis is therefore greater on the left side, and the outline of the glu~ teus medius can be seen. Abovc the pelvis. tcnsion is increased in the paravertebral muscles on the left; hypertoous. principally in the latissimus dorsi. is visible in the craniolateral direction. Below the axilla. oo\e the .promiilcnce -of the tcres major. The convex outline of the infraspinatus belo\\' fhc spinae scapulae can be secn only on the left side. Here. too. the upper extremity is adductcd and slightly ncxcd on the left side. The contour of the left shoulder forms almost an angle, i.e.. hypotonus of the deltoid muscle is noted. On the right side. on the other hilI1d. the waist line is deeper. and alxn·c it, tonus of the latissimus dorsi appears diminished. The lower anglc of the scapula is more prominent on the nght sid~ and the shoulder is drawn forward. Increased kyphosis in addition to scoliosis are evident at the cervicothoracic junction. The he.ad and neck arc inclined and rotated to the left; [h(' car is clearly visible. There is also some hypenonus at (h(' upper trapczius on the left side. but the lower fibers of thm muscle as wcll as the middle trapezius ;lrc flattened .

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MU;:)l;ULAH DYSFUNCTION BY INSPECTION

ANALYSIS OF RESULTS

From Ih.: ('hall=:~s in hody sl:lli(:~ and comp'lnson of the p;Jinprovoking and rdid' POSiliollS. it follows that the main and prillwry disturb~lI1l'c is al th~ pelvis: the parallellincs (sec Fig. 7.:l2b) show maximum divergence toward the left. and pch'ic

dc"imion is signifk.mt. In the relief position. on the olher hand (sec Fig. 7.34b). less deviation is noted. consistent with increased lension of the obliquus cx(crnus abdominis on the right side ;Illd of the qU;ldrmus lumborul1I on till; len side (see also Fig. 7.20), The other important change in body statics is the forw;mj·drawn posture wilh lumbar hypcrlordosis. It can be infcrn.:d thal)hc straight abdominal muscles arc nOI primarily wei.!k. out arc inhibited becausc of the shortcned lum~i.Ir :-;.cclion of the back extensors (including the quadratus lumhorum). Spasm of the external obliquus on the lef, side is clearly visible. and it is spasm of the abdominal fllusdcs that is the most frequent cause of the forward-drawn posture.

141

The numerous asymmetries of muscular tonus described arc mostly compensatory. In the legs, it involves the biceps femoris on the right, the adductors on lhe left, and the hamstrings and triceps surae on both sides. In the trunk. it involves the pectoralis on the right and the latissimus with the (eres major on the left. Othcrs include the slcmocleidom
o I

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3

11

r'

12

1./

13

13

4

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5

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Fig. 7.34. Back view of Patient K. in the relief position: photograph (a), diagram (b), diagram of dysfunctional muscles (c).

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M~nI'\Oll..III'\IIUI'" Ur- I Ht: '=ir'INt:: A

PRACTITIONER'S MANUAL

!, 1

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)

,~

A

B

c

o

E

F

G

H

Fig. 7.35. Diagrams of patient K: (a) Dysfunctional muscles in the pain-provoking posilion (dotted lines, changed muscle conlours): (b) Dysfunctional muscles in the relief position; (c) Disturbed statics in the relief position, back view (black. changes in ver· tical outlines); (d) Disturbed statics in the pain·provoking position, side view (gray, change of horizontal lines; angle a is open in the direction of body deviation); (e) Disturbed statics in the pain·provoking position, shown in the same way; (I) Disturbed statics from above. (1) head. (2) shoulders. (3) lower thorax aperture. (4) pelvis. (5) knees. (6) feel; (9) level of spinal dyslunclion; (h) side view.

,. before and after treatment. Inspection works fast and at a distance. Its results. however. must be checked by using other methods of clinical cxamination~ in panicular. palpation. testing of aClive and passive mobility-the full range of physical examination.

6. Janda V: Muscle Function Testing. London. Buttetvlorth, 1993. 7. Koga.n OG. Va~i1yeva LF: Atipichniy lokomotomiy pattern. diagnostik;l i Iccheniye. (Atypical locomotor patterns. diagnosis and treatment). No\'okuznelsk. 1990.

Acknowledgments REFERENCES I. Lcwit K: Manipulati\'e Ther.Jpy in Rehabiliution of the Locomotor Systcm. Oxford. Bunerworth. Heineman. 1991. pp 23·25. 2. Rash PJ. Burk.e RK: Kine$iology and Applied Anatomy. Philadelphia. Lea & Febigcr, 1971. 3. Kogan OG, Schmidt JR. Vasilyeva LF: Visualno-palpatomaya dingnostika patobiomeck.ani$tiehcskick iSll1cneniy posYonochnik.a (Diagnosis of palhobiomechanical spinal disorders by inspection and palpation). Manualnaya Medicina 3:10.1991. 4. Janda V: (1990) Differential diagnosis of muscle tone in respect of inhibilOry techniques. In P:Uerson JK. Bum L (cds): Back Pain. an Intcmation;ll Review. Bostoll. Kluwer Dordrccht. 1990. p 196. 5. Vasilycv:I LF. Kogan 00: Manual diagnosis and manual therapy of atypical motor p;mems. Presented at the IOlh International Congress of the Federation Intcrnation;lk de Medicine Manuelle (FIMM). Brussels. September 1992.

I am grateful to my teachers for their contribution to the ideas of this publication, particularly concerning the role of the musculature. il.. functional anatomy. and biomechanics. i ant gr.t1cful to Dr. Lewit. who firM opencd the door of m.mual medicine to Russia. I am indebted greatly to the work of Janet G. Travell and David G. Simons: to Vladimir Janda for his ide.ts of muscular P;lt· terns: and 10 a.G. Kogan and I.R. Schmidt for their help in analysis of slatic dysfunction. I thank Karel Lcwit and I. Lcwitova for their painstaking and constructive criticism and active editing of the text. Last. but certainly not least. I thank I. Litvinov for the wonderful illustrations in this chapter. Ludmila Va... i1)'cva

,

i

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t5

.t;valuatlOn of Lifting LEONARD N. MATHESON

,

'

CHIROPRACTIC FUNCTIONAL CAPACITY EVALUATION As the chiropractor assists the patient in restoring pre-injury functional capacity, periodic functional capacity evaluation is necessary. Functional capacity evaluation (FeE) denotes a form of work cvalumion consisting of a battery of tests that focus on selected work tolerance areas. Matheson' defined work tolcr~nccs as the observed and measured physical capabilities of the cvalucc thilt affect competence to perform the physical demands of work tasks. The term jUllctional connotes purposeful, meaningful. or useful activity. implying a definable task that has a beginning and an end with a result that can be measured. The term capacifY connotes the maxi~ mum ability of the individual. beyond the lcvcl of tolerancc that is measurcd. Capacity is the cvalucc's potential. The tcrm el'(l!uar;oll is a systematic approach to monitoring and rcporting performance that requires the evaluator to observc. measure. and interprct the cvaluec's performance in a structured task. Thc information gathcred in thc FeE is descriptive and, when standards of performance arc available. normativc. Descriptive results arc used to compare the cvalucc's ability with thc physical demands of ',vork or with thc evaluee at a previous point in time. Normativc rcsults arc used to compare the evaluee to a reference population. An FeE requires lhallhe cvaluee put forth maximum voluntary effon for the dcfined- task. The dcfined task may require full strength, full velocity, endurance. a target number of repetitions. a maximum nUe of responding. or some other "full effon" performance. When the measurement of function is less than maximum. the evaluator must bc able to dctermine to what degree this deficiency is a function of the biochemical. cardiovascular. mctabolic, or psychophysical limits inherent in the cvaluec. LlI'T CAI'ACITY TESTING For scveral reasons, the cvaluation of lifting capacity is a key ingredient of most FeE. Lifting is an important component of many jobs. because of either the proportion of job activities that require lifting or the criticality of the lifting task as a component of the job. Lifting is important because it is a cell· Iral organiz.ing wlr;lIble that provides an excellent estimate of general work capacity.' Additionally. lilting is an important

variable because lifling tasks appear to be relaled 10 both increased frequency and increased severity of industrial injuries. 2- S LII'TING AND LOWERING Lifting is defined as the vertical displacement of an object with mass that is accelerated vertically through the application of force along the direction of the lift. Lifting is generally considered movement of an object held by onc or bolh hands in opposition to gravity. Le.. lifting upward. Some FeE systems consider lifting separately from lowering. Lowering is a distinct task and is dell ned as the controlled movemcnt of an object vertically downward. The force applied to initiate movement is gravity. The individual's max~ imum lowering ability is taken as his or her ability to resist this force so that the object remains under control or. at the least. is controlled at the tcnnination of the vertical move:' ment. By contrast. vertical movement downward of an object accelerated by gravity without resistance applkd by the worker is considercd a "drop" rather than a lowcr. In practice. when lifting and lowering arc evaluated jointly, the maximum lifE-lower usually is the individual's Iift~ ing capacity. People gcncr'Jlly arc able (0 lift approximately 20% less than they are able to lower. ahhough this percentage varies from person to person and depends on the swrting height, the vertical displacement of the lift or lower. and the frequency of the task. LWflNG CAPACITY FACTORS Several factors inherent in the lifting (ask imulll load that can be lifted.

innuenc~

the max-

Horizontal Displacement of Load The distance belween the center of gravity of the load held by thc hand or hands and the cenler of gravity of the worker is a crucial dctcrminanl of maximum lifting capacity for ~evcral reasons: I. The human biol11cchanical sy:,tem exponcntially mulliplies the effect of the load on the human body :'0 that it rapidly increases as horizontal displ~lcel11enl inl.:'rcases. 143

B

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J'--~""----~--------------------------------------------------

REHABILITATION OF THE SPINE: A PRACTITIONER'S MANUAL

144 2. The stability of the worker-load system is maximized when horizontal displacement is minimized. 3. Risky lifting~lowcring maneuvers arc minimized or eliminated as horizontal displacement is minimized. Certain behaviors such as torquing of the spine when moving an object through a lateral arc of motion can be eliminated entirely if the horizontal displacement is sufficiently slllall so ,IS to place the object against the worker's abdomen or pelvis.

Location of the Hands at the Origin of the Lift The common reference point for lifting and lowering is the position of the hands on the object. This positioning is taken as the point of origin of the force and the center of resultant force vectors. Lifting is accomplished most easily through intemlediate vertical ranges so that the biomechanical system can be used most efficiently. At the extremes of the range upward or downward. workers arc less capable of full,muscular exertion. Different muscle groups arc called into play depending on the starting height of the litt some of which are more inherently powerful or fatigue-resistant than others. In addition, secondary limitations occur that depend 011 the starting height of the lift-lower, including cardiovascular demands and effects of various strategies of trunk stabilization on the cardiorespiratory system.

Vertical Displacement of the Lift The vertical range over which an object is lifted or lowered affects the workers's lifting capacity in the same way and for the same reasons that the starting height of the lift affects lifting capacity. In addition. however. the vertical displacement of the lift affccts lifting capacity in tcnns of the amount of work that is required in the liftMlower. Work is a product of force applied over distance. Muscles have the capability to produce power, which is force per unit of time. The biomechanical system is limited in terms of both power and the ability of the system to sustain that power to produce work. The amount of work performed is directly related to the distance over which the object is lifted or lowered.

of his or her biomechani("al couplings. A linn stance 011 a stablc surface and a strong and comfortable grip 011 thc object arc the two most imponant issucs with healthy workers. \Vhen thc evaluation con("crns an individual who has one or more impaired biomcchanical components in thc linkage. that linkage may becomc critic:.:llly limiting. depcnding on the de~ grec to which thc task and/or the posture and mo\"Cnl\.~1l1 of the worker stress this component. If the task and/or posture and movcmcnt of the worker do not stress the impaired component, the effect may be negligible. Conversly, if the component is stressed. it may be the primary limiting factor.

Aerobic Capacity For tasks that arc prolonged at loads that arc signifkantly less than the worker's maximum lift capacity, the aerobic capacity of the worker becomes important if the frequenc)' of the task is sufficiently high. Generally speaking, aerobic capacity becomes important if a light load is lifted once every 2 minutcs or more often or a heavy load is lifted once every 5 minutes or morc often. In regard [Q tasks that involve lifts more frcquently than six to eight times per minute, aerobic capacity may begin to be importam after the second or third minutc of continuous activity.

Anaerobic Capacity This capacity of the \vorker is important in high frcquency tasks involving loads below the worker's maximum single lift load and in low frequency tasks involving loads ncar thc worker's maximum load. Anaerobic capacity is a function of the load of the task relati\"e to the worker's maximum and the mix of \l>'Ork to recovery time in the task.

Metabolic Capacity This capacity of the worker is important in repetitive tasks with a frequency of once every 5 minutes or greater than are sustained for more than I hour. Tasks perfooned less frequently or of shorter duration generally are not affected by the worker's metabolic capacity. unless it is substantially impaired as a comequence of illncss or severe dietary problems.

Frequency of the Lift-Lower Because of the inhercnt power and endurance limitations in the worker's bi0111cchanical system. the number of times a lift-lower task can be repeated is limited. This limitation is directly related to several factors that interact: Degree to which the load approximates the individual's maximum single lift capacity Duration of thc individual task Rest period after each individual task Duration of the task set

Biomechanical Couplings Both the maximum load and the consistency of the worker's ability to lift and lower arc directly affected by the adequacy

Test Instructions and Performance Target The type of instructions provided to the evaluee significantly affect their subsequent performance. Coaching during the activity affects thc evaluec's consequent performance. Although few studies ha\'e addressed this topic. the effects they have reported have been substantial. l • As one compo~ nent of the instructions given to the evaluee. the "cogni~ tive target" provided in a maximum strength task is an important component of demonstrated liftMlower capacity. The difference between "your maximum possible lift.. and "your maximum dcpendable lift tha! you can replicate sevcral times per day" is subst
_..

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145

~

o lIorizonL:d disph.c.emenl iii Vcrtic..l displaccmc:nt

El f-rcqucncy of wk

EI Anaerobic/acrobic/melabolic capacity

E! Instruction5/pcrlorTlU.nee Gill MusculoskelctAl

strength

tatSCl

Fig. 8.1. Factors that contribute to maximum performance in a lift capacity t.est.

Musculoskeletal Strength The worker's strength is the largest single contributing factor to his or her ability to perfonn a maximum lift. Depooding on the other factors listed, however. the contribution that museUM loskclctal strength makes to the ability of the worker to perfonn to a particular level will be limited. In the simplest case. musculoskeletal strength is limited by the "weakest link" in the biomechanical chain that cxists between the surface on which thc cvaluce is standing and the grip that the evalucc maintains on the joad.'·~ This factor, however. presents only a level of the potential performance that cannot be exceeded. This ceiling can be approximated in lifting tasks that arc in M frequent. or that arc performed over a limited vertical range. involve holding the object close to the body, and with good biomcchanical couplings and tcst instructions that are perfectly understood by the evaluee. Figure 8.1 is a graphic depiction of the author's estimation of the degree [Q which each of these factors contributes to the ability of the evaluee to perform a maximum lift in a work setting. CLASSES OF STRENGTH TESTS

I

i J ~

Lifting and lowering is a synthesis of the worker's biomcchanical. cardiovascular, metabolic. and psychophysical capacity. The development of tests has been innuenced by progress in hardware technology. so that the focus in this early phase of the development of lhe science of lift capacity testing has been on the biomcchanical system. Anyone of the four domains. however. may be the most limiting in any single tcst for any given evaluee. Usually. strength tests are limited primarily by the cvaluec's psychophysical capacity. Psychophysical factors affect the worker's ability to lift in tenns of the degree to which maximum voluntary effort approximates inherent biomcclwnical, cardiovascular, and metabolic capacities. Factors such as fear or anxiety about the task or confidence in his or her ability to perform it directly innuence the level of effort that the worker is willing to put furth. Other attitudinal fnctors, such as the relative risk-tOM reward ratio or work-ta·value ratio as perccived by the

worker also affects the level of effort and. th~reby. the worker's performance. Three general classes of strength testing have been identified. They are differentiated in terms of the effect of the test on muscular contraction, considered in terms of both the mus M cles' force of contraction and the rate of shonening.

1. Isometric. Under load, the muscle length does not change. Force is measured in one biomcchanical position. 2. Isokinetic. The muscle lengthens or shortens at a fixed ratc as a consequence of external control of the velocity of movement of thc biomechanical unit. Force is measured throughout the range of movement. 3. IsoineniaL The muscle shortens at a variable rate in response to a constant external resistance. As the biomechanicaI trigonometry changes to accomplish movement. changes in muscle length occur at varying velocities. Constant resistance is inferred from the con- . stil,ncy of the mass that is moved. Acceleration is assumed to be negligblc. Various technologies have been developed to assess these general classes of strength tesL'i and arc identified by namc in tcrms of the type of function that each iwends to assess. Some confusion results in that, because of the complexity of the bio M mechanical system involved in lifting and lowering. the external system .used to tesl the biomechanical system may not be able to control the tcst at the level of the individual muscle's function so that the intended mode of tcst is actually achieved. For example, although isokinetic testing intends to evaluate the strength of the biomcchanical system at a set velocity, accelerative movement occurs carly in the task up to the point at which the desired velocity is achieved. Even after thm point. a rebound phenomenon may occur before stabilization at the desired velocity is achieved, As a result. each of the modes is inexactly sampled by the technolog.ies lhat it is intended (and advertised) to test. A lifting task usualiy involves a combination of types of muscle contractions. depending on the biomcchanical scg-

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140

ment that is considered. These lypeS will change dunng the task. For example. a "squat lift" from floor (0 knuckle, whether accomplished in an isokinctic or isoincrtial mode. usually involves the upper extremities in isometric actiyity if the worker's style of lift emphasizes IO\\'cr extremity extension. Conversely, with a lifting style such as that used by competitive weight lifters. this same vertical range might be undertaken with the bwcr extremities perfonning isometric stabilization whik the upper extremities provide :m accelerative force to overcome the inertia imposed on the mass by gravity as it sits at rest With these ca\'C3ts in mind. the description of each lcst technology is grouped in terms of the type of function that each is intended to address.

Isometric Testing This form of testing is the simplest type of technology and tends to be the most reliable in that. because the body is tcsted in a static posture. the geometry between the biomechanical linkages (termed "kinematics") can be controlled and. thus, replicated. In terms of safety. however, isometric strength testing has prompted debate. On the one hand. Garg. Mital. and Asfour,'> Chaffin,1O and Caldwell. Chaffin. and Dukes-Dobos ll reported that isometric strength tests are safe. Because it does not allow acceleration and. thus. the increased inertial loads that are a consequence of acceleration. isometric testing should place less stress on the body and inherently be more safe than other methods that allow acceleration. On the other hand. Kishino and co-workers. 12 describing their experience with isometric strength testing of individuals diagnosed as having spinal soft tissue injuries. found that most reports of muscle strain or prolonged soreness occurred as a consequence of isometric testing. They hypothesized that this result was attributable to the longer period of time that peak force must be maintained in an isometric test (typically 3 to 5 seconds). whereas the peak force in an isokinetic or isoinertial test is transitory. Battic et all; and Zeh et all": raised the same issues after finding problems with prolonged symptomatic responses and a small incidence of reported back injuries after testing nominally healthy people in an employment setting. Three important issues with regard to the safety of isometric testing have not been fully explored on a scientific basis. The first issue relates to the value of psychophysical limits in terms of producing safe lifting performance. Psychophysical limits arc developed throughout the individual's lifetime as he or she is involved with tasks that place demands on the biomechanical. cardiovascular. and metabolic systems. The learning proceeds through trial and error so that the individual develops internal controls. termed "work func~ tion themes:' which in essence are rules that the individual follows to remain free of injury while involved in work tasks. These rules are applied unconsciously and require input from the individual's sensorium in terms of the degrce to which a task places demand on the individuars functional capacity. This feedback is applied as a consequence of the worr..cr's

RI::HAt::SILlIAIION OF THE SPINE: A

PRACTlTIONER'~

MANUAL

jlt:r(t:pi~'.Ill of the difllcully of the task. Informat ion abollt task difticuhy is supplied through feedback loops that provide the indi,"iduJ.1 ,vith inform:nion concerning, initially. the biol1lechanical demand. and socm thereafter, the cardiovascular demand 0f the task. The biomechanical demand depends on sellsors that function best when joints and muscles are in 1ll0\"Cment. Thesc scnsors arc less fUllctional and. thereby. less useful when the biolllechanical system is static. Thus. isometric strength testing has proven useful for differentiating individuals who arc pUlling forth various levels of maximum voluntary effort because it is difficult for the individual to gauge the degree to which he or she has put forth ef1'011 and. thus. maintain consistency with less than a full effort trial. It is precisely for this reason that isomctric strength testing, unless used carefully, ha.s the potential to place workers who have inherent defects in the biomechanical system at risk for stressing the defcctive segment to the point of strain. A second issue COllcems the unusual nature of the isometric task. Whereas isometric tasks with the fingers and hands arc relatively common in everyday lifc. isometric whole body tasks are extremely unusual. Thus. the worker involved in an isometric "lifting" evaluation is performing a task that has lit tie familiarity. Although posture is controlled. the psychophysical skill brought to the task in terms of achieving maximum performance efficiently and with safety is less than it would be in a task that is more familiar. For example. the first trial in a particular posture is often wasted because of problems with balance. The third issue relates to the care and precision with which instructions are given. Because the technology is relatively simple. clinicians may tend to use less care in its appli cation than otherwise would be appropriate, Rather than beginning the lifting task gradually with a "ramp liP" to full effort. many evaluators allow the evaluee to increase explosively to full effort before the mechanical system's inherent elasticity has been entirely diminished. This situati011 results in inertial effects that greatly increase the force within the biomechanical system. Isometric strcngth testing has been demonstrated to be highly reliable, with test-retest correlation coefficients exceeding r = .90. 5 Coefficients of variation have been in the neighborhood of 10 to 13%.15 \Vith regard to validity. one disadvantage of isometric strength testing is that force values arc mcasured only at a specific segment in the arc of motion. Selection of the segment to replicate is an important consideration to allow results in an isometric strength test to predict performance in a dynamic task. Perhaps more importantly. it may be that the spine responds differently to an isometric task than to a dynamic task. Marras. King, and Joynt It· found that electromyographic (EMG) activity was highest in the latissimus dorsi muscles during an isometric task, whereas the erector spinae group produced greater EMG activity during an isokinetic task. In spite of concerns about safety and validity. isomctric tests can be useful because they arc brief and so are the least costly type of tcst to administer. The ARCON ST is an exal11w

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pk~ Dr thi ... l~-P~ (}r 1l:~1 lhal is llsed widdy. (Fig. X.2l. Additionally i..olllciric {C~! ICl'hnoll)gy ha~ hl,.'cn in cxistCIKC for qllit~ some limc and thll:- i" less cxpcl1si\\~ to m;lIHll";:IC[lIl'C and is widely ;l\·ailabk. l.kl';:HI~C of Ihe way in \\ hidl i:'()IllClril..: II:"', handle inatia. Illl..'y h~IVl' the /JOrnl/ill! III k quill' ,,;Ik, Onr.: mClhod to im· pm\"\,: s~lkly i" 10 provide pafOn1Wlll.:C I"cedh~tl"k so Ihal 11K' cvalucc is ahk 10 im:rcasc P"~ chophysical input and, lherch~·. st.'nll.:d sl:paratl.'ly frlllll ldt h'IIH.I\k'rforlllam.:c aeros:-; thc S,IIllC st.'al.:. usin,g I\H) difli:rclll l:olors f(\f thc furl'\.' l:urvc.

I.'wkinctk Tc.:sting Thl..' cOllcept of i"oJ..inclit: l.::\l.:n.:isl..'" was lir... 1 inlrodul.."cd hy Ili:-lllp allli PCrrilll..·.'1 '1'\\1.; tam is\lkindic fL:fcrs 10 dyn;lInil:

or kl1~thl.'lIillg or a llltl:-dl.: ill cOl1traclioll pCI''' fllt"llll:d at a 1..'011"(;1111 "d()cit~ rcg:lrdk'ss (If llie fon.::: ~CIlCr;I(l;d

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Fig. 8,3, ERGOS Work Simulator {Work Recovery Tucson, AZj.

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cal, West Sacramento. CAl.

by the muscle. Accelcration is minimizcd so thatlhc force CX~ crteu is equal to the force necessary to move the object at a constalH velocity. Because the inertial effects of force application arc controlled. maximum force can be measured throughout the entire range of elongation or shortening. Isokinetic testing has been found reliable in several stud~ ics."l - n Isokinctic lifting simulation was shown to be reliable in studies done by Porterfield and colicagucs. 1J Frykman. Harman. and VogcL:!~ and Alpen described the reliability of isokinctic lifting stimulation.:6 The Janer researchers used the

LIDO Lift, presented in Fig. S.4. Some critical issues have been raised regarding the usc of isokinctic testing of Iifting.l:!.:~ Although isokinetic testing is dynamic. it docs not mimic functional activities because work is not usually performed with a fixed speed. Kishino ct aJl~ rcported that although isokinctk equipment can be ~\ useful tool in industry and rehabilitation. it had important equipment limitations that limited its ability 10 predict pcrfonnancc in an actual work setting. Til11m~'~ reported that lifting is composed of various combin<.ltions of isometric. isotonic. ~lOd isokinctic effort that isokinetic technology may not mimic sufficiently to be effective as an evaluative or rehabilitative 1001. Mayer ct nl"'J compared isokinetic lifting on the Cybex Liflask with a Progressive Isoincrtial Lifting Evalu.llion (PILE). and fOllnd the correhuions between the two tcsts were low_ They concluded that thc tests do not evaluatc the same pamlllc1cP.' and ~anl1ot be substituted for each other. Alpert e1 al.: tJ however. found isokinetic testing a valid predictor of subscquent progressive lift capacity testing.

Iso inertial Testing Isoincrtial dellotC:-i :a dynamic lest of lifting capacity in which the muscle is cOlltr
constant resistance ~i1ong a vector. The constam-resistance assumption is violatcd in !i(ting and lowcring because of the accelerative nature of fr.::.\:iEY. Thus. [he force imparted by tilt: person performing the ~ift is ~Kl·derativc. As a consequence. true isoincrtial lift (t"';lng is nOl possible. Various testing strategics have been de\ doped. howcver. to cOl1sTraillthe opportunity for rhe evalui':c to us~ acceleration. One such strategy involves testing (l\-:r limih:d vertical ranges that com~ spond to lhe range of rr'<Jtion ayail fleets his or her MA\'·. given th~ frequency. size of the box, and both Ihe: stOlrting hdght and venical I'~mge over which {he box is lifted. K
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America and Auslr;t1ia. I'vlathcsOll n reponed Ih;1l Ihis ;11" proach has good inlrah:st rdiahility wilh l"(lI:fIiciCnls of \;tri· :llioll of k:'\:\ than Y·k. Jacobs. Bell. and PopcJ~ lIsL'd a .... illlil;lf progrcs!'i\"c lifting cap,Kity appro"lch in lhe: Opcr;uional I.ift Task (OI.TJ. III lhis [CSt. \\\:ight in a craIe is illLTCiLSt.:d illl.:I\,'mentally until the subject is unable to lift thl' load. Another pmgn.:ssi\"c lil'! c.tpacil)' ;tpproach to isnincni:li mt:asurcl11cnl or lifting pcrfonn
Il'sls. llw WEST-EPIC;: I. whidl lISI.:S lh\..· ELC pmlOcol. is 11I\·S\..'llh:d in Figmc X5. Tht' ELC has ht'(lUllC a "gold sland,tnl" ;1~;lillSt ,dlidl to measure the v;llidity ll( othel" more expl:lIsin: t~ p\..'~ or lil't lest tedmology. Tilt: dl.:\'ell)p~rS (11' the. EPIC I.ifl Clp:lI..'ily lcst implemenled a lr"ining ,lIId ccnilicaliOll \'1"\1;;1";1111 I'll!· lesl II."C!'S that provides l:l:nilk,lIiol\ 01" proli..'ssillll:II, and (11" lcdlllil·i'lIh. PmlCssion;lls tire ccnificd 10 pcrfo1"ln Iht' \..,,·;t!Il:lIiOIl within theil: area or tr:lining and expl;nisl'. Tlll.:y Ill"y ;dsu Stllk'nisc h:dllli\.:'i'llls. Technici;lll:-; arc cenilil.."d (0 prm'ide lhe CY"lu'llion under the supcrvisiolll,f lhe ccnilil.."J profl.."ssioual. The primary issuc that distinguishes the profession'll from the lechnici'lll is the prokssional's lraining. whidl pro"ides the ahility to make correct judgments COllL'crning Ihe appropriate rcsponse to s)'lllpiolllS that occur as lhe lesl pmgr~sscs. In lhl: isoim:flial approach. till.': ohjcL'IS lIsed arc similar to thosc found in re:t1-world l;lsks. As .1 cunscquence. this 'Ipproach is gellcr,lIly considered 10 have good validity. SOllle researchcrs. however. havc raised concerns about thc safety of this ;lpproacb: 1 Others noh: that tllc practicality of lhe tcsl is limited in that it typically requires 20 10 30 minutcs to dc·

137 CIIl. Matheson ct al JI provided further elaboration of this approach. U~ing the samc four repctitions with ,\ 30-sccond cycle anti "masked weighls:' which limil the evalucc's knowledgc of the amount of weight lifted to the .Icwal experience of the lifting task itself. these researchers demonslrated good reliability on a test-retcst basis: test-retcst reliability of r = .77 for the lif[ from floor to 76 CI1l and r = ,81 for the lift from 76 Cl1llO 122 cm with a frequency of four lifts every 30 sCL'onds. This b,l:-;ic protocol hu:-; been revised by other researchers. Alpert cl aPO used il frequency of one repetition per 30-,second cycle and a slaning point of S<Jlit of the subject's isokinctic maximum; they reported tcst-retest rclinbilil)' of I' :::;: .91. U~in,g thc ollc-repclition-pcr-cyclc frequcncy over li,·c vcrtical ranges. Goldcn demonstraled good test-retest
Fig. 8.5. WEST-EPIC Uft Capacily Test (Work Evaluation Systems Technology, Signal Hill, CA).

MI:t1P.OILil PI IlUN Vr I Nt:: ~!"'INt:: A ~HACTITIONEH'S MANUAL

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Fig. 8.6. Comparison of lill capacity evaluation technologies using !lle National Institute 01 Occupational Salety and Heallh test selec!lOn crileria.

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Factor

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_.__

.

tcnnine the MAW for any p'H1icul'lT cOlllbin;:llion of frequency. starting height. and \,(:nic;:,1 displacement. and lhat both the time \lnd effort expended by the worker is SUbS!imtially more th"l11 is found using an isometric or isokinctic 'lpproach.~h _ The potential value of isoincrtiJl ~lrcnglh (esting with a disilblcd population depends on it . . relinbilily .!Od validity. With lhis nppro'H:h !O testing. bOlh lcsl-retcst aod intcrrater rdiability depend on lhe C'Irl; with which the lest is COOdUCICd. Within-test "rdiabililY checks" in the ELC arc available to conflrm the e\'alll~e's performance reliability through a comparison of pal'orm
A: In\'eslig;uionfo. of the relation between low back pain and occupatiun. III. I)hysical rl.'<)uiremcnls: sitting. standing and weight lifting. InlluSl Med41:5. 1972. 5. Bigos SJ. Spengler OM. ~fartin NA. Cl al: Back injuries in industry: A rClTOspcelivc sludy. II. Injury factors. Spille II :252. 1986. 6. ~~atheson L. Moone)' V. C.:liOl1.O V. ct ;II: Effect of instructions on isokin.:tic trunk strength \·ariability. i'diability. absolute value. and prcdicti\"e valid!I)·. Spine 17:914. 1991. 7. Andersson Gll1, Ch:lffin DB. Pope MH: Occupational biomechanics of the lumbar spine. In Pope MH. Andersson OBJ. Frymoycr J\V. (cds). Occupation:11 Low Back Pain: Assessment Treatment and Prevention. S\. Louis. Mosby Year Book, 1991. pp 20-43. H. Ch"nin DB. Andersson GBJ: Occup:'Ilionat Biomechanics. New York. John Wile)' & Sons. 19S4. 'J. Garg A. Mil:l! A. Asfour SS: A comp;lrison of isomelric strength :ll1d dynamic Ii fling cap;lbilil}'. Ergonomics 23:13.1980. 10. Chamn DO: Diomcchanic!< of manual malerial handling and low b"c:k pJin. In (Xcup:!lional Medicine:: Prindples and Pracl;c31 Applie:'Ilions. Chicago. Year Book. 1975. pp443--467. II. Caldwell LS. Chaffm DB. Dukc...·Dobos FN. CI al: A proposed st:mdard procc.:~urc for st:lIic muscle !otrenglll testing. Am lod Hy~ Assoc J 35:201. 1974. 12. Kishino ND. MaycrTG. Galchc1 RJ.'::I al: Quantificmion of lumbar fune· lion. P,I" 4: Isometric and i~okinetic lifting simulution in nonl1a!lIubjccts and low·h:lek dysfunctional paticnls. Spine 10:921. 1985. 13. Baltic Me. Bigos SJ. Fi!ohcr LO. ct ::II: Isometric lifting strength as:l pre:· diclOr of industrial back pain reports. Spine 14:851. 1989. 1.... Zch J. Hansson T. Bigos S. el al: Isometric strength testing: Recommendations ba~ed 011 a slali~lical antilysis of procedure. Spilll' 11:43. 1986. 15. Chamn DB. Hemn GO. Keyscrling WM: PrccmplO)'menl slrength lesling. An updated posilion. J (Xcup Med 20:403. 197~. 16. 1'.larras WS. King AI. Joynt RL: Mcasurcmellls of loads on the lumbar spine under isomelric and i~okinetic conditions. Spin.c 9: 176, 1984. 17. Hislop HJ. Perrine JJ: Thc isokinctic (onccpt of ex.ch.-isc. Ph)'s Tlicr ~. Ma~or.t.

47:114.1967. IK. Aitkens S. Lord J. Bernauc:r E. ct al:

19. 20.

2 I.

22. REFERENCES I. M:uhesOIl LN: Ill1lu~triill Rehabililalion Resource Book. Sanla Margarita. California: Performance Assc~~lIl(~llI & Capacit}' Testing. 1991. 2. Pheasant S: Grgotlornics. Work and Hcahh. Oailher:<>bur£. MD. Aspen. 1991. J. M,lgOTa A: Illveslig:1110tlS of the rdalion Ix:lweclI low bad: p;lin :md O{'. cupalion. Indust Med 39:31. 1970.

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of the \';1\;dity of lhc UlI(l DigilOlllsokinclie Sptcm fresearch p;1pcr). Da"is. California: Uni\'cr~ity of Califomia. D'I\·i~ School of r.kdidne. 1987. BurdclI R. V:m Swearingen J: Rdi"bilily of isukinetic muscle em!ur:lllc,: Ic.~IS. J OCClIp Sports Phy'- TIler R:4S4. 1987. L:lIlgr:lIla NA. Lee CK. ,\1cxander H. e! al: Quantiwti\'c :lSSCSSIlICllt of back strcngth using isokinclic testing. Spine 9:287. 1984. l'.-lcCrory r-,'IA. Ahkcns. SG. A\'ery CM, cl <11: Rcliabilil)' of concClllrk and el.:(.·entric measuremenls of lhc LIDO acli\'c isokinclie rehabilitati Exerc 21(Suppl}:SS2. 1989. Rose 5. Delitto A, Crandell C: ReliabililY of isokinctic lrunk muscle pcrform;lOce. Phys lller 6S:H24. 1988. Smilh 55. Mtlyer TG. Gatchel. RJ. el al: Quanliflcation of lumb;lr funclion. Part I: Isometric and multispeed isokinelic trunk strength mcasure:. in sag,iHal and axial planc~ in normal subjects. Spine 10:757. 1985. Porterfield JA. MO!'lardi RA. King S. el al: Simul:lled lin te.sling lls;n~ (oll1puterizcd is(lkinelie.\. Spine 12:6:'0. 1987. FrykTll:l1I PN. 1-l;mn;1O EA. Vogel J: Using a new dynamometer to Ctlll\· rarc Ihree lift stylc... (abstraCt!. Mc~ Sci Spon..<; Exerc 10:87. 1988.

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57:146,1988. W. Kn)ClIlcr KilE: ;\.n isoincniallcchniquc to a.<;sess individuallifling capa· hi'it)'. HUIll Facturs 25:493, 1983. 40. Ma)'er TG. Barnes D. Kishino ND. ct al: Progrcssh'e isoincnial lifting evaluation. I. A standanlizcd prolocol :\IId nonnativc dataha!Oc. Spine 13:993. 1%8. 41. lvblheson L. ~. 1ooncy V. Jarvis G. CI al: Prog.ressi ...c lifling cap:lcily witlt masked wc,:ighIS: Rdiahi!it)' study (abslract). PAR Rcsc:m;h Found:ltion. Physical Assessment ;tnd Reactivation Ccnt~r. Irvine Mcdical O:nler. Irvinc Califomia. Presentcd .It lhc 1"lt'nllltim",1 Society fi)r t"c' Study of ,he: Ul1JllJur 5I'i/l('. Bosloll. MA, June. 1990. 42. Golden NS: An .:lssessment of inlerr:lter reliability .:lnd inlcrtest correl:!· tion of a progressive psychophysical lifting evaluation which me.:lsures oceasionalliftinf:, cap'lcily (thesis). University of Iowa. Augusl. I99{). 43. Malhe!OOn L: EPIC Lift Capacity EvalU.:ltion Manual. S.:lnta '\03, CA, Employment POlcntialllllprovemell1 Corporation. 1991. 44. Matheson L. Moonc}' V. Grant J. el.:ll: A test 10 measure lift Cap.:lCil)' of physically impaired adults. Part I: De... clopllI~nl .1Ild reliability testing. In press, Spine 1995. 45. N:Jtional Institule for Occupational SafcI~' and Health: Work Pruclices Guide for ~'bnu.:ll Lifting {Technical Rcpon 81.122]. Cincinnati. OH• Division of Biomedical and l3ehavioml Scicnce. NIOSH. 19S J.

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NEW PERSPECTIVES IN BACK PAIN EDUCATION

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new infonmuion ubout back pain. During this lime, dingnos-

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to describe the general purpose of the buck school and the role it plays in the prevention of back pain 1O describe the historical development of the back school to review the literature regarding the effectiveness of the back school

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PURPOSE The back school is a panicular method of teaching back pain prevention and self-care. It is a precisely directed presentation conducted in a setting designed and supplied for the sale purpose of educating the patient This process of education may take many directions. The programs used by the author are directed at patients with back pain and at workers with back injuries. These programs include the following categories: Introductory back orientation program (Basic Training).' This type may be used as an introduction to back safcty for patients and/or for employccs <\s part of an industrial safety program. Back training and exercise program for all patients and employees wi"th a history ofb.ack pain-the classic back school (Put Your Back Problems Behind You!!!)' Intensive back training and exercise program for pa· tients and employees currently receiving some form of disability or compensation for b;lck problems-back school plus specific rehabililation procedures Back safety and injury response training for management and supervisory personnel. An extended program designed to acquaint those involved in \Vork~rclatcd injuries with the realities of back pain. The principal goals of the back school program arc education and self-responsibility. A necessary step in decreasing Ihe impact of any health problems involves improved understanding through patient education. In addition. to resolve the problem. patients must accept responsibilily for their own health. As a practicing chiropractor. I have treated many patients with back pain. Most recovered quickly. but as so often OC153

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to describe some of the better known back school programs to discuss the various formats used in presenting a back school program to discuss the physical requircmcnls for presenting a back school program to discuss the various applications of the back school in a private pr.:tctice. as a public service, and in the workplace to discuss the most common problems and the limitations of the back school

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154 curs, many had rCCllrrcncc~. Like many authors who have ad~ dressed the topic of back pain. Ill)' interest in prevention be· gall after personally experiencing recurring back problems. As my interest grew. I suc("cssfully applied the principles that I learned to my own back. Pleased with the changes 111<11 I experienced. I implemented a back school in my private practice. My initial .ittcmpts (0 educate patients in back pain prevention were based on existing programs described in theiitcratufC. Over the pas! decade. I have lllodihcd my ideas COI1-

REHABILITATION OF THE SPINE: A PRACTITIONER'S MANUAL

back school.13·1~ Thousands of back school programs have since developed; some are fonmil and involve the use of specillc audiovisual aids and materials. whereas others are more informal and involve readily available props.

STATISTICS

The impact that patient education programs havc on the out~ come of any disease is diftkuIt 10 gauge. Some l·\iJcnce illdi~ catcs that certain diseases. such as measles and typhoid. have been positively impacted by these programs. Objective evicerning the treatment and prevention of back pain. I flnnly dence regarding the effectiveness of the back school. however, believe that treatment is \"inually useless withoUl the cooperis mixed. Some studies have shown that the back school ation of everybody invQI\"t~d. including the patient, the c1ini~ has a positive effect on patients with low back pain.12.IS.17 cian, the employer. and the provider. This cooperation may be Other studies have shown that the back school makes attained ani)' through proper education. Iiule difference when compared to more common and traditional approaches. HI In an extensive review of the literature, Linton and Kamwendo state support is limited for the HISTORICAL PERSPECTIVES idea that a low back school can influence factors such as Although often described as a disease of modern society. back sick leave, work status, pain intensity or duration, etc. 19 pain is nO( a new problem. Man has been afflicted with Berwick et al found no measurable impact in L:umfort or back pain since ancient limes. Work~related back injuries date level of functional status.20 On the other hand. Feldstein back as far as 2780 BC.~ Likewise. attempts to reduce the in M et aFI demonstrated that back injury prevention programs cidence of back pain through educ~ltion programs date back were successful at changing behavior, at least in the short term. several centuries.1> In modem times. however. the emphasis on One study by Brown et alu offers some encouraging supeducation has increased in an ancmpt to minimize the impact port for the use of back school. The study investigated the of back pain. This process began largely because of the obcost effectiveness of a 6 M weck back school and rehabilitation servations of Fahrni in the late 1950s, who noted a significant program in terms of decreased lost work time and medical difference in the incidence of back pain in a "groundcosts as compared to a control group. A key finding in this dwelling" population when compared to industrialized socistudy was that back school participants had half as many reineties. He anributed this difference in part to postural or juries as nonparticipants. Data indicated that the back school lifestyle variations. Fahrni claimed that ground-dwelling was helpful in reducing the number of reinjuries in these populations spent more time in a flexed posture, and that deworkers for at least 6 months. The back school group had a creasing the lumbar lordosis would assist in preventing probsavings in medical costs of $9.743 during the postintcrvention lems from developing. He was one of the first physicians to period. The authors concluded that the back school group had teach therapists in patient education techniques.' less lost work time. lost time cost, medical cost. and injury At about the same time. \Villiams developed a series of during the postintcrvcntion period..!.! back exercises (\Villiams flexion exercises) in an effort to re~ In contrast to the relatively scarce support for the back duce the incidence of back pain.1( \Villiams thought that flex M school in the literature, a number of studies in industry indiion of the lumbar spine would eliminate back pain. and he cate that back pain prevention programs, including the usc of urged that every effort be made to reduce the lumbar lordosis. a back school. have a significant impact on reducing back McKenzie also thought environmental factors contributed to pain costs. ~~ Some examples arc as follows:2~ the development of back pain. but he recommended an en~ tirely different approach. one that incorporated extension exAmerican Biltrite saw Workers' Compensation claims drop from $ ISO,OOO 10 $40,000 annually at the end of a ercises in an effort to increase the lumbar lordosis. 9 The back school as a formal approach \V<1S first mentioned back school program. in the literature ill the early 1970s with the work ofZachrisson~ Southcrn Pacihc Transportation Company saw a 22% Forsell. What was koO\vn as the Swedish back school was de~ decrease in the incidence of on~lhe~job back injuries and a 43% reduction in lost work time. They calculated veloped in an automobile factory in response to an increasing problem with olHhe-job back injuries. Ill• 11 This program was the savings at $1 million in a single year. designed for a specific population group and was probably a Boeing Company participated in a controlled study of response to the lack of effectiveness of the then current treatthe effectiveness of back education on its workers in ment r.pproaches. BerquistMUllman and Larson published the which 3424 workers were provided with a back school and 3500 were not. Although the overall incidence of first statistical studies regarding the effectiveness of these cd· lIcation programs in 1977. 12 The next few years saw the develback injuries was not statistically significant between opment of several other back school programs, including the the two groups. those in the back school group were Canadian Back Education Units (CBEU) and the California demonstrateu tv illlVe lower lost work times.

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When one COllsitkrs tht.: staggering costs of back injuries 011 the work forec. even a small reduction in injury rales or lost work time hilS a signilk;.lllt impact One aspect of the back school that appears to be consistellt in the literature is the positive impact of this type of program on the patient"s attitude. Dutro and Wheeler cite different slUdics (h'll indicate that most individuals attending back Sl:hool progrmns found them useful; in addition. most felt the program hold indeed lowered their level of pain. ~~ UCC,lUSC much evidence points to a variety of psychosocial factors. including motivation and lack of control. as key factors in the development of chronic back pain and/or disability, this effect on patient attitude. may be the most important role for the back schooL In fact. I contend that lhe b:lck school is morc uscful in changing an individual's attitude about their back problems than it is in changing the way they lift

(15 10 20 subjccts) and a variety of professionals serve as the instructors. including an orthopedic surgeon. a psychologist. a psychiatrist, and a physical thcrapist. Class I. This session is taught by an orthopedic surgeon and focuses on anatomy, mechanics. and lhe aging process of the spine. Class 2. In this session. a physical therapist leaches proper body mechanics. First aid methods for obtaining temporary relief from back pain are also included. Class 3. ll1is session addresses the psychi:Jtric aspects of chronic pain and the influence of emotions on back pain. The instructor is a psychiatrist. Class 4, The final class is team taught by a physical ther, apist. who leaches basic back exercises, and a psychologist. who demonstrates relaxation techniques and discusses stress management.

PROGnAMS

The California Back School"

Sevenil programs h.lvc been eSlablished as major contribulors to the evolution of the back school, including the Swedish Back School. the Canadian Back Education Units, and the C.alifornia Back School. Although many other programs exist, including modifications of those listed, it is worthwhile to . view the format of these programs.

This program. developed by White Matmiller, includeS three 90-minute ~essions held al weekly intervals. A fourth followup session is scheduled I month later. Class size is small (4) and most classes are taught hy a physical therapist. Class 1. The focus of this discussion is on basic anatomy and aging of the spine. In addition. the natural history of back pain is outlined. Infonnation on pain relief and activities of daily living (ADL) is included, Each patient is evaluatcd using an oh<;'f;ldr: cOIln;e and an exercise tolerance tes!. Class 2. This session concentrates on ADL and'coordination exercises. The obstacle course is used to train pntients in lifting techniques and other ADL. Participants learn back exercises and on·the·job safety procedures. Class 3. This class includes a quiz on [he information provided. along with a second texl on lhe obstacle course. Instruction is given on more complex ADL. and individual problems arc addressed. Patients arc given a stress tcst. Personal Concerns Inventory (PCI). and instructed on its use. Class 4. This session focuses primarily on problem sol\'ing. PatieOlS are once again tested on the obstnc1c course. The PCI is rcviewed and suggestions arc made for reducing stress. Each of the programs discussed provides participants wilh esseOlinlly lhe same basic information. including anatomy. poslure, body mechanics. first aid, exercise. stress reduction. nutrition. and lifestyle habits. Although the format varies slightly. each has similar goals. To be dfective. a back school should be able to adapt to the panicular environmcnt (i.c.. priv<.He practice, industrial, etc.) and to the needs of the participants.

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The Swedish Back School Developed by Zachrisson-Forsell. this program consists of four 45-minute sessions conducted over a 2-week interval. Each session includes a IS-minute sound-slide presentation followed by a 30-minutc presentation provided by a physical therapist. Class size is relatively small (six to eight subjects). Specific goals of the Swedish Back School are to (1) in, crease pntient self-confidence; (2) understand the role trcatmentplays in the condition. and (3) reduce the costs of carc. An outline of class content follows. Class I. The focus of the fir!:t session is on anatomy and biomechanics of the back. the development of back pain, nnd lhe types of trealment available. Emphasis is placed on resting positions and some trcnlment advice is given. Class 2. This session focuses on the stresses imparted on the back from poor poslure and improper daily activities. Exercises arc demonstrated for strengthening the abdominal musculature. Class 3. In thb more practical session. participants nre asked to apply infonnution gained during the first two sessions. Various activities of daily living (ADL) are demonstrated and practiced. Class 4. This session includes a review of lhe first three classes and patient is provided with a written summary of the information presemed. Pmicllts arc encouraged to become physically active. The Canadian Back Education Units :l'1

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THE BACK SCHOOL IN A CHInOPRACTIC PRACTICE Although the back school should not be viewed as the solution to back pain. it is an essential component in the {rearment and prevention of back pain. It should be an integral part of any encounter with patients with b~lCk pain. Bccause so many patients seen in a chiropractic oflicc have a primary complaint of back pain. the back school should be a standard part of

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REHABILITATION OF THE SPINE: A PRACTITIONER'S MANUAL

treatment. Anhur White staled. "Back school is the center of the fastest moving specially in health care today ... \Vc will see chiropractors using bO\ck school in all of its forms and it may change the face of the chiropractic hCJ.lth delivery system. Chiropractors have lraditionally delivered their lrealments .md moved quickly to their next palicnls. They have nol, in general. spent time 011 cducntion and prevention. If and when they do so. the public .\Od olher health care professionals will sec them as the I~lrgcsi body of spine care spcciJlists with the most tools with which to treal spinal disordcrs,"2'1 In addition to reducing the impact of back pain on p:tlicllts. the back school should playa role in preventing back problems. As costs for health care continues to escalate, the role of prevention is increasing in importance. As an example, the National Institute for Occupational Safety and Health (NIOSH) has SCI, as a priority, a national health objective for the year 2000 10 implement back injury prevcntion and reha~ bilitation programs in at least 50% of worksitcs. As of 1985, only 28.6% of worksites with 50 or more employees offered back care activities.-\{) A description of (he back school programs used by the au~ th?r follows. Although the focus of attention is on the workrelated back injury, each of the programs is readily adaptable for a general practice setting. Introductory Back Safety Orientation for Industry The purpose of this aspect of the back school program is to provide all newly hired employees with an orientation course in back safety, Topics to be addressed should include the folIO\\ling: Basic back anatomy and biomechanics. This section is structured to reduce the fear of the unknown. Anatomy is presented in such a way that those attending back school have an appreciation for the unique design and function of the human spine..The role of the muscles. bones. discs. and nerves is presented. The nature of injuries to each of these tissues and the type of treatment lIsed for various injuries are discussed. Cost of injuries. both to industry and to the worker. Individuals should appreciate the impact of back pain on everyday life. Most estimates p1:lce the toral costs of b,lck pain at greater than S50 billion annually. but this number is unmanageable for most people. More practically, discussion should include the average cost of visits to the dot::tor. the loss of wages that oflen result from back injuries, and the costs on home and family life. Overview of how back injuries occur. Too often patients view the onset of back pain as rapid. In fact, many doc~ lOrs also look at back pain in much the same manner. For example. when an individual bends to pick up a box and develops back pain, she or he tends to blame the box. The patient is often cautioned about picking up boxes in the fUlure. In contrast. an individual who picks lip a box and has a heart attack would not consider blnl11ing the box for their heart problem. The patient un-

derstands that, although the episode may have been triggered by a particular activity, the activity did not create the problem. Ii is imponant to understand that back problems arc like heart disease, they don't just happen, , , they develop, Causes of back pain. Back pain has no single cause. Rather. il is the result of an accumulation of stresses over a period of time. These factors include ~tress. poor posture, poor living and working habits. poor body mechanics. loss of flexibility, and an overall decline in health. To minimize the impact of future episodes of back pain, each of these areas must be addressed. First aid for back injuries. One of the most important aspects of any back school program is first aid. Because many people with back pain arc likely to have future episodes, it is imperative that they know how to respond when problems do occur. The response may have a significant impact on Ute severity and duration of the episode. When a patient sprains an ankle, the.y typically apply ice. For some reason, however. when a back sprain occurs, patienls often apply heat, many times at a doctors advice. In the event of back injury, patients should be instructed to: (I) stop whatever they are do· ing, (2) relax in a comfortable position, (3) perform some type ofUfirst aid exercise" (Le., press-up, knee-tochest, or standing back bend), and (4) apply ice. Self-responsibility. Ultimately. the solution to back pain lies not in the doctor's hands, but in the patient's. Consequently, the primary goal of the back school should be to provide the individual with enough information to allow them to take an active role in their own back care and to encourage them to accept the responsibility to do so. This orientation program may he presented in a classroom style format and should last approximately 30 minutes. It can be adapted to accommodate small, medium. and large groups.

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Back Safety Program for Industry The purpose of this componenl of the back school is to provide all employees with information necessary to avoid serious back injuries. Topics of discussion arc similar to those covered in the orientation program (sec previous section). The content is expanded and the fonnat includes active participation on the pan of the employees. It is suggested that two separate sessions be included in this section. Each should be approximately 30 to 45 minutes in length and scheduled within 2 weeks of each other. Class size should be limited to 20 to 25 participants to allow interaction.

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problems. J' ·)! In addition to the increased risk, these individuals typically arc more interested in prevention programs. For Ihese rc.~asons, this group requires more extcnsive training. It is suggested thai this group enroll in an extended back school program consisting of three 45-minute sessions. Class size should be limited to 10 to 12 individuals to allow individual auention to specific needs and problems. CI
157 Management issues, how to dcai with the injured worker (e.g., referral process, liglll duty, company
Back Safety and Injul')' Response Training Until rccently, the use of education and training programs reduce the incidence of low back pain has focused on the injured worker. One of the most significant components of any back safety or injury prevention program. however, is the training provided to supervisory staff. The way in which lhe "compnny" responds to an injured employee has a great deat to do with the scriousness of the injury. With this in mind. one must look at a somewhat unique aspccl of the back school. The purpose of this portion of the program is to provide the supervisory staff (e.g., management. store managers. union stcwards, etc.) with Ihe infonnation necessary to deal effectively with the injured employee when an accidclll occurs. The class is designed to consist of one full day of 6 hours duration; class size is limited to 30 to 40 individuals. Topics to cover include the following:

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Over the years. I have taught back schools in a variety of formats. including lectures to large groups, small group sessions with 6 to 10 individuals, and one·on-one instruction. Each particular fonnat has advantages and disadvantages and the design of any back school program should be adapted to the specific audience for which it is intcnded. As stated previously. many industri
158

REHABILITATION OF THE SPINE: A PRACTITIONER'S MANUAL

length. In OUf facility, c1.1sses afC scheduled on Mondays and Thursdays and participants arc scheduled on three consecutive nights (i.e., Monday, Thursday. Monday or Thursday. Monday, Thursday). Consequently, the entire series of cl3SSCS is completed in a period of 8 days. Cla...s size is limited (0 six

to eight individuals to allow individual illlcntion.

Group Versus Individual Training At times. certain patients may require individual attention. As a general rule, however. small groups of patients arc more productive. The advantages of lcaching back school in small groups include that the friendly environment reduces intimidation; patients learn from each others' mistakes and experiences; the variety of expcriences and questions is greater; those in the group provide psychological support for each other; in any state. it is encouraging to realize they arc not alone; tcaching several individuals at a single session is cost efficient.

Curriculum Although the curriculum varies from one location and program to the next. certain basic clements arc found in most back school programs. The infonnation provided should include the following:

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Anatomy-basics of spinal anatomy. It is imporwnt to describe the anatomy in· tenns that are clear to the palien!. Understanding the parts of the back enables the paticnt to better appreciate the role each part plays in their problems and in their recovery. In addition. the marc an individual understands aOOm the back. the less fearful Ihey become. Posture. Many authors have suggesled that poor posture ;Jlays an important role in the develQpmcnt of back pain. Although not everyone agrees on which posture is most detrimental or most helpful. it is clear that any posture [hm is sustained is. at the very least. a contributing factor to back pain. Patients should learn how to recognizc both healthy and harmful postures. They should be able to identify positions and movemcnts that allevi.ltc their symptoms and be trlught to modify their work habits to improve posture. Body mechanics. The relationship of acti\'ities of daily living to the development of back pain is an important aspect of the back school program. Patients should be encouraged to use their bodics in safe ways. which is accomplished by teaching safe lifting tcchniques and by demonstrating and practicing a variety of everyday movements and activities (c.g.. lifting. pulling, cle.) First aid. Thi~ aspect of the back school is one of the most impol1anl. Even if patients understnnd how to use their back and establish good back habits. accidents and injuries slill occur. \Vhen they do. the reaction to the injury has a great deal to do with the seriousness of the

condition. Paticnts should learn to respond to any future problems by relaxing. assuming appropriate 1l10V~111el1ts and positions. pcrfonning first aid exercises. and applying ice and suppon. Exercise. One goal of a back school program should be 10 teach exercises to minimize future back problems. These exercises will vary with thc background and philosophy of Ihe inslructor. hut they should include rdaxation techniqucs. flexibility and stretching excn.:iscs. strengthening programs. balancc and coordination procedures. and endurance exercises. Stress reduction. Many back school progmms have included specific ,mcmpts to reduce stress in back pain patients. Efforts [Q reduce stress ~nd tension arc a most productive 1001 for the management of many musculoskeletal problems. including back pain. and should be a focus of the back school. Nutrition and lifestyle habits. The relationship bel ween lifes.lyle and health is described to raise the level of pa~ tient awareness in this area. Topics covered include good nutritional habils. smoking, alcohol. regular exercise. :lod relaxation.

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Needs To determine the oplimal back school program that is both effcctive and practical. the following wamlO[ consideration: (1) patient population, (2) available space, (3) personnel, (4) availahle time, (5) available equipment, and (6) fees. PATIENT POPULATION

One of the primary considerations in developing and designing a back school is the nature of tile intended participants and the demographics of the community in which the program will function. Those panicipating in a back school may be current back pain patients. a general patient population. backinjured workers (Workers' Compensation). participants in an industrial safety program. managemcnt ,md safety personnel. school-age children. or pregnant patients. As stated pre\'i~ ously. it may be helpful (0 develop sevcral different formats aimed at rcaching diffcrent groups.

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AVAILABLE SPACE

The back school docs not require a large amount of space in which to function. It is possible to use separate facililies specifically designed for patient education. or you may want to "double up" an area that is used for other activities. If space is a problcm. teaching back school principles to small groups or evcn one-oil-one is marc practical. Scheduling back school sessions at a time when the office is not involvcd in patient treatmcnt activities is another consideration. A b'1Ck schoolth.1t includes an obstacle course and an exercise arC'l rcquires an open room with ;approx.imately 200 squarc fCCI of noor sp'll:e. The only rcquircmcnts are that the room he c
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159 follows a large lecture fonllat, you may want to consider renting a small meeting room in a local hotel. at the local public library. a nearby public school, church. or fitness center. In one instance, I found a nearby dance studio ideal for our purposes.

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READY. FIIlE. AIM! One of the most important aspects in developing a b~ll.::k school is dctermining who will provide the instruction. Some authoritic:; believe that only experts in lhe field of back pain have significant success in the back schooL.:n A great deal can be accomplished with existing office siaff. however, particularly those who have a history of back pain. The next option is" to look for help in the community. Every community has people with some health and/or education experience (physical therapists. licensed practical nurses, registered nurses. re~ tired teachers. etc.) who are eager and willing to work a few hours a day and enjoy interacting with peoplc. An advertisement in a local newspaper should provide a li~t of qualified pcapic. It is also possible to find the right person from among your patients. Whoever is selected. she or he needs to be friendly. uninhibited. and willing to listen and learn. (Note: This search should not be viewed as an opportunity to recruit new patients. Being serious about finding the right person for the job increases the likelihood that the back school will be successful.)

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The time schedule for back school sessions wilt vary. Sessions that take place during the nomlal work day while patient care is being administered. necessitate both space and personnel dedicated solely to this purpose. Scheduling back school sessions during nonpcak office hours, during evenings. or on weekends places less of a burden on your facility and personnel.

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AVAILABLE EOUIPMENT

One advantage of a back school is thal no sophisticated or ex-

pensive equipment is required. Most items needed are found around the house or on the job. such as a vacuum cleaner. suitcase. floor mop. grocery sacks. etc. It is helpful. however, to have n slide projector, a cnssctte tape recorder. and/or a television with a video cassette recorder. FEES

Perhaps one of the most practical questions concerns how much to charge and who is to pay. Fees vary from location to location. but a reasonable fce is the cost of an extended office visit. Many insurance companies P~\Y for these services and sometimes the patient's employer is willing to pay. \Vhatever the cost. and whoever pays the bill. il has been stated that, for everyone dollar spent Oil education and prevention. nine dollars arc saved!

In planning a back school, consider the options thai arl.· llHlst pmctic'll for your situ<'ltion and BEGIN! Anticipate changes ~tS yOll gain experience. Many questions will remain llllans\\"en:d a.nd the chances of success may be uncertain. If you w,lit Ul1~ til all questions arc answered and the best possible f~lcility. staff, and format arc secured. chances arc you \vill nevCf start. Certainly. the chances of success arc much better once yOll begin!

Promoting the Program To be successful. the back schoollllllst reach the intended au~ dienee. Depending on the type of program developed. this connection may take place in a variety of ways. If the back school is intended as a resource for your back pain patients. they simply need to enroll in back school. If the program is intended as a public service. making the necessary comacts with local service organizations or groups is required. Any interest in presenting this information to industry necessitates active "marketing" of these serviccs. The following information is provided to assist in the latter endeavor. Note: The back school will be ,an effective public relations program for your practice. Most people contacted. and certainly most participants in the back school. will h3\'c a positive feeling about the program and about you. Th~ back school. however. is not intended to be a marketing tool for your practice or a way to attract new patients. It is a service to those individuals wilh back pain and this fact must remain the primary focus. Use in industry remains one of the primary functions of this type of educational program. The chiropractor is widely recognized as an expert in the area of b;lck pain. and the: back school allows the professional to positively impact the indus· trial community. To introduce a back school into local indus· tries, the chiropractor must first make contact with the necessary individuals. She or he must establish themselyes as an expcrt and be able to convincc management that this program will be lIseful. This relationship bct\\'ccn the chiropractor ,1Ild industry. often develops gradually over a period of tim~: once established. however. it should prove to be of bene lit to everybody concerned. An initial contact is made with a representative from the company or industry. This first contact will hopefully lead to a most important step. the interview. which is used to cSl
The Interview After armnging 3n appointment with the :'Ippropri~ttc company representative. the real wOik begins. This first mecting is an

REHABILITATION OF THE SPINE: A PRACTITIONER'S MANUAL

IOU

opportunity to leave a lasting impression with the company and that impression should be first class. It is important to

know as much as possible about the company before this meeting: The following information is helpful.

What is the nature of the company. Le.. manufacturing. heavy construction. material handling. high-tech. cIC. How many cmployct::s docs the company have locally Docs the company have olher facilities or branches How long has the company been in existence and at this location What is the fUlUre market for the products or services of this company This infonnation is available through a variety of sources.

to the company. tilt: illl.:atioll ur job description wh~rt: lhe injuries occurr~d, and th~ manner in which the cbill1s wt:rc handled. Once this evaluation is accomplished. it may be helpful to do an on-silc evaluation or analysis or any problem arc;,s Ihal arise in lhe records review. or particular iillcrcsi me areas 111at have holO a high il1<:idt:IK~ of injury, especially back il1.iuri~s, Other areas of interest induoc slips .ll1d falls. knee injuries. .1011 and shoulder injuries. and wrist and hand problems. As with patient care. once problems have been c1ci.lCly identilied through a thorough case history and exmnin
The local library has demographic infom13tion on most industries, as docs the local chapler of the Chamber of Commerce. In addition, a receptionist or some other contact at the company will often provide a grcm deal of information. It is useful to vicw this first· meeting in much the S<.1mt: way as we look at an initial pcHicm inh.::rvicw. This first encounter is the time to identify the primary problems and to establish if there is a need for prevention services and. if so, what type of assistance is needed. For example. if

a company has a large number of repetitive stress claims for wrist and hand injuries but no significaJ1[ problems with back pain. it may not help them much lO provide a h
The Industrial Case History is designed to provide information about the demographics of the company. the nature of injuries and problems Ih31 arc common in their work environment, and the manner in which they view health issues. h is a most useful resource for this first meeting, It is unlikely that any company rcprcsemativc will have the answers to all of the questions on this form: they will need to do some homework to provide all of the information required. This situation affords an opportunity to schedule a second meeting and also helps to establish the nrst way in which one can function as a consuhant 10 the comp:my. Le.. 10 review thcir Workers' Compensation claims. One of the first steps in developing a prevention program \vith
NEW PERSPECTIVES

The significance of past advancements cannot be ignored. yel no single procedure has been shown to alter the long-term outcome for patients \Vilh back pain, As stated previously, even procedures such as surgery. show little lasting bcnent..\~ Similarly, the back school has not been shown to provide any long-term changes in persons suffering with back paill:1'I,JII Consequenlly. our approach to the back pain problem needs to change, One of the newest arC
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Costs of back injurics-to industry and to thc Individuai ClUSCS of back pain/types of back pain Risk factors. both occupational and personal Anatol11Y and biomcchanics of the back f-irst aid for back injurics on thc job Management issucs-how to deal with the injured worker (e.g., rcfcrr'll process, light dut)'. company ;luitude. etc.) Legal considcrations

THE "10%" FACTOR One of the predominant statistics in the litcntturc pertaining to back pain is that approximately 10% of workers account for

80% of the coslsY' To gain control of the back pain problem in industry, we must take a close look at this small group of individuals to try to dctermine why their situations arc so different.

The Injured Worker

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To understand bettcr the back-injured workcr who becomes chronically disabled, we must take a look at the situation from a ncw and different perspective. No longer is it adequate to equate the impact of the injury with the "seriousness" of the physical ailment. We must inslead differentiate between the disease of low back pain and the illlless associated with low back pain.-I7 The process of disease is defined solely as a biologic dis· turbance. The illness is the subjective experience of the dis· case by the person in his or her environment. As such, understanding the behavior of an individual with a disease or a disorder in the context of that environment becomes crucial. Two individuals with similar disease.\· often respond lotally different ways, One patient may be (O[ally disabled. whereas the other may be merely inconvenienced. In spite of the nurn· hers provided previously. there is some thought that the ,U...• ease of low b.lck pain has not incrc.lsed in incidence during the past several dec.ldes. whereas thm of the illness has increased dramatically. Part of our efforts in preventing. or managing industrial back p"in should be directed at identifying individuals al risk ..l,~

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Lm:k nf .h';' satisf;\ction/p <.: Hig.h str~ .." levels at work" Poor g~Ilc:r:.I1 hC;llth~l·/smoking·\1 RISK FOR DEV"_OPING CHRONIC BACK PAIN

Other raL'lor.. ,hml1icily JJ1"('clic:/ol's) lIlay 11:1\"1': rc!l:v.ll1ce· ill c\'aluating .: ~rollP of patients with aculC low hack p:lin to <.lclincate Ilh',e :; or I ()tIc who will (h.:vclop a chronic problcm: Clinil:al rrt:>,clltation of a palicm ovcr the initial weeks after injury Illay be a valuable guide in determining chrollicit~. Fal:wrs indudc: -Leg pain. particularly the.: presence or root tCI1SLOIl signs~' ;. -Nonorpnic signs. whkh may he assOl:iated with symptom magniticoltion syndromc. hypochondriasis. and/or malingcringl • l -Pain self-report. A pain complaint thal docs not conform to known physiologic patterns. particularly when coupled with om abnormal pain drawing"l -Nonspecific diagnosis. The lack of a specific pathoanatomic diagnosis is associatcd with a le~s f;jvorable outcomc('! Age. Indi\·iduals younger llwn :lge 25 years ;m: at greater ri5-k of injury but usually l'elUrn to work sooner,'" Those injured workers betwcen the age.: of 30 and 55 tcnd to h<:.\·c higher incidences of chronicilY and disabiliti-":' Sex. Eighty percent of back injury cOlllpens~Hioll claims ar~ tiled by I1)cn."\ although an occupatiOll~l\ly injured \\oman is more likely to remain disablcd.~"l· Educmion. An inverse relationship exists between educational le\"d and tow back pain and disability. with the most pronounced incidence in the least cducatcd.~··"~ Context of the injury. An ;lcute cvcnt related to lifting-. bcnding. or (wisting or an accidclH such .IS'I slip or fall. has a predictive \"alue for chronicity.-I·Inconsi!'h~ncy of medical carc(~1 Lack of <.1\·ailability of interim light duty workJ,~ RISK FOR BECOMING DISABLED

RISK FOR INJURY

In the gcneral uninjured pop·ulation. certain factors (injury (JfediclOrs) may serve to differentiate the group at risk for a back injury: History of back pain is the single most important pre· dietor l '! Trunk strength deficits. The probability of injury is [hree limes greater when the job lifting require· mcnts approach or exceed the individuals' functional co\ll
In addition to the factors just mentioned. 'l1lother set of pre· dictors (chronic' olltcolJle predictors) might be helpful in idcn· tifying those individuals for whom trcaUllL'11l or intervention is likely to fail. It is this poHienl who 1110st contributes 10 thc "high cost" of industrial back problems. Thesc racwf:O: in· elude: Compcmation and Iitigation 111 LIS time. The longer it takes for an injurcd Wllrkcr to receive care. the longer it takes for a referral to a specialist lO occur. and the longer she or he must wail for procedure, such as surgery. A chronic outcomt: i:- nK,rt: likely in this situalion.

REHAl:.illll A lION OF THE SPINE: A PRACTITIONER'S MANUAL

100:::::

\Vhcn surgcry is suggestcd but not pcrlorlllcd Lack of availablc work upon rcturn~"

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Total Management of the Back-Injured \Vorker Success in this task includes an unders!:.mding. of the following: The injured worker-whal Iype of worker is injured The injury-hO\\' docs the injul)' occur. \\-'hal types of activities arc associalcd with hack injuries Thc response to injury-what happells .lIlhe time of injury, to whom docs she or he report. who docs. she or he see, what help docs the company offer Return-to-work factors-what is the company policy. what is the employee. attitude and expcrience. Illodillcd work program. who arc the slake holders Wlmt makes an injury serious

SUMMARY Patients must lake a morc activc role in their n:covcry. Clinicians are being asked to abandon passive treatment in favor of mcthods that encourage patient activity and participation. After three decodes of interest. however. controvcrsy surrounds the effcctiveness of the back school as a means of combatting back pain. The back school is treated by somc as an important part of the solution to the growing problcm of back pain. By othcrs. it is considered unnecessary and unproductive. After 17 years of active involvement in back school programs, I havc ~een interest in this topic increase and decrease. The substantial commitment of timc, effort. and energy needed to establish and continue a successful b'lck school program in a chiropractic prIudy wilh len year:;. (If oh~cr"aloin. Spine 8: 131. 1983. 3. Hooper PD: Ba."ic Training. Di:uuonu Bar. CA. Injury Pr.:;\'cmiun Tcchnologies. 1992. ~. Hooper PD: Put Your Back Prol:tkm." Behind You!~!. Diamond Bar. Ct\. Injury Prevcntion Technologics. 1992. 5. Br:mdt-Rauf PW. Rrandl·F;'IufSI: History of occupation,,1 medicine: Rele\';\1\(e of Jmholcpand Edwin Smilh papyrus. Or J Jnd Med 44:68.1987.

6. I'dtlcr t: Til,' l>:ld ...:hl,,,1 ,'I Iklpcd\ ill ~·I0111pdicr. elin Onhllp 179:4. 1<):\.'. I. F:lhrni \VII: B;td,;;t<.:hl· ;t1ld I'rilll:lll'tlsllm,::. V;l\Icou,·cr. ~hNlucallll'uh.. 1.1.1.• 197{1. s Willblll~ PC: 1.0\\- Il:Id;, ;111\1 S...•...·k Pain: CI\ISCS
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1 ,N. Il.llIll. k ..' l.lll JA. 1I.\~·k ,dl,I,,1: Au ,\\,:n:..' \\ with sl)\,'dli..· rd..'r..'n.:.: til Ih..- C:lI1;tdi;1I1 kl':].., \',!II,;\li"JI unih, Clin (lnlll'l' 17'): Ill, 19X3 .10 t\l.lb..' r·:-'llllh'lI J:\. Cll.\,<· S~l. I'nnd. HS. ,'I ;11: :\ "'Illlll'llikd. 1'('''1>('..·· !I\ ..' ,Iudy It...'\"aIU;ll..• th..• ...·fk.:ti\"(.'n..•...' ,,1.1 h:Kl.. ,duM.1 in th..• rd,d·l.r .-l1(,'lIi..- Ihl'. Spill'" II' J ~(l. I"X(•. .11. B.lrn..':- D. Smith I). (;:lld,..:! R.l.'l ;\1: 1'.. ~ ..I"h.r•.:inl:l:"n"ll1i.: ph'IIKbJ"

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11\ \\"ulka:-' Cllllll'.:n',tlJ<>ll. I'J\'so:nl~·t1 at lh~' St:ll..: ... C"l1I!,":Ih.lli"n :\d\ i_'"r~ C"lllllliH~'\', S:lll Di\.·~". CA. Cklllhcr. J 97.t. B1o,:k AR, t\1''':Ill'':l' E. Gaylor \·1: Ikha\i,'r;d lfl.'atlll\·l1l Ill' ... hrpili,· paill \ari:ll:oks afli:.:tin;: (r'::lllllelll cfli..·a.:y. I':tlll S:Je.7. 19SII, Whilc !\\\'M: l.ow h:ll:k p:lin illlllell l'..''':",I\ Ill;: workl1'cns· ..·nmp..·n':llioll. em ~kd :\~~(lC J 9~:;\(J. 1966. Frymlly....l' JW. Pop..: ~IlL I{oscn 1. ":1_,<1: [rid.. . lllioillgi'" slllllie, of low h:li.:k rain. Spin.. . 5:-119, 19HO, '",:nl\l11 H: Chifl>pr:l(tic A modd til' lll... oq....'r:ltillg the illll.... s~ hch:l\'ior m\...kl in Ih..: 1":Ul:I;:Cll,..:llI III' low h:\\'I., r:.l;n Ilali . . 1l1s. J ~l:mipul:tli\"\: Ph~ ...itllllll:r 1-1:Ji ). 1991. ' 1'01:l1il1 I'll: I'r..'diclHr... III' low h:1d. p:un disahililY. In Whit..: AI-I. Amkfsoll R kd"!: Clllh.. . rv:llivc Cll'\.' (11' Low Back Pain. B;lllirnorc, Williallls..'\: Wilkin.... 1'1'11. Uigo~ 5J . ..:1 :11: A pro...p..:cliv.... ":\';llu:llilJn uf ,,:olllfllunly used pr..:-cmployrncnt s.:rr:cning trio!... fIll' anile intlu"'lrial hack pain. Spine 17:922.

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50. Chaffin DB, Park KS: A longitudinal sludy of low-hack pain :I~<'()ci;llcd wilh occup:lIional weight lifting f:lCl\lr<" .-\tn Inti I-lyg A"slx- J ,1~:51~. 1973. 51. B'~I\' 5J. 51'..:ngkr ()~1. .\-laflin r\A. Cl ;IL B:I,,;I.: injuries in indu'lry: ..\ rclrlhpc(·ti,·.... ~Iudy. III. [mpllly,,'e·rd:lt..:d fa~·h)f:'. Spine II :252. 1986. 52. --"trand NE: ~·1cdical. p'ydwlvgil.:;tl. 'Illd ... ~~ial f:lCtors :lssociall:d with hack abnorillalilic~ ;IIlU sclf-n:porlcd hack p.lin. Hr J Inc! ~'1cd J-1:J27. 1987. 5:;. ~1:tgora A: Ilwcstig:tlion of Ihe rd:lliull,hip between 1(lw hack pain alld occup:lIioll. Scand J Rehah l\kd 5:191. I<JB. 5~. Wc<;lrill C. H1rs..:h C. Lindcgard B: 11le flI.'"NJnality of Ihe I:o:t;:k p:.ti":lll. Clin Orlhop S7:20{,j. 1972.

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5:'. SI~'uKryk S. Jenkins CD. Rosc RM. Cl al: Thc prospectivc impact of pSyw dlt"l'....·i;ll vari'lhh:... on r.1l....s of illness and injury in profession:,icmploy_ c,· _J O":l.:Up t-.'kd 29:(H\ 1987. 56. Sr n~kr m.,1. niglls SJ. M:lrtin MA. C( al: Oack injuries in induslry: ..\ rL'lrn",pcl.:li\"e sludy. I. Overvicw and cost Oln:llysis. Spine II :241. 1'J:'h. :'i. Fr~mnyer JW. PIll"'" .\IIi, Clemcnls JH. et al: Risk f.,Clor." in low back p:lil1_ J BOlh: Jninl Sllf~ I t\1lI I 65: 184. 1983. 5S. Iham~.S"r":Il~1I F: A I'h"'pe..:li".... study of low ha..:k p:lin in :l gCIl":w! !"rul:l1il'l\. Sl':ll1d J Rd1:lh f\kd 1):81. 1(8). :"). Tr...up J1)G: Slr.lifill-Icg·r:lising tSLRI :Illd the qualifyint;. tcsts for illrr~"hed rUllt tCllsiun: Thcir predi,,·li\'!.: value afler back :lml s~iadc pain. Spill\' 6:526. 19S I. hO. W.I..l\kll G. M..:Cul1ou~h JA. KUlllmd EO. CI OIl: Nonorg:lnic physic:ll "'l~n... in lllw h:Kk pOlin. Spine 3: 117. 1980. (d. Kirkaldy·Willis WH: Thc dinicOII picturc-introduction. IN KirkOlldyWilli~ WH (cd): M:m:.ging Low Back POlin. 2nd Ed. Ncw York. Churchill·Livingstonc, 198R. 62. F~mo)'cl' JW, C:lIs-Baril W: Prediclors of low hack pain disahility, Clin Onhop 221:89, 1987. 63. Bigos $1. Spengler D~1. ~'larlin NA, Cl :II: Back injuries in industry: :\ rclrospcctivc study. 111. Employee-related (;tctors. Spine 11:252, 198b. M. F~'moyer JW: Back p:tin and sci mica. N Engl J Mcd 318:291,1988. 65. Klein BP, Jensen RC. Sanderson LM: Assessment of workers' compensalion claims for back !'ilrain.slsprains. J Occur Mcd 26:-143. 1984. 66. Dzioba RH. Doxey NC: :\ prospectivc investigation imo lhe orlhopcdic :lnd pS)'chological prediclors of outcome of first lumbar surgery foUoww ing industiral injuiry. Spine 9:614. 1984. 67. Dcyo RA. Tsui·Wu Y: Descriplive epidcmiology (11' low h:ICk p:\in :\nd its rdatcd medical C:lre in Ihc U.S. Spinc 12:264. 1987. 68. A"lr;lnd NE: Medical. p...ychologic:ll. and soci:!l factors OIs.~ocjatcd with back abnurmalilks and ,e1f-reporled hack pain. Dr J Ind r-,.·Ied 44:32"1_ I%i. 69, \\'ci~d SW. Ferfer HL. Rothman RH: Indll.~lrial low b'ICk pain-:! pro'pceti\'c c\'illualion of a sl:l1ltlarizcd di;)~nosli..: and tr..:atmelll prolocol. Spine 9: 199. 198-1. 70. Robertson LS. Kc....vc JP: Worker injuries: The dfccts of workers' compcns;ltion .1Ild OSHA inspections, J He:lhh Polie Polk)' L-lw R:~81. 1<J10.

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CRAIG LlEBENSON and JEFF OSLANCE

Pmicnt CdUC.l1ioll is as csscmiallO successful rehahilitation as afC exercise or other trc~HmClll stri.Hc:gics. Sometimes education. advice. :.lnd training arc all that a person lh:cds. Im-

proving a pmiclll's sining posture or recomlllending J llcadset for prolonged ll.:lcphonc work arc jUq two cXi.unplcs. Patient cducmioll is prdcm.:d over cxcrcisL' bee use once a person

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lc;mls how to rcdll<..' c strain. that Klwwll'dgc is with them forever. whcrc
mechanics. and preventive exercises. We place the most important areas to cover into four c;.uegorics. First. reassurance that the natural history of most pain syndromes is toward a speedy resolution. Second. body mechanic!' lhat arc univcrsally applicable (i.c.. workstation ergonomics. lifting advice). Third. the importance of focusing on function in addition to pain relicf as a goal of care for the subacutc. chronic. and high risk patient Finally. explaining the dilTerencc between hurt and harm so the patient is less likely 10 immobilize themselves and become deconditioned in their attcmpt 10
Close to 90% of back pain episodes resolve within 6 wccks:· liI This excellent prog.nosis should not. however. lead to a negligent approach to managing this problem. A review of 1989 \Vorkcrs' Compensation low back pain claims revealed that. "cases that go on to have prolonged disability arc the primary contributors {O the cxpense of low back pain.'''' It was deter· mined thnt "25% of low back pain cases accounted for 96% of the costs'" Persons who are still suffering ..,ftcr 6 weeks arc at considerably higher risk for 1;lsting disability and chronic. pain. According to Nordin. " ... there is a very small window of time in low back pain care: we must .Icl quickly within 4·6 weeks to bring paticIHs into an active reconditioning pro· gram if we expect to return them to productive lives and prevent recurrence."11 With recurrence rates around SO(k and the high costs associated with chronic disabling pai-n, aggressive conservative C.lre focusing 011 restoration of function and pa· tienl education should be the standard of carc. Unfortunately. because of the excellent prognosis for most patients. many health care providers arc misled into be·

lic\·ing. that c;'lrly aggressive conservntive care is not neces. ~sary for patients with low back pain. Experts and emerging consensus-based guidelines disagree vehemently with this lfodilional approach. sloling lhal the lypical managemenl approach of bed rest with medication is responsiblc for fostcring disability in those prone to it. Troup. an esteemed British orthopedic surgeon. stated that, "The first attack is the ideal time for active and perhaps aggressive treatment but if it is tacitly assumed that the vast majority of patients recover-from back pain whether or not they are treated then the opportunity may be missed."lO It is essemial to pursue rapid resolution of symptoms aggressively to minimize the likelihood of recurrent symptoms as well as the development of a chronic. disabling pain syndrome. The Quebec Task Force on low back pnin disorders said. "Management strategies should be directed at maximizing the number of workers returning to \.. ·ork before I month and minimizing thc number whose spinal disorders keeps them idle for longer than 6 months."t'> Prolonged disability or pain will lead to both physical and psychologic dcconditioning. which we should 'strive to prevent through appropriate care of acute episodes. In the early managemcnt of back pain episodes. manipulation is the single most effective treatment strategy. I: Rehabilitation with exercise 1m!' also been shown 10 hasten return III work tInct reduce the rate of recurrenccsY·l.1 Radicular syndromes arc associated with a less favorable outcom~. Nonetheless. ovcr 90% of individuals with pain below the knee and nerve root tension signs recover without surgical il1tcrvenlion.. ~·wrhe length of time prescribed for bed rest may be longer (up to I week), the value of manipulation less certain, and the overall length of time required to achieve symptom resolution more than 6 weeks, but the prognosis for recovery is still good. Thc prognosis is poora for chronic pain syndromes. Patients may henefit from a trial of manipul;Hivc therapy. but 11 biopsychosocial approach is detinitcly indicatcd. Exercise. education, and encouragement arc the mainstays of successful carc. Psychologic intervention may be needed as well. Focusing on function and reducing the patient's fear about movemenl arc critical to succcss. Carefully explaining that hurt docs not equal h;lrm and that wc do not follow a "no pain~no gain" philosophy is an important prelude to rehabilitation. Functional goa.ls must be clearly cst;lblished and objective outcomes used to monitor and demonstrate progress. 165

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166 in cnronic pam m.uwgcI1lCIiI. il

REHABILITATION OF THE SPINE: A PRACTITIONER'S MANUAL

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nnd nol cure ;,md to place )'(lur:-df in tilt: role of hdpcr rather lhan healer. n Rarely is back pain 11ll: prl'''l'luing symptom llf .1 serious disease. A thorough history and clinical cXillllin;l\i\l\1 should be obtained. howc"cr. to ruk oul inrcclions. 1ll1l10rs. and other serious disease=, (Iwt t;tIl mill1ifcs( with spin'll pain. Reassuring p:nicllts lhal their prohlem is IlIcl...'hanic:'l1 .llld not .1 sign of inlcflwl disCilSC is an important step in p;Uicnt edu-

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Standard of Care and Identification of High Risk Patients Over 80% of the population will cxpcriclltc hack puin Juring

their Iifelime. Only:; to ISCJ( of these individuals. however. will become chronic suffers. lkcause of thr: disproportionately high cost associated with chronic C:ISCS. much altention has been placed on linding bellcr treatment ~lnd prevention strategies for this minority. The :IlHhors of a large re"iew of worker's compensation low back claims concluded that. "the primary goal of low back pain management should be the prcvention or reduction of prolonged disability"'" A question posed by guidelines panels is. How many treatments 3re appropriate and for how long? The Mercy Guidelines concluded that 6 weeks of carc is usually sufrlciem for "uncomplicated" cases.-' Three to Ihe sessions per week for 1 to 2 weeks is appropriate. followed by "Progressively declining frequency is expected to discharge of the patient ..."$ Spinal manipulalive therapy has been shown to lead to a 34% better rmc of recovery (at the 3-week mark) when compared to other traditional forms of Iherapy.l" Between I and 19 sessions with manipulation have been proven effectivc over a 2-month period.'~ Shekellc said. "an appropriate trial of therapy is 12 manipul
Risk Factors The various factors lhm may lead [0 a slo\l/cr course of recovery arc presented in Table 10.1. The factors associaled predictively with chronic or recurrent episodes arc listed in Table 10.2. According to the British Guidelines. low educational attainmcnt and heavy physical occupation arc lesser risk factors. but will interfere significantly \vilh successful rehabilitation. s

Table 10.1. Factors That May Predict a Longer Recovery Past hislory of >4 episodes > 1 week of symploms before presenling 10 doclor Severe pain intensily Pre-existing structural pathology or skeletal anomaly (i.e .. spondy~ lolisthesis) directly related to new injury or condition (From Haldeman S. Chapmiln·Smilh D. Pelersen OM: Frequency and dura· tion 01 caro. In Guidolines lor Chiropractic Quality Assurance and Practice Parameters. Gailhcfsburg. Aspen. 1993. pp 115. 130.)

Table 10.2. Risk Factors for Chronicity (British Management Guidelines lor Back Pain) • • • • • • • • • • • • •

,

Previous history 01 10\'1 back pain Total work loss (because of low back pain) in pasl 12 months Radiating leg pain Reduced straight leg raising Signs 01 nerve rool involvement Reduced trunk strength and endurance Poor physical fllness Sell·rated health poor Heavy smoking Psychologic dislress and depressive symptoms Disproportionate illness behavior Low job satislaction Personal problems-alcohol. marital. financial AdversarLal medicolegal proceedings

(From Waddell G: The Low Back Pain Guidelines (British). Clinical $lnndards Advisory Group: Back Pain. London, HMSO, 1994.)

1I011Y MECHANICS

Reducing strain is essential to preventing recurrences. Tcaching office workers to take frequent "microbreaks" every 20 to 30 minutes can help immeasurably. Studies havc shown th<.ll tissue creep occurs after just 15 minutes. IX Also. if just 4% overload is encountered. a negative metabolic state is eswblished. I".~O Propcr chairs and workstations arc a must for patients with low back and neck polin as well as those .suffering from upper extremity repetitive strain disorders (i.e.. carpal tunnel syndrome). Work station ergonomics is a practical place to get started when looking for sources of mechanical overstrain. Go through the workstation checklist with your p<.lticnts (sec Appendix 10.1).

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Lifting Technique Lining technique is often debated; typically. squatting.is recommended over stooping. Unrortunatcly. Illost workers fail to follow this advice if repctitivc lifts arc required. Garg and Hcrrin lloted the increascd encrgy expenditure associ:ucd with squalling versus stoopin£.~1 What appears to be an attaintlble goal is maintolining the lordosis. independent of thigh and trunk angles.~~ Adams and Hutton reported thm less compressive load on ..I fully flexed lumbar disk (i.e., stooped posture) is needed to cause posterior herniation of nuclear materi'll than would cause end plate fracture in the uprighl positipnY According to McGill. "Because ligaments arc not rccruilt;d when lordosis is preserved. nor is lhe disk bent, it appears that the annulus is at low risk f"r failure.":: This statement was supported by thc work of Hickey and Hukins. ~~ Lifting while maintaining lordosis allows the further benefit of activming the musculature and thus prov.iding for neuro~ muscular control to protect ligamcntous tissues. Lifting technique is important, but when you lift may be evcn more significant. As a result of the increased fluid contcnt in the disk after lying down al night, disk bending stresses arc increased by 300% and Slrcss (0 ligaments is increased by

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Thus. th",' ri~k of injury during. forw..ml inl:rcascd in thc early morning.. Prol\H1~eu n".':\il\ll. SllC.::h as in sining. can rcnder the back '·ulner'lole 10 liftin~. ~-1cGill ,lUll Brown (ound lhat after jwa 3 minutes of full tk.xion. slIhjecls lost half lheir stilfncss.: h AJall1.'i anti Hutton nclievc thaI prolonged full flcxion nwy l';\USC ligalllclHoll.. neep and fender lhe spine sllsceptiblc to lkxioll ()\'crlo~~d dming liflil1g.:~ According to McGill. a brief I..'\lUrs~ of CXh:lbion exercises hcforc lining may prc\Icnt injury. ~.: XO'./r in thl;

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CO-""olllr,K'tion of thc lumbar erector spin;lc muscles during lifting app;;;lr... 10 redistribulc compressivc forces 011 the spine by adding guide }\'ires In a nexible rod. like rigging on a ship's masl.:: The i;lCrcasc in compressive loading on the spine is slI,!"lstmnial if even a small :Jmoullt of IOrsion is required during lirting. 22 To prc\'~nt injury. objects should nOl he lifted if they \\'ere awkw"lrdly placed. To reduce the extensor J1l0Il\elH. the load should he held as close as possible and lifted smoothly.:: :\ jerk lift is only appropriate for highly trained illdividu;ll~ who must lift light. awkwardly placed objects. The purpose of this lift is to avoid loading the spine in flexion for any longer tl};;lll is abs.olutcly nccessary.~~ Table 10.3 !'llllllllarizes current advice about lifting. Ergonomi<:: Factors One of the JllO~t delelerious activities people engage in is sit(ing. Erect sitting ill\'olves disk pressures significantly higher than th.it of normal standing, Sitting slumped forward (ante· riar sitting) increases disk pressure cven morc. and the greatest increase in pressure is associated with slumping backwards (posterior sitting),:!"~s Using a lumbar support or back rest reduces disk prcssurcs.~l A scat-backrest angle of 95105° reduces both erector spinae EMG activit)' and disk prcssure.~'u"

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The chair ~C!Oo I i Table 10.3. McGill's Rules for Lifting'12 Ma[ntah normal lordosis 00 nollill immediately alter prolonged flexion or rising from bed Lightly co·contract the back and abdominal muscles before and during lilting Keep Ihe load as close as possible as long as lordosis is maintained Avoid twisting 167 Thc proper dcsk hcight is normally about 27 to 30 em above the seaL"~ The shoulders' should be able to relax with the elbows bent 90° and the hands relaxed on the desk sur- f.cc. A slantcd dcsk (10 to 20°) may also be hclpful for rcducing neck str'lin. FOCUSING ON FUNCTION Functional restoration gels to the heart of a recurrent disorder more effectivcly than searching for the technique to "fix." the problem. Pain relief is enough of a goal for many first-time. pain patients. When pain is recurrent or chronic, however. or lhe individual is at high risk for a chronic. disabling condi· tion. enabling the patient to focus on function becomcs a high priority for the Ireating physician. \Vc should help the pmient to understand that a more fit back is less likely to become injured; whatever the cause of their pain (disk, facet. myofascial, etc.). they will be marc stable if function is restored. In fact, 80% of the time. an exact cause cannot be identified. but clusters of functional changes can .,ddrcs~ their symptoms.)) A deconditioned individual has lWO options for achieving lasting pain relief. First. they can avoid all strenuous activities. Second. they can increase their functional capacity (Fig. 10.l). These options arc really the only means available to prevent spinal problems. Either the load is reduced or the capacily to handle that load is increased. Convincing a patient to reduce external strain is optimal, because once they change their workstation or learn better biomechanics. they have that knowledge forever. If. however. only limited reductions in external strain arc possible. improving their intrinsic functional capacity or performance is the only remaining option. Exercise is always more difficult (0 accomplish than educ:Jtion because of problems associatcd with motivation and compliance. PATIENT MOTIVATION Achieving compliance in patients asked lo shure rcsponsibility for management of their pain rests on convincing them that body mechanics and functional improvement arc essential for long·tenn success, No amount of persuasion is adequate. however. unless their fears and anxicties arc also addressed. Most chronic patients fear that aClivity will cause them more pain. Explaining the difference between hun and harnl will help considerably (sec Chaptcr 2). Exercises that stretch stiff, shonencd tissues may in fact cause pain or discomfon but are not injurious, In facl. patients will learn how to stretch safely and to feel a comfortable "good hurt." Also, strengthening exercises arc best performed in a pain-less range, with pain only felt (he following day (sec Chapter 14). This postexercise soreness should involve only the lrained muscles and not be felt in any symptomatic spinal or postural arcas, Occasion>tlly. "McKenzie" exercises CJ:lllse some discomfort, but this pain should be local. These exercises arc avoided if any radiating pain is perceived, Learning that they can control their symp- REHABILITATION OF THE SPINE: A PRACTITIONER'S MANUAL 168 / ~ "c '"E "n'"; Injury c ~x W Non-injury Functional capacity Fig. 10.1. Relationship between external demand and functional capacity. , graph for c1inici:lIls. Repon of the Quebec Task Force on Spinal Disorde~. Spine 12(suppl 7):$1. 1987. 7. Bigos S, Bnwyer 0, 81"3en G. et 31: Acute Low Ba....k Problem$ in Adults. Clinic:tl Pr:Ktice Guideline. Quie\: Reference Guidc Number 14. Rockville MD. U.S. Dcpanmclll ofUc:llth and Human Scrvicc.", Publish H..:alth S..:n·ice. Agency for Ikallh Carc Policy :md Research Pub. No. 95-0643. D...ccmr.cr 1994. S. Clinical Standards Advisory Group (CSAG): Back Pain. London. HMSQ,1994. 9. Webs!cr ns, Snook SH: 111c COSI of 1989 Workers' COlll(lCnsation low hac\: p;,in claim!'. Spine 19: 1111. 199·t 10. Troup JOG: The perception of Olu~uloskclctill pain and incapacity for work: Prc\'cntion and carly IrC:Il111ent. Physiother.lpy 74:435,.1988. II. Nordin M: Early findings of NIOSH-CDC model back clinic reveal surprising observations on work-rel:tled low back pain predietol11o. Spine Leu 1:4.5, 199..t 12. Shekelle PG: Spine update spinal manipulation. Spine 19:858. 1994. 13. Linton SJ, Hellsing AL, Andersson 0: A controlled study of thc effccts of an carly inlcn'ention on aCUle musculoskeletal pain problems. Pain , 54:353. 1993. 1-1. Lindsaom A. Ohlund C. Eck C. et 31: The effcci of gl"3ded activity on palientlO with subacule low back pain.. Phys Ther 72:279, 1992. 15. Saal JA, Saal JS: Nonoperative trcatment of lumbar herniated disc with I"3diculopalhy. Spine 14:431, 1989. 16. Bush K, Cowan N. Katz DE, el al: The natural hislOry of sciatica associatt.-d wilh disc pathology: A prospccth'e study with clinical and indepcndc-nl radiologic follow-up. Spine 17:1205. 1992. 17. Fordyce WE: Pain history musings. APS J 3: t40, 1994. 18. Oogduk N_ Twomney LT: Clinical Anatomy of Lumbar Spine. 2nd Ed. r-,·ldboumc. Churchill Li\·ingslonc. 1991. 19. Andersson G8J: Occupational biomechanics. In Wienstein IN. Wiescl SW (cds): the Lumbar Spine: the Intcmation.3! Socict)' for the Study of the Lumbar Spine. Philadelphia. WB Saund.:,:;. ! ')90, ) me toms becomes a liberating experience for 1110st patients. As slated previously, the rehabilitation specialist should teach patients how to control their symptoms and not promise to "cure" or "fix" the problem. Patients need to know the exact goals of exercise. For instance, a goal might be to strengthen the "big muscles" (i.e., abdominals. glulcals. and quadriceps) to take strain orf the lumbar spine. \Vhen proper goal setting is aCl:omplishcd and those goals are mutually acceptable. patient adherence and compliance 3fC easier to achieve. If excessive fear and anxiety persist. then referral to a pain psychologist may be needed. A psychologist may be able to teach better coping strategic!' or relaxation techniques and can uncover hidden obstacles, such as drug or ~llcohol dependency. job dissalisf"ellan. or family stress, REFERENCES I. Aenn RT. W('I('Id PH: Pain in the back: An aucmpt to eSlim;l\e the ~izc of the problem. Rhl:umalol Kclwbil 14: 121. 1975. 2. Horal J: The clinical appc:ar'Lncc of tow back p;lin disordcrs in the city of GOIhcnourg. SWc...d cn. Acta Onhop Scand Suppl 18: I, 1969. 3. Ruwc ML: Low back pain in industry. J Occup Mcd II: 161. 1969. 4. Bcrqui!'t-Ullman M. L..l rsson U: Acute low hack pOlin in industf)·. Acta Orthop Scand Suppl ; 70: I, 1977. S. Haldcman S, Chapman· Smith D, Petersen 01\·1: Frequency and uurOltion of care. In Guidelincs for Chiropractic Quality Assurance and Practicc Parameters. Gaithcrsbag, Aspen. 1993, pp 115. 130. 6. SpilT.cr WO, Lc Blanc roE, Dupuis M. et al: Scientific approach to the as~!'i!'men{ .ll1d 1lI0lnagement of activity-related spinal di~orde",: A lllono- p213. 20. Sato H. Ohashi J. Owanga K. et m: Endurance time and f.3tiguc in st "J J i' ) ~ .~ ; ..) .' J ) 6:105.1975. 31. Oniz D, Smilh R: Ergonomic Considerations. In Basmajian JV, "'yb...-rg R (cds): Rational Manu"j TIlempies. B;I\timore, Williams & Wilkins. 1993, pp 441-450. b ".- ...... n1\1'"' I!:::H 10: PATIENT EDUCATION 169 .\2. Gr;tnJj\.·:lll E: Filling. th~ Task to Ihe Man. 41h Ed. London. Taylor and Fr:m..:i..:, 1988. ;\.\. Moffroid r-,rr, I-laugh LO. Benr)' SM. ct al: Dislingui~h:lblc groups or l1lu"..:uloskclclal low ll:lck p'lill (XI(icll1~ and .asymptomatic <,ontrol su\).. j..-Ch o3scd on physl\.'al lllcasur~~ of Ihe NIOSI-I low b.., d; al[::l.'i. Spine 19:1.':'O.199·t APPENDIX 10.1. How to Care For Your Back and Neck: A Section Addressed to the Patient Wllo is or Risk? Evcl)·one. BUI, those who silo bend. or twist a lot arc nt higher risk. Not liking one's job or having problems .It home also places one al higher risk. Finally. not being in good sha~.~~ciall}'jn your back and abdominall~-is an'~ddi(i;~al fa~tor. ---_._--_._-_._---- Whlll Call Br: DOlle? Surgery is necessary for back pain less lhan I % of thc time. Most b.nck or neck pain is what we call "mechanical" pain. One of the great myths is that arthritis and disk syndromcs are responsible for mosl peoplc's pain. In fact. one third of all people without back p~in h~ve herniated disks. h is now frequently considered a coincidental finding. Most spinal disorders can be trcated with simple conservative care involving m:lOipul~tion. self-t;:~c;_ advice. and exercise. If you are in acute pain, the initial goal is to stabilizc lhe painful ~We want to protect your back or neck by teaching you ~ow to find relief positions that take stmin off the painful.area. For insla~ce. you will be advised 10 avoid certain strenuous positions or movements. such as sitting or bending and twisling. This advice typically consists of prescribing limited activities and the usc of pain-relicving methods (i££, hCal. uh~d. electrical muse;..:: stimulation. manipulation. massage. tmction. etc.). A support may be given and bed rest recommended. but this regimen is used fOf the minimwn time possible to decrease the danger of dcconditioning (becoming execssivel)' weak or stifn. Perhaps most important is the reassuranc:;c thal you will receive that ),our condition has been evaluated thoroughly and that you do 11m h Fig. 10A.1. Spinal column (side view). (From Basmajian JV: Primary Anatomy. 8th Ed. Baltimore, Williams & Wilkins. 1982.) drome. which is resulting in pressure on a nerve. a diagnosis will be madc and appropriale treatment will be initiatcd. Thc sccond goal of care is to get yOll aClive agilin. This process is called rcmobiliz.ation. which is accomplished by reli.lxing tense 1ll1lS· C$S ',ocl loosening stiff joints. Gmdllillly and safely. you will be in: creasing the activitics you perform with Icss and less fear of reinjury. Stretching and light cardiovascul:lr exercises. along with nmniplll:l- Table 10A.1. Stages of Care SliJgcS: Goals: Treatment Strategies: Stabilization Pain RcliCJ. Reassurance. Proteclion Remobilization Acslore Mobilily Find relief positions Manipulation Limited bed rest Supportslbraces Physical agents (ice. heat, ultrasound, electrical muscle stimulation. etc.) Stretching Ergonomic advice (i.e .• how to sit) Manual therapy (manipulation. massage. traction) Analgesics or anti-inflammatories Cardiovascular exercise Reconditioning Improve Strenglh and FleKibility Strengthen ~big muscles" (abds. buttocks. thighs) Stretch postural areas (calves, back) Biomechanical advice (i.e .. how to tift) 170 REHABILITATION OF THE SPINE: A PRACTITIONER'S MANUAL lion. ;trc the primary mode:, of care in this siage. Fewer physicallhcr· ~py techniques an~ u!'cd and you will receive ndvice about how tu prevent or reduce strain in daily 'LClivitics. e.g .. how ~o sit withollt causing slf:Jin. (he third and fin,,' goal or c;m.~ is to achic\'~ reconditioning of vour "weak link," Typic~lIly. after a painful episode. movements arc ~~~(I;l-~l~~~akncss dc\'ch1p.... prcdisposc~ yOll Unless addrcs~cd, this condition \1 )~ --- ~~. ~. '"",=--- to future rccllm::nccs. You willlc.arn a combination Ii of stretching and sln.:lIgI11l:nillg exercises dc'sigm':d 10 impwvc lhe function of your b;ICk or nCI:k. AI this time. ;,IOVICC about lifting :lOd bending usually is given. The stages of C,Ire arc shO\\ n ill Table 10A.I. Nucleus pulposus WIIlII.DO('J tll(' Spine L(/ok Like? The spine is one of the most r<:m:trkable organs of lhc body. It's job is to protect the spinal cord and serve ;.ts ;a mQbile rod for bending the trunk. tllU~ allowing us great mobility. These two opposing functions of stability anulllobility arc both accomplished by this single ;'lmaz· ing slrllCllln.,:. The spillal columll has three curves when viewed from the side (Fig. lOA. I). E<.:tch n!nebm fomls a number of joints wilh ) its neighborin,g vcn~bral segmenls (abovc and below) (Fig. IOA.2). One of the most imponant spinal struclures is the disk. It is a cartilagil\ou~ ~mUCIurc each vertebrae. It has thai serves as a shock absorber betwecn <.I lough criss-crossing network of liga- ments (;.mnulus fibrosis) famling a prolective ring around its gel~ Fig. 10A.3. The disk. (From Basmajian JV: Primary Anatomy. 8th Ed. Baltimore, Williams & Wilkins, 1982.) like fluid interior (nucleus pulposus) (Fig. IOA.3). Viewed from above. you can see the spinal canal, which houses the spinal cord. and thus the relationship between the disk and nerve roots (Fig. IOAA). Wilen' Call the Puill COllie From? Nearly all the struclUrcs of Ihe back and neck can cause pain. Most commonly. muscles, (cndons.ligaments. or joints become sources of pain when Ihc)' arc irritated or overloaded. Sciatic (leg) pain comes from irritated nerve rOOls. ) . Certain movcments arc particularly likely to cause problems. Bending over to IiI"! something places tremendous strain all our backs. The combination of bending and twisting can cause damage II Th1! lUMBAR SPINE ~ ~ ~, , :~j! l Thl' t ~ Fig. 10A.2. Lumbar vertebral joints. (From Basmajian JV: Primary Anatomy. 8th Ed. Ballimore, Williams & Wilkins, 1982.) NERVES Fig. 10A.4. Relationship 01 the disk and spinal nerve roots. (From Kirkaldy·Wiliis WH: Managemenl of Low Back Pain. 3rd Ed. New York, Churchill Livingstone, 1994.) I"l .~ ~ ---------------------------- .--, I .L .... , 1r'\1 1 ~n IV: t"AlltN I , ) ,, ~ I ~ :~ 1, ,, t) i • ,I ' ; <'~ I~ () i !• II {) , § ~ • ~ -, I " I I , j i q !, I '~ I, even if we <Jon't Iirt anything in that position (Fig. IOA.5). Prolonged sitting. even in a Stiod chair. places a great deal of stmin 011 Ihe muscles :lIId disk~ of the ~ack. Being on the telephone or working at a compuler for long periods of time can strain the neck. upper bad. shoulders. elbows. or wrists. It is common for joints or muscles 10 be the source of pain referred to the low back. butlocks. thighs. between Ihe shoulder blades. neck. hc:.d. face. or arms. Figures IOA.6 to IOA.13 show c!,\ssic rcprcscnlatiuns of pain referred from certain key muscles. Joints and lig;,unclIls arc also able to cause local and refcrrcd (somc distance from its origin) pain. Figures IOA.14 and IOA.15 show typical refcrred pain pauems from irritated vertebral facct joint!' in the ccrvical and lumbar spines, respectively. The most famou!' culprit of severe pain is the "herniated disk" which can pinch on a nerve rool. sending pain or numbness .down the Icg~ even [0 the foot (Fig. IOA.16). If strained too much, the disk can bulge or ~ssibly [car, causing gel (nucleus pulposus) to herniale inlo lhe area containing lhe spinal ncrycs (Fig. IDA. I?), A bulge is comIllon ,md oftcn does not cause pain. Hcmiatio~s Ciln pinch on nerves or irritatc thcm. causing "sciatica" (leg pain). The fascinating thing is th:1t disk disorders occur in one lhi~d of all people who have no symptoms; thus. sllch a finding in a patient .may be coincidenta~. A thorough e~amina(ioll is necessary to dctennine if a disk problem is actually causing your symptom,s. Another structuml problem occurs when arthritic spurs (dcgener ,Hive joint disease) jut out from lhe. vertebral. joints and either pinch nerves (stenosis) or restrict our normal mobility. Here too. it is con ' man for degener.ttive joint changes to occur in the spine and be painless. In f:lct, arthritis increases with age. as docs graying of the hilir ,md wrinkling or'thc s~in. yet back pain peaks between ages 28 ilod 50 years. A .,~ q 1 171 eDUCATION ! <)! I, r~-,. '--'I, II ~: ..~ ~ , :1: "} l '-, "I ,~" = °1"}I '" i D' I! 0 () I i Fig,10A.5. >, Dangerous bending and twisting position. TP, Fig. 10A.6. Referred pain from the upper trapezius muscle. (From Travel! JG. Simons DG: Myofascial Pain and Dysfunction: The Trigger Point Manual. Vol. 1. Baltimore. Williams & Wilkins. 1983,) Whor COli I Da? Back and neck p,lin are interwoven into our lives, They arc normal yet unpleasant experiences that. if mismanaged. can become chronically disabling. In the past. docto~ believed bed rest. pain relievers. and perhaps somc physicallherapy (hC'l1. ultrasound. etc.) were all that was needed to lide someone over until the problem receded. Most of lhe time, such an approach succeeded in alleviating the pain. But. ~ i I,-=::.J ~ rI- ,- ~j ~ ' REHABILITATION OF THE SPINE: A PRACTITIONER'S MANUAL 172 Fig. 1OA.7. Referred pain from the levatal sl,;i:tlJuiae muscle. (From Travell JG, Simons DG: Myofascial Pain and Dysfunction: The Trigger Point Manual. Vol. 1. Baltimore. Williams & Wilkins, 1983.) ~rt~t ", , /:'" Fig. i0A.a. Referred pain from the scalene muscles. (From Travell JG, Simons DG: Myofascial Pain and Dysfunction. The Trigger Point Manual, Vol. 1. Baltimore, Williams & Wilkins, 1983.) . .......... .'..... 'LoI' IV. rMllt:I't' 173 CUUL;AIIUN ,: • 00:";' Fig.l0A.9. Referred pain from the sternocleidomastoid muscle. (From Travel! JG, Simons DG: Myofascial Pain and Oysfunclion~ The Trigger Point Manual. Vol. 1. Baltimore. Williams & Wilkins, 1983.) -, "---.J .~) J l v v v "v oj Deep Deep '---'.,." Fig.10A.10. Referred pain from the quadratus lumborum muscle. (From Travell JG, Simons OG: Myofascial Pain and Dysfunction: The Trigger Point Manual. Vol. 2. Baltimore. Williams & Wilkins. 1992.) f' I ,~ ell ~~---;, 'tj IJv ~._'-.: ~: __--, & I i t,J ~ _ REHABILITATION OF THE SPINE: A PRACTITIONER'S MANUAL 174 Fig.10A.11. Referred pain from the piriformis muscle. (From Travel! JG, Simons DG: Myofascial Pain and Dysfunction: The Trigger Point Manual. Vol. 2. Ballimore, Williams & Wilkins, 1992.) r ~I Fig.10A.12. Referred pain from the iliopsoas muscle. (Travel! JG, Simons OG: Myofascial Paln and Dysfunction: The Trigger Point tv1:::l.nual. Vol. 2. Baltimore, Williams & Wilkins, 1992.) 175 /~\ I .t ., j ! ~ I . j II 1 (') ", ....., ~ .. I \, "J I I ,"~ Ii n / ,~ 1 ,f,, "" ,j 1; 1 ,) l ,, ~ ~ Fig. 10A.13. Referred pain from the gluteus minimu5 muscle. (From Travel! JG. Simons DG: Myofascial Pain and Dysfunction: The Trigger Point Manual. Vol. 2. Battimore, Williams & Wilkins, 1992.) I ~ I ~ ") ~ (} Fig.l0A.14. Referred pain from the cervical spine joints. (From Dwyer A. April C. Bogduk N: Cervical zygapophyseal joint pain patterns: A study in normal volunteers. Spine 15:453, 1990.) ~ I, ':) .~ ~ I () ~ < "'2" v v v " "v " " -", v v u u 0- ), ! " Fig. 1GA.1S. Referred pain from the lumbar spine joints. (From McCaIlIW. Park WM. O'Brien JP: Induced pain referral from posterior lumbar elements in normal subiects. Spine 4:441.1979.) I j:~! § ~'-.':. ~V_ ij -----------------------------~- " ...... ",~,_."" .............. , , .... "", ......... " , •• r. ..... ' "'o.JU"'" v ,v,r.,vvr.,- .Kli\·ill<::- ,,(I we tJ~Jx:_B.~~ICI,:han.i~_~I!~U~~~~~tJ.r~.It III")' ;IIS(I hc nec.:I..·""an ((. paform "If:..',,::;..:,, durin!.! hn::lks In ;:IlIo\\' lllusc.:k~ ;lIld li~;\llll'l\;:- thai h;~~:~ i~l~:::~~·~~~~~·i;; .·til~;r--·~lr-engt1J. 1:[;''111)'. SlrCl\~lh":lIilll! cxcn:i~('" f,-'; .)llr ;lbLlullICIl. olluocks. Ic!.!s. ;L1ll! b,KK may IIC Ih::Clklllnhdr. t1 ... .;.\,:il~f;Jtiguc ill (lll";~~ck ;lllJi~l\n::r ll;ick. Acll'"i~;;;;ilCd p~;·g;;;1111~::::·.~~~)\I1ati{-:;~~;~ci~~·:;_'d CdlK,,{i7;'ii" \\·ill he d('\"j":..'d 10 llIee! your ;,::.. -1 .... Normal "pinal pOSIIIl"e h~·l~ . . r..:duce potelllial strain. Ul1f~)rh11lald)'. i uur moocrn lircstylc~. in c,'nI.'Cf1 Wilh the forces of !;r;l\'iIY. conspire tu min our he;llthy upright ~)sturc. The eldcrly arc oftcn slmnpcd iI ~e"use of bad postur\," ~lr somcliml.:s from osteoporosis (Fi'r.,. 101\.201. ·1l1;S habit of .~lu:i..ping begins in childhood when·we sit'ill I"rOlI1 of telcvisions. :-it in <non!. sit in ems. ele. Siair!E and imlCli\'- l I j Jf I ~ .~ i i I I 1 ~ ~ i Fig. 10A.16. Referred pain from an irritated or "pinched~ sciatic nerve root. (From Cox JM: Low Back Pain: Mechanism. Diagnosis, and Treatment. 5th Ed. Baltimore. Williams & Wilkins, 1990_) Fig. 10A.17. Herniated disk. (From Kirkaldy-Willis WH: Management of Low Back Pain. 2nd Ed. Edinburgh. Churchill Livingstone, 1992.) ! ij ~jJ; ! i I; i "I;i I 200 Ibs. Pressure 150 Ibs. Pressure 100 Ibs. Pressure ..J ~ ~ I 55 Ibs. Pressure i~ t 11 iI 1 ~ 200 Ibs, Pressure ;;; ~' I , Fig. 10A.18, Effects of posture on lumbar disk pressure. (Adapted from Dutro S and Wheeler L: Pregnancy and exercise. In White A, Anderson R (eds): Conservative Management of Low Back Pain. Baltimore, Williams & Wilkins. 1991.) ~ ,1-------------------------.", 25 Ibs. Pressure 100 lbs. Pressure ! _________~L~· ·. . . . ~., 177 • .., . • ,..,.,,-,,,. CVUI",M.llVN m.:.; tlpri1;ht puslur..... The n:sulting forward drawn or slumped poslur~' b rr.:inf(\(().:d hy gr;lvily. which makes it even harder to maintain :l lhlnn;l! uprig.llt posturc. The signs or poor poslurc include the f"!1,\\\in1; (Fig.ur.... IOA.20l: -\\r.:ighl mw thl: h;llIs of our feCi - ..\\;IY hOl!.::k -inI.:Tcascd Hllllldlll.:ss of lIlid.uppr.:r b'Kk - ..hOlildr.:fS roumkd forward -hc'ld forward -..:hin pokr.:d ) Til ~'orTcct poor pmilllrr.:. it is hdpful (0 .ttlClllpl the "military posi- ,, Z -~ lilm.'· which willmo\"y-you hack in the right direclion. A good rule (\1 thumb is 10 assumc thc '"military position" and Ihen back off about 10(;. tFig.JOA.21). It is a good idea 10 move in Ihis direclion about • r 1)( () () C\-r.:~ 2)( 20 milltlles as a way of "fine tuning" our posture until it il11- pro\'6 :Iulomalic;l,lIy. Aftcr just a few months. our new posture 3X wilt bccol1l......I habit. The military repositioning involves: Fig. 10A.19. Effecls of posture on neck muscle aClivity. For every inch that the head moves IOlWard of its normal posture, the compressive forces on the lower neck increase by the additional weight of the entire head. (From CurIO: Head Pain. Baltimore. Williams and Wilkins, 1994.) c -----_._ -llallcning your low back against a chair or wall .. -rolling your shoulders back and down-·· -tucking your chin in whilc ),ou glidc your head backward 111... ~iuillg poslure IS fatiguing because of the pressure it places on Ihe disks of our low back and thc amount of muscular effort r....quircd In keep both our b'lck and neck upright. The most import'-tnt thing to remember about sitting is to keep the low back str..light or '-lightly lh::n your. knees (Fig.. IOA.23). It is imporlantto have the scat far Fig.l0A.21. Fig. 10A.20. ~MilitaryM Slumped poslure. correclion. it}' autom,lIicaJl)' invite poor poslUrc. thus o\'-crstraining our spinal mllscle~. Iig;llUl.:nts. and joint:'. The SlumpetJ or Forw=trtJ Dr.IWIl Posture We arc born in the fetal position with our spines rounded forw Fig. 10A.22. Poor driving posture. lfti Hl::HI-\CIL.1 1.... 1 IUI"l VI"" I Nt: ~/""lt'H:: .... t-'HAI,j 1IIIUI'H:H :::> M ..... I... UAL that Ihl.' had is higher lh:1II Ihe frollt (or usc a fO;IOl wedge) (sec Fi~. IO.·\.~.'\). c A d...· ,k Ih;ll is IOI} 1(1\\ \\ill prmnnlc a !".lull1ped posture. AllY rC:ld- in,g or writin,g. eHn on:! J~·:d.: nf proper height. may C~l\lSC neck and sl1l1ukkr Il\"l.:rslrain (Fi~. It).·\.})}. III stich cases. studclIIs and desk wnrkcr, will h.... ndil fr\\m a \\Tiling wl'dgc or b()(}k sllppun (Fig. 1OA.~61. ,, -,, ""\ j Fig.10A.23. Heallhy driving posture. Fig. 10A.25. Typical slumped posture during writing. .) ) -, .J ., .j -) - -' Fig. 10A.24. Good sitting posture with arm rests. enough fOlv,'ard So you do nO! have \0 deville (shrug) your shoulders to reach the steering wheel. You should not feci lhe need to slump forward. When sitting in a chair. lhe same bOlSic rules "pply. Milke sure your feet rest comfortably on the floor and usc armreSls if they arc rt\'ail· able (Fig. 101\.24). When you perform work al a desk or computer. you may want to experiment with the lilt of your scat. It is oftell more comfortilbk for yOUf back and neck if the sea! is tilted so Fig.10A.26. Use of a writing wedge to improve posture. , .~ ----_._------- ._---- '." ,I 179 \,.,M1'\1"" I t:.H lU : t"Allt:N I t:UUCATION I 1, c ,, , :<, l L l B A Fig. 1OA.27. strain (b). Improper sitting posture (a) and proper silting posture for reducing finger, wrist. elbow, shoulder, neck, and back checklist of the important point!' to review with reg'lrd to your work· st:uiolls. \Vhen you sit or stand, it is imE.Qrtant t.h_~.t~_sho~ldcr~~ laxcd back and down. This pnsitioning will help prevent the slumped po$ture and, with it. the head· forward posture. Slumping eventually IC:ld~ to a pcnnancnt rounding of the upper back (dowager's hump) (Fig. IOA.28). Additionally. with the head in a forward position. the muscles in the back of the neck and between the shoulder blades are c Table 10A.2. WorR"station Ergonomic Checklist A I B Fig. 10A.28. Proper head/neck posture (a) and slumping and Ihe dowager's hump (b). When typing or imputing Oll'a computer keyhoard. your hands should rest on the keyboard without your wrists bent, your elbows should be bent ~ll a right ang.le (90"). and your shoulders should be completely relaxed (not shmgged) O\g. IOA.27), Table IOA.2 is a Chair ~-seat height adjustable Feet should be on floor and knees no higher lhan hips Arm rests Good lumbar support Seal back should be able to recline (95 10 105°) TIllable seal pan TIlt seat 10IWard for desk work TIlt seallylckv/_ard for reclining work Computer ~Center of monitor nose level No glare on monitor Keyboard height so that wrists are not bent, elbows at a 90~ angle, and shoulders relaxed (not shrugged) Other ~ """DOCument holder Head set YIN 180 H~n""OlL.. 1 , ,'U,'1 u r I n..:; v, IU'-. '"' , , ' " I ."-',~ ,_ ! j ,~ i I !! ~ '~ II I I " " '\ Fig. 10A.29. ( Postural exercise lor round shoulders and head forward posture. exercise can be performed frequefHly throughout the day for just 2() lO 30 seconds C"lCh time {(l pre\'cl\I Ihese ill effects of the ~ pmaurc. As shown in r:i,gUfl.' 10.-\.29. you can roll your shoulders ~~k Jnd down (by squeal"!! \"Our shoulder blades together), rotale your hands outward, and 1\lck your chin. This same exercise can also be perfonncd at home while lying on your abdomen. Hand weights can even be added for u greater strengthening effect. If ~. . cr b~~karchcs too much. you call try placing a pillow under your you will need n larger pillow than someone with narrower shoulder.s. Finally. it is important to placc your pillow betwcen your neck and shoulder. not under your shoulder. Lifting is probably Ihe area of greatest concern for all back doclars. The mOSI import,mt rule is 10 "keep your back straighl." abdomen. Your posture for sleeping is abo impoftanl. The ideal sleep posture is one in which nil the norm.1I spinnl curves arc maintained with mi[limum strai;-Th~~ fetal position achieves this 20111 (Fig. IOA.3e». Our lumbar spine and pch'is should not twist too much and a pillow between thc knees or thighs rna\' be :311 that is required to .wold the c~~oii-ha_lf lunlnly/half fetal ~Iecp posi.tion (Fig. IO--;\.3·1)~·\Vhen slccpi;lg'on 'our b'ICh. ~I riflo\\" u~idc~-ii~c 'knees will keep the low back relaxed to that it docs nOl o\'crarch (Fig. 101"\.32). Sleeping is orrell il uifficult advclllllrc for individuals with neck pain. Finding just Ihe right pillow can be Ol "nightmare." TIle ideal pillow will cradic and suppon your neck without distorting its nor· mal ~t1ignrnent (Fig. 10'\.33al. If your pillow is not supponing you properly. you might wind up with recurrent "stiff necks:' headaches. ) or~\''cu.referrc~.J~~.(~~~__~t~~9£!"~_~~ll\. or ha.'.W~.!!Jil!~;·ort~lnt't() ~\'oi~.~i_~.~_ t~. li.t_tle or 110 pillow. w!lich pl_;)..~1::~ __~he_ un.supported n~k under strain all night long (Fig. IOA.33b). It is equally unwise to .u~_W-!!!'!..nJ:"p'illow~~.or.[ 00 finn_oL4LP_~.~.hk~y,')hcsthe Ilt::,c;k_.lm.~-,~d.p.hl£!!'::~_l!~~j,?~l~!~l~)gcthCJ. tEig. J Q!\:J:?£l_!Y!1£ther ~u lie on your side or your back. your pilluw must be soft enough to mold !Ct.YEur head and yet still fill in dte space between your bed and your neck. Re~;;mber: your head is bigger Ihan your neck. so accommodating both wilhout distoning Ihe position of your neck is the key. Sometimes. a bohlcr or spcci Fig.10A.30. Fetal position. CHAPTER 10: PATIENT EDUCATION 181 Fig. 10A.31. the knees. Sleeping with a pillow between Fig. 10A.32. the knees. Sleeping with a pillow under () C) A B I \ c - - Fig. 10A.33. a, healthy neck/pillow relationship; b, too small of a pillow; c. too large of a pillow. Second, .\Void twisting when you lift. The combination of bending and twisting I!> the death knell for yOllr lumbar disks. It is also imporlant to try 10 lift objects as dose to your chest as possible; the farther the object is from you. tile greater is its "mass," Another reccnt disto\,cl)' documents Ihal the back is especially vulnerable immcdi· ately after sitting for a prolonged period (just 15 minutes will do it) or .1her;'1 night's sleep. Remember 10 usc good lifting habits. especially irnlllcdi,ltc]y ,Iftel' gcning up fH)'lll a chair or afler a night~s slcl.':p__ Whenever possible. try to avoid lifting from the floor; ph.lce things .It knee. waist. or chest height. Lifting children can be especially difficult bec::Iusc they obviously do not sit still like boxes do. Nonetheless. because we will do lots of bending and lifting if we have kids. the sooner we learn to do it rig.ll1. the less likely we arc to have recurrences of disabling back pain. Pigure IOA.34 shows Fig.10A.34. Proper lifting technique from the ground. the proper technique for lifting an object 011 the ground. Pigurc IOA.35 shO\vs poor technique in lifting ",ilh the back. bcnt instea(l of straight Table lOA.:; slllllrnarizes the key components of proper lifting lechnique. Reaching for things above shoulder h:vd is another strenuous activity for your back. Usc of a fOOL stool is an excellent w.IY tl) rl.'ducc the strain (Fig. IOA.361. If a stool is un;l\"ailablc. then a trid;. is to tighten your abdominal and buttocks llluscks so you flath.'ll your hack (Fig. lOA.}?). This maneuver will pr~vellt the tcndency \() :-tiek out your buttocks and ovcnlreb your back. Carrying suitcases. groceries. or a baby ;lrc all chalJ~n~C':, for a person with a bad back.. When p;'lcking. for ;1 vacation. it is Ixttcr to Table 10A.3. Proper Lifting Technique lift with your back straight Never bend and twist while lilting Keep lhe object as close to your chest as possible KJ:>J:>["Ithings that need to be moved at waist level whenever possible ---------------------._----------_. 182 REHABILITATION OF THE SPINE: A PRACTITIONER'S MANUAL ,, , Fig. 10A.35. Improper lifting technique from the ground. ) A B .,, ) , ..f / I B L Fig. 10A.36. Use of a stool for overhead activities. .J Fig.10A.37. a, Incorrect overhead reaching with back hyperextended; b, Correct overhead reaching with back flal. j pack (wo smaller suitcase!' Ihan one oversized one; you can thell h;llancc the loads and .\Void straining your back (Fig.. IOA.38). Avuid carrying a bahy or any other object with outstretched ;arms. By holding the \\'cighl close 10 your chest. you greatly reduce the pnlenlial sIr-lin (Fig. IOA.39). This :'Idvicc is particularly impOJ1ilnt when pUlling a baby in a car scat. By holding the baby c~c (0 you, you arc less likely 10 injure your b:'lck (Fig. IOA.40). Pushing and pulling can be yet ,mother source of lumbar str'lin. Given a choice between the (wn. pu:,hin!; is preferred bcc;ltIsc lhe legs can be used more effectively (Fig. IOA.4I). When huying. a carriage lor your baby, try 10 find one that is lilted 10 your heigh!. 183 CHAPTER 10 : PATIENT EDUCATION Heat is generally avoided in the acute stage because it can () A () 8 Fig. 10A.38. a, Too heavy a suitcase; b, Balanced carrying. 0' If you arc rull. the carriage will need longer amlS (Fig. IOA.42). In any case. try 10 keep your back straight and avoid slumping when yOll stroll a baby. The same is gcner..tl1y true when selecling a vacuum cleaner-a laller unit will help you to keep your back ~[raight. {) Changing your bahy is another opportunity fOf back slrain. The rule is (0 have a changing s!alion of appropriate height so that you do not have to bend too far fON'ard (Fig. IOA.43). Sometimes. a foot stool can be used to reduce back strain. The foot 5tool is a h.,ndy aid fOf much counter top work. (runing. cUHing vcgetables. folding laundry. and brushing your lccth arc just a few examples of situ;lIiOllS in which a low counter top can cause overstrain (Fig. IOA.44). If a foot stool is not available. it is sometimes possible to bend your knees <md lean them against the cupbOilrd (Fig. IOA.45). Pi nil aiel for CJ (lll (lell/c' B ('pisoc/(' of bad pain One of those acute. disabling e~odcs of back pain Cim easily provoke anxiety and even anger. ~nunatcly. such episodes typically arc tml1Sielll and usually begin to c~ll11 down after just 2 to 3 davs of rcs~ up 10 I week if they arc accompanied b}' pain./numbness bclo:........ _~~£.J;ne:V Proper C:lfe of the acute episode leads to dramatic improvcmcnrquiekly. Much C~1Il and should be done to ensure that an acute episode docs not mushroom imo a severe. disabling episode. Try to reduce ,lilY source of c~tcmal sWlin on your back. Assuming proper rest posi. tions is of vital importance. L}'ing~ your b,!S=k wi_tiLy.ou(.kQe_e~b£nt js...one...oL1h~clief" p2.ili.i.ons for the spine (Fig. IOA.46) in thaI o A it r@ces pressure on the di~~~.'.l.l1d r~t;!'~~lUh£_~~~i;~tNii~iyTng ie~__ ~2 minutes four to six times per day normally is a~"i~;lb'::J Fig. 10A.39. a, Incorrect carrying of a baby with outstretched arms: b, Incorrect carrying of an object with outstretched arms; b. Incorrect carry· ing 01 an objecl wilh outstre.tched arms; C, Corre!;t carrying of.. an object held close to the chest. ---------------_._-_ ... - , I . , 0;"';; 1 184 REHABILITATION OF THE SPINE: A PRACTITIONER'S MANUAL danger comes when leaning forward over the sink. In this situation. it is pruden! 10 bend your knees or usc a foot stool so that I II when you bend forward. all the pressure docs not go into your b3ck (sec Fig. IOAAS). Getting in and out of Ihe car is :.mother ...." chalh:ngc. Avoid pivOling at your waist; instead. keep your torso rigid as ),ou tum your clHirc bod}' 10 gel in nnd out uf the car. Until your back "goes OliL" you do nnl reali7.l~ jusl how many ac· tivities place strain on your back. Just pUlling on p.mts. sock.s. sluck· ings. ctc. usually entails stressful bending. Two -o'piio~s exist f{l~ aVOlclilig'tllis stress. TI)' either dressing on your back or standing against a wall (Fig. lOA. 52). Getting up OUI of a chair is another simple activity lhul seems like "murder" when your back is "out." If yOlI ~lre in a chair, scoot to the edge of the chair before rising and usc mill rests if available to push yourself up (Fig. IOA.53). Avoid bending ."1 forward if possible. Lovemaking. is another activity that can seem daunting if you have a bad back. It may be casier if you arc on your back with your knees bellt. Another possibility is making love while lying on your side. It is import...nt that a bad back not interfere with family life. if you can help it. Fig.l0AAO. Placing a baby in a car. Exercise A sedentary lifestyle is a recipe for back and neck pain. Exercise C~1r1y morning is always J critical lime. Not only arc we usually stiffest then. but also~r disks arc swollen from not bcine com- pr~scd by gr.1\'ilY. Getting Out of bed safely by avoiding doing a sit-up is absolutely crucial. It is best to get up on our side and try to avoid twisting or bending at the waist (Fig. lOA.5I). The next nourishes all the tissues of the spine and increases Oc:x.ibility ...s.nm.Ul\CJsi:i,~.sJh~ actually..caD.....CMus.c.llaffil are as follows: ') ." ) ') , A B Fig. 10A.41. a, Unsafe pulling; b, Safe pushing. ...--' _ __. _ - .. ... ,-,nl"\'" I t:H lV: t-'AllcN I EDUCATION 185 4- Lat Pull Downs. A great exercise. but not the way it is commonly pcrfoml~d. You should nO( have to crane your head forward to avoid the weight stack nor should you hypcrc.xlcnd the low back (Fig. IOA.57). Have )'ou;b;ct--'I~lhC-~iC ,1I1d plac~oOl far enough forward so 111:11 the weight can be lowe.red withOlI1 h:lVing 10 move your head oul of" the weights way. Also ~rform :t slight posterior pelv;c lilt by con- tracting hoth yourabdciimnals and iiui~~iisw"i)i~icrt'y(;urT(:;wcr bolek. -.-.- - . _.•..-.- .. ". -_. . @ncc y.0~!" pain i~~t~~~li~cd and your back and neck is ocginning to ....10Cl~~._L!p·~.flgain. itjs imponam t c ·) 8 A .} Fig. 10A.42. ,} at Stroller arms of proper height: b, Slumping be- cause stroller arms are too low. ) J! ,,) \ Toe touches. TIley stretch the back and hamstrings simultaneously. which is too dangerous (Fig. IOA.~4). 2 Sit-ups. Never come up alllhc way because the disk pressure is (00 high. Also. they can be bad for the neck if you pullan your neck or. poke your chin rorwar~ you come up (Fig. IOA.55). 3 Hamstring curls. The tendcncy is 10 o\'erarc:h (hypcrextcnd) the lumbar spine during this excrcisc (Fig". IOA.56)." as tion 0f.ya.c1. Reconditioning involving stretching and strengthening is CVC!)' bil as important as learning how to sit or lift. Beforc you go out and join a gym or gCI back into that \vorkout routine. however. you should be "awarc of somc of the morc dangcrou~ .:xercises commonly performed today. 11,e four mas! l.:(}n~tnon errors made in the gym are hypcrcxtcnding the low back slumping at the waiSl,fking the chin forwar . an CXC~SSI\'C s l!"U~<.!il!£ of the shoulders. The exercises in which improper fonn is seen most commonly include the foilowing: t. Hypcrcxlcnding the low back -sitting leg extensions -hamstring curls -Iat puB downs -supine f1ys -()vcrhcad press -lunges -squats -trunk curls on an incline board* -sit-up) -Roman Chair )1 . J \; >" f A ( Fig. 10A.43. a, Changing stalion height too low: b, Correct changing station height. 186 REHABILITATION OF THE ::;I-'INt:: A PRACTITIUNt:.H"::; MANUAL (' ! i ? -,,- .. ...... - j B B A Fig. 10A.44. a, Typical ironing posilion; b, Use of a footslool to reduce a low back strain. Fig.l0A.45. a. Brushing teeth with both knees bent; b, Use of a footstool to reduce low back strain. -, j A -"i 1 " Y " :1 B Fig.10A.46. Fig. 10A.47. cise. Back relief positions. Back extension "sphinx exer· M ..J ..... n1'\t'" ; I 187 eM IV: t'J\IICN I t:.UU\,;AI"ION i I I ,cO} 0 Fig. 10A,48. Single and double knee(s) to chest exercise. :> ) ;,.;- c ,} \ .. " ,-.' t) () Fig. 10A,49. Cal exercise. {} :', <\.'~ ",~ J' -cxcrci~c {~ ",~~ -stiff-legged di:,ld lift*' t) -bent forward rowing* 3. I-Ic;ld forward po~aurc' with chin puked fon.. .md -sit-ups ''') .J {'t 'iJdJ -stairll1:1stcr Fig. 10A.50. Prayer stretch. ~ .J ,j " ~J () , , 01' :;i I 0 t.:''J! ... i-----. ti' --~ } ~J bicycle -hmmtrillg :-;tn.:tchcs (toe touch or on floor) -exercise bicyck -l:It pull downs -pllsh-ups -st;lirclimbcr -push~u\ls 2. Slumping at the w"isl ·~sitling leg extellsiolls -sitling chest press -stairdimbcr 4. '-liking or shnlgging of lhe shoulders -rowing m;lchinc -hem o\'er rows -latcf.11 arm raises -overhead press -push·ups nc;n"'Oll.II""IIUN ut- IHt: ~"'INE: -. A PRACTITIONER'S MANUAL ., B A Fig. 10A.51. Technique for gelling out or in bed with a bad back, c A Fig. 10A.52. Sale back options for putting on pants, socks. elC. I ) .;(. B I - _ ..._-- ---_.- l\~ Fig. 10A.53. chair. Safe technique for rising from a -) J I o J B A Fig. 10A.54. ( v . .J Dangerous toe touches. ... _ ..•• " .......... ' I I.... '~ ... " ...... '~''''''''V''''1.. ! Ij spin.: .,~ainsl maintaining. a rdax!:d shoulder POSllW:. Desks Dr wm!\sl.lti\ln:- 11I:.ll arc ton high or poorly placed (or absent) arm l"L'stS l."lllltrihuIL· 10 elevalion of the shoulders. Again. proper pos- lllrL' alld fnnn Juring exercise is I\eccss~lry to prevent mlding furtha flld ((1 Ihi.. lin:. A ~uud rule of thumb is that the shoulders !'ohllUhl hl' rcla:l.L·d ha~k anu dnwn. It is ncvcr a gooJ ide;t during. ;lIll·:l.cl"t.:i:o;c hi L'itha rollihe :-hnullll'r.> furw<.lrd t)r hike them lip tnw;lnllh...: L·;lt·... SI/IIIIII/IIY [f you h,IV\' louffcre<J ;1 scvere episooe of bilck or ncck pain t1r yuu I.:xp.:ri::IlL·1' chronic p"in in these arc;\s. thcre is ,I proven way [n C('lllrol these :O;ylllpIOIll:'. learning h'lw to rcum:..: strain The long-term solution lIlld yuu rel."..:i\"t._· from your rch,.bilitation Fig.10A.55. ill Ihis handuut b llcsigncd Improper sil-Up. t[ These ftlUr cardinal error.> elll ...,"1 [0 illvol\'e~ improve poswn.::. Tht: advice spcei~llist help you (0 and that is indudc:d hdp yOllrself. Back Fig. 10A.56. Harmful hamstring (back 01 thigh) exercise. ) (lft;:n be l'urr~'tcd by p'lying: aHcntioll to proper jloSlUrC and form. Th... lumbar ~pilll.: ~hould Hormally bl.: kept in a "mid-range" p()~itioll. oflcn c;llI...d Ihe "nelllr,,1 positioll" or "functional raogc." This position \';lrics for everybody. Some people arc most vulner'-lblc whcn Ihey ~11l11lp. (llhers when they hypcn:xtcn~_ A g~nllc cQ·contr.Klillll of ~ (lUI' abdolllin:tl!'o ') tloopr !~!~_o-,h~!!~l}-'l!:,Y.~lf 1.'-~XQ<;.i2.!:'~.i!~_I11Cnlioncdc all hc pc!:: fortl!c_~_~a.rf:I)~:ccnail1 cxc'rciscs I ~ L hO\~'ever,-~'I~'~~ hI.: dil~i ~d C:()lllpl~tcly rr·~)lli;:j'l~~··ri}lltlii~-;:_l'Our·'·back spcci\llist'\~sllOW you.aJtc-rnative!'. -------- J ------- When your hC ,) vical spine under gr... ;1\ strain. P()kill~ your chin further irritalC\ the joill! between thc back of your head (\lc;ciput) ;lIld the lir:o;t vertebrae \11' tbc fled ( j ... a COIIUlHll1 probkm. EJtHltinnal tension kads to shoulder ;lIld neck tension. which results ill "having-;I;'~ -~\·~igi;l_oLthc-wodc..!~;;~i_y~).ur--:o;I~llul~JcQo.··r requCllt sighing is a tip off [0 Ihis OCC\lfrel1CC ..·\b·l).-ll-i;;~t ~j~sks alld (hairs COll- Fig.10A.57. Improper form during "lat pull-down" exerci::,;~. 191 \11' fwd, p;till ;Iri:-l':- frlHIl l'XPO~\ll\" In mCCh:lllic;ll slr.lin Ihal ~r;tdtl;dl~ :tl·..:tlllllll;lll·... yuur lifetimc. If you karn ttl ~il. li(l, hend. l·"n~. :llld :-kep ~lll;lficr. tile likdihlll1d Ilf di~ ,:tHl1(WI ;llld ri:'l~ uf ,\'.injll1')' is fl..'duccd. If yOIl 1l;ln.' d.:couditi,llll:J :I' ;\ I"o::-ult ,If kadil\;; :l "'l:,kllwry lift::~ayk Ilf frlllll fe· :-It'il'lill~ ~t'llr :ll"tl,iti\.', ;1:- ;, cOllsequence of pain. thell ynll , I I I • Ihrl1u;;holll I\lay abll lIc.:lI to sian a lhcrapclltic stretching and strenglheniftg program. Learning how 10 perform typical .t\.:tivitics of d;lil~ life without incn.:asing strain, and also training musck~ In he lll11n: fit. will enable yOll 10 control your symp- hllllS ;1IIt! pre\'ellt the likelihood of lIlore seriolls problems in the fUlUro.: . '~ ) ) () 'J IV FUNCTIONAL RESTORATION I. I ,, , Ii, ,{ ",1 ,j f ~ f ,, , ..' t ~ Ii ~ j ~> ; > I ,"j; <") ~~"') ; ) 1 ., ~ i -~ t; ". j "(1 "\"}i Si ci " •ii~ ::! 'j '""\ ',j ~ .' I• ~ I~ i ~ ;;l ~;) > '~ , ") , } ., ) , ) t '.j 'q O~ ~ ;• •1 I • I" ~ • I I I " % t " 3 , , .> .. >' ~ ,~ , .. J , ., 11 Role of Manipulation in Spinal Rehabilitation .KAREL LEWIT ~ ~ ~ ,, , ~ " ) I I ) !, !I ,.. I, Rchabilit.nion is dcfined :.IS the restoration of function in thc motor systcm. This definition implics rec..:upt::ration of Jctivc voluntary motion. To place emphasis on activc exercisc is therefore justified (0 achieve normal active control of movement. Structures that move passivcly, howevcr, such as joims. li,g.llllcnts. fasciac. and tcndons. frequently playa key rolc in this recovery. and passive tn:a(mcnt of these struCturcs C,IIl be effective. c\·en for severe muscle spasm. In fact. the usc of pnssivc manipulative therapy by a qualiflcd individual may enable <:1 patient to c..:arry out .lctive motion. whereas omitting thesc methods would result in frustrmion and loss of time. Manipulative treatment is an important factor in the restoration of passi\·c motion. particularly now thal up-to-date techniques affect not only joillls but ~ 7 j ~ I, ') •! ') i II , ) ) , "j1 • ) I I '. ) u I ') -''v & I 1 ,J -C) .." j ~ ~ "J • J, .J t~ )\ ~ iR iv ) CHANGES IN FUNCTION The condition affecting the motor system that most often requires treatment. including rchabiliwtion. is not the obviolls loss of 1110tor (;ontrol or motor function. bUI poil/. also termed lIIyofa.\'Ci(/f /W;// (i\'1 p). Use of (his descriptive term seems justified in so far as thi!'l pain. whatever its tlll~ origin, is expressed or felt mainly in Illuscles and their attachment points. Despite its enormous incidence, this 'lfIlictioll is poorly understood: flO pathologic structur ,) i"s ;J , • , < ~ oj ; cl\ 11 • .~" ) 'J ~ d ~ E &; ~ {) "':i, , -~ i ~ ,-", tj ,;:0 •~ J .I".. ,4; t) § i - 195 .:. ~, also true of othcr methods o!" what may be called "relk.\ therapy:' e.g.. acupuncture or local anesthcsi~l. Sudl iUHI".cdiate effects would hardly be possible if the underlying !.;;.I\lSI,;" Wl;rc a pathologic change of structure that requires hc..:alill~ and could not be reversed immediately. This concept is casily UIlderstood. however. if the existence or real it)' of c..:hant!.es in function is recognized. For stnlclUre ill the living org<:ln~slll ill general. and in the locomotor system in particular. b no mort: real than is function:'musclcs in spasm (with TrP). incapabk of lengthening; restricted joints (perhaps because of lllcniscoid entrapment and/or spasm): and short muscles or r;'lsciac rcquiring stretching (shifting):-iC' An examplc of an even l1lor~ elementary situation is'tension ano muscle pain thai Jccompanics an uncomfortable pnsilion: discomfon improves imlllediately with a change of position..l-;\s observcd by Brugger. if ,I person sitting in a round-shouldered position is examincd. the l1luscles of the shouloer !!.irdk.. 'Irms. and even of thc IC2s arc tcnse an.d~n der on p;ipationY'fhe moment lhe person changes into an / erecl (lordotic) relief position (Fig. J 1.1 l. the s.une muscles arc soft and painless. Nothing hilS ch;'lIlgcd except body sUllics. but relicf has been obwincd. A slrong reluctance rcmains. ho\Vcver. within the mcdic;1! profession to accept altered funl..:tion as ;'111 imponant cause of disease and suffering. In fae!. lhe term "functional" is widely used as <:1 cuphcmbm for psydl(llo~ic or even imaginary problem'. In il1lcnml medicine. some changes in function ;'lpp:lr~ ently arc accepted. e.g.. cardia(; arrhythmia or ~ndocrine dysw function. but such acceptancc remains an inSUrtllOUllWblc obst .J ... REHABILITATION OF THE SPINE: A PRACTITIONER'S MANUAL 196 Ihis selling is all the 1110re imponant in thallhc Illotor system carries oul volunlary movcmcnt and thus has no othcr mcans to protect itself against our whims. Pain rcceptors, therefore. are found precisely where tcnsion is most prominent in the motor system. i.c.. in muscles with their attachment points. joint capsuks. ligamcnls. meningeal sheaths. and lhe out::r laycrs of the annulus libmslIs.ll.l: From wlml h;IS hccn said, it C;llI well he 1IlH,lt;rslOod that MP is the Illost frequent Iype of pain experienced by Ihe human urg:.misl11. As dislurhed function plays the main role in causing this type of compl~lint. it is nccessary to cxpl'lin some basic approaches in dcaling Wilh it. The question is where and how to apply treatment. If we have a painful structumllesion. e.g.. inflammation. wc know where to apply trealment. Function. on the other hand, implies correlation and interplay of many structures. Therefore, "he who applies trC;llment to the sitc of pain is usually losl." This fundamental change in approach threatens the c1inici'l1l with the loss of firm ground: in fnee Ill.my who .In: involved in treating dysfunction tend 10 ;lpply these methods (e.g .. manipulation) mainly to the painful area and not In the.: re.:al source of dysfunction. ,,,~ ! -I j ! ~ Fig. 11.1. Brugger's relief (lordotic) posHion. ~ ~ ~ I "'~-< ? -:: ", 11 J OJ :~ ~ ,~ f i i -~ iJ • i £ I• § ;£ f; b -'; -,'i ~; if r] ~ I~ ,••• ~ I , ~- -f ~ I :t i1 I function is sometimc!' quite involved. Unfortunately, physiology is no less complicmcd than anatomy. As, however, changes of function arc by definition reversible. treating functional pathology of the locomotor system is a rewarding chal~ Icngc. .The ra~[ that some changes ill function are imm~d.iatcly revcrsible provides a rational explanation for some "miraclc cures" after treatmCnl by manipulation and other "rencx ther· apy" methods. Unl.<munately. locomotor dysfunction has rCllmincd a medic",1 no man's hmd.lost belwccn such specialties as rheumatology. onhopedics. ncurology. and rehabilitation medicine. In \'icw of its importance. a clear distinction bctween structural and ··functional" pathology (dysfunction) is fundamcnral. for di~gnosis and managemellt as well as for c1assificalion. It can be compared only {() the distinction be~ tween Iwrdwarc and ~oftwarc. If we accept c1wngcs in function as relcvant in MP, then we should be able to explain why and how dysfunction can truly cause it. This explanation seems relatively easy: whatever the type of dysfunction we trcat-a muscular TrP, a rc~ strictcd joint. a change in soft tissucs, or altered body statics or movement patterns. we invariably meet increased tension. In fact, impaired function of the motor systel~l is associated less with inability to movc than with pain resulting from in~ crcased tension. If we movc in the direction of a restrictcd joint, overstr.lin. assume unfavorable positions. or perform strenuous work, the common JCl1omin:uor is increased tension (strain). The link between strain and pain should be rCi.ldily under~ stand able. Pain is. in lhe first place, a warning sign of im~ pending danger and. in the locomotor systcm. is an indicator of the need 10 proH.:ct 'lgainst overstrain. The role of pain in Chain Reaction in Functional Pathology Experience has shown lhal changes in function follow' cert , ."--''h ~ .,'1 I r ....... . ! } ') I .- !} ,") :,1 197 ..... nl"\,... I en II : NULt: ut" MANIPULATION IN SPINAL REHABILITATION Table 11.1. Galt: Stance Phase and Swing Phase- Table 11.4. Upper Extremity tJrehension Stance Phase Extension 1. Increased tension: 1. Increased tension: 2. Tender attachment points (referred pain): , iI Ii 3. Joint dysfunction (blockage): Swing Phase·lIexion and internal rotation 1. Increased tension: Extensors of the loes and foot, tibialis 1! I () ~ Il ,, 2. Tender attachment points (referred pain): 3. Joint dysfunction (blockage): anterior, hip flexors, adductors, recti abdominous. Ihoracolumbar erector spinae (upper extensors) Pes anserinus (adductors), patellae (rectus femoris, tensor fasciae lata e), minor trochanter, symphysis (upper and lateral aspect), xiphoid Knee, hip. sacroiliac joint, upper lum· bar spine and thoracolumbar junction, (atlantooccipilat joint) ·Chain rcactions arc related to the stance phase of gait concerning lirstlhe physiologic extensors and external rotators of the lower limb. Group 1 lists the functional sequence 01 muscles to become involved. Group 2 lists attachment points (or relerred pain) olthc above muscles that are likely to become tender if the mUSCles are hyperactive or tensed. Group 3 lists joints likely to develop dysfunction (bIOCj{~~f!~ in 'hi:<; (:h~;ro r"!~r.lion. Joints ;:He not related 10 single muscles. their dysfunction is lhe result of changed static and dynamic lunction as a result of (mainly) muscular dysfunclion. i i I Table 11.2, Ii i 2. Tender attachment points (points 01 referred ~ 3. Joint dysfunction (blockage): Flexion 1. Increased tension: 2. Tender atlachment points (points 01 referred pain): 3. Joint dyslunction (blockage): 1. Increased tension: points (points 01 referred pain): 8~S Tension in muscle parts Sternocleidomastoid: short craniocervical extensors Scaleni and deep neck lIexors: levator scapulae. upper trapezius Iliopsoas and recti abdominous: erector spinae and quadratus lumborum Tender attachment points (points 01 referred pain) Posterior atlas arch. transverse process of atlas, spinous process of C2. linea nuchae, medial aspect of collar bone, upper and vertebral margin of scapula, xiphoid. symphysis, lowest ribs. ilia~ crests . . Joint dysfunction (blockage) Cranioc:ervical.junction, cervicothoracic junction, upper ribs, thora· columbar junction. !umb.osacraJ anp sacroiliac: junction Finger and wrist extensors. thenar. supinators and biceps, deltoideus, supra and infraspinalus. upper lixators 01 shoulder blade. interscapular muscles Proc. styloideus radii and latera! epi· condyle. attachment points 01 supraand infraspinatus, attachment poinls 01 levalor scapulae. and spinolls process of C2 (referred pain) Elbow, acromioclavicular joint, midcervical spine, cervicothoracic junclion. upper ribs Finger and wrist flexors, pronators ,subscapularis and pectoralis. slernocleidomastoids scaleni Medial epicondyle. medial end of clavicle. sternocostal junction, Erb's point. transverse process 01 alias Carpal bones (carpaUunnel syndrome). elbow, glenohumeral joint, cervicothoracic and cralliocervical junctions Table 11.5. Head and Neck: Food Intake, Mastication, and Speech 2. Tender attachment () I Toe and plantar llexors. triceps surae. glutei, piriformis. levator ani. ereclor spinae Calcaneus (plantar aponeurosis and Achilles tendon), fibular head (bi· ceps femoris). ischial tuberosity (hamstrings). coccyx (gluteus max· lmus. le....ator a;;:), mnc crest (glu· teus medius. lumbar erecior spinae), greater trochanter (gluteus medius, piriformis), and spinous processes L4·S1 (erector spinae). Midloot joints. ankle. tibiolibular join!, sacroiliac joint, low lumbar spine 3. Joint dysfunction (blockage): Masticatory muscles. digastricus. sternocleidomastoids. short extensors of craniocervical junction. trapezius and levator scapulae, deep neck flexors, pectorales Hyoid. posterior atlas arch and transverse processes. spinous process of C2. linea nuchae, medial end of collar bone. upper margin of scapula. and angle 01 upper ribs Temporomandibular joint, craniocervical junction. cervicothoracic junction, upper ribs Structural Versus Functional Pathology A short survey of the main chamctcristics of dysfunction as cOl11rastcd with structurill pathology may bc useful to demonstrate (he fundamclltal differencc in approach. I. The step is to decide whether the probkm de· by Ihe patient results I1winly from dy~rul1t' lion or from structural puthology. 2. A strucwrallesion frequcntly c scrib.cd Table 11.3. Lifting the Thorax at Respiration (Typical Respiratory Oysfunclion) 1. Increased tension: 2. Tender allachment point (referred pain): 3. Joint dyslunclion (blockage): Upper section of abdominal muscles. pectorales. scaleni, sternocleidomas· toids, short extensors of craniocervical junction. levator and Irapezius Posterior atlas arch and transverse pro· cess, spinous process of C2, linea nuchae, medial end of clavicle. upper margin 01 scapula. sternocostal june· lion (referred from scaleni) and upper ribs Craniocervical junction. cervicolhoracic junction. upper ribs, thoracic spine manifestations. 3. The reversibility of dysfunction makes immcdiate cure a possibility. whereas structural pathologic change requires hcaiing. 4. The aim of structural diagnosis is to IOC:'lliz~ :.mtl dc~ termine th(: nature of the lesion: in dysfunclion. it is csscmial to illvcstig;'l!c correlations and interplay. i.c., the chain n::''1l:tiollS. diagnosi~ aims at the organ at fault, functional diagnosis at tht.~..J.).rgi1!Jj~ a whole. 6. In cases of Jysfunc!ion. structural diagnosis gives ncgalivc results. whereas with functional diagnosis. we typically lind lllMe than we expcct from the pati~nt's history. 7. Tile aim of therapy of pathologic change involving a structure is hcaling or excision; in dysfunction. it is 10 treat the rclcvant link of the chain'. S. In slructural pathology. modern technology plays an evcr-increasing role. whereas in functional pathology, clinical methods rcmair} unchallenged. 9.. 1n structural pathology. the relationship betwccn . cause and effect is unambiguous. whereas in dysfunction. cause and effect arc frequently interchange- S. Structural ity of soft tissue structures one against the other: skin against muscle, musck:s and fasciae against bone, not forgetting the important task of movcment palpation in joints and mobile segments of the spinal column. In this effort. we use not only our sense of touch but also proprioception. One of the most degam methods of diagnosing superficial hyperalgesic zones (HAZ) is skin drag: we move ovcr thc skin, and in areas with more moisture (s\vcat). resistance (dr::~) is in~rcascd. Most ~nlethods have-(}Jlc thing in common: during palpation, we move our fingcrs or hands. The diagnosis of a TrP. which is discussed in anothcr section. has another important feature, which is more pronounced in this case yet common to other methods of palpation: provoking a twitch response, i.c.. we establish illteractioll with the patient. In this way. a most important feed M able. back rclationship betwecn doctor and patient is established, In. Methods and techniqucs of "altermnivc" or "complementary" medic inc arc relcvant mainly in disturbance of function. DIAGNOSTIC UTILITY OF PALPATION AND THE BARRIER PHENOMENON As statcd previously. dysfunction causes increased tension in various structures (tisslles) of thc motor system. and this ten· sion relatcs to pain. The main tool in the diagnosis of changes in tension is palpation. Palpation is an art that was once impOl1ant in medicin_e. T02ether-·,-,viih--inspection-'andauscultalion. wa-slhcbasis of clinical medicinc; regrettab-Iy. it is nmv Iargcly neglected. For this rcason. it is necessary to gjve a concise analysis of palpation in relation to manipulation. 1-t-1I Palpation The flrst step is to apply our fingers to the body surface and to conccntrate 011 what we want to investigate: resistance to prcssure. temperature. moisture. smoothness or roughness of skin. and tissue mobility. If we intcnd to proceed from one tissuc layer to the next. we never simply increase the pressurc. but shifl our attention and apply small movements, i.e., we ch providing a we?lth of information and at the same ti~lC ProM viding the basis for effective therapy. This relatiomhip devel M ops when_ applying all typ~s of massage, and the good therapist. whether consciously or not, profits by this feedback, sensing the refjction o(the patient's tissues and correcting his or her moves accordingly. Barrier Phenomenon To make both palpatory diagnosis and treatment more etIeetive and better understood. we must be -end Barrier A Ph Path N~ N, Ph A CI?~~~r-~-'--------,. Fig. 11.2. Palpation. Fig. 11.3. Barrier phenomenon: anatomic, physiologic, and pathologic barriers. ;", CHAPTER 11 : ROLE OF MANIPULATION IN SPINAL REHABILITATION 199 Fig. 11.4. Palpatory changes preand posHrealment. logic barrier. Barriers arc found not only in joints. hut also in tissues that call be stretched or shifted against each other. However useful the barrier phenomenon may be for di .. g~ nosis and trcallncnt. it also has an important protective function. This role is Illost obvious in joints: resistance increases before full range is reached; however fast we may stretch our "rm: the antagonist SlOpS the movement in lime to prc\'cnt damage. Other protective mechanisms come into rlay \.. . hcn we stretch connective tissue or cause shifting between diffcrem tissue layers. e.g., fascia against bone. The stretch renex is part of this protective mechanism. To usc the barrier phenomenon for diagnosis and tremment of pain and dysfunction. take the following steps. By engaging the barrier (taking up the slack). wc determine the range of movement (shift or stretch) and recognize the location and quality of the barrier. After engaging the (pathologic) barrier. we wait: after a few seconds, the barrier "gives" and myofascial releasc is obtaincd. Release may last from a few seconds to half a minute (or even more); this release must be sensed. making sure we havc normalized the barrier. i.e.. normalized tcnsion and thereby obtained relief of pain. As shown subsequently in discussion of specific techniques. this release is as true for joint mobilization or muscle rclax~tlion as for skin stretch or shifting fasciae or subperiosteal tissues. using the bmTier phcnomenon as common denominator. The clinical importance of release lies in the relief of pain originming in the structures treated. Palpation thus provides an invalu;'lble criterion of painful lesions without slructur.i1 pathology, Le.. in cases of dysfunction. In fact, if we have obwined release. we know that the structure treated will be less p,.inful. Unfortunately. the ,evidence for these statcments is only clinical, based (Jll p.i1p'.Jtion, .lI1d the charge of subjectivity cannoL be ruh:d out. As the palpating finger (hand) is COI1siantly moving, changing both intensity and direction. meaningful measurements are difhculL to conceive. This situation is complicated further by the feedback relationship bctween therapist .ll1d patient. The problem of palpatory diagnosis has been further un· dcrlined by the discovery of palpi.llory illusion. On palpation of the pubic symphysis. and even more so of the ischial tuberosities in the recumbent patient, shifts as greaL as 2 em c;:ln be noted. After simple "reposition maneuvers" or using L _.'-'.-_._-_ ..---- - _ soft ti~:,ut: techniques. symllletry is readily reswrcd. :llld yet· r'ldiographic cX DlAG:\OSIS AND TREATMENT OF SOH TISSUE LESIONS In a simple outline of the IllOst useful techniques. lhc bmricr phenomenon offers the most useful basis. The with \\ hich to stan invol\'es the soft tissues, the skin. simpk~{ model lk'~il111il1g with ... '-<'====""=,-=-===.====== ':' \ Fig. 11.5. ... ~Low·tech" --------- medicine. 200 REHABILITATION OF THE SPINE: A PRACTIT10Nt:.H·~ MANUAL in the same dircction); no springing thard "cnd f~d") is 1l001.:d on engaging the barrier. If we hold on after engaging the barrier without increasing stretch. the barrier gives after a hllcncy period of a few s('.conds and release takes place. Relcasc may last from :'1bout 10 seconds to half a minute. We then lind a nonnal barricr (like on the normal side) and skin drag is restored to nom1al. This reaction is found regularly: if there is an underlying cause of the HAZ. it soon recurs. I I, ~ ! I Connective Tissue (Fig. 11.8) Fig. 11.6. "High-tech" medicine. ..--.. - ,\ The most useful diagnostic technique is to create a fold and to stretch it (never squeeze!). Again. when creating a fold. we reach a barrier where resistance is first sensed. a resistance that differs from normal if there is a restrictive lesion. After engaging the barricr and holding it, release takes place after a fcw seconds and continues up to a half a minute. until the barrier is nonnalizcd. Such connective tissue is found most charactcristically in hypcrsensith·c scars with tender spots wherc tissue tension is increased and pain is ea5ily elicited. Such scars arc usually surrounded by a HAZ with increased skin drag. They arc a source of increased nociceptive input, comparable in some ways to a diseased, painful visceral organ or joint. Release can be obtained by stretching the skin overlying such a scar :'Ilong with the deeper connective tissues. 26•27 Shortness of the connective tissue is most chamcteristic for short (taut) muscles. usually in overactivc muscles. Producing a tissue fold and stretching it is the most cffective way to obtain lengthening because the stretch reflex can be avoided. Such a fold is useful wherever it can be produced: in the m. trapezius, pectoralis. the quadratus lurnborum. the stcr-) nnclej~jd.ai1dm'OSi' of the muscles of thc cxtrellllties. This mcthod is not suitable for muscles with TrP: in such cases. p.Qstisol1lctric relaxation should first be used. ) ) i) .} ) Fig. 11.7. Palpation of skin drag. ~' Skin (Fig. 11.7) Hyperalgesic skin zones (HAZ) arc found most convcnicmly by using skin drag. which consists of moving the cushions of the finger tips ove.r the surface of the skin. sensing resistance or drag. Drag is incrcllscd in HAZ owing to increased mois~ lure (hyperactivity of sweat glands). In the same areas, the skin fold is thicker. and if we stretch the skin in this region. we meet resisl'IlI~t: sooner than on the nannal side (stretching J J .. ; , Fig. 11.6. Palpation 01 connective tissue changes. j 1 I L '_,'; CHAPTER 11 : ROLE OF MANIPULATION IN SPINAL REHABILITATION 201 / Fig. 11.10. Stretching (shifting) the gluteal fascia. () o {) Fig. 11.9. Pressing deep soft tissue. , l Pressure (Fig. 11.9) Even if pressure is used. it is most important (0 eng~lgc the barrier with a minimum of force: after waiting for a few seconds. the finger will sponwncously sink deeper into the tissue. This method is most effective in muscles with superficial TrP. where it can replace postisomctric rel~xatiC?1! (PIR). \Vllen the -will'-reach the nonnal barrier finger sinks into after approximately 10 to 30 seconds. but if the direction of pressure is slightly changed. funher release may be obtained. Such change in direction is important in large muscles. e.g.. the gluteus maximus. Fig. 11.11. Stretching (shilling) the dorsal fascia over the shoulder blade. Sitc:s of restricted fascial mobility also occur on the chest (charactc:rislically in mastodynia): on the buuocks. frequently in a cranial direction: in the groin: around the elbow and knee; and around the ankles .lIld wrists. In addition. some structures bcha\·c like fascia: the scalp should move easily in all directions in rdation to the skull. Restriction in any direction is frequcnlly linked with headache, and treatment mcthods that follow the same principles <:IS for fas.cia can be most rewarding. Shifting and Stretching Fascia (Fig. 11.10-11.12)""" (fllercfore. examination of scalp mobility is warranted for paWhen using this import<1nt technique. the most chamcteristic tients with headache and/or vcrtigo. Another such structure is the SOfl tissue pad at lhe heel. which should shift easily in all finding is thaLmusc!cs (or all the soft tissues) on one side do directions on the calcaneal bone. Rcstriclion is characteristic not ~.Jlli.S_asily on th~ underlying bone ~s those on the other...si9c if moved in the same direction, i.e.• the barrier is of a painful c.l!c,mcal spur and should be treated. rC~led sooner on one ~ici~-;rni~ol'SPri~-:Iti~Tmpor. The rnetatarSi.l1 and metacarpal bones can be shifted each tant to note that the restricted side is not necessarily the against its neighbor: they are connected only by soft tissue. and resistance to this shift is characteristically incr~ased in painful sidc. A "tight and loose complex," i.e.. one sidc is rc· stricted and the other side is hypotonic. is frequently noted. nerve root syndromes radiating to the toes (fingers). Not only Shifting is examined and treated in a craniocaudal or cauis exacllocalization of the involved root possible. but ,1Iso. by docranial direction on the back. but it should be assessed and engaging the barrier and obtaining release (in a dorsoplantar treated in a circular manner around (he axis of the neck and or palmar dircclion). we can obtain striking Ihernpeutic rethe extremities (sec Figs. 11.10-11.12). sults. This restriction is usually linked with a HAZ of the Because the fibers of most fascia arc intertwined with skin fold between the toes (fingers) in the corresponding segment. This fmding. too. can be di<1gnostic and can be treated muscle fibers. frce mobility of f'lscia is essential for norm th"cnluscle:"it 202 B A c o E F G H Fig. 11.12. Stretching (shiiting) the cervical fascia, CHAPTER 11 : ROLE OF MANIPULATION IN SPINAL REHABILITATION 203 the Il\:rhl~h.. al I'lIilll 011 Ihl.' llofillal sidl.'. \\"111..'1'1.' we lilld n::aril.'lit\l1. lI~\l:d[y ill :llatl~I,.·Jl[ial directioll \{l (l11..' p:lin point. WI,.' lake up lhe :--Iack lir~·a for di:l~nu ... i:-> and Iht"1\ hI ohtain rck·;I~l·. Unlike pcri\l~[l..'alll1assa~1.'or "deep fr;l·tion:· Ill!,.',\,.' sofllis.'lh.' 1 1 ~, , ".--">. } IcdUliqul.'s arc gentle: pressure is lIot dircdl·d 10 the p;lin point. but l"allll'l' t Soft Tissue Syndromes o \) () ) (J o o or ti~suc syndromes" arc grcat practic Two "soft Fig. 11.13. ForNard·drawn posture (left); after soft tissue treat- ment (right). Both these :;.yndromcs affcct most of thc postural musculature. and lherefore symptoms may arise in any pan of thc motor system. including headache with restriction in the craniocervic;.11 junction. and even tension in the masticatory IlllISdes. back I'OSTISO~IETRIC RELAXATION (I'IR) IN THE TREAT",iENT OF MCSCLE SI'ASM (TRi'J'-'-'·'-·" Postisolllctric relaxation produces rclc:.Jse in Illuscles in spasm. the moq frequent type of spasm in myofascial pain (MP) being the Irigger point (TrP). This technique w~s introduced by Mitchell for joint mobilization. and it is in its essence a type of son tissue rnanipul ~U4 holding it isometrically for about 10 seconds. followed by the order to relax. (lct go). After a few seconds (wailing at the h i 1 Ij rier), release takes place and the muscle lengthens (dccol1~ tracts) for anything from a few seconds to half a minute. Clearly, a subtle, yet important differcnce exists in the mcdl~ anism of release in PIR rdati \Ie {O olher techniques of IIl~Ulip ulation: whereas connective tissue must be' pas!'iin:ly stretched during rclca:-e. ~llthnl1gh wilh lillie force. muscle de.,;. conLrilction is an llct;I'e process. just as is muscle cOlllraclioll. and is only monitored by the therapist. "You cannot relax the t. { ii I: :~ I I I I ~ patient's muscles for him, he has to do it himself." The moment the therapist tries to stretch the musclc, the patient produces the stretch reflex, which is counterproductive. If PIR is not satisfactory at the first attempt, we repeat the procedure (from the barrier reached after the first auempt) and prolong the isomclric phase. Post isometric relaxation is highly specific. tlnd it is important during the isometric phase to contract precisely those muscle fibers that are in spa!im. especially fal1~shapcd muscles such as the pectoralis major. It is also essential to usc'minimum force, because we then increase the likelihood of stimulating selectively those fibers with a low threshold of stimulation. Le., those harboring TrP. Relaxation of the muscles brings aboUl relief not ani)' of the painful TrP, but also of the painful attachment point. as well as regions of referred pain (Fig. 11.1.4).'· As stated for the techniques described so far, accurate diagnosis is essential to the success of PIR. In some types of muscle spasm or cramps. the diagnosis may be obvious. Some TrP. however, may be excessively painful on palpation and yet are not felt spontaneously by the patient; these must be REHABILITATION OF THE SPINE: A PRACTITIONER'S MANUAL sought alll.! illclllilied. C1illl,:;i1ly. thl:)' m;lllifest thL'l1l.. . dn.~ . . hy referred pain. which call ~ far from its SOlin.:..::. and il is important to know the sitcs (,f pain referral. Palpation ll.:('ht\iqtl~ must also he mastcred. L' "ually. slight hypenolllls is no Led ;lhon.: a muscular Trl'. hut it is frequCl1lly so di . . creet ;IS 10 avoid tktcl.:tion ;lIItl'di;lglllhi,. By making the lllu:,de harhoring a TrP slip 1I1H..!L'r our lill~as. howc\"L'r. we prodlH':c a fL';lClion in precisely those 1i~. ·. rs thai arc perceived as ;1 ""tau! band'" The rrP lies within Ihis band. and at this point. we should be able lO evoke refared pain and the twitch reactio[\ (Fig. 11.15). Interestingly. the mOTe superficial a TrP, perhaps in the forearm or the erector spinae. where the pmient is Illore likely to be aware of it. the better he or she tolerates examinntion. The hidden TrP. such , ,; Using Eye Mo\'cmcnl'i, Respiratory Synkinesis. and Gra\'it), with PIR For these reasons. combining the lise of PIR with other "neuromuscular techniques" ha, improved our results and is particularly of value in promoting self-treatment. The Iirst such combination is with eye movements. If the patient looks to the I I , .> , J I' ~ I I I .. ~ p ~ ¥ It I ~ ~ ii J Fig. 11.14. Post isometric relaxation of wrist extensors (left); self-PIR of the wrist extensors (right). I1-----------·-.--------.- ---- ----- 1 I >. CHAPTER 11 : ROLE OF MANIPULATION IN SPINAL REHABILITATION 205 and to inhal~_Whil.e_§looping, This principle is equally lrue for side bending, and even during backbending. maximum exhalation is required to obtain synkinetic contraction of the thoracic erector spinae (producing mobilization into trunk exten- sion, Fig. 11.17). o;xhalation is coupled w;.!.h forward nexioo in a neutral erect position. whereas in a lordotic or prone pOSItiOn, the reverse holds true. This fact is borne out by IsomcLr'lC m~ll1ual traction \vith the patient prone; owing to lumbar lordosis, the erector spinae contra(:ts during exhalatiori. moving the buttocks upward. This'movement is resisted during the isometric phase. During inhalation, the erector spinae relaxes and the bUllOCks move caudally (Fig. 11.18). In lhe cervical area, lhe opposite occurs: on inhalation, the neck muscles contract (isometric phase); on exhalalion, relaxalion lakes place. For traction trealment (Fig. 11.19), il is sufficienllO cradle the patient's head during the isometric phase, followed by relax- --_.-..--_."....::: ,..;.... ation during exhalation. This traction technique is apparently the most gentle and the most effective, particularly in acure wry neck, because no active put! i:; required (it can also be ap- plied wilh the palienl sealed). Respiratory synkinesis applies tn particular ro respiratory muscles (the scpleni, ~~,~~~ocleidom~.lil9.i,d~,JtI,~~.t5?~~,les. ansLgt}il~.t":~.l!~ lumbQ...~f.I!2!.~hich con~~ct ~uring inhalation and decontract during exhalation. The rcversc'hoids-for-t"tte abdOmiri"arandin partlcuiar-for the masticatof)' muscles. which arc aClivated during ex~alation and inhibited during inhalation. In contrast. the digastricus and mylohyoideus are facilitated during inhalation and relax during exhalation. This action is best monilored with the Ihumb in contaci with (he latcral proccss of the hyoid, where it is possible to sense resistance at inhalation and relaxation at exhalation-when the thumb sinks toward the midline-witham exerting prcs- () {) sure(!) (Figs. 11.2010 11.22). D :,) Fig. 11.15. Palpalion of a trigger point by identifying the taut band. (Fmm Travel! JG. Simons OG: Myolascial Pain and Dysfunction: The Trigger Point Manual. Baltimore, Williams & Wilkins, 1963. p 61.) right. he or she facilitates rotator muscles th direction. Ihese muscles will relax. If he or she looks up. the muscles in the ba<..:k and neck contract and can be resisted; when looking down. they will rclax (Fig. 11.16). Here. too. Ihe pmicnt must lir:·a sense the b~lrricr.J7 Respiration plays an import:',"t role in PIR. inhalation having a fncililalivc and exhalation an inhibitory effect, particularly as it affects structures in the head, neck, and trunk and less so the extremities. The effect of respiration is particularly evident in rcspiratol}' synkinesis. This term dcscribes when movcmcnt in onc dircction is coupled with inhalation, whereas movement in the oppositc direction is coupled with exhalation. As an example. straightening up is linked with inhal.ltioll whereas bending down is linked witlfexhalation, indeed because it is difficult to exhale while straightening up- Respiratory synkinesis is <1lso noted in regard to eye movement: looking up is coupled with breathing in and looking down with breathing out. This correlation i~ c;J,sily explained. because under natural conditions. looking up is followed by straighlening up (the body follows Ihl: eyes). and looking down by stooping. In fact. it is diffkult to exhale while looking up and to inhale while gazing downward. Therefore. combining looking up with inhabtion (double facilitation) would be effective for lreatment. whcrc;J,s combining looking down with inhalation would be counterproduclive. Whenever possible. Ihe force of gravity i~ u:-;cd for both isometric resistance and relaxation. Gmvity is lI:-;~d for rcsislance when the pmient isometrically contr'lets tht:' muscle h'lrboring a TrP, and again for assistance as the patient relaxes the tense muscle. According (a Zbojan. when gravity·induccd relaxation is used alone, the contraction and relax:ltion ph.lscs should each last for at least 20 secondsYlf thi~ tt:'chnique is combined with respiration. however. the timing of contraction and relaxation should coincide with that of tht:' rcspir.<.\wry phase. Therefore. respiration must be slow. The patient is told to hold his or her brealh after inhalation and. if necessary. " " .._---""_.~~---"-_._---"------"-"-"-" 206 REHABILITATION OF THE SPINE: A PRACTITIONER'S MANUAL ., ....... , .""\ Fig. 11.16. PIR of the short cervical extensors using facilitative eye move· ments during resistance phase {left} and inhibitory eye movements during relaxation phase (right). .,,, '..7 Fig. 11.18. Isometric manual traclion 01 the pelvis. ) Fig. 11.17. PIA 01 the thoracic erector spinae using respiralory synkinesis. Fig. 11.19. PIR traclion of the cervical spine using respiration only. , '.J-. CHAPTER" : ROLE OF MANIPULATION IN SPINAL REHABILITATION 207 Fig. 11.20. PIR ollhe scalenes. even after exhalation. Gravity-induced PJR lends itself naturally lo sclf·tfcalmcnl (Fig. 11.23 to 11.28).:n All of the neuromuscular methods described (0 this point can be combined to obtain the best possible effect. This combination is accomplished by a summation of physiologic stimuli. making the entire procedure automatic. so the paliem <.:an apply treatment 'even morc than once a day. However adval1lagcous ,lOd effective the combination of methods m;ty be. it requires careful thinking'to identify the mOl-a dfecti\"c method ;.md to avoid incompatible or useless Fig. 11.21, PIA of the maslicatory muscles; self· PIA of the ticalory muscles. combinations. An ideal combination to obtuin relaxation of ity is the stcrnoclcidom;.\stoid (also sclf-Illobilii'.lltioll of occiput! atlas) follm\.'s. The patient is supine. with the hcad rotated over tile end of lhe table acting .1$ a fulcrum. The patient is in· structed w look ww,ud the forehead i.lnd to breathe in: at II cCr( relaxmion. ma5~ rehlXCs (sec Fig, 11.28). In both c;IS~~. looking up f;h:ilil~ltCS inhalation. which in turn racilit::lte~ the muscles in yucstiOll and lifts the head and straightens the- trunk. The fon.'l.~ 1...... ( gravadcqu~te for r~siSlimcc and for obtaining rcka:,l.' during Wheneq:r the combination of eye movemcnt 208 REHABILITATION OF THE SPINE: A PRACTITIONER'S MANU':'!... Fig. 11.22, PIR ollhe digastricus and mylohyoideus; self-PIA of the digastricus and mylohyoideus. ) Fig. 11.23. Sell·PIR l.sing gravity. (ji ihc lJpper irapel.ius Fig. 11.24. Sell-PIA of t!1e infrtlsplnalus using gravity. CHAPTER 11 : ROLE OF MANIPULATION IN SPINAL REHABILITATION 209 Fig. 11.25. Self·PIA of the subscapularis using gravity.. () o Fig. 11.26. Self-PIA of the piriformis using gravity. o tnlpczius would occur. Therefore. the correct command for the relaxation phase is: "let go ;lIld breathe OUl.'· For l1lobiliz;uioll in the ccrvicOlhoracic or thoracic region inlO side bending. the operator instnlcts the pmicnl to look lip and to breathe in (after ttlking up the slack into side bending). followed by "hold your breath" and then "relax and breathe our.'· The oakr to look down would make the patient bend forward. which would be incompatible with ctTcctivc mobi~ lization in Ihe ccrvicothoracic .uH.lthoracic regiolls. For gravity.induccd PIR in trunk muscles. we make usc of the facilitative cffcl.:l of inhal;ation during the iSOI11Clril: phase and of the inhibitory effect of exhalation during lhe relaxation phase. beginning by telling the patient 10 look up. to fadlit'lte inhalution. and thcll (wilh a few exceptions) to look do\vn be· forc breathing out and relaxation. To make the rhythm as slow by relaxation for at leas.t an additiOlml 20 se<.:onds (sec Figs. 11.23 to 11.26). .JOl:\T \IOBILIZATION (MANIPULATION WITHOUT THRUSTING) Joint mobiliz~ltion without thrusting makes usc of the same principles tlwl·apply to all the manipulative techniques so far dc~cribed. namely. engaging Ihe barrier (laking up lhe l'lack) ,lIld obtaining release. This goal CUll be achien:d by simply waiting and ~\pplying slight pressurc or by repctitive springing of the barrier. Many practitioners lind these techniqlll'~ time consuming and in the end less effectivc than Ihrul'ling (front Ihc barrier!): it has been Ihe mcrit of oSleopaths to COll1illllC with their usc. This situution hal' changed greatly since {he introduction of neUI"OI1111SclJlar techniques into manipulation. m<'lking mobilization more clTcctivc ;lIld working within the barrier gelltler. safer. and Icss time consuming. The reason for this result is that in a restricted joint. il is Illusck spasm that is first met at the harriL'l". making slo\\' 210 REHABIU IAIIUN Ur I Ht:. ~t-'lNt:.: A t"MA0. II lVPH::n .:J IV',..," ............ ., J Fig. 11.29. PIR 01 the upper trapezius using a combination of methods. Fig. 11.27. Sell-PIR of the sternocleidomastoid or self-mobilization 01 CO-C 1 using a combination 01 methods. .~ <J --~- ) Fig. 11.30. Mobilization ollhe sacroiliac joint. Fig. 11.28. Self·PIR of the Quadratus tumborum using a combi· nation of methods. IIh 1bilizaiioll less SllCCC ......J ul. Wilh the ;.tid or IlCUHlllluscular Il·..: hniqlll:.... this muscle :-.pa";lll i~ ~l\'crcomc :'\lIo. in some \.';1:'1.':". the p;'lticn(s l1lu\ch;" may even help in lllobilizOl' IiI 111. i.e.. WI.: make lise (If the 1110,,1 phy\iologil.: means-the illh..'n:lll I"nn':l;S or the patient's nr~;\nism. Exceptions han; , hl..'l..'11 nOled. hO\\'c\'cr. For jllinls thai afC not 1110\'1.'0..1 by lllll~ d ..'~ and there fort: .,:,mllol ht: rt.:stril."tt:d hy l1111sck :-pa:-'Ill. ="llch as the s;'lcroiliat:. acnllllit!t'la\,i(ular. ;lI1d lihi(llil'lll;lf jt\int~. simple passive mobiliziltion is slillll1o~l ..:frecti"t.' (Fi~s. 11,30 III 11.3J unL! 11 A.i 10 110451. ~'Ios( 01" whal has hCl:ll "aid about IlCUrolllll." . :\l\'Il' ll.'dlniqul..'s in the treatment of musek SP"~lIl (TrPl is "'\j\lally lrut.' fl1l" joint mohiliz:HillJl: indeed, \\"111.'rl'\'(:r muscle... ;\1\: rt..'laXl..'ll. lht.' r;lI1gc of !11O"cllh,:nl ill,o innl.'a",\,.'s in joints. ~ S\'m,,' ;luthnrs maintain [hat 11I0Vt:lllt.:nt n.:,tricti\lll is lllo,tly ;l\lribul:lhk' t\l lllll:,d.: spasm: in 11Iy vil.;w. this l'\lllClll'.. ioll C<\lIll\'l ill' dra\\-n in "',,cry <':i1SC, ;IS l.'xpliliJll.;ll in Iht: prC"iOll'.. dist."lI:-:-i\\JI of tilL' "';\l,:roili"c anti other juinb, ". ;'. i\ parti<.:ubrly dfct.:li\"C Ilcurol11uscul,u" tl.;chniqul" for 111(\biliz,\lioll was dcscrihcll by Gaymans for side hl."ndill~ Ill' Ill1.' l·I.'I"\'ical and thoracic spine,l" Dllrill~ inhalation, Ilh:rl.' is altcl'nating in<.:rc;'lscd rcsistar\t:c ag;lil\:'1 sidc bcndill~ ill lhl.' i'l'('// ,\'C',l.:I1I('III,\', sudl as CI (1I1In"Clllelll helween oc<:ipul :lnd albs)" C2 (lIloVclllcnl bl.'I\\'t.'t.:l1 C2 allli C:;l. ('4" dl·". \\ hi.."1i ,-dax lI';,lt I'.rlwlcllhm, ResiswllCl: illt.TI.';Isn. Oil IhI.' \'IIII,,'r hand. :lgaillst side hl:lldill~ al exhalatillll in thl.: odd SI'.<..:III('/IfS \C \. .> , ",.; l ' .....> I I .. ...... no"'r 1 c:n II . n""l-l- vr IVlfW.jI/""ULI-\IIUl~ 11'1 ::Jt""INAL Ht:HAtlILlIP.IIUN •, (rig. ! L~J~. Th;~ cffc::t !~ ~!r,:,~~g('''1 in the upper cervical region and dccrc:;,\scs in the lower thoracic region. in particular , in the odd segments. The ~mol\gcsl effect of inhalation and exhalation is in the segment COil: it is felt in all directions. The first order is "look up (toward YOLlr forehead) and breathe ill:' followed by "look dO\\'I1 (ww,m! your chin) and breathe OUL" except into rClroncxion. in which eye movements \\lould he ;,It \'ari,l1H':c with the direction of l1\obiliz;,lIion (Figs. 11.35 to 11.37). In C2J3. postisom~tric traction secms as specific as side bending. So strong is lhe release effect of exhalation in thesc segmenls thal usually no or only one repetition is required. in rotary mobilization. we combine inhalation with the isometric phase and exhalation with the rclax:.uion phase. In the cervical region. however. it is usually more appropri:ltc to give the order "look up" during the isometric phase and "look ::1 ," j . , l IJ I; .1 , .) ; ......... ,: "; .; ......... I"j I I 211 Fig. 11.31. Mobilization of the upper part of the sacroiliac joint. .~) Ii () I, ~:~ TI I I I i i ! I h I -J! I " "~i \: , ¥ ~, ! J Ii) I lUII Ii , ·ii ~~ I l I i~ .,;.< {1 ""...'" , , j 'e:..J t1 { ,: Iu ;; j ... Fig. 11.32. Mobilization 01 the upper part of the sacroiliac joint. C3. CS). which relax dar;",; i/flwlar;rm. making mobilization casy. Resistance in all segments of the ccrvicothorac.:ic junction (from C6 to T2) increases during inhalation. and rclax:.ltion occurs during exhal.ation. From T2 onward. increased resistance during inhalation is again noted in the cven segments (T2. T4. T6. T8. and TIO) followed by relaxation during exhalation: conversely. during exhalation. resist:mcc in~ creases against side-bending in (he odd segments and relaxation (i.e.. mobilii'.alion) lakes phlcc during inhalation (T3, T5, T7. T9):'" The most effective coml11,lncl for mobilization into siCie bending in the even segments is: "look up nnd bremhe in," followed in the cervical region by "look down and breathe out:' In the cervicothoracic and thoracic regions. the command again is: "look up and breathe in:' followed by "relax and breathe out:' to avoid increased Ocxion of the cervicothoracic junction and the thoracic spine. which is most unfavorable for mobilization. In the odd segments. however. combination with eye movemcnts is unsuitable. bec:'lUse look~ ing down would not increase resistance against side bending and looking up would not help mobilization into side bending Fig. 11.33. Mobilization of the lower part of the sacroiliac joint. Fig. 11.34. Side-benning mobilization of the cervical spine. " ... , ,............. , , ...... , ' ...... ,,, ...... , down" during thc relaxation phase instead of "look to the right" if movcment restriction is to the left, followed by ','look to the left," as is required in the cervicothoracic or thoracic region (Figs. Il.3S '0 11.40). Just as in PIR for muscle spasm. il is esscntial in the mo· bilization of joints to wail for the release effect. Release usually occurs late during exhalation (or inhalation). and it is best to avoid useless attempts to force it-it must be sensed and be free of intcrfcrcl:ce. evcn by the order to breathc out, as long as relaxation continues. Once release has set in. it goes on. even if the paticnt continues to breathe normally. Postisometric relaxation is not the only neuromuscular technique. We may inhibit antagonists by active motion, e.g., inlO rotation (Fig. t t AI). In some cases, we may use rhyth· mic contraction of a muscle for mobilization, e.g., of the scaleni for mobilization of 'he first two ribs (Fig. 11.42). The original Muscle Energy Technique (MET) as described by Mitchell, Greenman, and others is similar to PIR, but more complicated in that it tries to reach the barrier in three planes at the same time and to apply resistance accord· ., .......... "" ........... , " ........... " , 'v''' .... n v IV' ..... ''1U ..... L Fig. 11.37. Mobilization of CO·C1 lateral flexion. Fig. Fig. 11.38. Mobilization of restricted rotation in the cervical spine. Arrow. fixation by the thumb from behind, Fig. 11.35. Mobilization of CO·C1 retroflexion. Fig. 11.36. Mobilization of CO·Cl an!ef!exion. ingly. "Functional" and "counterstrain" techniques achic'Yc release by moving the patient to a relief position in which spasm subsides, and then carefully bringing the patient back into neutral position. finally making sure that the full range of motion is well tolerated without recurrence of spasm. Such techniques can be useful in the acute stagc. being gentle and well tolerated by the patient..t1A~ As described in this chapter. PIR has the advantages o( simplicity and the possibility of combination with eye mo\'cment. gravity, and respiration-making many of these techniqucs automatic and thcrefore well suited for self·treatment. onc of thc requirements of the rehabilitation process. In joints that cannot be moved by thcir own muscles. it is important to remember the absence of spasm that could inter~ fere with passive mobilization when the barrier is engaged. Simple passive mobilization can be obtained by a minimum of force just by springing those joints, The importance of minimum force lies in that the joint has to spring back into neu~ tral after applying a springing force. and the intrinsic forces of lix u '1"\1' 21:; ...... HAI"" I tH 11 : HVLt VI"" MANWULAIIUN IN ;jI""INAL Kt.HAtHLlIAlIUI\l j'lillb h.\:" an cXL"cptional position. Here. the barrier is engaged in a "illldar way, but then a fast impulse (rdatively) little t'on:e and s111.111 amplitude is applied. separaling the joint faL'l'b \\ hell a click is usually heard. At this 11l0lllelll, the resiSlallCL' ,lr the barrier "uddenl)' breaks dowll (Figs. 11,46 to 11.-1~ l;b it is "taken by surprise." In other words. whereas all method .. described so far only normalize the barrier. the thrust suspend ... it. and with it. its protective effect. As a result, hY/lcnllohilily is produL"t.xl. which is ,Issuilled III be only temporaL;>. ~, ": or Fig. 11.39. Mobilization of rotation at the cervicothoracic junction. It i... easily under"tood that most complications ascribed to manipulation and related to thrust techniques and that repeated thrusts at short intervals produce permanent hypennobility. 3. condition cvery experienccd clinichin \·iews with apprchen"ioll. Complications arc, in fact. most frequently the result of repeated (ullsuccessfult thrust manipulation at short illlcn ;t].;.. il is clcar that the question of contraindication for manipulation 'mainly concerns thrusting. Propcr techniquc is of vital importance when using a thrust. \Ve should never thrust until the slack has been properly taken iJut and the patient ha~ relaxed: therefore, \Ve should never thrust in a painful direction. Nor should thrusts be applied where movement restriction is pronounced; in fact, if therc is scvcre restriction in all directions. this is in itself a contraindication for a thrust manipulation. Because most serious complicmions after manipulation arc caused by vertebral artery injury, the comb ina- V CI';,I~ve i.~lnch ILL.'lCk ~ngc of .'\\Jch :Ic"imd Fig. 11.40. Mobilization in slight kyphosis, with the lower vertebra fixed by the therapist's hand and thumb, '-.,-,--I_r~--'c-~---=--_ !====~~,~R~\=*\=== Fig. 11.41. Active repetitive mobilization of the lumbar spine with the patient lying on a side, such joints arc smalL Examples include the sacroiliac joints (sec Fig. 11.30 to 11.33) as well as the acromioclavicular. sternoclavicular. and tibiofibular joints (Figs. 11.43 to 11.45). In all techniques producing release. the operator is constantly in a diagnostic situation. making correction possible and knowing when and where release has been achieved. THRUST MANIPULATION For many if not the majority of practitioners, the term manipulation is synonymous with thrust techniques. To this point. our main criterion has been the barrier and release phcnomcnon dcaling not only with joiiHs but also with most structures of the molOr systcm. In this respect. thrust manipulation of j- Fig. 11.42. Repetitive mobilization of the first and second ribs by isometric rhythmic contraclion of the scalenus. A B Fig. 11.43. Mobilization of the acromioclavicular joint by shifting the clavicle against the acromion ventroctorsally (a) and craniocaudally (b). lion of rotation, retroflexion, and traction should be excluded from our techniques on principle, because for the most pan such complications do not arise with signs of clinical in- volvement of the vertebral arteries. Thrust manipulation should be carried out with little force; if a "little lUg" is not effective. we should change to neuromuscular techniques. the thrust (tug) serving as tcst to sec whether the joint or mobile segment is prepared to accept Fig. 11.44. Traction~mobilization of the acromioclavicular joint. Fig. 11.45. Mobilization of the fibular head against the tibia. it, but ncvcr as a forced procedure to achieve the click. Our aim is not a click, but rather relcase and nonnal function, obtained by thc most appropriatc mcans.~~-52 The usual list of "contraindications" involving tumor, acute inflammation, fracture, etc. is out of place becausc no competent practitioner would knowingly usc manipulation in such cases as those. No one is infallible. howevcr. and diagnostic errors are a possibility. particularly in the carll' stages of disease. Even in such cascs, howcvcr. neuromuscular techniques are usually harmless and may even give temporary relief. Clearly, to rely mainly or exclusively on thrust tcchniques is bad practice, the more so as it deprives the practitioner of such effcctivc manipulativc methods as soft tissue trcatment and PIR. Nonetheless, a successful thrust gives intense, immediate relief and therefore remains a popular and useful pro~ cedure. \Vhen thrusting is properly administered and judi~ ciously used, the ratc of complications remains small. and therefore it is important to know when thrust manipulation is particularly uscful. The most frequent situation is whcn symptoms persist and release and relicf is not fully achicved aftcr application of neuromuscular techniques. In this situation. the patient has also been well preparcd (by these other methods) to receive a thrust. The utility of thrusts if joint rcstriction is the cause of nervc cntrapment is understandable, as the irritated nerve may ------- .rl vM ..... r- I cn I I • nULc v r 1VlJ-\I\llr-VLJ-\IIVI\I 11\1 ;:,r-II\lML nCMMOILlll"Il 'V'" ~IO TIC\CTlO:\ TIlERAPY " ~ \0 ,~ T('n$IOn on kq " Fig. 11.46. Relationship between distraction force and joint surface separation for a joint that cracked when a distraction force was applied. (From Roston JB, Haines RW: Cracking in the metacarpo-phalangeal joints. J Anat 81:165.1947.) The nbjL' . :t l,lf manipulation is to n~ctify mechanical problems. Thc S:Il11c is trll~ of traction: in our opinion. the bcst form of tractioll is lI1(//lIIa{ tructiol/. Curiollsly. manipulators show remarkably link interest in traction and. more frequently than HOt. al'(' nil{ well ;lcqu:linted with the t~chniqlle of manual tr:lCt i!.l11. ThL' most (:ff(:ctivl' techniquc for therapy in the cervical arca is postisollletric traction. which has already been Jescribl.'d. It is indicated for individuals with acute wry neck and root syndrollles. and is specific in the treatment of e2/3 restrict ion (SCI,": Fig. 1l.19). For anatomic re:tsons. traction in the lumbar spine affect joints only minimally. but it is specific in the treatment of disk lesions. ~n fact. clinical improvement after traction is potentially diagnostic of a disk lesion. ---=='~' E, E S c o "0 o ~ .:; J ;f;r~ I t ._._' --:---:-~---::-,,---~ 6 ~ 10 12 \4 16 Tension in kg Fig. 11.47. Comparison graph to that in Fig. 11.46 for a joint that did not crack when distraction force was applied. (From Roston JB Haines RW: Cracking in the metacarpo-phalangeal joints. J Anal 81:165,1947.) t be edematous and therefore profit from the extra freedom given by temporary hypermobility. Its value is evidclH \vhcn the carpal bones Fig. 11.48. Radiographs of the third metacarpophalangeal joint during the resting phase and distraction phase, before and after manipulation. a, Pretreatment. nondistracted joint space; b, Pre· treatment, distracted join! space; c, Post·treatment. nondistracted joint space; d, Post-treatment, distracted joint space and gas arthrogram. , . . . . . . . . ~,_ • • • " I ' ...... , . . . . . •• , ...... , " ..... 1"\ r n/"\ ..... 11 I IVI'lc::n ;:) IVlf"\I'llUI-\L til{' hack of 111\' !":lticn(..; knl,'~ lln~r his or ha thigh and u:-;~~ lhe pt.llient"s kg as a leva. rhythmically lifting the patient's pelvis and low back from the aable and rocking it (Fig. J I .)_"' lI\s mentiolled prc\'iollsly. postisolll~tric tral'tioll in thc lumbar region makes usc of respiratory synkinc:-;is: the..: tha~l~ pist resists the buttocks Illo\·ing.upward during exhalation and make:, usc or rcl:lx.uion during inh:llation (~Cl' Fig. 11.1 S J. Whill; prone. with the kgs hanging over the end or a high table. the patient may carry out sdf-treatment. lifting the but· tocks on exh'llation .md dropping them. rcl'lxing. uuring inhalatioll. As with other mtltlipulativc techniques. tr a b Fig. 11.49. Traclion high·velocHy thrust on the os capitum: a; Finding the os capilum and making contact: b l Taking up the slack and making the thrust. The following techniques are mO~l useful. In rhythmic traction prone (Fig. 11.52). the patient holds the end of the table while the operalOr pulls rhythmically with his or her hands around the patient's ankles (which should not be squeezed!), after first making sure that the patient is relaxed. The operator must then establish the correct rhylhm to localize the effect in the low back. If the rhythm is mo slow, the patiem's whole body will move up and down on the table. By quickening the rhythm, the therapist will find out when only the leg and pelvis move while the rest of the back remains still. the low back being like a nodal point in a sianding wave. Rhythmic traction prone can also be carried out by pulling only one leg. which also produces a slight side·bending effect at the same time. If the prone position is poorly tolerated because of forced lordosis. traction is carried out in kyphosis with the patient supine. The therapist stands at the side of the table (which must be lowered) and place5 his or her foot on the table. the thigh and knee should be horizontal. The thcrapislthcn places .> .,~ THEORETIC CONSIDEIlATIO:-:S All manipulative tcchniqucs dcal with mechanical probkl1l:'. The barrier phenomenon. with all its rcllcx implic.ltion:-;. i:, :llso it mechanical problem. yet its nature is not surlicit:'lllly understood. However important muscle spasm and TrP may be. they cannot explain rcstriclion in such joints as the sacroiliac and others. let alone barriers in connectivc tissue SInK· tures. One fact pertaining to joint and spinal mWlipulation that is well established. however. is that manipulation restores nlO· tion and that its object is revcrsible movement restriction. The: implication of this statement is thaI the imponance of the relative position of bones or vcnebrac should not be overrated. This has practical relevance, because asymmetry, particularly in the pelvis, may appcar considerable. bUI asymmelry with· out dysfunction does not require manipulation. Recent experience and research have shed some light on this question. First, it has becn shown that typical pelvic dbtortion with clear asymmetry of the anterior and posterior iliac spines is not regularly related 10 sacroiliac dysfunction and C<:ln. as a rule. be treated. successfully by manipulation of struclUrcs outside the pelvis. m05t frequently those of the craniocervical junction. Second. lindings show that th~ nt:u- .. _~ i , ... ~ \ .. } Fig. 11.50. Traction high-velocity thrust on the cervicothoracic junction. .) - ~~ .,, i I "J < Ii I Fig. 11.51. Thrust manipulation 01 the lumbar spine with the pa· tient on her side. in kyphosis, the lower leg bent and upper hanging down over the edge of thi table. I ti I I~ q ~ " I . I ",'\ J Fig. 11.52. Rhythmic traction prone of the lumbar spine. I '~ lfal position in the spinal column is not absolutcly consHmt; aftef maximum side bending of the ccrvical spinc or rotation. the vertebrJe do not return to exactly the same position (Fig. 11.54).~" Finally. we hav~ learned thal static loads can change the positon of \'cnchrae. If we rC~lOrc nonnal mobility oCthe spinal column and the pelvis. it will adopt the optimum individual position required for the prc\'~ljljng conditions. which arc by no means constant. If. for example. ventral and dorsal flexion is restricted, we arc fully justilicd in mobilizing in both directions without regard 10 the position of the adjacent structures. For the sacroiliac joint. for example. it is adequate to restore springing at its upper und lower cnd. i.e.. in what seems "opposite directions" (see Fig. 11.30 to 11.33), ..IS long as mobility is fully restored. ! II ~ M I j i '~ I I dysfunction is pain with sitting or standing, especially when ocnding forward. Under nomlal conditions, static equilibrium should be maintained without excessive muscular activity. Rash and Burke fUI1her specify that, "in stationary posture the center of gravity of each body segment should be vertically abo\'e the ar~;] (1f ilS 5uppcrting base, preferably ncar its center. If pcr!'is.h~nt gravitational torques are being bome by ligamcnts. or if excessive nuscular contraction is required to maiutain balance. this principle is being violatcd.":'>(, For the slatic function of thc ~runk and the spinal column, the position (tilt, inclination) of the base plays a decisive role, but assessment by purely clinical means is impossible. The exact position of the promontorium, of L5 and even of L4, can only be revealed radiographically under standard conditions-standing. The ideal method is radiographic examination of the entire spine. If this study is not available, a plumb line can show the position of the external occipital protuberance in the anteroposterior view and of the outcr meatus acusticus in the side vicw. The position of the feet must be held constant; in the antcroposteriof view, they should be symmetric to a line of the noor corresponding to the center of the xray screen. In the side view. thc feet should be placed on the same line at the site of the outer ankle (Fig. 11.55). The mechanism of balance differs in the coronal and the sagittal planes. This difference is readily understood if the effect of (1 heelpad is considered. An artificial difference of more than I cm in leg lenglh is felt imi'iicdi<:atcly {~iid resented) in the coronal plane, whereas raising. (or lowering) of ~ , r j DISTURBANCE OF BODY STATICS I I 217 CHAe I eH 11 : HULe UF MANIPULATION IN SPINAL REHABILITATION ,) m k l' I ,) Gutmann and Vcle sUllllllcd lip the import:'lI1ce of st Fig. 11.53. Rhythmic lraction supine of thl lumbar region. ~ !i i - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - $ ~ Ht:.HAIjILlIAIIUN OF THE SPINE: A PRACTITIONER'S MANUAL I ,, l ! ~ t .~ Fig. 11.54. Radiograph of neutral position before side bending (left) and after side bending (right). both fecI is hardly noticed. The responses differ bcc;.lusc. in the coronal plane. the line of gravity passes between the tW(1 hip joints (stable equilibrium). and one can crfectively correct pelvic obliquity by lifting one fool. The physiologic reaction to pelvic obliquity-obliquity of the sacrum (!)-is scoliosis to'the lower side. rotation to the side of the scoliosis. and pelvic shift lO the higher side. The summit of the scoliotic curve is in the midlumb.u region. and the thoracolumbar junction should be above the lumbosacral junction. 5 \Vith the most frequent type of abnornlality. Ihe thoracolumbar junction does nol stand above the lumbosacral junction but i~ deviated to one side. more frequently to the side of scoliosis. Rotation depends on the degree of lordosis. If the lumbar spine shows 110 lordosis or even kyphosis. there may be no rotation or cvcn rot::ltion to the side of inclini.uion (not scoliosis):'" The most important point. howc\·cr. is that obliquity must concern the base of the spinal column. not the pelvis as such. Unfortunately, neither difference in leg length nor pelvic obliquity necessarily correlate with obliquity of the sacrum or L5 or even L4. Therefore, we may easily create an oblique b::L"ie of the spinal column by correcting pelvic obliquity and/or leg length inequality. In other words. we correct the morphologic appearance of the legs and pelvis. but seriously disturb static function or balance of the spinal column (Fig. 11.56). Because lhis most relevant obliquity CimnO( be seen or palpated. radiographs arc essential for correct ~ssessmen(. Radiographic evaluation is equally es~cntial for the assessment of spinal statics at [he base of the spinal colul11n as for lhe in which casc nur intcnded correction may make thing5 even worse. This cirCulllsta11l.:c. too. c,m only bc rc\'cakd radiogr.lphically (Fig. 11.57). This failure ofren occurs if the pelvic obliquity is compensatory. as is the case in idiopathic scoliosis. The criteria of improvement after sUltic correction are as follows: the lhoracolumbar junction returns to stand direclly above the lumbosacml junction: scoliotic curvature decrcases: and the pelvis and h~ad (plumb Iinc) return to mid- C) line (Fig. 11.58). The same static disturbanc~'can be caused by obliquity at the base of the spinal column. thus erell/illg pdvic obliquity. hut normalizing spinal statics (Fig. 11.59). In this case. obliq\Jity is caused by asynH11ctry inside the pelvis. This obliquity. unlike that caused hy leg length inequality. pcr~isl!' when lhe subject is sc.::.ltcd •.lIld should h~ corret:tcd by a board under the ischial tuberosity on the 100.. . er side or obliquity. If correction is (0 involve a hcclpad. it is essential to consider whether the spinal column can react clinically to m~ chanical com.:t:tion. Such a response is not possible in th~ acute stage of lumbago or a root syndrome with obvious alltalgesic posture. un.rol1l1ll , ..J ----------------------------_.... , ," CHAPTER 11 : ROLE OF MANIPULATION IN SPINAL REHABILITATION A c 219 B D Fig. 11.55. Radiographic technique of the IU,mbar spine with the patient standing. a, Positioning of the movable plumb line; b, Device prepared for radiographic examination, anle'roposterior view; c, Positioning of the plumb line; d, Device prepared for radiographic examination, lateral view. (After Gutmann G.: Klinisch-roentgenologishe Untersuchungen zur Slatik der Wribelsule. In Wolff HO (ed): Manuelle Medizln und ihr wissenschaftlihen Grundlagen. Heidelberg, Physikalishe Medezin, 1970, pp 109-127.) .•• _ . , . , """'V""'-"~"""V '''''M''IUMl. A Fig. 11.56. Pelvic ~bliQuity. a. Peh!is lower on the ~;ght (short right !'=-g) wilh a horizontal sacrum, the lumbar spine is straighl; b. V....i:h a righl heelpad. sacral obliquity a;Jp~ars. with a dS':ialion ollhc lum::ar spine 10 the leI; and slight dextroscoliosis. , j A B Fig. 11.57, Pel'/ie and sacral obliquity owing 10 a short left leg. a, Lea scoliosis wilh deviation of the thoracolumbar jllllction to the Ie::: b. Less pelvic obliquity alter application 01 a left he~Jpad. but no imorovement in lumbar slatics. ,.. Fig. 11.58. Pelvic and sacral obliquity owing to a short leg. a, Before correction; b, After correction. A Fig. 11.59. Sacral obliquity without pelvic obliqui::. a. Betore correction: b, Afler correction. B C Fig. 11.60. Disturoed s!alics in pelvic distortion. a, Pelvis straight. obliquity at LJ with deviation of lumbar spine II> t:-::, ~~Il and sligr.t sinislroscoliosis. b. No ~mprovemenl after IlppJying a left heelpad. c. Afler Irealm:?:,: ol <1 blocked rlilM,;,;o·Qcr.;ipilal jc:r': -ormal statics and no pelvic dislorllon , RI::::HAt:HLlIAllON OF THE SPINE: A PRACTITIONER'S MANUAL ; 1 I1 aled and h~lpful. If, howe\'er. it is resented, but radiographil.: findings show marked improvement. then the patient is advised to try to get used to it if possible. i.c., to wear a heel pad only temporarily, so long as it does not calise discomfort or i, 1 pain. Once the patient has adapted. it is belief 10 raise the heel of the shoe on onc side or 100vcr it on the other side; if. however, the difference is more than I CIll. il is best to recommend I a thicker sale on one side. so as not to spoil the shoe. In the sagittal plnlle. the pelvis and spinal column arc po- 4 ! 1 i< I I ~ I ,~ I I I 1 I " j I It I I ~ sitioned above the perfectly circular femoral heads. and b:.i1ance is maintained largely by muscular action, which should be kept at a minimum. Spinal curvature is largely a result of sacrum inclination: if this is considerable. lordosis will be considerablc. Under normal conditions, the thoracolumbar junction is somcwhat behind thc lumbosacral junction. so that T12 lies 4 em behind L5 on average.~K If the thoracolumbar junction is in front of the lumbosacr stability. MANIPULATIYE THERWY AND ALTERNATIVE ~IETHODS From a method of treming mainly articular dysfunction. mOl· nipulative therapy has developed into a method thm is used to tr~at dysfunction of any structure and tissue in the motor system. and it is possible that ~Oll1~ ,·isceri.ll dysfunc'tion mny bc influenced by manipulatiq~ techniques as well. The prerequi. site for all this applicmion. is the (lrr o!po{pario/l. Palpation is however. first and foremo.1:,( a di~lgll()stic procedure. and so manual functional diagnosis has become the most important dinical contribution of manipulation, enabling us to make pcnincnt diagnosis of all tissllcs and structures in the motor :o;y:-;lcm. Prcciscly because of lhcs~ diagnostic possibilities, wc have' learned thai importalll tissue changes lie far from the site \vhcre the pmiclH feels pain. nnd th.lt. in f::let. slI<.:h changes r-----· :1 , .~ I .. usu<J.ily <.tIl: Ilhm,; lIullh;l\lll:-O lhan those recognized by the patient bccnuse of pain. NOI only ) ) ) () CLINICAL IMI'LiCATIONS The importance of the diagnostic side of manipulati\·c techniqucs has been stressed. It is the clinical implications that illustrate this point. The Illost frequent symptom of our patients is rain. which is. in itself. a diagnos.tic problcm for most praclirioners. \Vc havc consistently shown that with our methods. we arc able to dctect well-defined changes in almost all slrllctures of the molor systcm and beyond: in skin. the \"·<.~nnective tissues, muscles. fasciac. and joints in both tht:' ~xlrt:l1litics and the spinal column. Consider headache in a patient with "ncgati,'c.7''' Ilt:llI'O, logic. orthopedic, otorhinolaryngologic. stomatologic. or rheumatologic lindings. We may llnd tension in th~ masticatory and submandiblllllr muscles. with deviation of the hyoid: a scalp that docs nOl freely move on lhe skull in som~ places (and in some direction): hyperalgesic skin zones in Ihe cervi~ cal region: TrP in most of lhe neck muscles al1d in the cervicothoracic _-------------------,--------- \.) CHAPTER 11 ROLE OF MANIPULATION IN SPINAL REHABILITATION B Fig. 11.61. Forward-dra'.... ,: posture with thoracolumbar junction ir' front of the lumbosacral (a) and with s:raighlening of a cervical curve (b). A with hypcrtollus of the glutei. and fauh~ motor patterns O\ving to muscular imbalance. faulty rcspintion.•md/or cxogcnic rcasons. e.g .. al the \\orkpbl,,:c. This ,\C(Olll1! of the possible findings is certainly not (Olllp!e(C. but what is true for headache is as true for . . houldcr pain. leI\\" hac\..; pain, elc. in regard 10 "negative lindings.'· The clinical impliGllion of func- ,I tional pathology-nol a question of -.in1;lc method but of a different clinical approach in which dy,>functioll is as real as structural pathologic changl' ,Ind therefore must be adequately diagnoscd, i\-1anipulati\'c !t:('hniquc.. have thu:, opened the way to what i~ no\\' \\iddy ('ailed "m;oskektal" or "musculoskeletal" medicine. dcallllg with the l11(1st frcqucilt alTcction, of the motor sy'-.tclll and cvcryda;. ailmcllls, REFERENCES I. 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WiI"m AS: Th,'ncrve ~urJ1ly o!' l1h' hlll\l:\Il1ul11b;n illl,T<~;~hr;ll di~b. J l\n::\ I ~2:Jq. 19KI. lJ. L':\',i~, K: Chaill l'c:tclion, iil di~lllrbnl flillUioll 01' lb<' I1h'lpt' ~y~ll.'rll..1 M,\I;c;~: .\led ":27, 19X7 I-Ilk r! \1(" 1,Illli"c' BUrIl' ~::-.:rn"ri:d k,'(ur,' 1\:rn'jlli"11 :':~,'u:,:h palp:lli\'11 J i\r; (),\I"llp;,:11 '\"'0(; :~'I 1,'-\ ••• _ i I 1i i ~ §. 1 ~ ~ I i ~ I '"i! I I II i Ii 15. Chaitow L: Palpatol)' Lite;;icy. Lo:~:!nl\. "!"!~nN'!~'i. !(H.)!. 16. Greenman PE: Shichtwcisc Palpation. Manud!.: MeL! 2~:46. 198-1. 17. Travclt JG, Simons 00: Myofaseial 1';,il1 ;mll Dysfllllt'lil1n: The Trigger Point M:lI\Uill. Vol I. Baltinl0n:. William>: &. Wilkins. IlJS3. 18. Bourdillon IF. Day EA: Spin;"!) f'.hnipul:ttioll. 41h Ed. L~lIld(ll1. HeinelUann. 19S7. PI" 38...40. 19. Lcwit K: Pelvic dysfunction. In P:IlcrSt111 JK. Burn L: Ib~'k Pilin. 1\1l IntcnlOltion;11 Review. Dordrecht. Kluwet. 1990. I'll 271-2:\4. 20. Keating lC. ncr~lJ):llln TF. Jacohs GE. l'l al: Illh:r,,:x;IlUilll.'r rdiahilil)" uf eil~hr evalu:tlj\'C dimensions tlf lumh:lr \C::ll1cnlal ahnOl'ln;llil\". . M71llipulativc Ph)'siulllK'r 13:463. 191}U. 21. Boline PD. Kealing Jc. Brist J: Il\lerex;lllliner reliahilily of palp:tlUr)' evalu;ltion (If the lumhar spine. Am J Chiropr.lI.: MCll 1:5. [9S1\. 22. IXOocr Kr=. H:trll\on R. Tutlle CD. el al: Reliability stlldy of dctc.:til\l\ uf sOll1,·1ilnudlc Med 311:75. 1992. 31. Sih"er~lolp..: L: A pathological erCClOr spin::..: rdlex-:l new sign tlf Ill":' ch:mical pelvis dysfunction. 1 Manual ~·kd 4:::2K. 19N9. 32. Silverstolpc L. Hcl:-ing G: Cranial visceral symptoms in mechanic.,1 pelvis dysfunction In P:ltcrsQl1 JK. Bum L (cds): Hack P'li11. All Inlcmalioll;ll Review. Dordrceht. Kluwer. 199U. 33. GOCKIridgc JP: Muscle energy techniqu~: L>c!initioll. expl;m;lliun. meth· oJs of procedure. 1 Am Osteopath Assoc S I :2-l9, 1981. 34. Stiles EG: Muskclenergiclcchnik (MET,. Thcr.'llo:Ulische Grund\I;':": ulld praklische Anwendung. In r=risch H (cdr M:lIluellc Mediz.in HeUle. Berlin. Springcr. 1985. pp [50-156. 35. 1'r::I\'(.·.I1 JG. Simons 00: ~l)'ofasciain and OysfullCliun: The Trig.gcr Point Manual. B:lltimote. WilJi:lllls & Wilkin\. 19SJ. pp 4. 5-L1. 30. Lewil K: Po:i1isoll1Clric rcl:Jxillioll in combination wilh olher I1lctllfKh of muscular facililalion :md inhibition. J ~-tanual ~kd 2:101. 19S6. 37. Zbojan L AllliJ;ra\'il cna rcl ,-"" 'V'''\:.rl .:> .v "lUJ-'oL -, :lK Kiln 1fl.1: Prnpl'iuI:cph'r_ .llId sumati.: IlysIIllH:,itlll. J Am OSICtlp;lIh ASSH,: 7-l:6JS. 1975. "IJ. 11,c lIlus\'ul:tr anll ;tMl":llbr (;Klllr in 1\10\,'11\":111 n.·str'i':lillll, 1 ~Ialll101l ~kd 1:8". 19S5. ..tn. G:lym;lIls. I:: ni..: IkJ~'Il11llll! lk'r AICllll~T~1l fr die Mohilis;llinn der Wirh...· 1suk. i\·l;ultldk \kd 18:96. I')XU. .t!. JOll<:S L11: Slraill .1Il.! C"lllillcrstniin. l\'l·w.uk. OIL Till' t\~';I\klllY III O"tctlp:llhy.I'JX1. ":2_ Gr~'Cllll\;1l1 PE: Prill~·lpk .. "f "'·t;mu;11 ;\k.h,·lIl,·. Iblli"ltlfl:. Wdh;lllI\ .'\:. Wilkins. IIJX<J. pp 101·_·1115. 4". RU:'ItI11 In. I-I:lill...·s RW: Cr:l.:kin~ in Ih..: lIk'I:I"::lrpt'ph;\I;lIl~""ill j"inK J '\11.11 SI:HtS. 11)47. ":-1. Mi..:rau D. Cas.>:idy JD. Wmn:n V: ~'laniJllll;llioll ;lIIt111lllbiliz:llitlll tlfth..: third met:u':;lfl'0-llhal'an:;e;11 jdill1. A 111I:lllIil:lli..·..: r;uJio~r;lJlhk f;tltg..: III 1II0lil11l Sllldy. J M;IIlU;11 ~ktI3:1~5. I'JXS. 45. Dvorak 1. Or..:lli F: Wi,' !:!L'lhrlih ist ,IiI.' I\Llllil'ubtioll lkr I-LllswirhL'I\IIL" ~ Malludlc ~...ted 2U:..:-I. It)S~. -16. Grnssinrd A: Les a~'cilknls l1CUf(II'l~j(llle~ d,'\ 1I1ilnipliialitlllS I..'..:n·kak·.... Ann Me(I Ph)'s 9:21'.l. 1'J(}{l. 47. GUlmann G: VCfkIIUIl~""lI del" AII,·I·i;1 \,'llchralis tltu'dl lllillllldk ·111..:rallic. Malluelk ~l ...d ~ I :2. l I Jx.'. ..tH. MClllor::mdullI of til,' G...rm.m Assllciati\llI "f ""1;\11\1;.1 \'vkdi..·in..... Zur V..:rhlllng von Zwi\ch<:nrllell hci l!c/.klln !l;lIltl~rifr·Thcr;lpj.... all Ikr tl:llswirtlo:ls\lle. M;llluclk Mel! 17:53. 1'J79. oll). Smidt RA. E."lridge ~l\': Neurolu~ic \'olllplic;ltilll\S of h....,ld :nld IIct:k m;mipul:llion. JMvl,\ [S~:5. 1%2. 5'" Fu\sgf\."\:11 J: EdiloriaL Cnmplic:lti\lll~ in m;ullI:.1 lII....dicill..·. J M;IllIl:.1 Med (diJ. 1991. 51. Dvorak J: In'lppwpri~l"" illdkaliolls ;lIId \·olllrailltlit·;llillll.>: of l11illlU:!1 themp)'.l M;IIIU:.1 Med ('I:H5. 1991. 52. Patijn J: Complic:lIion.. 111 m:U1l1almedicim:: A re,·i..:w tlf Ih.: lih:ratur...•. J M,lIlllOll Mel.! 6:89. lYlJl. 53. KirOl.ll J: Persistence orynkin..:tk pallefll\ .. I" til..: .:cr,·i\-"I spill...•. Neuwr,ldiolll£.Y 18: 167. 1971). 54. Gulmann G: Klinis... h-rncnlgcl1(l1tI~ishc Unll:r~m:hllllJ::cll I.ur Sl;llik d~'r Wrihclsuk. In Wolff HD (cd): M;ultldlc Mctlizill IIml ihrc wi ... · \Cn\chaftlihen Grundl:.gcn. Hciddhc~.:. I'hy\iloi:llishc "·kdi/ill. I'JiO. pp lU9-J27. 55. Gutmann G. Velc F: D;l\ :llIfredl1c Slchl!. Wcsh.klll~ ...hcr V"'I'Ia<:L·. FllN.:hungstlo:ridllc tk_ L1f1dl:s Ntlrdrh..:in· \\·...."'If:lhl:l1l Nil ~7l)(,. Fadl· gruppc Medi7.in. 1978. 56. R;:L~h Pl. Burke RK: Kincsioltlgy and l\pr1it:d !\l1al\l111Y. I'hiJ:tddphi:1. Lea & F~big~r. 1971. 57. Lovell R: L'ler:l1 CUf\:I!ure (11' the spinc alld ~hllulders. J>hiladclphi;l. Blakiswn. 190i. 58. Cramer A: Funklillnclk ~lerklllak der Wirbd..ukll..:l:.til. III Wirhc!\uk in Ftlrschung und 1'ra'j.... Slultgarl. I-lippul.r;,lc.... IIJ:;X. pp X.I-9.'\. ---"J ) ... ---.J ., j I ~ I ~ I i I I 1', ~ •• .~ *# ,~ I _ ;::,plnallnerapeutlcs tsasea on t<.esponses to Loading IL. GARY JACOB and ROBIN McKENZIE In this chapter, we explore the clinical reasoning for spinal as- ria on which assessments and therapeutics of the spine arc sessmenl and therapy, variously referred to as the McKenzie approach. protocols. or system. Ou~ purpose is to explicate the underlying philosophic and practical perspectives of the predicated The Issue 01 when and how cntelld thct MG~JE!= approach. as it ~.c_c_ounls for.p.~e!lQm.~Jl~u~J.ated to spin.~~..ding :ind il~--':I'-"Jqu~!Jlanncr of satisfying the "de- QUESTION OF CRITERIA tTI ••mds" of rehabilitation. This chapter is not intended impart c1inicnl competency regarding the skills necessary to usc the McKenzie protocols in practice. Such competency requires study of "The Lumbar Spine"] and "TIle Cervical and (0' Thoracic Spinc"2 by McKenzie, as well as the formal instruclion til.., applies the clinical rC APPROACH TO CLINICAL REASONING In the following attempt to expand an understanding of the McKenzie system, new terminology is introduced. Hopefully what such terminology distinguishes will stimulate established and future students of the McKenzie approach 10 further appreciate its imrinsic principles. Relation of the McKenzie Approach to rvhmipulation Rehabilitation ~md Both Jllillliplll~ltion and rehabilitation usc movement .IS ther- apy_ In milllipulation. movement is used as therapy when the clinician moves the patient's spinal joint structufCS to end range. The rehabilitation tradition also uses movement as therapy. but with a preference for "activity as therapy:' i.c.. patients performing.the movemcnts themselves. As with manipulation, the McKenzie approach uses spinal movements to end range. As with the rehabilitation traditioll. thc preference is for palient self-generated movements. The significant difference belween Ihe McKenzie approach and that of tradilional manipulative lherapy, however. is not thm of rejecting manipul.ltion in favor of patient-generated movements, althmlgh the latter is always preferred. Manipulation is aL:tually an option according to McKenzie protocols. when patient-generated movemcnts prove only partially successful. The most significant difference between the McKenzie •lpproilCh ;ll1d other melhods of treating the sp::1e is the crile- The criteria according to which any inquiry is conducted for the purpose of resolving a problem profoundly affect how the solution is conceived. In Olher words. the am:wcr:, you get depend on the questions you ask. The McKenzie thcn.:by rC\'~alil\g an entirely dirr~n;1\l dini\:al picture. Similarly, the mechanic.1I or symplom'lIit: rl'spon:-c.: iO aSSUlll· ing a particular positiol1 fllf a fe\,\, lllUllh':lIls miglll he r;luicall)' different from what would O\.."'.:ur ;Ifl~r assliming Ih;1t idl:lllical position for it fe\\'" minutes. Just as l1lc,:hanical and sympll.llllalic r(;spOl1SC~ aTC rardy consi(krcd I j I ~ ! :f n:~:lrdillg their l\'bli\lll"hip III n:pL'liti\"e,: tllO\'C- menls :.md/or sustained pll~ilillllillf. Iillk inquiry i~ dircCh:t..I hI' how mcchanil..";11 ;\lId :-ymptolllalK rc"pollsCS rel;I!\,: /0 ('((cli other; i.e .. ho\\' [hey n:spLllld ill (;mdclII to lllO\,Cllll:111 ;mt.! po~ sitioning. The possihility of 111l:(,.'hanical and symphull;uic responses serving as Illcaningful criteria 011 whidl to prcdic'lt~ treatmCIlI is precluded if cognition of such is wanting. Unfortunately, many spinal examinations "ln~ all 100 often only cursory formalities, serving as preludc~ In prcdetcrminctl trcatnlc'l1I plans, indepcndent of sped lic a""C"'''lllent linding... Treatment \Vithout Spcdlk Criteria Treatment for spine-related cOlllpl::lims is often routinely .lIld ceremoniously applied in the exact ~alllt: llWl1I1t:r for each pa· tient. even though distinglJishing mechanical und sympto· miltie prcsemations PUlling Pathmumtomic Criteria in Their' Place Predicaling treatment on a priori COl\struct:-> rooted in the pathology model h"s led to wh<.Jt h'l:-> h~~l\ t:allcd the "r:lilure ..-- of the patholugy l1lodcl."'lllese :.I priori constructs. based on hypothesized pathO;JmHomy. have gencrated trcatments that may br.: t'llIgr.:lltiallO lhe patient's ne~ds and obscurc the clinical pcn.:eplioll of phcnomena :\pecilic to the individual pati~llt's si\ll:tlioll. FtJr t.:xampk. if all spine-rcblcd complaints afe perceived. a priori, tn hl' th~ result of inflammation. this preconception limits the clinil'i'lll·s ahilil)' til appreciate the po:\sibilily of mcchanical slratcgies for palielH C'lre. It conceptually pronltltcs tre case. Patho.1I1atomy :md the McKenzie Approach The McKcnzic appmach recognizes pallerns of mechanical and symptomatic phenomena th.1t arc labeled "syndromes." Although the McKenzie -~ or Objective Signs Alone Arc Not Adequate Criteria Some clinicians maintain the a priori notion that conc~ntra[ iog on lllcchaniGl1 or other objectivc signs alone (and [ht.~r~ fore ignoring symptoms) is a more sci~l1tific approach. becalise signs are more amenable to measurement. Mechanical .or other objccli\"c signs. however. such "lS range of tll('1,iOll measun:lllents or spinal imaging. do not ::Idcquately ~K\'·l,'1l1nt for the phenomcna of spine-relatcd complaiTlls. \Vh..1t might a[ first seem to be indistinguishable obj~~tive me,lsurCl11ents between two patients. may. on closer in::~c tioll. prove to be p.m of different ~linical pictures when judged in the broader cOlllext within which they occur. The identical mechanical sign may be associated with different symptoms, or cven different other mechanienl signs, from pa· lient to patient. In nddition. thc OfJfUlI'l'lIlly salllc mechanical sign may respond differently to identical movement and/or pusitioning stimuli rrom p"llicn! to ""tien!. --------------------------- OrtilUdox \"«.:rsu:'\ Alh:rni.ltin~ i-ic~lilil C:.tft: Signs In onhodox medicil1\.'. the rm:us on signs and the a priori as- sumptions of a patho:lIlatomic lllod(:1 is the n.:sult of. or leads to. an inability or unwillingness ,10 r;,uion related symptomatology. Thi~ same i.lpproach taken ~y Ihe socalled ":i1tcmmivcs" to onhodox medicine entails the lise of ·'ahcrn;.nin:'· signs. which also avoids the recognition of symptoms . IS meaningful. In this regard. no alternative is n::- I t .r", -~- ) I· I , , ! I Subjective Symptoms As Potentially Valid Criteria I o I I I I I I , N I, {I' ~ ;; Symploms are an impon3nt key to the puzzle of spinal complaints. Signs and symptoms are important diagnostic components in most health care specialties. Unfol1unately. when the specialty concerns common spinal complaints. symptoms arc usually denigrated to the status of epiphenomena. principally because of the confusion that has resulted from the inability to appreciate rationally the symptomatic responses to spinal IO Subjective Symptoms Alone Are Not Adequate Criteria (J I~ ally being offered. Alternative approaches. often described ;Is "holistic:' frequently m $,,-, As with mechanical signs. symptoms taken by themselves do not account adequately for the clinical presentation of spine· rclaled complnints. Both the symptomatic (llId the mechanical responses 1O spinal loading must be considered to best appreciate common spinal disorders. Responses of Mechanical Signs nnd Subjective Symptoms 10 LO~lding As Criteria Thc ML:Kt;J1zic .approach i\ Illcl'hanic!l and SYlllPIOJ1l~llic responscs to the !'timuli of loading (applying forces lO) the spinc. This rccognition is dcrin:d from historical information relal~d by thc paticnt as wcll as clinical limlings that comparc mechanical .l1ld symptomatic rcspunscs hd'orc. during. Assessment Therapeutic prescription Monitoring the course of therapy Prophylaxis SPINAL LOADING Spinal loading refcrs to the administration of a force lo the spine. No matter what position the spine is in. at least the force of gravity is IO;'lding the spine in thal position and imer/l(// Iorn'J (within [he disk) arc at play. Allhaugh it is understood that the 1I111001i/ed spine refers to the reclined position. it can also be viewed as a differel/r kind of loading. Unloading thc spine. as il is cOlllmonly understood. may diminish external axial forces to a motor segmcnt while in~ creasing internal forces as a result of the inhibition of fluid. These distinctions may havc some impon;.mcc considering the con\'entioni~1 Loading can be viewed as a mechanical stimulu~ to which mechanical and symptomatic rcsponses occur. Loading may be considered the independent variable. with the resulting mcchanical and symptomatic responses the dependent v;lriables. LOADING TACTICS l.oading tactics refer to individu loading strategy. They include the following: Dynamic loading Static loading Lmlding intensity - Loading frequency - Loading :lInplitudc (o\'crprcsslIn.:. mobilization. maniplll<Jlion) Loading within ;1 ~pccilic JIlovcmenl plane direction Loading within a specific range of a movement plane Loading at a ~pcd(jc.:: point of a movement plane l-':::...----~---------------------------------------------- ,'il f Lll;l\lifl!; p\)sturc Loadinl! SOlJn:~ \S\l\lrI;C \ll" h)r~c) - l)alicnt·~(,llaal('t1lacli ...:, - P,lIicnt ;I:'C of :Ippliancc or Ill;u.:hill~ - Clinicia!l.!.!l~ll('rall.'d t:lI.:tirs _ Clinician ~Sl' uf tool, 'lppli:llICC. or lll;lChtlll' l)ymll1lic I,oading This term rl.'rt:rs In ;1 sySh.:m of I1.H\:CS IHl th~ spinc ;f! or 111ulcr~\)illg II/OI·('IIU'/Il. under spL"cilk l"lluLiitions. I1/(lT;OI/, Static Lnadinl! Static loading refers to a syst~1ll or forcc.s ·0[\ the Spill~ at r~st. or during positioJ/ing. ullder speLilic conditions. St:.Hit.= loading or th(' .,pint.: ill a specilic rmsitioll for a prolonged pcriod or til1lt.: may h~ referred lO as ,'iIf.wui/f('d !'m;r;rl/l;"g. thoughl to bring spinal joint structures beyond voluntary end r;lIlge. to\\''lrd physiologic end r;.Ingc. M'lIliplilatie:~ is (hought to bring spinal joint structurcs beyond physiologic end range. just shon of anatomic end rangc, For th~ McKcnzie approach. the mcchanical and symptomatic responses 10 overpressure .md/or mobilization arc carefully lloted ill order 10 predict wh:.n the mechanical and sympwm;Jti, responses would be to m:.lnipulation. In other words. tltt', responses to 10~l(.ling at physiologk enu rallge scrve ;IS a criteri;:l 011 which to predicate loading toward anatomic end range. Only thcmpcutieally beneficial r~· SPOI1SCS noted with the former permit perfoffilancc or the lallcr. Complete rccovery by IllC;lIlS of the former obviates thc latter. Manipulation is appropriate when loading of lesser intensity evidences bencficial responses that are not complcte. Loading \Vithin a Specific Movement Plane Direction Loading Intensity Intcnsity is ddincd as tensioll. activity. or energy. Curiously. the woro intensity i:-: derived. in pan. from the Latin vcrb. lCUdere. to strctch. Illle/Isity rekrs to the frequency al1~lIor the amplitude accomp'lllyillg loading. To incrca~c thc intensity of lo'lding. thc frequency and/or thc amplitude can be increased. LOADING FREOUENCY Loading frequency refers to the number of loadings pcI' unit time (cycles). In dynamic loading. 10'lding frequency refers (0 the number of movements performed per unit time. In static loading. loading frequency refers to sustained positioning per unit time. LOADING AMPLITUDE (OVERPRESSURE. MOBILIZATION. MANIPULATION) Loading amplitude refers to the :.unOllllt of force applied during c;,\ch cycle. For the purpose of thl': McKenzie appro'leh. loading <.lInplillldt.: usually refers tn the amOUlll of force applied to promote movement of the.: spine toward a morc COII/· plete end range position. This movement is accomplishe.:d by the application of overpressure or In:'lllipulation. Overpressure applied during dynamic loading permits further mOVCntcm into cnd range with cvery cycle. Ovcrpres. sure applied during statk loading. :1( end range pcrmits posi~ tioning even further into that end range. It may bc accomplished strategically by the patient's <m'n means or with the usc of a device or .111 appliance. It 111<11' ;,liso be <.K'Complished by the application of a force by the clinician. using a "hands on" wchniquc. with or without. alollc or in combin'Hion wilh a device or appliancc. Whcn the clinician's hands perform the overpressure in ;1 cyclic ,fashion. this practice is called mob;lizatioll, The chiropractic concept of "taking the sl;lck out" corrc~ponds to moving a joint to end range. Th~ cyclic performancc of this movement is mobilization, The greatest I(lading amplitude i~ applied by means of spinal l1Jatlipnllllioll. Ovcrprt.::'surc :lIIU mobilization arc Movement planes arc derived from dimensions in space. '1 .r Movement planes contain two opposite potential direction" in which loading can occur. referred to as I/I(}\'cmem I'lmu' l!irc(·ticm.'i. SAGITTAL MOVEMENT PLANE j in this plane. also called the anterior-postcrior movement plane. movement occurs about the coronal axis. The opposite movement plane directions arc referred to as nexion an::! ::;-~ tension. Special featurcs regarding this movemcnt planc an: noted for lhe cervical spine. Protrusion of the hC .J Movcment occurs about thc longitudinal axis. The oppo:,ite movcment plane directions within this pl III Ihis pi<Jlle, also called the frontal or lateral n)(,w~ll\el1t plilllC. movemcnt occurs .Ibout the :-:agittal axis. The l1ppo:-.itc movcment plane directions used by the McKenzie appfll ror 1 -? ,.J .. _ ....... ,~ ..... v .......,,;) VI"\.:lC:V VI" H.t:~I""'UN::;e::; P\I.. itilllling within this llH1VCl1lCllI planc results inlhe clink'"l I'rc"'I..'nt"lioll of Ill...• ··..t1Halgic Ii:,!." This pll"iliPlh:d rclatin: till' inferior anatomic P:II·1. Luading Within .1 Spl'l'ilic Range of:.l rVlo\'cl11cnt Plane .----;.. Whl'll dynamic IO;lding {1l:<:urS.il Illay involve movemcnt to end ral1~c or only W wilhin mid-range of a movcment plane. Dlirill~ dyn:lmit: loading. e;l<:h poim in the mlWClllclH plane has a "dirct.:tional ('(lIllP(lllClll" defined by the int\}lidcd 1110VCIllCIlI pl end r;lngc;. Susl~lincd po~itioning mid-r.mgc or in mid·rangc may have a di- rccti(ln~J! compollcnt n:I;ltive to :I previously assullled suslaillc;o positioning. S{~lli( loading al end range is usually referred to ;;IS h~l\'ing lh~ 1I1()\'Clllcnl plane direction of which. that end range is the culmination. Loading Poslure Thi~ term refer:>: to thc oricnt~l1ioll of the body (~landing. sitting. t.:tc.). Consider lhe ccrvic,ll spine lo.u.lcd in the movement plane dircction of eXlension. The patient J11~IY be stmlding. sitting erccl. siuing slouched. lying prone. or lying supinc with the head and neck off the end of a lr~ Source (Source of Force) Loadmg tactll.:~ ma\' bt: gCllclatcd or modified by patients themselves. appliances or machincs. as well as by lhe clinician's intervcntion. Certain npplianccs or machines ~lrc rC~ld ily used by patients themselvcs. whereas other dcviccs (because of expense. mechanics. or expertise required) may bc used only in a clinical setting. IV LUADING 229 PATIENT USE OF APPLIANCE OR MACHINE V,lriOUS devices lhal affccl spinal loading and do not require tht:" assistance of the clinician or presence in the clinical setting :.Ire 'Ivailable to p.ltiel1ts. These appliances range from maUrc;ss and dl.lir lypes to br Force introduced by lhe clinician may be combined with. or aran from. pmicnl ..gcncratcd forces. Clinician~il1troduced r(lfL";..• ... r;mgc from mobilization to manipulation. Mobilization Ita:o; becn characterized as forces that do not bring joint struclUrt~ beyond physiologic end range. whereas manipulation has b~cn characterized as bringing joint structures beyond physiologic end range. but short of anatomic cnd range. CLINICIAN USE OF TOOL, APPLIANCE. OR MACHINE This category includes certain appliances or machines unavailable to patients because of expense. mechanics involved. or thc need of a c1inician's expertise. Examples include sophisticated traction units. "drop tables" that enhance manipuI,Hive procedures. treatment tables permitting various spinal positionings. and continuous passive motion units designed for the spine (Fig. 12.1). Surgical interv~mion is certainly a ITlcc!mnical illlcrvention lhat reprcsents a loading tactic. I'REFERRED LOADING STRATEGY Str - Delayed sequl'ncc: introdllctitm of prcviously avoided loading t;sctic PATIENT·GENERATED TACTICS I-t ~ t.;..} [ t t% l -lJ !:>' MovcmClHs or position:-;. may be accomplished by patients themselves. Patients may perform movements activcly by recruiling muscular struclures that specifically move or maintain posilions of spinal joint structurcs cQnccrned. They arc also able to stralcgically perform "passive" movements of lhe spine. For example. palients Illay rotate the cervical spine by using the pressure of the hand against the check without recnliling the intrinsic neck musculature. Similarly. passive cxtension of the low back may be accomplished by performing ;1 "press-up" from the prone position with the pelvis remaining on lhe cxercise surf'K:c. lhus recruiling only elbow cxtcn~ SOfS and not lhe extcnsors of Ihe b;lCk. Fig. 12.1. McKenzie Repex (Repeated End range Passive Exercise) unit. ::;;--'..:.~-;-----.,-------------------------------------------------~ n LvV "" , ,n.' ~ I dt:t:m~d _ •• _ ••••••• _ •• - Fig. 12.2. Right lateral shift as a resull of clinician overpressure during right side-gliding. Tactics to Avoid Specific loading tactics , therapeutically detrimemal arc to be avoided as comaitucnts of the preferred loading strategy. The practitioner Illuq lake into ;lccount the effccts of avoiding specilic IO;'lding taclics ;'IS much as he or she considers the effects of pursuing spccific loading tactics. Avoidance can be of equal. if nol greater. illlpol1ancc in resolving an individu;I1's spinc-rdah.:d complaints than which tactics 10 pursue. Tactics to Pursue Simultaneously The preferred loading slr.ueg)' always involves the simultaneous performance of loading tactics: for example. it may concurrently load the cervical spine dynamically. in the movement plane direction of extension. while sitting. with ovcrpres~lIrc. and a CCI1<1in frequcncy of rcpetition. Tactics to Pursue Sequentially .--~ , 7 Loading tactics applied one afler the mher. IMMEDIATE SEOUENCE This term refers to loading tactics applied immediately. onc after the other. c.g., loading the cervical spine in the movement plane direction of left lateral flexion. immediately followed by loading in the movement plane direction of extension. DELAYED SEOUENCE This term is used to describe the application of loading tactics separated by a significant length of time. h usually refers to the timely re-introduction of previously avoided loading tactics. Loading tactics once considered ther••pcut;cally detrimental. may. after the appropriate delay. prove to be of significant therapeutic benefic For example. on Day l. it is detemlined lhat right side-gliding (Fig. 12.2) is the most (hcr~ apeutically beneficial movement plane dircction for the IUI11bar spine. and loading in all other movement plane directions is considered detrimental. On Day 2. it is detennined that the previously avoided loading tactic of extension is now ther:.!peutically beneficial. and in fact. necessary for fUrlher resolution of complaints. On Day 5. it is determined lhat the previously avoided loading tactic of flexion is of benefit for the patient so that full function may be recovered. PROPERTIES COMMON TO MECHANICAL AND SYMPTOMATIC RESPONSES TO LOADING Although mechanical \~ersus symptomatic responses to loading have unique features or perspectives, they have certain common response properties or parameters. described here Response Value Mechanical and symptomatic responses may be considered the S:'lIllC. better. or worse after:J particular loading strategy is pursued. Considering before and after possiblities. responses may be: • Nonnal before and remain nomlal afterwards • Nonnal before and remain abnormal aftcrw Response Temporal Faclors factors include frequency (~r camp/aims. timc required to dicit a respm,...e. ::md n..·.tpmJs(· persi.wem.:£' a}[cr loading ce.t.'latioll. 11lCSC FREOUENCY OF COMPLAINTS (RESPONSES) ) The frequency with which mcchanical or sympwl11;,uic rcsponses to loading occur during a specified time: paiod milY be charnctcrizcd as OIlC of the following: Tot;'11 absence of the response (no complaints) Intermittent frequency of the response (intermitt~llt COIllpl:.linls) Constant frequency of the response (constant complaints). A plltien( may have no symptoms. experience symplOllls intermittcntly. or experience symptoms constantly during a spccillcd period of time. Similarly. a patient may hayc no restrictcd r.mges of motion. experience a restricted i.mgc of motion intermittently. or experience :1 restricted r or ,--J CHAPTER 12 : SPINAL THERAPEUTICS BASED ON RESPONSES TO LOADING TIME REOUIRED TO ELICIT A RESPONSE Thi~ p;lraHh~lcr n..·f.:r.' 1(1 th~ lHlmh.:r or duwtion of dyn:llllic Of st;ui,: IO;lding q'<.:k:-- required 10 elicit ;1 mechanical or s)'mp101ll:ltk fl.'SPOllSC as. wdl as the tlday. if ;lIly. for the r,:"ponsc W OL\:ur aria lo;ulil1:; ((,;lSCS. Till' I/lIl/Ihcl" (lOom/illg cycles refer.:. 10 the frequency of a mt)\"I,.'llll,'1ll ~lr susl;lincd positinl1ill~ pl'f unit time: Ihc:,c may hl' rd:ttin.:ly few (11' m:lll)'. IJllmlifJll r..:krs to the amount of. timl' a -.u'[;tlncll pll,,,jliulIlng is held. All illIIJ/cdi(l((' I'('SI'0Il,H' to d~ n;llnit.: loading or :'\waainctl positioning m:t:urs Oil the ini(If the loading t:ll.:tic. A tlcla.wd rcsprJ11sc occurs some lilllt.' ;,1'11..'1" loading l:cast."s. The [;luge or pl.ls.,ibilili~s arc: tialion No rt:"'p\III~l.: dicil..:d. r...·~;lrulcss tlf Ihe numher anUltll' uuralitll1 of loadin~ l,:ydc.. . ~ RC"'I'0n~ ...• didh.:d tlll Illiti;llioll uf h};JdillJ,; eycle (illlllledi;lIC rc- ."plll\'-':' () Re~p"n~t: didtcd after relalively fl'W and/or slu.lfI duration of cycles Rc"pnn.. t: eliciled :tlkr rdalivdy l1l:lIlY and/or long duration of lO:I\..lill~ cycles Re ...ponw dicItcd aria l.:cSsatioll of l(ladin~ cycle (dcl:l)"ed rcloadill~ slwn"c) COI1~idcr (h~ following scenarios. Rc"pollses elicited 011 initiation of the hlading cycle Omll1edi~ltc response). for eX~llnplc. would be the patient who. during the performance of one dYlwmic extension or on initiating ~tatic extension. expericnces symptoms or dc\'iation from the intended movement pl.me direction. Another pa· tient's rc"pol1se could be the relief of symptoms .lntl ,' or "long dur'ltion" of loading cycles. for eX~lI11ple. would be the patients for whom 50 dynamic ~pin;11 extensions or sustained extension end·r;lI1gc positioning for 30 minutcs is required to expericnce the onset or resolution mechanical and symptomatic rcspon ...cs. Responses e1iciled .tfter cessation of lhe loading cycle (delayed response) are. by definition. responses that oc· cur after the responsible dynamic or static loading stimuli ceases, Medicolegal bsues arise concerning the meaning and the credibility of delaycd responses, proportional to the delay. 231 Responses do not persist afler loading ccss;ltion RC~POllSCS persis! for a short period 01: time aftcr loading cess3tion Rl:sponscs remain aner loading cessation Consider Point of Response Elicitation Mechanical :mdlor symptomatic rcsponscs may occur as a result of loading at end range or between the two end ranges (mid*r,lIlgc) of a particular movement pl i\:lovcment Plane·Specific Responses Loading within ;\ particul~lr movcment plane dircction may have mechanic tlHlVCI1lCill plane Responses in lhe sJme lllO....ClllCIl1 plane direction a~ loading occurcd Responses in the movemcnt pl;tne direction opposite RESPONSE PERSISTENCE AFTER LOADING CESSATION Mechanical and symptomatic responses may demonsrrate a v;lrying dcgrce of persistence after cessation of the loading slrategy responsible for generating the responses. The possihilities arc as follows: b 10 the load- ing direction Rc.o;ponscs in iI movcmenl plane differcnt from Ihe lo:uling lUm'l'- ment plane Responses in the s ""'" of most clinicians. The patielll wh Mechanically Impeded End Range: The Mcchanical-SJ'Olptomalic Interface· "Mechanically impeded end range" is a signilicam phI> nomenon that call be perceived by both the clinician and the patient. That it is recognized from both perspectives makes mechanically impeded cnd rdnge an "interface:' in a sense. bctween "objcctive:' clinically assessed mechanical and "subjectively" perceived symptomatic phenomena. Consider patients who have restricted range of motion. but no significant discomfort; i.e.. symptoms do not interfere with the progression of movcmcnt. Thesc patients repon that further movcmcnt is not possible. Not only is this limitation observed clinically. but also. if the clinician attcmpts to move the spinal area passively. an early cnd range is detccted by the clinici REHA~ILlIATlON OF THE SPINE: A PRACTITIONER'S MANUAL PROI'ERTIES UNIQUE TO MECHANICAL RESI'ONSES TO LOADING I. Mech:tnical responses or objective signs constitutc c1inic;11 cvidence (signs) pcrcepliblc to the e: Normal End Range and Curve Reversal Curve rcvcrsal rcfers to the ability to movc the spine from the extreme of one movement plane direction to that of the opposite movement plane direction. Curve revcrsal includes· both the ability to revcrse the "normal" anatomic curves in the sagittal plane and the ability to introduce curves in the opposite directions of the coronal movement plane. Flexion in the sagi·:tal plane 1"('l'ff.'ieS the cervical lordosis. increases the thoracic kyphosis. and reverses the lul1lb:~r lordosis. Extension in the sagittal plane increases thc cervical lordosis. rel'i?r.w.'s the thoracic kyphosis. and increases the lumbar lordosis. I-,tcral flexion or side gliding in the coronal plane promotcs a convexity in Ihe direction opposite that of the movemcnt pcrfomled. TI1C "nannal" ncutml spine has no curves in the coronal plane. These curves ilrc introduced or created when movement in this plane is performed. Under normal circumstances. full range of motion from onc extreme of the coronal movcmenl plane to the other is, accompanied by the ability to rel'er.H: curves th~lt were introduced by movemenl and arc 1101 present in a neutral. resling. anatomic position. OBSTRUCTION TO CURVE REVERSAL An obstrm;l;oll 10 oint' rtl\'crsClI i.s a significant mechanically impeded end range lhal prc\'cllls spinal Illotion frolll progrcssing past the neutral position il1to the opposite movcmcnt plane direction. Loss of the ability to reverse spinal curves result.s in such clinical conditions as torticollis. acute scoliosis. and fixed kyphotic or lordotic deformities. MECHANICALLY IMPEDED END RANGE Althoul.!h loss of run~c of motion may resull from factors othcr tl~all ll1ech;lllicali y impeded end mngc. only lhis factor is considered in this di~cussion. The degree 10 which curve reversal and normal end range lllay be accomplished mfc:lulllicafly, when compared before and after loading. is listed in the order of diminishing succcss: Reversible cur"..: achic\"ing full. mechanically unimpeded end range Rever.-iblc cur\-..: Wilh mcch:ll1ically impetlcd end ran~\.· Ohslrucliul\ {(l ~llr\'c IC\'crsal wilh nleCh;Hlically imp\.'dcd end range ,. "'>. ._ • _ ~ ,~, ~ 1 "f ~ ~Ii -, , I II ;:, ~A:;,cU UN RESPONSES TO LOADING A revcrsibh: curve achieving full end rnngc would indicate that 110 mcchanically impeded end rnngc is presenl. A mech.mic;,llIy imr>l:dcd end mngc may be present. but curve revers,lI is pcnnittt:d nonetheless. i.e.. the progression of movement is mcchanically impeded after curve reversal is accomplished. If the progr~ssion of movement is mechanically impeded before curve re"ersal is accomplished. the result is a substanti •.! loss of movement and an eXlremely early mechanically impeded end range. referred to ns a deformity. antalgia.list, or shift. I ! ,~, 111L;nl"'lf'""t:U II " , .\ ivtoycmcnt Quality Moyement quality refers to the ability to remain within the course of Iltt:: intended motion plane direction. It is tlSscsscd as: .'''''., "'-,} ,I' ' ) .~ .~ No t.lc\·j"tioll frum movement plane direction OJ Value of i\Jlechanical Responses p It is generally considered beneficial to effect mechanical responses to pcnnil curve reversal with a full range of morion. as well as the ability to accomplish. without devialion. the intendcd movement plane direction. s') 1 :i () ') PROPERTIES UNIQUE TO SYMPTOMATIC RESPONSES TO LOADING i The symptomatic responses related to spinal disorders commonly considered amenable to mcchi.1I1ical care arc pain. paresthe~ias. and' similar symptoms of discomfort. Other symplOmatic (subjective) phenomena. however. arc equally impor1anl. Symptomatic (subjective) phenomena refer to: .,.~ , .'''." .....) ~.J ~ , Symptoms of discomfort - {opography of symptol11atic responses (ccnlr II , ...$ < .J' ~riph Symptoms of Discomfort · I . -~ These symptoms include pain. numbness. p,ucsthcsias. burning. and the like. They may be experienced during motion or .It Ihe end range of morion, Not only do the symptoms of discomfort havc different qualities. but also their location may change in response to spinal loading. The location or topography of symptoms is a key feature of the McKclli·.ic approach. I .j <) Topography of Symptomatic Responses , t} Symptoms may be cenrral, which means they arc experienced about thc midline of (he spine. Symptoms may be symmetric. I~ !1'_=-.....i~ ,~ t . . .,J ~ ] j ~~ ,I, CENTRALIZATION RESPONSE In this symptomatic response to loading. lllore peripheral symptoms diminish or resolve and more ccntml symptoms remain. ;:Ippcar. and/or increase in severity. PERIPHERALIZATION RESPONSE This symptomatic r':sponsc to loading. wherehy more peripheral symptoms incrcnse or appear. mayor Ill'l)' not be associatcd with chiJngcs in central symptom::ltology. Judgment of Fear , _.~ .,... meaning they arc equally positioned on opposite sides of the spine. Unilateral symptoms affect one side of the spine only. The further from the spine symptoms arc experienced. the more peripheral arc the symptoms, \Vhen the topography of symptoms ch:lIlgcs in response to loading. they may become more central or peripheral, referred to a~ the cclltrali:.m;oll J"l'sponse or the per;p!taoliwr;oll rcslumsc. respectively. Devialion from the intendcd movemcnt plane direction ~.. .-" i 233 i , '-.j L· -,- Fear of symptoms of discomfort. or fear that they might worsen if experienced. is also an important li'ubjeclive phenomenon because it may affect an individual's willingness to pursue a specific loading str"tegy. \Vhen possible. it is import:'lIlt to dislinguish berween nn individual's willingness and the individu Subjective Perception of Meclmnicall.y Impeded End R:mge Patients often report lhe inability to perform a spin:.il motion p.ISI :'1 certain point because of a sensc of being "blocked." They may report thaI. "Something is in there." "It feds like there is :.I rock or ball in there:' "A wedge is in there:' or the like. This subjective perception pn:n:nls further movement. Often. il is the perccplioll of a mech:'1I1ically impeded end range. wilhOlU any symptoms of disl:omfoI1. that is rcported by the patienl as the reason for r"ilure of further mo\·cment. The patient's subjective pcrcepliol1 rc~cmblcs what is felt at the end rangc of norlllaL unrestricted spinal range of motion. At other times, symptoms of disc(,lml\m occur at lhe sallle time the subjectivc perception of thc "carly" mechanically impeded end rang..:: occurs. Value or Subjective Phenomena Responses It is tltcmpeutic:'lily bencficial to diminish the subjcclh'c perception of mCc!l _ r ! I, i\ I ~ I I 1 I ~ the severity of central symptolllS may incrl,?asL::. This mcrease; is usually followed by improved mechanics .md Ihe ultimate reduction of central symptoms. Peripheralization responses ::trc therapeutically detri~ mental if they remain after cessation of the responsible IO I i ! LOSS OF RANGE OF MOTiON II Loss of range of motion plays a considcmblc role in Ihe cV I I I ~ ~ "ReasonsH for Loss Loss of r~Ulge of motion d()e~ not result soldy from mechan . . ical factors that can be observed clinically or ~olcly from subjective factors thm can onl)' be reported by the patient. Understanding range of motion loss requires integrating both of these perspectives. In slllllmarJ\ wnge of Illotion loss nlU)' be attributed to symptom:- of discomfort. judgment of fear. and mechanically impeded end range, which were described previously. This underlines the imponance of appreciating the patient's symptomatic experience in order to .H.:count full)' for mechanical disorders of the spine. The clinician, howevcr. continues to 1'1..1)' a ke)' role. The clinical decision regarding the value of symptoms based on their topography. ,md not just on their intensity_ is critically •• , • ~ • • . • __ . impurtant. Till'; \\L1~ Ihl.: diuician educates thc P;l\i~lll t1r;lll1~H'" ically affcl:IS thai p..Hknl·sjudgment as LO whcther ur nOI fear is appropriate. Laslly. regarding mcchanically il1lpeded end r'lllge. patiL::l1ts oftcn p-:rceivc Ihis carly i,,:lId rangc ;IS "normal" hecause th~ir subjt.:L'livc perccption (lr tll1.: ill1pclkd t.:11l1 range may he idcllIicli {(l how "noflll;lF \.·lId range feeb. The dinid:m's assessment of lllct.:h'lllk;dly illlpeded r;lIl::c a" ;1 Illl·· ("hallical sign play~ all import anI ft_lt.' in l!losc l':l~t.' ... ill whk'!l p:l1iel11s do not realize any motion has heen 10SI at .111. ~IECHANICALLY ". ... ..... , , ; IMI'EDEIl END RANGE The lerm f1!e('/ulI/inllly im/)l'dnl n/rl IW1,t:C refers 10 an "Ihnonnally early end range that interfcres with the progress (If motion and mayor may not hc act.:lllnpanicd hy ~ymplollls. Patients m"l)' perceive the samc proprioceptivc I.:UCS (10 11:111 Illotion) m lhe mcchanically impedcd end range :1:-. they do :Ii normal and full end range. The c1inici:tn and the patielll bOlh. in their own ways. may perceive lllcchanic:llly impeded end range. Thc patient sllhjcctively perceivc:, Increasing Loading Intensit), to Differentiate Restricted from Obstructcd End RangL'S If loading of sufficient intensity (cycles or ovcrprcssurd is not applied, the mechanically impeded end range may be unaccompanied by symptoms. Ov<:rprcssur~ is imponalll ill order to load joint structur~s funher :\t lhe mechanically impeded end range. thereby "overslating" typical end range rt.'sponses that occur there. The mechanical and symplOmali<.- rt.'sponses to loading mechanically impeded end ranges with ;1 greater intensity differentiate mechanically impeded end ranges into two types_ res/ric/ed end range ~nd ObslrllCll'd end ran.f!.('. RESTRICTED END RANGE This mech~lI1ically impeded end range behave:-. as if lh~ progress of Illotion is limited. restrained. or "held back," It i:, slow to develop or resolve, wilh no mechanical or SYI11Plll~ matic responses during motion. Any mechanical respol1:'t.' (e.g.. dcviation from the intended movemcnt planc direclitm-' occurs at the restricted end range only. If no symptoms arc rt.·ported at the restricted end (;.lnge. incrc'lsing the inlensily I I I loading at the restricted end range will elicit mechanical and symptolllatic responses in a characteristic fashion. Celltral tlr periphcr ) ,) CHAPTER 12 : SPINAL THERAPEUTICS BASED ON RESPONSES TO LOADING i i frequenc)' of restricted cnd range loading docs nol change the characteristic rc~ponsc. During the initial examination. no 1 ~ change in how mechanics or symptoms respond to dyn ~ s(;l{ic loading at the restricted end range is appreciable. I, OBSTRUCTED END RANGE : '~ ? I ~ 1 i 1 t I i I I I C) i I B '§ ~ i I ti ! I This mechanically impeded end range behaves as if an "obstacle" or "blockage" is interfering with the progress of motioll. h ma)' oc quick to develop or resolve. Mcchunical :'ll1d symptomatic responses may occur at any point of the involved movement plane direction. 3$ well 35 at the obstructed end range. Mechanical andlor symptomatic responses may develop immediately or aflcr a delay in response to a particular loading strategy. If no symptoms occur at the obstructed end range. increasing the intensity of the loading will elicit mcch:.mical and symptomatic responses in a characteristic fashion. The centralization response or the pcriphenllization response may be noted durin!! motion or at an obstructed end r;.lnge. Elicitation of, or changes in. mechanical andlor symp· tomatie responses to loading may persist after cessation of loading. Overpressure or increased frequency of loading at the obstructed end range may radically change the mechani· cal and/or symptomatic responses during motion or :It the obstructed end range. Overpressure at the obstructed end mngc miJY result in Ihe centralizi.ltion response. the pcriphemliz;.Ition response. or the -resoiution of mechanically impeded end range, or it may cause its occurrence earlier during the runge of Illotion. During the initial examination. an appreciable change in how mechanics or symptoms respond (Q dynamic or static loading at the obstructed end range is usually notcd. 235 Assume that with rcpctitin: dynamic loading to the obstructcd end range. every cycle of mOVClllelH results in a lesser dcgree of mechanic~i1ly impeded end range. i.e .. permining morc and Illore extension range of Illotion with each cycle of 1ll0WmcnL If discomfort was associmcd with loading: at the obstruct~d end range. the Giscomfon would occur furlher and funha into the range of motiol\ with cat:h cyl.'1t.· as the stepwise pattern of improvement occurs, Rcg:mjin& ~lalic 10 Differcntiating Obstructed End Rangc Symptoms from Symptoms During Alotion. Mechanically impeded end McKENZIE ASSESSMENT OF MECHANICAL AND SYMPTOMATIC RESPONSES TO LOADING ranges have been described as exhibiting two differcnt response-s. one lypical of;) restricted end range. lhe other of an ob!<>tructcd end range. LO The McKcnzi~ npproach is that of assessing the responses. rc.lctioIlS. or effects of spinal loading. During Ihe inilial encounter \,"ith the patient. this ~lssessment is performed by evaluating Ihe history. posture. and quality of mo\'ement of the patient. and by using dynamic and static testing procedures. History In addition to the usual history taken regarding neck and back compl;'lilllS. the McK~nzie assessment makes particul;;lr inquiries regarding the following: • Arc ")'UlplOm" consl~uu or intcrmiucnl? What is the t{Jp0gfaphy of symptoms? Arc symptom" bcucr (lr worse with :Illy of the following? - Bending - Silling - Rising from ~iuing. - SI;;lI1ding - Walking - Lyin,e ~ ; "I~ __-'b ! f, _ H.t::nI-\CILlII"IIIUl~ u r 1 Me .:::)t-II'H:: !"'l t"'l'"'IAv IlI1Ul\lcn ;:, IVI ..... I'iUKl. - Rising from lying - When still - On the move Inquiries regarding whether patients arc better or worse with acth·j· tic!; of daily living yield clues regarding the loading effects thai movements :md positionings have Oil mcch:lllical and :i-)'mplo1l1:ltic responses. Ccrt:lin m:tivitics load Ill\.' spine within the 11l0vcmcnl plane direction of llcxi(Ul (hcndillJ;. siuingl. whcf\;;\!'- Hlhcr :Ictivitks have the rdati,'c cffct:1 uf lu;tding. the ~pinc ill the 1I1U\'CIllCIH plane direction of extensioll (standing). posture On initial examination. the patient's sitting and standing postures are noted. This inform<'ltion rcvci.lls how the spine is habitually subjected to static landing by the p.1ticnt. An inquiry may also be made as (0 what posture the patient assumcs at home or at work. Ql!antity and Qualit)· of Movement The patient is usked to perfonn a singk movemcnL fur cach movement plane direction examined. The cxaminer conccntrates on mcchanics (qu.unity and quality of movement). llot on symptoms. At Ihis poiIll. the examiner .llso docs nol concentrate on mechanical responses to loading. Quantity and quality of movcn~ent refers to the ability to achievc end range with curve revers.l} and without deviating from the intendcd movemcnt plane. Fig. 12.4. Cervical flexion. Fig. 12.5. Cervical retraction. II Modifications from typical range or motion studic:, include udding protraction and retraction to Ihe cervical :,pill~ examination and replacing rot.ltion ;.md lateral nexion ,,·ilh side gliding movements to the lumbar spine .cxamination. ~ CERVICAL SPINE STUDIES }1 ,\! .~ i Fig. 12.3. Cervical protrusion. Protrusion (Fig. 12.3) Flexion (Fig. 12.4) t ~ -~ !------------------------(, Ii , ___ . • ~.~ "<.-n rc::Vllv,:, OM':'C.U Ut~ Kt:.tit-'UN::)l::S TO LOADING 237 repetition ()( lILt: S;lllll: 1Il0VClllCnl. Till.: etfcl.:ts of loadillf 111 a certain 11l0WlllClll plaUl: llircClitlll ;\l'C n:vc;i1cd hl:st h~ rqlclitioll or sU~lail1cd st;,uic IO;lding, I)yn:llni.., loading or "lHaillcd positioning (sttltiL~ loading) hCltL'r dCll1\lllslrale:- m~.:halli<.:al :md:-~ mptolilatic respOllses to h':lding thall dtleS (11k' 1ll1l\TIl\Clll (Ir :\ !Ilo111Clll'S positioning_ \\ hi\:h may give a 1";:1,.. . lirsl illlpre".. j()!1. ;;:-: ..,;- :",:, ,:1..:1' Fig. 12.6. Cervical extension. ) Retraction (Fig. 12.5) ExtelJsion (Fig. 12.6) Side·bending ri~lll Sidt:-bcndin£ len Rutation right Rotation left LUMBAR SPINE STUDIES Fig, 12.7. Lumbar flexion. Flexion (Fig, 12.7) Extension (Fig. 12.8) Side-gliding right (sec Fig_ 12.2) Side-gliding left (Fig. 12.9) The mon:mCnl plane directions evaluated for both the cer\'ical and lumb'lr spines arc those within which the clinically prcsellting Cinlalgic postures occur, The movements required to achieve these antalgic postures arc thought to be or value f(,lT both assessment and therapeutics of the respective spinal areas. Complaints. assessment, mtd therapelltics arc. therefore. connected by similar mechanical considerations. Dynamic and Static TcSl') Aflcr quantity and quality of Illovcmell( is assessed by the performance of single movements in each movement phlllc direction, dynamic and static tcsts arc performed. These tests load the spine in a morc aggressive manner than the single n.:pctitions lIscd (0 evaluatc quality of movcmcnt. The paticnl is monitored closely concerning the mechanical and symptol1l:Jtic responses to dynamic and/or static loading, especially concerning the most pcripheral symptomatic compl • Fig. 12.8. Lumbar extension. " .... ''"' .... , ..... 'f''\''VI~ VI " , ' - ..... ' ,,~ ......... r n ......... llllvl'lc:n~ lVI ..... I'IU ..... L loading ill tht: 1ll0\'~1l1~1\I plan~ direction of concern ceases. The usual progression of dynamic tcsts for the cervical .111<.1 lumhar spine follows: Fig. 1:l.g. Left lateral shift as a result 01 sidegliding left. CCITiwl Spine Fkxioll ~iHill~ Rl"lr.tl"lion ,illin1; Rl:l 1':1(1inll-lllcll-C:..1CIISitlll ~illillg Rcir;l(tioll lying. (h~ad off l'Og.c or Ircall11Cll1 t•• ble) (Fi1;S. 1:!.I 0 :tlllll:!.II) RctraClitllll:xtcllsiull lying \hl:ad off cLlgc Dr treatment table) (Fig. 12.12 alld 12.13) II " I II I ~n I1 :~ I I Fig. 12.10. Retraction lying. Dynamic loading in silgittal movement plane directions is typically explored first. unless the patiem has signific the coronal movement plane is explored first. If the patient :lppears amenable (0 therapeutic spinal loading str.ltcgics in the sagittal movement plane. dynamic or !-Otatic loadings tcsts in other movement planes afC usually not pursued. If a clear clinical picture is not revealed. dynamic loading in the coronal plane is explored, which c"[(iils lateral I1cxion for testing the cervical spine. and side-gliding movemcnts for the lumbar spine. Should loading in the coronal plane not provide s.llisfactory answers. the transverse movement plane is explored. For the cervical spine. this process entails rotation. whereas for the lumbar spine. rotation is performed side-lying combined with flexion. This lumbar movement is typically loaded at cnd range and is a stntic test. Static loading tests gcnerally arc used when dynamic tc!-ts do not provide u clear prcferred loading strategy. As with dynamic testing, the sagittal plane is explored first. Olhcr movcmem planes and static tests arc secondary con~idcr.ltions to sagittal dynamic testing. Fig. 12.11. Retraction lying with clinician overpressure. , ,J DYNAMIC TESTS J Dynamic testing proceeds by performing a single mution within the movement plane direction being studied. followed by repetitive motion in the same movement plane direction. The clinician closcly monitors how mcchanics and symptoms respond during motion. ,il end r,mgc.•llld "ftcr the dynamic . Fig. 12.12. Retraction-then-extension lying. _._---_._----, '_._._----------~----------- ..... n""r .:ti I t:M IL : ~I""II'H\L 1Ht:.HA .... t:.U IH. tiA~ED ON RESPONSES TO LOAD,o,'G 239 if required: Protrusion :,ining Retr'H.:ICd :-iJe-b":l\ding ri~ll\ .. ll\il\~ t Fig.12.141 Relr.lclcd :-iJc-hending. 11..'(1 _,inillg Relracled wlalinn righl Sillill~ ll:i~. 12.1:\ I Rclr:\ClCd rol:.tliUIl k'fl sillill~ I.umbar Spine Fk\ion ,1:lllJillJ; EXICnsi(lll ,I:.mding Flexion in lying (SUpillC kllL'C \(1 (:hesl) (Fig. I ~.Ifll E:((cnsiol1 in lying (pnHlc "~kKellzic·· pn:ss llpl (Fig. 2.17) if required: Side.gliding right !\landing or prone extensiun with right );lh;ral shift (Fig. 12.18) Fig. 12,15. Retracled rolation right silting. Side-gliding left st.mding (scc Fig. 12.9) or prone left I,ltcral ~hift I,.~xtcn$ioll wilh STATIC TESTS Fig. 12.13. Clinician traction-retraction-extension lying. Static loading is often used as an of/cillary test 10 cOllllnn dy~ namic testing or to further explore the effects of loading when dynamic testing yields no definilive conclusion. In panicular. headaches of cervical origin often require sustaincd static loading to diagnose or treat the syndrome pattern in\"(;lvcd. Choices for static testing folio\\'. Cervical Spine Protru~ion Flexion Retraclion (siuing or supine) Retr:lclion lhen eXlcl1!'ion (silting. palilc. or supine) Retracled .. ide-bending right or left Relracted rotation right or left Lumbar Spille Sining sloLJ\:hcd (Fig. 12.19) Sitting crect (Fig. 12.20) Slanding \Iouchcd Standing crecl Lying prone in extension Long sitting Laleral ~hift right or left Rotation in llcxioll USE OF OVERPRESSURE Ovcrpres~urc Illa)' Fig. 12.14. Retracted side-bending right sitting . .. i "~y l be used in comhination with dynamic and/or st'-ltic \(';sling. permitting further I,,;nd r.II1gl,,; PI-l:-'ilioning. REHABILITATION Of' I Ht::: ::iI-'INt::: A. I-'KALi 240 1IIIUI~C.M ,;:) IV ..... I'IU .... l.. A loading tactic may he L'onsidcred <\ loading stimulus. A loading stralcgy is considacd the Slim of stimuli. A reSp('~lSe is iI n:;lClioll to loading stimuli (lactic or strategy). whereas hdl:lvior rckr~ to the sum of responses. The lvld\.col.ic <.Ippnl:lch rc(.'ognizcs behavior paHcrns as syndromes ;uncnahk to tllcch;mi(.'<11 lO;'ldillg strategies. 1 I t £ -, ,\ '-', .-~ J ':5:.~.,: __ ~1'r-~';:·~~· :·.",-:~.~~:~~i~§~, Fig. 12.16. Flexion i~ !) lying. Fig. 12.18. Prone extension with right lateral shift. l ·d m Fig. 12.17. Extension;n lying. Such overpressure may bt: paticnl craled(Figs.12.21 Lo 12.231. gcncr~ltcd or c1inici"lll gen- ,) Spine.Related Responses Versus Behaviors A response may be deli ned () tomatic reaction. The McKenz.ie approach di<"tinguishcs between (ondi· lions thilt demonstrate beneficial response!'> IU mCl.:h;lllicul loading stimuli and those thaI either do nul respond or demonstrate detrimental responses. !'eedless to say. it Illay not be fruitful to pursue mechanical therapies in cases thaI show 110 or dctrimenwl responses to Spi;l Fig. 12.19. Sitting slouched. -'"'' ...... , . , . ~'ll'l""'L. Int:.HAPt:UTlCS BASED ON RESPONSES TO LOADING 241 or resrxlHd In the mechanical inllucnce loading strategics in a predictable l11allncr. Retrospectively. these conditions arc con. sidcn..·o I1\c(:hanical spinal disorders arter they prove amcnahk.. to Illcchank'll mel hods. Spinal complaints that do not rL'spolld Itl. or arc made worse by. the mechanical innu. I.'IKI.' (II' l(lading strategies arc screened out. including those ctlllditioll.., that Illay rcprc.:scllt meclwnic:'11 disorder!' not ;1I11cnahlc to IO:lding. ps)'chogcnk' entities. inflamuwtory COI1dititlllS. ur those of e\'CI1 more pernicious ci.lu!'ation. In these conditions. responses 10 lllcch'l11ic.1l Imlding strategies arc :.!typical. I:'l(:king. or delrimental. t, 1 Fig. 12.20. Sitting erect. Fig. 12.22. Cervical retraction with cliniCian overpressure. Fig. 12.21. Cervical relraction with patient overpressure. THREE SY~DROME PATl"ERNS Tile clil\ical reasoning illlrinsic to thc McKenzie approach or· g'lllizes mechanical and symptom.Hie responses 10 lo'lding into three syndromc patterns. These patterns describe :J dis· cn.:tc sel of mcchanic.l1 spinal conditions that respond to loading Slmtcgics in a specific m'lllncr. Clinical Rc~..soning ' and Utility Tile syndrome pallcrns do not encompass all spin,11 C(}I11pl.dnts :llld conditions.lnll rather dclinc spin:d condilions IIl.1t Fig. 12.23. Extension in lying with clinician overpressure. 5i S t §_::.'v::' .:;; _ >(>~"'~/,ill'~'i>J~~~"''i~~~:.;~,~~¢>~'MMkI""-,,,"'<=J~''Wi''"\'>:f''''''~JWi>'''''''!.';\W'';;'''·~:'',WJ,'>'i"'"'J'>'''''''·~·'iJ'''ij·~~\'l'<~~1,,*,,\~,'''.'~M"",\\:U4,\'«","".,·".,!-\,~<>,·"t""'">"",'"""",\,.I.,, "~'I,\ """""'"'''''''''~~''~'''''V'''''''~'''''''''''''·''''''''''' """ . . ""...,,.. ., ".,,;"~_.•:.. 1:=,e<~'\>"""': Table 12.1 Summary 01 the Three Syndrome Palterns • Rate or Syndromo Rosolution Responses During Molion Ocl3yod onsel oller SVSllllllOC olld fnnQO po. Si!ionillg None Weeks No", Sympl~tic Nono ollisl Movement pl3flC dJ/celion spocllie AVol(j symptoms Igr,l/oflCo, IntlQvo, solfconscious RCSlriele 'mmcdjlllO O. resl~ted end /3ngo Nono Mon!l,s Non" Nonc McchnnleiJl and symplomatie Movemenl pl3nc dircctiOo spt!· eirlC Pvrsuo symploms Avoiding SyrTlptoms Dvriog motiol'\. obslructed or unobslrueted end rllngo Imm~3toor Olien persisls Days Yo. Mcdlflfl!eltl and symptomatic MecMnical and symplom:t\iC ton Pursvo ccnlrllfizo· lion. avoid poriptloraTiz:tlion Avoiding symproms of ccntrlllizalion Frequency or Complaints (Responses) Point of Response Elicitation Rale 01 Response Elicilalion Postural Symplomatic only InlormlUenl Suslninod ond rango Dy!>!unclion $ymplomatic and m"ehllnic,1! Ifllorm,tlcnl Oerangomcnl SymplQrnilliC nnd mceh3nical tnlcrmitltmt or Coo!>t3n! t:::: "'" ,'," '~ ,~.~) (foI3YOcl. dvring motiOn. 01 obSli'\Jcte ...4 'V Responses at Mechanically unimpoded End Range Responses at Mec!'lanieally Impeded End Movemont Plane Specific Rosponses Rosponse Persistence affer loading CCssolion Mechanical or Symptomatic Aesponses Rango Preferred Loading Aoasons lor Potient Falluro Strategios may affect un- othcr ~ /' <"Mf! ;' WH' ;",;) ...J ,,) '"" ",,,,,j' ,; «,,., ."' ...... " ... , I .... ' . '<:' , uf' P,ltho;lna(UlIli<: I I $ I .~ ' .. ... ~ ~ I, ,, i .. I ~ Ii I I -, ) I nCt1f\t"'t:U 11l.,,0 tjAot:U UN S~'IHlnlll1C Ht::~I-'t>NSES TO NOl11cllcbturc Till.' syndnlllll' p;llll'rns ar~ idl'IHilkd by l'l.'(ognizillg groupings or Gltl.'goril'~ \If lll~l.:hanical ,\ltd symptom,nil.: r~spons~s 10 loading. 111\1 lh~ p;lthO,Ill;IWlIlic hasis ror Ih~lH. NOHI.'tlJl..'kss. the sYllJnlm~s Il;Iv~ bl.'~11 lI:tllll:d al.·l.:ordillg 10 the hypoti1l.'si/.~t.I p:lllh1;Ul'ltmni..: ba:,i", fpr their hdl:l\"iors. While IhL'sC hypothL'sc, aI'\,.' lhe McKl.'ll/,ic s)'sll.:ln's "ilL'sl gut:s:-::' it j", imp0rlalll (0 rl'memher t\V(1 ",,\lient points regarding the Il;Ithoall;llomil· lith.':-, for these syndromcs. Thc lirst is lh'1I lhe 'yndromc:-: arl.' gnHlp~d ;u.:nm.ling 10 responses and I/O( p;uho;lI1aloI1lY. If resc.m;h provcs the rvkKcllzie palhonnawmic hypotheses aroncolls. the ohserved grouping or rt:spollses will remain as empiric f'lel. Thc. l<;cc:ond point is lhat the p.lthoanatol11ic.: litles of the syndromes help the clinician remcmber the conligllntliol1 of complaints so named. It also helps hoth thc clinician ,111d the p..uient to remember the rules ~urrounding trcaimcll( of the ~yndrol11es. Bcc:allsc tht: ulility of the syslem rests in its ability to 01'g~nizc. dassify. and predict associated mechanical Postural Syndrome II Symptomatic responses characterize this syndrome. No mechanical response.. :Ire noted. ~ <") I I I P.S. POINT OF RESPONSE ELICITATION RCSPOllSt;S an; elicited .It :I Illechanic P.S. RATE OF RESPONSE ELICITATION , U This syndrome exhibits delayed onset of symptoms in response 10 sustained slatic loading at end range. Sustaincd positioning at end mnge l1Iust be assumed for a relatively long period of lime (c.g., 20 minutes) before symptoms arc elicited. The delayed onset of symptoms in response to sus~ tained slatic loading may 110t be evidenl during the initial CX~ aminatiol1 becausc of fOlilure to provide adequate static load· ing time for the delayed onset response to occur. ., l' "~ .~; ~ P.S. RESPONSE PERSISTENCE AFTER LOADING CESSATION \~) -U I "{j i t: } t 243 P.S. RATE OF SYNDROME RESOLUTION The charnCltristic responses of the Postural Syndrome may take weeks 1(1 ch.\nge with propcr therapy. This period of time may be rcquir~d before it is possible to sustain positioning at the L'llipahl~ end range Curve rc\'cr~1 and the abilily to achieve mechanically unimpeded end range without de"i There is no deviation from the intcnded moveme.nt plane directions. The symptomatic responses occur only after sustained loading at lhc culpable mechanically unimpeded end range. Ovcr~pressure docs not change symptoms significantly. Symptoms are central, bilateral, or unilateral. depending on the nature of the sustained end range positioning. The centralization or pcripherali7.3tion responses are never noted. Responses that do occur do not persist ancr loading ceascs. <" .~ P.S. RESPONSES AT MECHANICALLY IMPEDED END RANGES Mechanically impedcd end ranges do not exist in the Postural Syndrome. P.S. FREQUENCY OF RESPONSES (COMPLAINTS) The frequency of responses is ilHcrmittcnL ",,",_-7 • ~ LOADING P.S. MECHANICAL AND SYMPTOMATIC RESPONSES C) I, """"L Symptomatic responses elicited aftcr sustained static loading at end range resolve once that loading taclic is terminated. This bclmvior is typical of the Postural Syndrome and contributes 10 the intermittent nature of complaints. P.S. MOVEMENT PLANE-SPECIFIC RESPONSES Loading in the symptQIll In the Postural Syndrome, avoiding the symptomatic end range is of paramount importance. Pursuing symptoms at the culpable cnd range is detrimental. Whcn the symptomatic cnd range is avoided over a period of time. symptoms at end range are morc difficult to elicit, and cventually the PoslUral Syndrome re~olvcs. Whcn static loading at the symplomatic end range is frequently pursued, it rC!T~!uatcs the syndrome .. __ and may diminish the delay regarding elicitation of symp· toms. Constant vigilance regarding. avoidance of the symp· lomatic end range is rcquired to resolvc (his condition. which gencrally is accomplishcd ovcr \Vhen paticnts do not sliccessfully resolve Ihis syndromc on their OWI1, it is bCGmsc Illey :.Ire not avoiding thc symptomatic end range for long cnough periods of time. Postural correction is required. and the paticnt mUSl be \'igilant to ..\Void the pm;· tural habit that holds the spinal joint al the "offending" end range. Pntients may feel too awkward or be too concerned about their appearance if this requires them to maintain \Vhen joints are held at end range. whether they arc extremity joints or spinal joints. noncontractile structures such as ligaments and joint capsules arc stressed. An example is the bent finger illustration. If the index finger is hypcrextcndcd. dis· comfort is experienced almost immediatel~·. !f :: ::; hdd just short of the point of immediate discomfort, discomfort would be experienced within 20 minutes. No pathologic condition need exist for this abnormal stress to cause discomfort in The particular PoslUral Syndrome is named according 10 the movement plnne" direction of which the offending sustained position represents the end range. The particular Postural Syndrome. therefore. is named in referencc to the particular end range at which stntic loading occurs. Somc examples arc: sustained extension. sustained flexion. suswincd right lateral shift. and/or a combination of movement plane directions. Susrailled extension of the lumbosacral spine may bc experienced during poor standing posture. especinlly in pregnant patients or lhose with a "beer belly:' In nddilion. sustained extension of the upper cervical spine is experienced commonly with the poor sitting posture of head "protraction. Sustained fJe:(ioll of the lower cervical. thoracic. and lum. bosac-ral spine commonly occurs with poor. slouched sitting postures. A sll.'ilained lateral sllift may bc seen when all weight re~ts on one leg in a standing position. thereby shifting the I I • , '~L.. UMI.. ,w,,,,'~ thorax nnd pel\'is in opposite directions wi!!lin !h': movcment plnnc. ce~~!l~~1 P.S. SUMMARY INCORPORATING HYPOTHESIZED PATHOANATOMY When noncontr.lctilc. lignmclHous. capsular. etc. slrlll.:tures are held at sustained end r Dysfunction S)'ndromc ., , Jl u Dy.S. MECHANICAL AND SYMPTOMATIC RESPONSES Symptomatic and mechanical responses characterize (hi:syndrome. Oy.S. FREQUENCY OF RESPONSES (COMPLAINTS) ) ) Responses arc intermittent. Dy.S. POINT OF RESPONSE EliCITATION Responses are elicited al a mcchanically impeded end of the restrh:lt'd elld range varicty. raT1g~ Dy.S. RATE OF RESPONSE EliCITATION The Dysrunction Syndrome exhibits an immcdi:'llc elicitation of symptOimuic and mechanical responses at the resrrict('d emf rallge when sufficient loading ovcrpressure is prescnt. u Dy.S. RESPONSE PERSISTENCE AFTER LOADING CESSATION Mechanical and symptomatic responses elicited immediately when loading at the restricted end range rcsolve once that loading lactic is (crmimued. This behavior is typical of lhe t * i ¥"'-'---~,----------------------------------- :,J CHAPTER 12 : SPINAL THERAPEUTICS BASED ON RESPONSES TO LOADING Dysfulll:lion Syndrome and contribUlcs to the intcnlliucnl na(un.:. or ('otllp1:linls. Dy.S. RATE OF SYNDROME RESOLUTION The charact~ristic responses of the Dysfunction Syndrome 245 nnd pcrhnps pennits the mechanically limited end range to becomc marc restricted in the future_ Daily frequent and repetitive motion to the symptomatic end range is required to rcsolve this condition, which generully occurs slowly over 6 to 20 weeks. may lake as I{lllg as 6 to 20 wceks to resolve. CIWllgCS ill the lllccilimil:al ;llld symptomatic responses char;Il':lcl'istic of the syndrome ('annol be m:complishcd during the initial evaluation. Dy.S. RESPONSES AT MECHANICALLY IMPEDED END RANGES Restricted end range usuall), occurs in only one movement plane direction. If it occurs in morc than one movement plane direction, n:sponscs ;It the individu Loading in thc symptomatic movement plane direction docs not result in mcch.mical or symptomatic responses within thc opposite movement plane direction' or other movement planes. Conversely. loading in the opposite direction of the symptomatic movement plane direction. or in another move~ ment plane. has 110 effect on the mechanical or symptomatic responses in the symptomatic movement plane direction. Frcquent Sialic or dynamic loading at or to the restricted end r.inge helps resolve the syndrome over time. Swtic or dynamic loading in the opposite direction of the same movement plane, or in another movcment plane. selVes no thcrapeutic benefit. The only therapeutic action is thal of pursuing the symptomatic premature end rnnge. All other movements or positionings arc equally ineffective regarding resolution of the syndrome. Dy.S. PREFERRED LOADING STRATEGY In the DysfLlnction Syndrome. pursuing lhe symptomatic restricted end range is of paramollnt importance. Avoiding the symptomatic restricted end-range pcrpcLUatcs the syndrome Dy.S. REASONS FOR FAILURE OF PATIENT STRATEGIES l\tticl1ls may avoid th..: r~:-.triL:lt;J t:IlU ntllgt= UCt.:"IU:-,t:= ur lh~ discomfort involved as well as the proprioceptive clle of reaching the limits of motion. In so doing. they avoid "therapeutically beneficial" restricted end-range discomfort and perpetuate the Dysfunction Syndrome. Pain or anti-inflammatory medication cannot correct the mechanical problem underlying lhis syndromc. which requirc.1:; restricted end-range loading for its resolution. Dy.S. HYPOTHESIZED PATHOANATOMY As a result of chronic postural habits tha! avoid bringing spin:ll joint~ to certain end ranges. or as the result of tissue damage leading to scar fonnation. adaptive shortening or dysfllllctioll of tissue may occur. A loss of elasticity occurs causing restriction of spinal movement. If a perfectly nonnal elbow is cast in a flexed position for I month. the ability to extend it is restricted when the cast is removed, nn example of the dysfunction behaviors just de~cribed. Scar tissue. which shC'rtens over lime. may fornl at the site of disk derangement or spinal surg~ry. After significant derangement or surgicnl intervention. an at/herem nerve roof may develop. exhibiting the typical mechanical and symptomatic responses of the dysfunction syndrome. The ndherent nerve root condition may involve the peripheraliziltion of symptoms to an extremity without an associated "centralization response:' This pcripheraliz.uion response occurs at the restricted end r(l1I~(' of the flexion mo\'ement plane direction only. Olher special conditions must accompany this endrange flexion to elicit adherent n~f\'C root responses; e.g., extended knee for the lumbar spint:' and btend flexion of the cervical spine combined with $houldt:'r ;:lbtluction. The pe· ripheraliz<1tion response noted with the adherent nerve root docs not remain after the precipitaling loading actions ccase. Trc The particular Dysfunction Syndromc is named according to the movcment plane direction limilt:'d by r('stricted ('11(/ range. EX:lInples include the following: Extension dysfunclion Flexion dysfunction Undudcs "adh~'r~nt nerve rooC') Righi rot,llioll dysrUnr.:ll011 Len rowliu!l t.Iysrulli,:li~m Right hl(Cral ncxion dysfunction Lcft latent I lh:xion t.Iy:,fUtlClioll .. _ I pcd':-l'.:Il'!l • Right side·gliding dysfunction • Left side-gliding dysfunction Typically, rotation and lateral nCXiOll dysfunctions upply to the cervical spine. whcr..:as the side-gliding dysfunctions apply [0 the lumbosacml spine. Because of the predominance of flexion in the industrial lifestyle, extension dysfunctions develop cOlllmonly in the lower cervical spine and lumbosacral ~, SpillC by middle age. Bec.lUse of poor sitling posture, protr '""' I ,\ lllidr~ll1ge ' , I 'VI~""" >J IV'MI'lU L motiol1. or during mid- Dc.S. LOADING TIME REOUIRED TO ELICIT A RESPONSE The Dcri.l1t~~ll1-.:nt S)'lldrol11~ nlay exhibit illlillediatc clicit:ltion or dclay-.:d onsct of SYlllPI{)l\l:lliL' curs, which involves extension of the upper cervical spine. Flexion dysfunction of the upper cervical spine commonly occurs as a result. Dy.S. SUMMARY The cause of the syndrome is shortened. nonclnslic structures that restrict spinal movemcnt. Rcsolution involves stretching these structures. The loss of range of motion or deviation from the imcndcd movement plane direction results from in· clasticity. Avoiding symptom:·: only perpctuates the syndromc and may. in fact. slO\\lly enable it to develop funher by approximating the ends of structures that arc then pcnnincd to shorten further. Frequent and repetitive elicitation of discomfort is required to improve quality of movement Periphcralizalion to the extfemity occurs only when the healing process subsequent to disk injury or surgery results in the tethering of neurologic structures. which limits and is challengcJ by the movement plane direction of flexion. Therefore. adherent nerve root is a subcategory of flexion dysfunction. For didactic purposes. this syndrome has been described as displaying syrnptomatic fesponses at a restricted end range that cease once loading at that end r;;mge ceases. For all in· tents and purposes. this description is truc. To differentiate this syndrome from the Derangement Syndrome, 11Owever. one must be cognizant of the possibility of a symptomatic re· sponse that will not cease should overstretching occur. Such symptom~llology is considered evidence of an inflammatory response to overstretching and damaging tissue. The potential inflammatory response to overstretching shortened tissuc must be kept ill mind to differentialc this contingency from the constant symptomatic response attributable to mech'lI1ical factors of the Derangcment Syndrome. Derangemenl Syndrome De.S. MECHANICAL AND SYMPTOMATIC RESPONSES Symptomatic and mechanical responses characterize thc Dc· rangement Syndrome. De.S. FREQUENCY OF RESPONSES (COMPLAINTS) Responses may be inlefmittcnt or constant. De.S. POINT OF RESPONSE ELICITATION Responses are elicited at mechanically impeded cnd r~ngc(s) of the obstructed end range variety. al mechanically unim. De.S. RESPONSE PERSISTENCE AFTER LOADING CESSATION Responses or bdlaviors dicited as The char;'lctcriMic responses of thc Derangement Syndrome may changc rapidly and ntdically during the time provided for the initial cvaluation. Resolution of this syndn.}mc may he possible within a matter of da)'s. De.S. RESPONSES DURING MOTION The obstructcd end range may be significant enough to prevent curve fcvcrsal. An obstructed end range exists in :11 least onc movement plane direction.•md ma)' exist in multiple movcment plane directions. Deviation from the intended movement plane direction or symptollls during motion 11\:1)' be nOled. The centralization or pcriphcraliztltioll responses may be noted during motion. De.S. RESPONSES AT MECHANICALLY UNIMPEDED END RANGES Deviation from an intended rnOVCJ1lell{ plane direction 'lIld/or symptoms may occur. Overpressure may change mCl..·hanic;,I! and/or symptomatic behavior. Thc ('entn.i1iz~ltion rc:,pollse docs not occur: the peripheralization re~ponsc may OCC\lr. De.s. RESPONSES AT MECHANICALLY IMPEDED END RANGES Obstructcd end ranges may occur ill ;1 single or in Illulliple movemcnt planc directions. If an obstruClcd end range occurs in more than one movel1lCJ1[ planc direction. responses at the individual obstructed end range may affect etlch other. Mechanical and symplOl11Jlic responses may be elicited immediately or exhibit delayed onset as ~l result of loading at lhe obstructed end ran~~. Deviation from the intended movement plane dircction may occur at the obstructed end range as well as at thL' unimpeded cnd range. Lo'1ding at the obstructed end range may bc accompanied by the subjrttivc perception of a mechanically impeded end range. CHAPTER 12 : SPINAL THERAPEUTICS BASED ON RESPONSES TO LOADING .. ~ If discomfon is nor preselll nt the obstructed end range. create it. and this discomfort may then ex· hibi( it cemf De,S, MOVEMENT PLANE-SPECIFIC RESPONSES Loading in a symptomatic or asymptomatic movement plane direction may change mechanical and/or symptomatic re· sponses of the opposite movement plane direction or of i, iI < olhcr movcmcnt plane dircclion, Thc,c changc, may bc thcr- () apeutically beneficial or dClrimcnwl. In Ihe Derangement Syndrome, (he therapeutically bene· ficial IO I, d < ~ ) Ii "l ~ ) 1 I % S '~ " 1; t' " ~ I c .. ~ ,~• (J • ~.-J • , I, J ,) I "< ~ ,\.J -:~) k cJ De,S, PREFERRED LOADING STRATEGY :":,j ',~ Pursuing and avoiding certain loading tactics. as well as lhe ordcr in which lhey arc accomplished. is critical in the care of this syndrome. In gcncral. symptomatic responses arc pursued if char'lcterized by the centraliz.;uion response and avoided if ch'lraclcrized by the peripheralization response. The "key" obstructed end range is the one that exhibits the centrali7. ',) \" f{ , Ii ~ i i (j ] J J iu i I i B ~ , ij \i 'ti" f; -~ ~ 247 , ',] \.Ji tJ -- The preferred loading strategy revolves "round rcducin2. Inc key obstruction. This effon may be ..ccompanied b\' th~ rapid resolution of symptoms. or by the temporary incr~ased symptomalology of the centralization response. after which symptoms resolve. Phenomena related to the resolution of derangemcnts exhibit varying degrees of complexity. The simplest GISe involves only onc obstrucled end ran~c in the saginal plane. which is lhe key obstructed end rang~. The c~ntral i7.ation response may be noted at the obstructed end range. The peripheralization response is elicited typically by means of loading within the opposite movement plane direction. Peripheralization by means of loading in the movcment plane direction opposite to that of the obstructed end range may be elicited immediately or by deluyed onsct: i.e.. mechanically unimpeded nexion may pcripheralize. whereas extension to the obstructed end r.mge centralizes. The less common. but opposite simple sagittal pattern. may also be found. More complex situations entailing multiple obstructed end ranges, of which only one is the key. may mandate an initial preferred loading stra[egy within a coronal or transverse movement plane. Consider a case involving an obstructed end range in one sagiual movement plane direclion. a.~ well as an obstructed end mnge in one coronal movement plane direction. In such cases, it is possible that loading in both the unimpeded and obstructed sagiual movement plane directions elic its the periphcralization response. Loading in the coronal or transverse movemCIH plane is at first required to elicit the centr;jlization rcsponse. Subsequently. loading in the sagittal plane becomcs necessary for further resolution the syndrome. It is possible in cases involving muhiple obstructed movemenl plane directions. for loading at a single (key) obslrucled end range to resolve all obstructions. without requiring the scquentiul end range loading just dcscribed. p or De,S, REASONS FOR FAILURE OF PATIENT STRATEGIES The ccntralizJlion response that occurs m the key ob:,tmcted end range may entail a significant increase or creation of centr.ll symptoms. which patients understandably avoid. Because the ccntralization responsc is associated with an increase of marc central spinal symptoms, patients may choose the therapeutically detrimClHal strategy of pursuing loading tactics that diminish spinal discomfort, even though 'lesser paiphcral symptomatic complaints and significant mechanical disorders arc perpetuatcd. De-S, HYPOTHESIZED PATHOANATOMY The model for this syndrome is the derangement of imradiscal material or substance. whether it is solid (nuclear. annular). liquid (watcr. electrolytes, etc.), or gm;eous (e.g.. nitrogen). The bchavior of symptoms and mechanics changes according to migmtion and/or accumulation of intnldiscal substance or materinl in the anlerior. posterior. or lateral aspects of the intervenebr'll disk space. • , .... " , .......... n, ''-'I~ ..... , Imagine a simple cas~ iii whid: :nli:idisc..: Iiia:.:ri;i: ...:..:ranged in a posterior direction. callsing ohstrucled end r.mgc I z I j I Ii I to extension. Flexion would remain ullobstructed but would further promote this posterior derangement, eliciting pcripheraliz be imagined as well. Consider a more complex situation ill whid. illlradisl.:..ll malcrial migrated in a posterolateral direction; flexion may further this migration. An obstnlcted end range could exist not only for extension. bUl also for sidc~glidillg as well. If the Iilt~ eral component is significant. extension may only serve 10 squeeze this material more to the side. In Ihis case, both the mechanically unimpeded flexion C1nd the ·obstructed extension could elicit the peripherali7..C1tion response. Loading in the coronal (sidc~gliding) or the transvc~c movement plane di~ rcction (rolation) may be needed to reducc the key lateral ob~ struction and elicit the ccntrtlliz;.nion responsc. After this step, Ihc previously aVOided extcnsion component becomes lhe key obstruction, and loading in extension may be needcd to furthcr promote the centralization response. The laleral component has been reduced sufficiently, and the task is then to n,> duce the posterior component. When disk material has migrated, both posteriorly and laterally. obstructed end ranges exist in the respective sagittal and coronal movement plane directions. If loading in Ihe movement plane direction of extension reduces both of the obstructed end ranges, the lateral component is not considered relevant. If loading in the ~oronal movement pl<.lnc direction is required first. the Imeral component of disk migration is considered relevll'" to a loading str<.ltegy involving a nonsagiual movement plane. RELATED TERMINOLOGY Postuml Syndrome terminology is predic..1lcd on the positioning that precipitates symptoms. Dysfunction Syndromc tcnninology is predicatcd on the movement of the person that precipitates symptoms. Derangcment Syndrome terminology refers, in pan, to the lInatomic dircction of intradiscal derangement. In contrast 10 the Postural and Dysfunction Syndromes. 1\\"0 classification systems arc used to organize Der;.mgemcm Syndrome phenomena. Similar to the Postl"lral and Dysfunction Syndromes, the first method dcscribes dewngcmcnts based strictly on the behavior of mechanics and symptoms in response to loading tacrics, and namcs these bchavior patterns by p;'lthoanatomic inferences--derat,gemetll belwvicw tlomcnclalttre, The second mcthod refers to the presenting symptolll lOpography ;.md deformities. in 'Iddition to the dcr;'lIlgcl11ent behaviors-derclllgemcnf bellavior-fOpCJK ral'hy·deforllli fy (87D) tlomenclature. Derangement Behavior Nomenclature, This tcrminology is descriptivc of the anatomic direction in which the intradis- " ' ....... ' " ....... 1"\ rnr\\.... I II IVI'Icn ;:) IV1MI'lVJ-\L Jer;lllgclllcllI i:, thought 10 h:l\'e occurred. SWlcd another way, it i~ descriptivc of hdta,·iors noted as ~,. (krangellh.'m of imradisL'al 1l1:11erial occurrcd ill the dCSL'rih~d anatomic directioll" The Dcr;l1lgl,.'Il1~11t Syndrnmc" ~Ire named :lI,xording t\1 tlte hypothcsirl'd ;1lI;lltllllil· dircClill1l ill whidl disk ll1;llcri:l! Ir;l\'dkd and I.::lu"".. d ;1Il oh"tnll.:tcd cnd r;lIlgc: ~IIltCfior. po"t('rior. and J:Hl'r;t!lkran;;l'!11l'llIS. Am"r;or (/<'I'Ol/g<'/I/C/l1 d~s(rihes hcll:l\"iors liS ~r ;1l11crillr migrati(lll ()(" intlatlisc;'11 m"h:ri,,1 (lL'currcd. An accuiliulati(m in thc anterior companmcnt of lhe disk makes llexion I11C-. <.:hani<.:ally difli<.:uh to perform. In cxtn:me cases. lord(l~i;'o is fixcd <.Illd irn:\'crsibk. Extension pronHHes the migrati{lll 01" lllateri;.i1 to the ;uHaior ('olllpartlllelll. Extensioll Illay bl' accompanied by pcriphcraliz ";:1: '., or "j ",."..0' CHAPTER 12 : SPINAL THERAPEUTICS BASED ON RESPONSES TO LOADING cral component. it is thought that an accumulation of in· tradisc;:IJmalcrial to one side or the other of the coron.l1 plane is sufl1cicllt lO require a unilateral loading lcchniquc. Whcn there is a "relevant" lateral componem. movCIllCll[ in the sagitlal plane not only may f sponse if further lateml mi£r:llion of intrtldiscal material n> suits. After rotation or side-gliding is performed to reduce till' lateral component in these cases. the situation may require sagitlal plane techniques to reduce the cClllr;i1 anterior or posterior derangement. An accumulation of disk malerial in the lateral companment resists side-gliding to that side becausc of the obstructed end range. In extreme cases. a list or lateral shift is ilxed ;:lnd irreversible. Side-gliding in the movemcnt p!;:iIle dirt~c lion of lhe patient's lateral shift has (he potential of promoting the further migration of intradiscal material. aCCOIllp~\I1icd by pcriphcraliz..1tion of symptoms during motion or ..It end range as a result of derangi~g material more latcrally. Any limitation of movement in the direction of the lateral shift relates to intolerance of symptoms and not to a mechanically impeded end range. Pcripheralizatioll may occur below the knec because lhe nerve radicals are easily affectcd by latcml distortions of the annulus when a posterior component is prescnl as well. Side-gliding in the movcment planc direction opposite 10 the latcral shift is obstructed and ,,, I II j I :~ ~ n I" 1 ! -'-, ~ I I .7 ',-,,- ',..J .)'j ~ ! Ii "; " .,F ) I 1 I ... I ~ -•..Y ) , ''~Ii ,) ,) {:..-~ <';"";c l ',& ~ £ '-.) I :~ d I I oJ , --:\,_/i • ~ 1;'( ~ Derangement Two: C~l1tral or s)'1l11l11.:!ric symptoms alwut the spine With or without shoulderhlrm or hUl10ckslthigh symptoms With defurmily of kyphosh .("". J i)~r:lll':;Cllh.:1l1 Thr~e: UnilLlll'ral or asymmclric SYlllPlOlIIS ahOlll thc :,pinc Wilh ur \\ ithuut shoulder/arm tlr bllthld,~thi:;h ~Ylllptlllll .. N(I deformity J)~ral\gcllll't1t Film: Unil:lll'r:11 ur aSYlll1l1elrk ~YlllplOlllS ahoullhl.: spint:o Wilh Ilr \\ilh.mt shoullkr/anll \If bll!hll.:bllhi:;h ~yl1lplllllh With tkft1rlliity (If turtil,,·\llli .. ,Ir lumhar "'l'lllill~i~ ()crangclll~nl fivc: Unilah.:ral or asymmctric ~YlJlptnms "hml1 lhe spinc Wilh ur without shuuldcr/ann ur hUll ods/thigh S),lllph1l11"; With symptom..; cxtcnding bl.:low the dhnw or knec No deformity Denlngerncllt Six: Unil;ltcr;:tl or asymmetric ~ymptOlns ahout the spine With or witlluut :-;houklcr/arm (If bUlhl(,:ksllhigh symphllll"; With symptoms cxtending ot:lnw [hc dbow or knce With dcfonnity of acule kyphusis. IUr1icullis. or lumhar si,.'i1!i(lsis Derangement Seven: Symmetric or asymmetric symptoms about the spinc With or without Shollldc.:r/arm or bUHocksllhigh SYl1lptC01~ Deformity accentuated lordosis m,ly or may !lot be pre5Cl1l or The "couplet" system of symptom topography. without and with deformity. does not extend to the anterior dcrang-:ll1cllts. An anterior derange1l1elll with central symptoms. unil:ucml symptoms. without deformity or with deformity. is classilicd as a derangement sevcn. The BTD nomenclature is reduced to behavior nomenclature only for anterior dcrangel11~lH~. which arc assigncd the number 7. PARTIAL PATIERNS OF DERANGEMENT One distinguishing feature of the Derangement Syndrome is the exhibition of parli;ll patterns. Because of Ihc l'omplex mechanical and symptomatic responses associ"tco wilb the Dcrangement Syndrome. the absclH.:c of some of the typical dcrangcmclH responses docs not diminish Ihc ability w recognize thi!ol syndrome. Examples of partial beh'l\'ior pallcrns of demngcmcnt arc as follo\\'s: Periphcr.slization rcsponse persisls without Ihe ability 10 dicit a centralization response Periphcr The goal in the Dcrangcmclll Syndrome is 10 reduct:' the dc~ r;U1gcmcnl of illtradiscal material by having it migralt: back t.) ~5~ "'",], ~ \i, . \~ DerLlllgl.:l11cm One: Central or ~Yf11metric sympwllls ablHlt the spin(: R~ln':l)' shuulder/:mn or butl()eksllhi~h symptoms No dcfurmit)· , 249 b - ------------ ---------------------------- " ••• _ ._ •••••• ~,. 'oJ' ~,,;"ai'':: ;:.... n:::ntcr of the di~k Sp'ICC. Ohslructcd end r;U1gc in purely ilntL'rior or poslcrior dcr:lllgcl1ll'J\ls occurs in one movemem plane direction. Obstnlcled I.'nd range GIll CXiSI in more lhan one mow_mcnt plilllC dircl.:tion \\ ilh eilhcr rdc\·;Int or nonrek\·anl hueral C(lmpllncnts. If nlhtrU<.:tioll 10 mo\\> Illelll in tilL' cornnal pl:tll~ is dilllillctitivc rcduction and der.lIlgclllcnl of disk m'llcrial in rcspon~c to the patient's 1ll0VCI111::I1lS ilnd pusilionings during thc d;'ly. A const'lIlt symptomatic response involving the Dcr;'lllgcmcni Syndromc rcpn::scnts a mech.mi· cui dispbcclllcnt of disk material llO! reduced by the llSU;.iJ movcments and positi()nill~s or the paticl1I. Prcscriptive load~ ing (a prd('rr~d IO In the previous dcscriptions of syndromcs. each is presented as if it exists "by itsclf.·· In clinical prilctice, multiple syndromes may coexist. .Ind all thrce may be seen in one p,ltiellL SIMILAR SYMPTOMS, DIFFERENT RESPONSES The importancc of invcstigating me.:chanical and symptomatic responses to loading tactics cannot be overemphasized. Information concerning a single mcch'lIlical or symptomatic rcsponsc to a single loading tactic is not the nccessary and suffieiclH condition by which to diagnose a syndrome. Symptoms associated wilh siHing. may be aHributablc to a postural syndrome of sustained nexion. a Ocxion dysfunction syndrome. the promotion or a posterior derangcment, or the reduction of an anterior derangemcilt. Symptoms associuted with standing may be associated wilh a sustained extension postural syndrome. an extension dysfunction, the promotion of an anterior derangement. or the reduction or a posterior derangement. A thorough investigation of mechanical and symptomatic responses to IO~lding helps to dirrerGntiatc among these possiblc caus , , ' ......H- .... c:. 1"\ r-H"'U., 1IIIUNt:H"t; MANUAL pcripherali/.~ltioll rcspun:'~ with i.I Dysfunction Syndrome l , -~ () APPROPRIATENESS OF MANIPULATION lvlanfpul;.Hioll. within the.: McKenzie <Jpproach, is considered inappropriatc in l1lovcme.:nt planc dire.:etions that do not possess Illcchanici.llly impeded end ranges. Therefore. manipulation is in'lpproprialc for the Postur~ll Syndrome. Only postural correction is warrantcd. Rcgarding the Dysfunction Syndrome, manipulation l11ay bc contraindicated at first. becausc of lhe danger of overstretching shortened tissue. Symptomatic responses to loading persist only when shortcned tissue is strctched too fast or 100 far. causing tissue injury that results in chemical. non mechanica I inflammatory pain. During i.l manipulative thrust on a patient with a Dysfunction Syndrome, the operator may feci as if he or she has "bounced off' as a result of the resistance offered by shonened structures. In the Dysfunction Syndrome. manipulation is appropriate only after the adaptive shortening has been reduced signiflcantly. Manipulation is in· appropriate as ~l main fonn of therapy in this syndromc be· C .,~_.~_._-------------------~ .--"~ -) ._.. _-~-~~. , ' .. ---' CHAPTER 12: SPINAL THERAPEUTICS BASED ON RESPONSES TO LOADING live thrusts. h is impol1am to note th:.u the 1lI0\l:IIICIll plall\.: direction of the manipulation cOlllcmplalcd is tktcnnincd by mcchnical and symptomatic rCSpOll$CS (0 loading. incJudil1!;!. patient-generated movements. patient rcp0r1~ concerning ccnlraliziJtion. and bOlh patient and clinician ohsa\,;l1iolls 1.'011· ccrning mechanic;\1 observations. Lastly. n;~3njillg the relationship In chirnpral'lic. Ih..· McKelvie <'lpproach docs not claim lO be the llfst or unly ;11" pro I (,I ~ ercise technique, therapy, and theory at (C.1SI as c '/" j treatment is predicated on medmnical and symptomatic responses to loading. In m;.my cases, extension .is indicated: however, ill many C The McKenzie approach permits a thorough exploration of which movement plane directions may be pursued and which must be avoided. based on the mechanical and symptomatic responses to spinal loading. A progressive resistance exercise program is often possible much sooner than would otherwise be permitted because the clinician possesses a clear understanding of how a patients' spine reacts to moyement and posilioning at the outset of such a program. THE McKENZIE APPROACH AND DEMA:\DS OF REHABILITATION The McKenzie approach distinguishes itself among other rehabilitation methods as being useful to patients with either acute or chronic spine-related complaints. As such, it is often an appropriate first step before considering passive therapy or other aClivity therapies. When explored first. it often proves passive Ihcrapy is gratuitous and safely guides the course of subsequent activity therapies. such as strengthening roulines. "Rehabilitation:' (0 some, equates to therapy in general, aflY kind of therapy. Used in this,manner. the term loses its in- tended meaning and is even applied to passive methods. such as hOi packs and ultrasound. Rehabilitation is not any means to flllK'tional ends, but signifies fll11CfiOllCl1 means to rUrlCtion'll ends. The key concepts defining rchabilit;.ttion relate (0 cswblishing an individual's skill (0 be able to "maintain :1 maxilllUIll level of independent functioning such as self C;'lrc ;.mu emploYlllent'·" In rehabilitation, the actions of the patient arc of p;'lr~11110unt impol1ancc. Guidance is provided by the practitionl.'r. but the burden of treatment involves what the pmient do(·.... ,md nOI what is done 10 thc p;'llicnl. 6 251 FlIIlI.:iiulI.::d rcslOralioll.~ work cOllditiollill~.s and work h"lfdening" pf(\~ral11s usc (his striCI dclinition of rdlf.lhilir~lion. The of carc."I~ FUllctional restoration, \\"ork conditioning. and work hardening program, ufC used on chronic c;.lses. Oftcn patlclH:, arc referred to surh programs af\l.'r passiyc lll~thllds. Ill~di('atioll. or no lhcrapy at ;,111 (thc tincwrc of till1l:) fall 10 resoh'c the chronic condition, III th~sc i,.. in':lI111stall~cs. passive cart:' h:1Snot helped the individu:'ll. but Ill:'y hayc .:ICIU;llly ··cncour;lgcd lllusculoskeleull morbidity.··" Patients presenting (Q ·'rehabilitation" centers with acute conditions often recl.'ivc passive therapy initially.n Thb therapy continues until the demands of an activity program le.g.. progressive weight rc~ist;'lIlce) can be tOlerated without harm. The disadvantage of such initial passi\"l~ carc is (hat it 1113y ullimately serve a purpose contrary to that of the physical and psychologic goals of rehabilitation. Passivc therapy. if ilHroduced first. has (he potential of ··~poiling" the paiicnt·s chances of progressing to unassisted. actlvc functional Jl..'tivilies as thcrapy.<~ and incrcases the possibility or thc dc\·clopment of abnonnal illness behaviors.l~ Sl,ll1lC authors:~ state lhat much lo\\' back disability is iatrogenic and results fr0111 the medical prescription of rest fm simple bnck;'lche that is based on the misCOIll".'l.'ptioll lhat inl1;'ll11l11ation or olhcr p.:1thologic change pl:lys It ~igniticant role as a caus.ative faCll)r. A rehabilitation approach in the a("utc phase can prlwidc the physiC'll , ..... ' 'r\V''-' '''I 'UI,. The paticlH lcarn~ that therapculic movement and positioning may be accompaniL'd by incn:a:,cd pain wilh improvcd funclion .•1Ild thaI ccnain p.lins ;lfC 1101 to hc avoided. COllgruclll with the ~trictL'st rehahilit;ltiOli prillciplL's i.' the "halld~ off' first approach. If rcsuh~ ;trc limiled. lh\.' ;Ipplil'ation nf passive approachc!'l is :.tl\\'a)"!'l p\lssihle. hut Iht' l'OI\1ml of treatmcnt is returned to Ihc patiellt :IS !'loon 41S l)(l:,-"ibk. R.egarding. thc 1!ll.·\.'I!:lllil'i1I ;llld physiologi..: prilicipks of rehabilitation. the r-vlr.:Kcll/.ic appro:ll,:h m:lkcs m:tivity and sell' trcalment p(,ssihk duril1~ the itl.;utc ph;tsc. Pt'flllillillg continuous. rclativdy passi,'c spinal motioll to hI.": slrategic.:ally pCI'· formed by the paliclH. Tht:sc llHIVL'IllCl1tS cnh'lllcc tilt: organi. zation of "ncw" tissue along lht: lines of stress. with th~ formation of Ikxiblc scar tisslle, Ii T to a"sume rc~ponsibilit), for acti,·c participation in their treatmen!. pruvi(Jing the inslructioll :1Il(J cducation process is firmly and vig(,rou~ly pursued."ls forts. r:'cw patients filii ur- I Nt: ~t'INt:: A PRACTITIONER'S MANUAL be CdllC:ltcd in ;:1 mclhud of IrCatmcnt lhat ellahks him to reduce his own pain and disahili!)' llsill~ his own underst:lIu..ling and resources. hI.' should n:r.:eivc that education. Evcry palient is cntitled 10 !hb illfuflnation. and ,,:"l.'I"y th..:r::lpist ~h(llll(J he ohliged lo pro· \ ill..: it:"" "[f there is the sliglllcst chance tllat ;:1 p~l\iCllt C:iIl HEFEHENCE.."i ~kKell/.ie RA. ·1111.' lumbar spille: r..k..:halli\:;ll Diagnosis and Ther;lflY. WaiLlIl:le. New '1...::11;md. Spinal Publkalions. 1981. 1 ~kKcn/.1c RA: 1111: Cen'iI;al ;Illd 'nlOmdc Spinc: Mech:lIlic;l1 Diagnosis :1ll~1 Tller-IPY. W:libu;lc. New Zcal:lIld. Spin:ll Publkaliolls. 1990. .'. 11:IIdl:lll>l1l S: North AlIleril'all Spine $oeiel)': Failure ~\f the palhology m\~ld III pn:dicl back p;lin. Spinc 15:718. 1990. -l. Hcrbst RW: GCUlsle;lL! chiropral:llc scicncc and :m. r.,·11. Horch. WI. Sci· thi l'uhlic;lliullS. J9XO. :i. 1l:lrrak R. Di:lIl1ollll R. Fiboll R. 1.'1 011: M;lIlipulalivc m:lIl;lgelllelll hUHh:lr disc bulge. Chiw Tedl 1:87. 1989. 6. Dculsch P. Sawcr H: Guidc 10 Rchahilil:uiull. New York. ~·t:ltthew lIcncler.'<: Co., pp :W-'O. Suppl & Rc" 1989. 7. Mayer T. Gmchc1 R: Funclion:11 ReslOr:llion for Spin:11 Disorders: The SP()rts tvk'tlidnc Approach 10 Low B:lck Pain. Phil:ldclphia. Lea & h:higer. 1988X. hcr:lhagcn S: Work h:mlcning or work conditionillg.-whal's ill a n;II11C. Il1du~1 Rehahil Q He:!l:7. 1989. 9.....·lalhe:-un LN. Kelllp OJ: Work h:udcninl;: (kcupalion:lliher.,py in in· du~trial rchahitilalion. Am J Occur TIler 39:314.1985. In. Troup J: 111e perccplion of musculoskdelal pain [lIld incapacil)' for work: Prcvcnlicll1 :ll1d early lre:lllllel\l. PhysiOlherapy 74:435. 1988. II. !'jtowsky J: Abnonnal illness behaviour. Psychialr Med 5:85. 1987. 12. 5..:11 J: Inter\'ertebr:tl disk heOlialioll in nonopcr::ltive tre;ltmClll. In Phy~ic;11 Medicine and Rehabilil:ll;on: St.. lc llf lhe An Revie\\"s. Philaddphi:I. Hanley & Dcllfus. 1990. p 185. 13. Mi\(:hclt RI. Carmen GM: Inlellsi'.e active c~ercisc pmgi,llll. Spin,,; 15:51-l.1990. I-I. Dcrcherry VJ. Tullis WH: Dehl)'ed recovery in the palient with a work (Ollll'ICns;Ihlc injury. J O~'cup Mcd 25:829. 191D. I:; . Ww..k kll G: A new clinical lIlodel for the lreallllelll Ill' !OW·h:1Ck pain. Spine J2:(.32. 1987. J 6. Allan DB. Waddell G: An hi~loric;11 pcrspccI.ivc on low b;le!.: pain and di~abililY. 1\(1:1 Orltl(lp SC.Jlld 6O(Suppl 234). 1989. 17. E\,:.lns I): 111c he:lling process 'It cellular level. Physiolher:lpy 66:~. I, I\}SO. IX. McKerll,ie RA: The Ccr\"ic31 and Thoracic Spine: Mechanic:\1 Diagno· ..i\ and Therilpy. W:lik:lOae. New Zealand. Spinal Publications. 1990. p Ifn. 19. MeKe",~ic !{A: ·nlc CerVical amI l11OT:lcic Spine: Mechanic:II Diagllosis :Incl Ther:lpy. Waikanac. !'\cw Zealand. Spin~ll Publkatioll.~. 1990. p 113. 1'" l' :I :1 ,-" I , 10 ; Ii I Manual Resistance Techniques and SelfStretches for Improving Flexibility/Mobility CRAIG LIE BENSON I I ~ I I I I The origill~1 Ill;mu,d rt::-.ist.1l1CC h;(;hlliqll~:'\ (Miff) have tllci .. origin in tht: pro:'rim:qHi\"c llt:llrol1l11~cul:.ir r;.Jc:ilitation lP\!:J philos()ph~ of physiGd tha;'lpy and the mu:-;d..: energy pn.lCc· dun:s (\IEP/ of the oSIt:opathy. These techniques illYO!VC manual re"ist;lllcc of a paticnt's isometric or isotonic museu· lar efron. This resisted elTon is typic"lly followed by a slrclch of a light or tense mllscle. The MRT arc primarily used to rcl 1 I I II their associated fascia. Many different methods have been de- I I ) 1 • .~ I ) I iI {) ~, veloped depending 011 the clinical goal. To achieve these positive clinical dICciS. tvlRT t'.lke advantage of two physiologic phenomena: postcontraclion inhibilion and reciprocal inhibition (RI), The MRT arc in":lluable workhorses in the re!l;Jbil· ilatian of the motor system, These techniques ilre also used to facilitate or train an inhibited or weak musl:lc. Because the doctor or therapist pro· vides the resistance. precise patient positioning and movement cnn be controlled to;'1 degree not possible with machines or even free weights. Manu;'11 COIlt;'lcts also allow for proprioceptive stimulation to facilitatc an inhibited muscle during ;'ll;' live resistance. The v:due of clinici;'1l1 control over rcsistancl.~ exercise cannot be underestimated. especially when the go,li of impro\'ed coordination is as importi.HH as lhat of strengthcning. Publications about thc lISC of PNF to facilitate ncurologically weak nluscles lirst appeared in the late 1940s. ' Soon. other reports followed. staling that spasticity responded to this type of therapy as well.: This positivc response led to the d<:vclopment or various forms of PNF (i,e.. hold-relax. COI1tracl~rc1ax. elc.) that could be used for onhopcdic ;'IS well ;IS neurologic problems. The osteopaths primarily used Illuscle energy procedures (MEP) to mobilize joints, They abo dc\'eloped I,_t)."-----_. ------",---! I t.) ~ ~ alion l'"llil"r to hold-relax), which W;'IS npplicd lrac-till: portion of ..In overactivc llHlsde. lO the con- ,,1·;UIIO'IUSClII.AII ,\1\[) IIIOMECHANICAL BASIS OF FI.EXIBILITYTII,\I"I1\(; Two a:-.pects to MRT arc their ilbility to relax an o\'eractive muscle lincreased neuromuscular lens ion or "spasm") and their ability to enhance stretch of a shortened muscle or its assm.:iated fascia. when c{}nnectivc tissue or \'iscoelastic changes have occurred. Whcn using MRT. it is important to n:h\:-: the neuromuscular (contr:lclilc) componem before attcmpting any aggressive stretching maneuver. Often a "release phenomena" Ol..:curs so that a length change occurs llUtom;'ltically after merely relaxing excessive neuromuscular tension (~ce Chapter II). In such Cases. treatment serves as a di;I~Hl0qic lest. differentiating neuromuscular (contractile) from nmnecti\'c tissue (noncontractile) probkms. Even if noncontractile p;lthologic changes have OCCUlTed. it is still wisc to relax the ncuromuscul"r apparatus before stretching. This \ler \\'ill inhibit the stretch rdlcx and allow the patient to tolerate more vigorous ·stretching. Two fUlldill1lentHlncurophysiologic principles account for the neuromuscular inhibition that occurs during application of Ihcse Icchniques. The firsl is postc{)ntr~lction inhibition. which stale\ Ihal ;'lfter a muscle is <':olltracled. it is automatically in a relaxed q~ltc ror a brief, latcnt perioo. The second is RI (reciprol:tJl inhibition). which sl;.ltes lhat when one mu:,dc is contr 253 n"" 1~""""" I~I IV'" v r Inc .;::)rIlU:, 1'\ t"'NJo\\... 1IIIUI~t:.N \:I MI-\'~U"'L ~ t I II fI I, I I I I I ,~ Ii ~ I ~ i I 1 I joints." Measurements of the Hoffman renex activity (reprcsCnlativc of the excitabilily of the motor neuron pool) show activity is inhibited ror up to 15 to 30 sCl.:onds after an agonist or antagonist contraction. \\'ht:I\~aS inhibition only lasts about 10 sec~nds during sratiL' slr:.:tclling. 7 This effcL:1 has been found to be neurologically m~di;.ncd .md not a result of any mechanical dfl..'('·t.:< Mu!'clc fiber:' also han:: l.:LI"tain billlllt:chanical dmractcristics thai ..Iffecl their stilrn~ss_ SJ.:'.:lctal muscle f1bcrs arc known to adapl to imposed dcmands. For instance, during growth. muscle length incl"l.."lsCS as new sarcomeres arc added (in serie.s) and inJividml1 libcrs illcrc.lsc their girth." Prolonged iml\\obitizi:llion of a limb joim in"\11 extended or shortc,;cd position resui(s in all increase or decrease in the number of sarcomcres. respectively."·I" Whcn immobilized in a shortcned posilion. musdc sliffness incrC\lSCS. 1O It has been observed that an il1l::rcase in connective tissue occurs with iml1lobilizHtillll in ..I shortened positien. II Conncl.:tivt: tissuc proliferation is minimized if the immobilized muscles arc placed in a lengthcned posilion or their contruclile aCli\·ity is m.lintaincd with c1cctric<.11 stimulation. IIl· 11 Thereforc. either p.lssive stretching or maintenance of contractile activity in immobilized muscles can prevent muscle sh0l1cning and connective tissue proliferation. Shortencd muscles that have becn immobilized require about 4 weeks of treatment to return to their pre-immobilil..ation lcng[h. lU Muscles stiffncss in response to streich varies on the basis of intrinsic molecular propcrlies of muscle fibers. Muscles that are kepi still increase their stiffness twofold in just a few minutes.l~ Conversely. oscillations and isometric or eccentric muscles contractions all reduce muscle stiffncss. I~"L\ :This plasticity of muscle fibers in response (0 passive or active movements is described ~IS thixotrophic behavior. This lhixotrophy relates [0 changes in viscosity and resislance 10 deformaliOlI of the intrinsic molccular make-up of muscle fihers that result from shaking or slirring motions. Both intrafusal and extrafusal muscle fibers have thixotrophic propcnics. 14 Thixotrophic bonds are thoughl to occur between actin and myosin filamcnts. 14 .15 Such bonds or cross bridges form casily in muscles. According to Hagbarth. "After stretching or passive shortening. it may take 15 minutes or more before muscle fibers spontaneously return to their initial resting Icngth."14 He also statcd. "Strong iSOI11clric contractions and muscle slretching maneuvers arc likely to dissolve preexisting actomyosin bonds and thereby rcdul.:c lhe inherent stiffness of the cxtr.lfusal muscle fibers."l~ stabilization. The HR technique involves isometric resistance and is u.•.:d mostly for pain relief. Used for relaxing and stretching tight musclcs and related soft tissues, CR incorp{)~ rates isotonic resist:.mcc and l1lultiplanar (usually diagonal) movemcnt. Both "lgonist and •, Fig. 11.3). The MEP were developed by o,teopalhs as allernatives to thrust manipulation procedures for restricted joilll mobility. In these cl.lscs. the usc of fairly gentle forces arc required. 1lley were also used on muscles in a way similar to PNF. In Eu·rope. milnual medicine physicians soon began expcr~ imcnling with Ihese methods. Gaymans and Lcwit~ wrote ofsuccess when using these techniques in an extremely gentle fashion. At first, they used the rhythmic stabilization appro~\ch borrowed from PNF. Latcr. Lc\Vit~ focused on the HR approach. He found that by positioning an overactive muscle in a full stretch position and then resisting a gentle isometric contraclion. exccHc.. ~ ;;dilAz.tio;~ und an improved resling length of the muscle could be achieved regularly. Lewit lcnncd this approach postisomctric relaxation (PIR). Gaymans and Lewit4 also incorporated specific eye movements. asking the patient to look in the direction of contraclion and then in the direction of stretch. For most muscles. breathing in facilitates contraclion, ..md cxhaling aids relaxation in the overactive muscle. Lcwit believed only the gentlest force was requircd.~ Janda used HR with signilicantly greater forces for treating true muscular and connectivc tissue shortening. Ii This adapt ) .) J ) DIFFERENT METHODS Proprioceptive Ilcuromuscul Table 13.1. Manual Resistance Techniques Pcoprioceplive neuromuscular lacifilalion'C. Hold-relax Contract-relax Rhythmic stabilization Muscle energy procedures,) Postisometric ee!axation~' PosUacilitation strelch 11 I -' ... ' , , , " , ""-"'V'--". ,' ..,,"', nl~V"" ,~.., '- , , , :,lrCII,:hing for spon D S sll'L'IL'hingl; Callil'l:". llsing l1l11dilil't1 rhYlhlllic ~[;,hilil.ati()ll: and LiL'bC'llSnll ..",': ll~illg ;\lo."livc lllU",eh: re1;\.\;11101\ lechniques. The various ~Hrf :11\' Sllllllll;lril.cd ill Tab": 1.,.1 " , "",'-', ' .' . Table 13.4, Goals of Manual Resislance Techniques Muscle inhibi tion· relaxalion/decontraction Muscle stretch Fascial stretch Muscle lacitita,lc~ Joint mobilizallc,n CI.ASSIFIC\T10N OFTI!;ItT Olt TENSE \1l!SCI.ES i, :\lo."lo."unling to bllda. il is p{lv,ihk hI divid\'" lIl11sd~ hYPl.·r· tOil icily inhl a vOlriety of diffl.'rCnl lrC;llllll'1\I·specilil' l';UC' g{lrics.:· ;"ll1~de dysfullction i, typic;dly ;111rihul;,hlc tu cilha neuromuscular or Clll1nCclin.~ li~SllC r.K(Ors. Dilfcrclll Iyp'-'s of dysfulll:lioll include rclk.\ ~paslll. il1lCrneUHlll f;ll,:ilitati\lll frolll j(Jint llysfuIlCli(lll. trigger pili Ills, cCllIr;,1 nel'\'\HIS systcm inl1ucllccs (i.e.. limbic ill\·o]vcmellt). or gradual uvcnl~"':~ (Tahlc 13.2). For a full discussion of tlll.,:se diffcn':111 rilctor~. see Chaph.:r .::, j\...1akill~ a precise asses~mcm of soft lissuc fUl\ctiol1<.l! palhology helps to guide thc trcatll1cllt dC'I~loIHnakil\!.! process. In the c'lse ur mu~clc tightness <.Ir tension (T "" ,J -, I, -~ I ~ i, , '--1 , ) •, , ) ,, ,~, ~ I CLINICAL '\1'1'LiCATION I M~IlHl:lI1\' rC''1sted exercIses arc the perrCl'1 bridge to ~lcti\'c carc because thcy take place in the lreatment room •.Illd the doctor providC's appropriate resistance to specific movements tlmt are being trained. Whcn pcrforming rvlRT, it is hcl pl"u I 10 realize that although many different namcs Iw\'c been used for different techniques (PNF. i\,1EP, PIR, eIC.). there arc certain common clements to successful MRT applk:Hioll, The MRT involve isometric. concentric. or eccentric COIltr:IctiOllS. They arc used to relax muscles. stretch muscles or fascia, mobilizc joints, or fucilitatc mllscles. The clinical indic:ltlollS for these methods arc summarized in Tuble 13.4 ~ :; 1: c-; - -~ j' :~ i§ , :'§ ~ i ) I I Table 13.2. Classificalion of Tight or Tense Muscles Neuromuscular Reflex spasm Interneuron Trigger point Umbric .) ~) , ~ 1 1 ~ ~ Type J ,j ~ Table 13.3. Specific Treatment for Differenl Types of Muscle Tensionmghlness l~_.J" ~ l Rellex Interneuron Trigger point Limbic Muscle lighlness , '''~ -~ -J.• ~ Connective tissue Overuse muscle lightness :'_.--1 1i I• dysjifllCf i01/. 1I1'1'Iyillg M RT may re.m! t ill iI/eli reet mob;!;:llIiOfl l?f' a joilll or at least make (11/ mljltSfmellt ",On: comforrable C//IClloflg-laslill:: for fhe plltienr. Thll.'i, their mai" a/,p!icar;(m i.'i ill dirc('f {/Hlilllellt of fire IIlf1sclIlar ('oll/Iument so as to 1.:11lranee the efficacy of jO;nf adjf!,ttmenfs. For both acute situations. which involve muscular guarding (neuromuscular tension or ··spasm"'), and chronic cases, which involve muscle and fascinl shortening (connective tissue changes). MRT serve as invaluable c1inic.allools. These techniques may be used 10 rcl'lx tension in muscles before thrust manipulmion. If, however, we desire to stretch shortened muscles or fascia. then chiropractic adjustments should preccde any aggressive stretching. Following an ad~ justmcnt. MRT can be used to reinforce neuromuscular reeducation. The MRT require activc patient participation and arc therefore les~ llkely thun p or *i I, ivl'lIlua! r~:-i~lancc h:chniq'!es havc bcen presented as altern;'lli\,cs 10 thrust manCllvers. but in the context of this chapter. they 'Ire :-C'(:11 primarily ~ J Cause (i.e .. remove appendix) Joint manipulation PIR or ischemic compression' Yoga, meditation. counseling PFS or eccentric MEP 'Abbrcviations: PIA, poslisomnttic rcla:o:alion; PFS, postlacifitalion strclch; MEP. muscle energy procedures. !W: .l.. cuI! to flnd an active movement that docs not provoke the symplollls. Th~sc posilional rclC'lSC n~clhods (finding a .r~.:ain less muscle or joint posilion and holdlllg lhere) arc a pamless and effcclivc means 10 n.::ducc irritability and incrcnsc motion in II pntient with soft tissuc p'lin. . . The MRT and Spray .ll1d Stretch have sundar goals and may be used interch:lllge,.lb.ly. ~~oth arc consi?cred alt.ematives 10 dry needling and IIlJccllon of anesthetic for relief of painful trigger poi:lls or rcriostC.11 auaciuncl~1 poil1l.sJ-I Spray and Stretch is p The thrust of modem management of chronic pain is aW::IY from passive therapy (physical agents) and toward active patient involvement in the rehabilitation processY~1I This focus does not c1iminmc the role of passive thcrapies. bUl rather dir~cts patiel1ls tml,'&lrd functional restornlion in nctivities of daily Jiving. The MRT &lrc ideal bridges between passivc and active carc. To summarize. when wc lind an abnormal restriction of motion in a certain dircction. we have encolJlllered a pathologic barrier at that point of resistance. This barricr may rcsult from joim blockagc. muscle shortening. or II combination of the two. Manual resistance techniques arc one approach 10 eliminate this barricr and to restore normal r RULES FOR APPLICATION \Vhen using MRT. Ihe more specifically we can facililiJ(~ contraction in Ihe dcsirt:d muscle, the betler our results Will be. Table 13.5 summarizes some of the keys to 3chicving successful facilit:ltion. For inst.lI1ce. how the patient is prepositinned affects how easy or Iw,rd it is to actiV I .'"'1. , ·l ) l,;HA .... 1tH 13: MANUAL Ht:::SISTANCE ANl) ::it::LF-STRETCHES t-OH IMPROVING FLEXIBILITY/MOBILITY Table 13.6. Safety Rules Stretch over largest. most stable, least painful joint PI<.lce joints in Mloose packed~ posilion Avoid uncoupled spinal movemenls Do nol streIch nerves. it iuitaled ~ ~ n:t:tioll or ~kv;ltiOI1. Ouring relaxation ;1l1t1 strctch, we take out the s1;l<:k o\'~r Ih~ larger, more stabk shoulder and avoid taking out slack ill (he neck, ex.cept perhaps in ncxion. AnOlher ruk is to avoid stretching related SlrUCLUrcs, such .IS a nerve root, if il is irritatcd. N Hopefully, every clinician kltlJ\vs not to streich the hamstrings if the sciu.tic nervc is irriwtcd. Another simil:.tr arC;l is the femoral ncrve anti rectus femoris. or the br;lchi;11 plexus, which C:.lll be stretched when ;utcl1lpting to stretch the scalene or subscapularis muscle. T"lb1c 13.6 summarizes these import:.lnt safety tips during slretching. How wc "wind-up·' the muscle, in other words the order wilh which we lake out the slack in the different movement dircctions (rot;llioll, Ocxion/cxtcllsioll. side bending), dramatically :.liters when the p;lticnt fccls most of the streteh.~o,l Playing with this v;'lri:.lblc allows for bcltcr isolu.tioll of the relevant tissue. Most people use too great of force when they lirsl begin to usc MRT. According to Larricq, the forces used during MRT should be "as little:.ls possible for as long as neccssary:'~'1 According to Lewit, the time of the contraction can be lengthened for up to 30 seconds if inhibition is h:.lrd to achieve.~ Whether to adjust joints before or after MRT is a common question. If significant joint restriction is encountered during attempts to stretch, it is crucial to adjust the joint first. Otherwise, adjustment is easier and thereby requires less force if we wait until :.lfter the contmctilc clements have been relaxed. Different ways to improvc MRT results ;lre listed in Table 13.7. j i ~ ) JI ~ l i 1 j j 1 ~ < I , I~ J I, " ,*? '"", i'" -11 ~ ~ ";; .'" -~ li y, $ ,~ .~ I I ~ ,) -;.,.<-~ , it '\-,~~ I, ~.J I• u -~ ~ i I ~ ~ Success wilh Ihis method depends on precise posilioning of lhe body part 10 isolale lhe lense muscular bundles involved. Il is also essenliallo lake out all the slack in the muscle and to stay at lhe end point of the available ROM throughout the procedure. Indications for its use include increased neuromuscular lcnsion (i.e., trigger points) and joint mobiliz:.ltion (gentle). A second valuable MRT, particularly for patients with myofascia1 shortening (viscoehlstic stiffness), is postfacilitntion stretch (PFS).11 Tl,i:'> ,','ldIl0u ilhl)lve~ the following steps: Postisomctric relaxation (PIR) is one of the most useful MRT. This method is Lewit's modification of the gentle. indirect isometric MEP that osteopaths applied to joints. s It is also similar to hold-(clax. The main indication for PIR is relaxation (decontraction) of a hypertonic (contractcd) muscle. Posti~omctric relaxation is the preferred method if the patient has difficulty relaxing or you simply want 10 use a "soflcr" ap.proach until you gain the patient's trust. It is ideal for trigger points, joint mobilization, and neuromuscular tension. Postisornctric relaxmion (PIR) involves the following simple s(eps:~ I, li 3. Having "let go" and rela,.ed fully. the musclc is slowly, passively lengthenLJ toward a new resting length as far as relaxation wilt allow. 4. Without b;lcking away from the new end point. perform two (0 four 'ldditiOllal rcpclitions. 5. If rdu;atiun is nut achieved. tf)' the following: • Be slIrc the palient hrcilthC5 ill during contraction phase :Iud exhales during rcl;Jxation phase Fur most (< SPECIFIC I'ROCEI)URES ) • oj I. Passively Icnglhcn lense muscle 10 a point JUSt shon of pain or where rcsist.lOee to movement (barrier) is feh. Avoid bouncing. 2. Have palient gently contract lhe ovcracti ....e muscle away from barrier fur 5 to 10 seconds. 'ntis movement should he resisted with equal cuulllerforce. creating an isometric cOlltr.lction. For most muscles. the patient should breathe in while contracting the muscle. C) , N , '4 l, :g Jr ~ ;; !.. 257 .••._...•.... _------- I. Place shortened muscle in a position approximately midway between its fully approximated and stretched positions 2. Have the patienl contrJct isomelrically with m:.Lximum effort for 7 to 10 scconds. and resist this movcment to create a nearly isomelric eOlltmction 3. When the patient has "let go," perform a quick stretch to the final end point (:lv()id bouncing) :U1d hold for up to 20 sl:conds 4. Allow the p.llicnt to rc!;\x for 20 to 30 seconds 5. Repeat three H) live times 6. Inslruct the patiellt 10 perform an activc RO;\t l.'xl:rcise lhrough lhc new r;mge After pcrfomling PFS, \V30l the patient that feeling wannth, weakness, burning, or tingling in the :,tretched tissue is normal. An appropriate series or such stretches \,.'Ould include six visits over a 2-wcck period. [n PNF, two of the most famous MRT arc holti·re{ax (HRl and contract-relax (CR). The former invol\"t~:' positioning the patient in the stretch position Jnd pushing ilHo the "barrier" of resistance while u.sking the patient lo hold. Thi~ step encourages an isometric contraction. After the rc~i~tcd contraction. Table 13.7. Ways to Maximize Results of Manual Resistance Techniques up" muscles 10 maximize isolalion Slart gentle and add (orce only if necessary Increase contraction lime up to 30 seconds Adjust restricteQ joints first ~Wind ...., SELECTED Table 13.8. Matching Therapeutic Goals to Manual Resistance Techniques Techniques' Inhibit Muscle PIR HR + + CR + PFS Eccentric MEP Stretch Musde + + + + Stretch Fascia ~IRT PI~(}C:~ntJI~ES Manual resistance techniqu~s can be used for a "ariet)' of purposes. Thc)' Jorc ahcrnativcs to adjmamcnls or soft ,issue work. The)' ,Ire powcrful facilitation and strengthening techniques. They ar~ most famolls. howcvcr. for tht'ir Mobilize Joint ... + + •.. 'PIA, postisomctric relaxation; HA. hokl·relax; CR. con\racHelax: PFS. post facilitation stretch; MEP, muscle anergy procedures. stretch may be increased either actively (by the patient) or passively (by the doctor). When performed actively. the patient is activating the antagonist to move toward the restrictcd barrier. This effort engages RI. which inhibits the tight muscle even more. When performed passlvcl)'~ the doctor must not overstretch the tight muscle to avoid activating the stretch reflex, which would only increase the tension in the muscle and defeat the purpose of the eOlire exercise. Con'r"ct-r~I;lx involves laking out the slack and then commanding the patient to "push against mc" or "push toward.... (an objcct or t PIR Procedures for Muscle Relaxation and Stretch The format for this scclion is designed for casy clinical 'lppJi. cation. Rei:ldcrs arc encouraged tu rdcr to Chaplers 5. 6. I·t and IS for morc dct:.lil rcg;lrding spcdlit.: te~;(s. rclmcd strengthening exercises, or treatment protocols. The following hendings are used for most ()!' the musdcs described: Referred Pain: Location (If pain cmnpl:lilll Clinical Result of Shortened Musclc: Relal~d dinic.:allimtlngs Activation or Perpetuation: \Vlmt activ:l1cs (l( pcrpctu,lICS trigger point Obscr\'<Jtion: Postur..11 analysis Triggcr Point: L(X,;;\tio!l Pcriosteal Point: Localion E\'alualion for Q·icr".JctivHy: How muscle Y (lvcr:lCtivily w(luld be seCIl E\'aluation for Muscle Shortening: Test fur muscle tiglllllcss Joint D)'sfunction: Rehllcd joint dysfunctioJl Corrective Actions: Exercise Other MRT Stretches Self-Stretches HAMSTRING (Fig. 13.1) Referred Paill Lower bunod: to upper c:lIf Clillical Result oj Sltortelled Muscle Recurrent pulled hamstring::- /\cti,'atioll or Perpelllatioll Compensation for weak glutcus maxinms Compression of posterior thigh from a chair that is ton high Being in a shortened posilion from prolonged silting .J Trigger Points Midhdly .J Periosteal Points Ischi:J1 tuberosity Fibular head (biceps femoris) E"alllati(JJJJor Ot·erar..'ti"ity Knee flexion during prone hip extension tes! per d3)' 7. Aftcr stretching. actively contract the muscle and move it throut!h a full ROt\'1 a few times "", EI'allilI/iQil Jor Shortenillg Strai~ht leg rai~illg tcst (If less than ~O" CHAPTER 13 , MANUAL RESISTANCE AND SELF· STRETCHES FOR IMPROVING FLEXIBILITY/MOBILITY 259 Stretch 10illt !)ys!uflctioll 15·SI • Flexion of hip while m~lintailling knee in extcnsioll /:ihtll"l" hl,.';\d C:"n'('din' Action I::ll·ililal..: {Ir "'lrl·Ilg,!..h;:J.L!J.~ ~hll":U~.!t!~~\illltiS :\\oil! prnllllt,::..:d ~iHin~ COl1lmelll Care should be t"ken whenever stretching the h:lIl1strin~... that the sciatic nayc tcnsion tests (Lcsaguc's tcst or Str~i~ht Leg R:lising lest) ar~Jlcgativc. Also. in lhe casc of lumb;.u- j\")int irritability. :he opposite hip and knee Illay be Ilcxeli h) rl'dllt::~ strain on the lumbar spine. Other iURT Stretches. Additional hamstring PIR procedures arc shown for the medial fibers (Fig. 13.2a. L lateral fibers (Fig. 13.2b). and the one joint hamstring-the biceps :H NT .'·trctch PI/tina /'(I.\·ir;/I/I Supill": llip Ikxcd ;1110 kllcc I.:xlcl1lkd 1l1l involvcd limh Slal1lling Oil ,id.. . of tr.. . aling limb C.... pllal.ld hand proximal 10 patdlac maintaining. kncl.: in eXll.:n~iu[\ 1';\lil.:lIl's h,.-g ,upportco 011 doctor"s shuulder or ill crook of dbuw to pu"h kg down IOWi.m.lli.lblc Effort i~ rc!'>i~tcd by doctur 10 keep cOIllr.lctinll ;IS close (0 isometrit' a:- ptl:-~ihk Alh.:mpls femoris (Fig. 13.3). Self-Stretches. For hamstring self-strelches. the back mu Referred Pain Groin. inner thigh. ~Il\tl.:ri()r knce. ;lIld shin Clinical Result of Shortened Muscle ~ .. ~ .• Hip or ,,;wrniliac di-.;ordcl's or medial kn.... t: pain "). Diffkulty wilh squats ....;. Difficulty \"ith activation of gluteus mt:dius '; Activation or Perpetuation Hip arthritis. horscb;ll.:k riding. hill nl1lning. st!tkkn ~... \'t.~r1oad (slipping) Trigger Poillts Muscle belly Periosteal Poil/ts Pubic symphysis Fig. 13.1. Hamstring PIA. • Tihi;t1 tubcrdt: (pes Fig. 13.2. Medial and lateral hamstring PIA. ;1Il:;.... rinu~) (two j{lim ;Idductors) .. ,_ .••.••,... ..... ', EI'!ll!!~!f!.':: ,v,~,-n.;;) IVII-\I,/UI-\L ,, ,, for .':I::::·tL·llillg Wilh p;llil'lll :-upinl.:. ahl!ul..·1 llli~ll Wilh ~nl.:l.: olL'ndl'd (l\Ilrlllal is 4(0) Fkx kl\~c ;\llli ;lrdllclion :dl11uld itl~·rl..'as.c s.lig.htly )o;"t !)ysjllt,ctiotl Hip joinl '\ M NT ."(rctch: Supinc PaticlI! Posirioll Supinc Leg ;lbduc(cd (knl.:c Ih: . . . cl! or ~Xll.:llllcd to i.·'Olall' mJductu(s., n:spccti\'c1y) until rCs.i~t;\IIl.:C is fdt Opposite kn~1.: i:- bellI (Ill\..' or 1\\'(1 joinl , J [)oClOr Po.\-;tio" Swnding with Fig. 13.3. Biceps femoris PIA. on~ leg hl:twcl:n P:JliCIII"s ahduc[l'u thigh and lhl' table PariclI! \ Actin! E!fort AllcmplS to ru~h lhi£h inlo mlduClion Effort is resisted by doClor's leI; [0 keep conlractioll:J~ dos.e to is(I- mctric as po;;siblc Stretch Doctor lhen takes out slack intn further ;ltldw.:lilll1 MRT Stretch: Side Lying Parietlf POJirion Side lying invoh'cd side up Nontreated leg bent at knee and hip Thigh abduclcd (knee ncxcd or eXlended 10 i:;olate nile O( l\\"ll joinl adductors. respectively) lIIuil rcsismnce is felt ) () Fig. 13,4. Hamstring sell·strelch, Fig, 13.5. Hamstring self·stretch. \3 vM"~ I eH '" : MANUAL RESISTANCE AND SELF-STRETCHES FOR IMPROVING FLEXIBILITY/MOBILITY , .- .- _-/... ~ -.: ~rY~~ , Fig. 13.6. One and two joint adductor PIA. Fig. 13.7. One and two joint adductor PIA. Self·Slrelelles Doctor Pos;lh", Standing behind patient Abducts p:llicl1l's Ihigh. caudal hand hooking 11lldcr patient's kllc~' Cephalad hand SI Self· stretches ilrc shown in Figure 13.8. ILIOPSOAS (Fig. 13.9) Referred Paill "otie"':.. AClin' Effort Attempts 10 push thigh jilin adduction toward table Effort is resisted by doctor's caudill arm ((l keep contraction a... c!(lSC 10 isometric as possihk Slreleil • Doctor lhl'" Low back and s'lcroiliac joint. anteriur {high Clinical He.mlt of t.111scle Shortelling Poor hip extension Forward-druwn posture Difficulty with posterior pelvic till Activation ()r Perpetuation lakc~ {lut sl;lck inln further abductiol1 Recenl irllCfvcrtchral di~k syndrmnc 261 ••• ~ ~ . . . . . . . . "'" • .-.1"\ ..... , I ' ,v",~n ~ I'II',...I'IVI-\L ~ .,. , , • 'T,'. ''!, Fig. 13.8. AdduClor self-slrelches. Correc/il'e Action SW,ly b,lck (pSO;\$ must act ,IS a checkrein) Prolonged sitting Compensation for weak abdominals Avoid prolollg~d ~ilting Facilitate ;lIld :-l~ngthen abduminals Sln:teh cn;Clnr ~rinac Trigger Points MRT Stretch: Supine Anywhere in muscle belly Evaluation for Overactivity Pmh'lIt POJir;oll Sllpine Lumbar spine Ol.:iy be latemlly flexed away from psoas Contr.llalcral hip and knee held in full flexion against chest Involvcd hip frcdy extending off end or side of wble (prefer-lolc with table height of al le,lst 40 inches) lmlbility to keep heels on floor during kncc bem sit-up Eva/ua/ioll for Shortelling Modified Thomas test Patient pulls opposite knee to chest Allow tested Icg to extend off table Posltivc (cst if hip raises without knee extension (tigtll rcctus femoris) or abduction (tight TFL) Doctor PO.'iirirm Al ~;\lne ~idc of l:Jblc as invulved limb or al end of table One h'lml IwlJ, cnntral;\tcr:ll knee to chest. thereby stabili1.jn~ pelvis Oth~r h:llltl t:olll.:in:- proximal to knee or eXh:nded leg Joint Dysfunction TIO·L1 Pari£'1ll \' Actin' • Rai~cs [:.:flo'" involq::d thigh up towmd ceiling ) Fig. 13.9. Iliopsoas PIA. Fig. 13.10. Rectus lemoris PIA. ..... ' ,n,' ll::n l~. IVl""~VI"\L nr.:.~l~ If\NLot: f\1\lU ~C:Lt"-~ I He I LoMc~ ~Ur1 lMr'HUV1N(,:i t-U:XIBILII Y/MUI:UU 263 I Y ::: :hc attempt to tak..:: -.:!lthc lordosis out of lh~ lumbar spint:o Somelimcs. it i" l\L'n''' ... ~:ry 10 perronn trat.:tillO or PIR mobilizalioll Oil thc \Jppl1sile hlp. 01' PIR on Ihe ilior'l~:.lS or adduclOrs 10 IOOSClllhl..'llip suflil·i ...· IUly In allow fur full hlp flexion. Ot1w,. MRT '\Irt'/t:},cs. Ollter rc1all.:d hip lh.'~or PII{ pm· ("l'dures illdlld~' Ihl.' reClus r"':llll11'is (Fig. l~.l(ll alld pI"11i1:..· iliopsoas (Fig. 1::'.11 l. For the prom: iliopsoas. thl.~ hip . . !h11lId be internally r~llJtl.'J and Ihe spine laterally hl.:llt away. C·,tl"l.' i~ needed to avoid :Jbductillg the thigh. This pn1(cdurl' I' Pl'!'haps lhe most :-~cilic iliopsu u;:~!nn ::~ay r;"~lr.;::-;: "b;:;,::';'i;j~ ,~f:" Self.StretclJes. When performing self-stretches ((lr Ih~ hip flexors, the patient should feci the strctl..'!l in the alH('ri(l1' hip or thigh and not in the low back. For the iliopsoas. better stretch is accomplished if the patient holds a posterior pcldc tilt and internally rotates the hip while stretching (Fig. 1,...... 1~). The reclUS femoris stretch requires some knee nexion t Fig. 13.13) and ;l1so benefits from a posterior pelvic tilt. To enhance pso:!~ i~olation. patient tolt! to sistance orfcred by ther ~tlpin"tc fool against n,:. TENSOR FASCIA LATAE (TFL) (Fig. 13.14) Referred Pain L:IICf:11 :1~Pl;'ct C);. .~·,,.~;r(·/, Clinical Rewll of SllOr/cncd i\1uscle Once patient ha!> fully relaxed. doctor takes up sl;lck by extending hip to its new cnd point while sl;tbilizing opposite side Co/llmenl Knee extensor mechanism disorders Sacroiliac problems QL myofasc:ial di"orucrs Actimthm Palients orten complain of discomfon in the fully llcxed hip (the onc not being stretched). which may bt: provoked by the passivc o\'crprcs~urc rcquired lO nallCn the low back. This sit· Of .._._ . --_._-_.._. Perpetuation Repetitive' strain frum funning LHeml pelvic ...hi!"1 Forcrunt inslability (ex.ccssive pronation) Pro!ongeu sittinf wilh hip too ncxcd Cmnpells:llinn u, :1 wC;lk gllltcu~ l1Ieuius Fig. 13.12. Iliopsoas self-stretches. L thigh III knee \) I.--~~ ,i J ,''1: , ,,' Fig. 13.13. Rectus femoris self-stretches. '~ I -' Trigger Palm Superior or mid porti(ln of muscle Observation Groove presellt in iliotibiJI b~ll1d Ll1cral dc\'i'Hion of pafdlac EvaluatiolZ for I, MilT Streich ! Pot;elll Po.\';r;OI1 Side lying. invoh'cd ~i(.k up NOlltrc;\tcu leg hem at knee ~lrlcJ hip Thigh addllctcd behind patient unlil rcsisl~IIU;C is felt O~'eractil'il)' Hip flexion during hip :.lbdUClio!l (gIU[Cll~ medius) test El'aluatioll for Shorteuing /)oc[or Po.\'ifhm Sl~lndillg behind pali~nl patienl's Ihi~h with caudal hand a!:x)\'c kncc Ober's (cst Addll<:l~ Resistance to addllction of thigh Cephalad hand stahilize, pelvis 10illt Dysfunction Sacroiliac joint Patdlofclllor.ti joiut Corrective Action "Short fool" cxcrcisc~ Foot orthotics racilitatc and strengthen glutclIs medius Patient\" Acri\'" 1:.1Iorr Attcmpl\ tn push Ih;~h ill\o ;lbduClioll 1tl\vard ceiling i~ n.:sistcd by d<.Klor's c;lmlal !l;l1ld to h:cJl COtltr;lL'tiol1 ;IS c1(l~C In isollleiric a~ po.."iblc Eff(.Jr1 '-'; Strctch Doclor then takes out ~Iack into further adduction Other MRT Stretches, The TFL C Referred Paitl Posterior thigh. buttock. and sacroiliac joint Clinical Effect of Shortelled Mllscle Fig. 13,14. Tensor fascia latae PIR. Sacroiliilc disorders Entrapmenl neuropathy fst::i;llic ncrve) • CHAPTER 13: MANUAL RESISTANCE AND SELF·STRETCHES FQR IMPROVING FLEXIBILITY/MOBILITY 265 ._------'= :\tNT Stn'tdt Pp,it;o1/ J'{lf;I'1/i SUpilll' llip Ik\,:.! ;.hl'"1 -1;," (lIl:t.\illllllll of ()(J"J I\.lll·l' th:\l'd ;11'11111 \)l)" SI;tllliin,:: ) Fig. 13.15. Tensor fascia [alae PIR. () .1Il1ll\tlh .... d :--Id•.: , f;ll-illg paticn( CCl'hahtd t"orcann \111 paticll!" thigh SUpplll'h:d hy d{ll·({lr·~ dlc!'ot Ccphabll 11;1111.1 pllslws Ihroll~h knce. down shaft or femur Dnctur [lll,hc... pallcnl's thigh inlO adtlllt..'ti(lll Caudal !l;llld gra:-.ps paticllt's calf or ankle and produces internal nllallllll i i' Push.:" thigh outw;ll·.. i inhl dodll!"':,> c.:hc.:"l (al"luuIUlli Also pu\hc\ I(lwcr Iq~ inward in Ilppl)sitc din:c.:ti\lll.l·r.... a(in~ an ex· ! J ternal wt;.lti(!/l furce ) Stretch Once p,lliclH has f\llly relaxed. uoclor ;lddllCIS ;lllt! im.. . rnally roo lates P;lIiCIII'\ thigh iii ,I IWW c.:nu point ) Other .HNT ,\·/rett:hc.\". PIR can also be performed on the piriformi:-- supine in adduction (Fig. J 3. J7a), in full flexion with lhe hip externally rol<:llcd (Fig. 13·17b), or prone (Fig_ 13.17cl with lh~ knee flexed 90". Selj-Stn:l<:JH!S. Self-stretches for the piriformis are possible in a \'aricty of positions (Fig. 13.1 R). Figure 13.19 shows a strong posterior hip capsulc streIch that also addresses piriformis shortcning. ) ., j Fig. 13.16. Piriformis PIR. () ) QUADRICEPS /\ctiJ'at;oll or Perpetuation Short leg Long drive with hip flexed OJnd 'lhductcd C(lll1pcn~ali(ln for we,lk ~lU1Cll'" medius , ,.. ObserWllioJJ fouul lurnc(J ) (lUI in :.I'lIIdinJ; pusture TrigKer Poim ~'lus<:lc ) helly l\.·-lllscul'lf guardillg elicited on light p'llpation over sciatic nOIl;'h h"wlhwfioll for Overaclil'ily !-lip c:\lcrrwl rotation or pelvic rOlillion during hip abduction teus mediu!'» tcst (~Iu· Evaluation for Shortening (J Palien! !-upinc. flex hip less ll1an 60°, Apply compressive pressure IhrUll!;h femur tu hip. and mJducl fully: fecI resiliency to internal wlatiun of hip ') Joint Dy.~fll"cliall L4-L5 am! sac.:roiliac joilH ,.....J\ Correct !'ohnrt fOOl Carrective l\ctiOlI Improvc chair F;11:ililalc l) b :-lrell~lhel1 gltlh:US lllcdiu!'o Thc quadriccp:-- is morc commonly weak than i( is tight. Ortell. n:clll . . fl.'llloris tighillC.. . S is mistaken for quadriceps tightlll'S\. \\'cak ljlladriccp.. . typically kad iO stoop rather than squat lifting lcchlliquc, which leads III lumbar O\·l.'fstrcss. Squats ;101i lunges arc the most fUllclional exercises for training the quadriceps. Postborlll:tric I'daxati()ll on the quadriceps is l.'asily perhlrnlcd while PH)ll\.' (Fig. 1.1.2(»). Tllis pro<.::cdurc is like the fcmoral nerve strc{l:h tcst ill that if the ilssol:iatcd nerVe is compromi\cd. thiS strctch i:-- contraindil:iltcd. Self-stretch can be aided by the tlSl,; of a belt looped around thl' fOOl (Fig. 13.21). Self-Pm. l:all l:asily be' ac<.:omplishcd with this mcthod. GLUTEUS MAXIMUS Stretching Ihis prim,lry hip extensor is orten 110t necessary. except for those lndividuals in whom this muscle is very light. The PIR techniClllc is also a good way to facilitate this muscle for (raining with posterior pelvic tills. bridg~s. and other strengthening cxcn.:ises. Self·stretching is per· rormed .il"t like (ht: Ir;ulition;a) Williams cxef(:i~l..·s (Figs. I ~.22 ilml I ~.2:\ I. nCnnl,.Jll-.' Inl IV''1 u r ,nc ,;,rll'lc. n 1IIIUI'lCn,;, IYI ..... I'llVnl.. B A c r n .... v Fig. 13.17. Piriformis PIA. Fig. 13.18. Piriformis self-slrelches. . . _..- ._-------------------------=. CHAPTER 13: MANUAL RESISTANCE AND SELF,STRETCHES FOR IMPROVING FLEXIBILITY/MOBILITY 267 , I !,, • ~ j ! , ~ " I 0' Fig. 13.19. Posterior hip capsule and piriformis sell-stretch. '- .." I I Trigger Polms Bencath erector ~pin:le l1luscic \;llcr;lIIO tr:.lll$Vcn.c processes Best to palpate with patient side Iyin~ II , -; Periosteal Poiws .•, lIi;IC cn:!'l aHachm\:llI I EJ'lIlu(lliml for O,'cractivity 011 hip ;llxlu,;\ioll fn)lll sidt: lying POSillt1ll. monitor for early pelvic c1cva\ion § ;~ fu I I EI'(l{U(ltioll for Shortcuing , St:rccllill~ le't: si\h: I~ in:; patient r.lil'l.'l' tfunk lip \\'itlt hand or foreann tllll.h:r .. hmlllk'r. P\lsitive result i:, ;lhsellCc of smooth COllvexil): of lumhar Spill\.' \\1w;1fl1 down side. "j I J joi"t lJy...ftmc:timt i';: '1'111,1.1 ~! Fig. 13.20. Quadriceps PIR. I , I HIP INTERNAL ROTATORS PRONE .I Postisol11ctric relaxation for rC~lric!cd hip external nH,uioll i... similar to the prone piriformis technique (Fig. 13.24). The pelvis must be firmly st<.tbili~cd during this procedure. \.) ,*.', OUADRATUS LUMBORUM (OL) (Fig. 13.25) :v '~ Referred Pain !! i.J ~ 't ~ > • Ctlrrct:t Illlkn:1 pd\ i.. when .. ittiu); F;lciliw{c (If strl'n~!h\.'11 ghllells medi\l:' Te;ll.:b proper liflil\~ 1\'l,,'hlliqllC MRT Strelell Porie,,' 1'0,\';1;011 Side lying. lnvolwd side down Pdvis {lH:kcd so 1\1['S\1 is slightly Hl!;\{l,:d hack ward 1lips and knccs 11..':\\.'\.190" wilh ankks \'wsscd Lah:ral fibers-iliac cresl and laleral hip Medial fibers-sacroiliac joint. deep in buttock ; "'..I Clinical Result of ShorICllccl/Husc!e I, () Low back pain Ill.:rpctuatioll or sacroiliac di..,ordcrs Abnormal hip hiking during £;,tit 'if .~ Activatioll or Perpetuatioll ~ J ~ Lifling \\'ilh tnmk Iwisled I \.) Su:"taincd OVCrlll;\d as in ·m ~ ~; ,~ ;.. " N i I l .,', I Corrective Action 11:); ("iIlTCl,;\ .. hon i , g;lrdcll;lI~ Of working in sl()(lped pusition Fig, 13.21. Quadriceps self-PIA. Mt:n .....CILIH\lIVN Ut" I Ht: ::it-'INt:: A PRACTITIONER'S MANUAL \ Figs. 13.22 and 13.23. Gluteus maximus self-stretch. Clillical Effect of Shortellcd Mllse/e Low back pain Inhibition of abdominals Activation or Perpetuation Postuml overstrain (sustained slumping or stooping) Sudden overload when lifting with hack twisted or Hexed Compensation for weak or il~hibiled gluteus mllxililllS Observation Increased lordosis Muscle hypcnrophy at 11lIubosacr.11 or Ihurac(llulllbar junction Trigger Point Anywhere in muscle belly Fig. 13.24, Hip inlernal rotators PIA. Periosteal Points 'Spinous processes of L4-S 1 Doctor Positioll At side or table. facing patient Doctor gr~lsps patient"s ankles. raising them Patienl's thighs rest on doctor's caudal thigh. Cephalad hand rree 10 palpalc down side ercl.:lllr spinae muscles for contraction Evaluation for O~'eractivity During hip cl E,'aluatiolt for Shortclling F:lilure of lumbar lordosis to n::\'crsc on lingcrtip 10 floor tcst O!" Sit Patiem:.. Actil'(' Eff0l"t and Reach lesl Pushes feci down tow..ml lltl{lr Arter c(llllr;.tl.:ling QL for :lpproprialc period. is go" or rdax cllc()~lragcd \(I "let Stretch J Pelvis in lUckClI position Hip flexion and degree of pelvic tucking may need to be modi lied 10 isolatc 1m\' back muscles during bOlh colltmclioll ,uld slrelch Other IHRT Stretches. A light or tense QL cun b~ relaxed or stretched in a variety of ways. Prone (Fig. 13.26a) and side-lying tcchniques arc possible (Fig. 13.26b-d). Somctimes, it is diftkult to isolate lhe muscle with PIR, and intcrmiuent cold and stretch (formerly spray Referred Pain Sacroiliac join!. diffuse area in low hack. hUllock ------.---- Fig, 13.25. Quadratus lumborum PIA. J. CH,\PTER 13 : ',IANUAL RESISTANCE AND SELF· STRETCHES FOR IMPROVING FLEXIBILITY/MOBILITY 269 . j I i , I ~ 1 , .. J ") :i ~ i ,I () • i ) 1 -,, ""'.". \..1 l A c - ] ;;; ,• ~ ) f , ~ ~ .J '-'-=1 ¥ '" 1 ! -~ I• J t I , f, ~ () ~) Fig. 13.26. Ouadratus lumborum PIR techniques (a·d) and self· streIch (e). ,) .) ,} 3 < ! , .. () ~ .f. .~y I, ......J ~ ~ ~ f . "" " " ~) I !f ~,-J ~' ',:; { n .f ~ ,-". ') , 1 - D -; -::' .- - : v.~_ Fig. 13.26. (Continued). 'k.<.:t. _, ~- - . E REHABILITATION OF THE SPINE: A PRACTITIONER'S MANUAL c.,IU Up side ann h;1n~ill':; olltahk in I r\IlH Down side k£ ll~\l.'d at hip and kn..·c I'll" s(;lhili:t.;tlitlll Up side hip in sli,ght cxh:nsi(lll su to hang kg uff (1:n.::k Ill' lahk DOClOr Posirhm St;.mding ill fWllllll" hehind p:llit'lil Fixes pelvis at :lIl1erinr superiur iii:...· :-.pinc (ASIS, wilh IIllt.: hand Other hand (and furcilrln) tlkc:-. hnl:ld \..'0111;\1.:1 uwr up:-.idl.' lumh:ll' muscles Pulls ASIS Inward himsdf Ilr hl.'r~dr ;IIllJ rnlah:s lumhar ~pillc away (Icn rOlation) tu take up shu.:k (i.c.. eng.;lge barrier) ill muscle Patient :,. ACli,'e Effotl • Turns upper body backwards against rcsislance while hrc;llhing· ill (may Fig. 13.27. Erector spinae PIR. Streit·" Fingenip to noor distancc not villid for IUlllbar flcxibility bccausc of hip motion, hamstring tension. and rcl;ltivc lIiffercncc between ;Unl and torso length versus leg length joillt Dysfunction Segmcllt .It corrcsponlling Ievcl. c.~pcciilily L4~L5 and L5-S I Correc/;w:, "rtim, Strengthen abdominals Facilitatc or strengthen gluteus maximu:" Teach proper lifting tcchnique Strengthcn MRT Stretch Pllliellf Posilioll Side lying. inHllvcd side lip Down side arm back and behind paticlH Upper torso rowtcd forward After contracting erector spinae, palic:nt askelllo rdax am.! hreath\..' out Whcn doctor feds Illusclc has "leI gu," he or stll.' tal\es 11tH slack toward new barrier Otller A/RT Stretches. The ereclOr spinae may he !oilrctchcd u!oiing a !oiupinc lechnique laught by Jnnd'l l Fig. 13.28). or in the seated position (Fig. 13.29). Care is needed If stretching in flexion. be sure to rotate and side bend to the same side. If stretching or mobilizing in a neutral or extended position. place the patknt in rotation and siJc bending to opposite sides, Self-Stretcltes, Self-stretchcs for the low b~lCk lll11sdt:'s arc abundant (Fig. 13.30). A simple sclf-PIR technique is :llso an excellent way for .~ J , --t>, " ,]i o Fig. 13.28. Erector spinae PIA. ___ .---10 c;HAPIER 13: MANUAL RESISTANCE AND SELF-STRETCHES FOR IMPROVING FLEXIBILITY/MOBILITY 271 f)oC(orl'ositio/l AI sid..: uf (ahk nn invulved sid..: Cephalad fllrcarnl pusllcd :;houldcr backward (';nlll:tl It;IUd ;1Ilt! wrist pull pelvis rorward I l'aJ;t'lIl \- Aelin' qrurl RUI;I(C~ lorsn t'urwOlrd whik Illoving ElTon i... rcsi~h..d .~ hy p~h'is hackward 111l\:lol';o kCl:p cotllraeti\ll1 as dl'''L' til ISUllll'\· ric as possibk Stretch Once patielll has n.:laxcd fully. 1l0l.:lm 1Il;IY laKe sla..:~ (Ill I IowaI'd lIew harrier hy pushing should!.:f h:lek",;ml ami pdvi ... f\)rward POSTERIOR CERVICAL MUSCLES Referred Paiu Up (0 suboccipital region Down 10 upper shoulder girdle ForchC LUMBAR MULTIFIDI (Fig. 13.32) M lIT Stretch IJulielll j'lJ\ir;oll Side l~ in:; T(lr~\l nll,tled ha\:kw.\rd 1'..:1\+, n.lah:d f(1rw;lfjj Clinical Result of Shortened Atuscle "Short neck" or ccryicocranial h)'p~rext~nsjon Cervical headaches Dizziness of cervical origin Cervical zyg,tpoph)':-cal joint disordcr~ ,\ctimtioll or Perpetllotioll Susl,lincd neck (h:.:... i,·'ii '''':lik. rc.I\lill~ ;1111.1 writing FOl"wurd-l1rawn or slunpcd pos!lln.' Trauma (i.e .. whipl;lsh) Trigger Poillts Occiput, suboccipilaltri;mglc to C.l-C5 I.·. U i' ) {i ,) Fig. 13.30. Erector spinae sell-stretches. -_....... _------------_._-------_._--_.,,~-_._--- 1"- Fig. 13.31. Erector spinae self-PIR. SEMISPINALIS CAPITUS !Fig. 13.33) ., MRT Stretch f Pmielff Pos;t;on • Supine Doctor POSiTio/l At hCscd arm... whik doctor's hands arc pl;J\,:cd Oil patil:n(" "llllullkrs Bring head into forward flexion. stopping as reSiSI;11lCC i:-- fell "I" il" paticnt percei\'c:-- any ... tretching p;lin t ~ f \ , :, ) Fig. 13.32. Multifidi PIA. Parieflt\' Actil'c E/fort AnelllplS to gently pu:-;h head hack and hn'::'llhe in while dol'lOl' fer:-- lllatching resistance Afler S to 10 seconds. inil!rUl.'teo to "kt );tl" t\r· ) Stretch Whcn doctor pcrccin:!> patient has fully rd:'lxeo. p:.ttiCIlI a...kctl hI lake deep breath in and out A!'> p ?; t I ~ ~ I Fig. 13.33. Semispinalis capitus PIA. Periosteal Poilll.'i • Transverse process of the atlas ~ § il! ~ < (~'g. 13.34) I\1RT Stretch, Combine llcxion with rotation ami si<.k bending to thc samc side (coupled motion). If the patient fl.'ports provocmion of joint pain, an adjustment should be per· formed first. Very gentle forces should be used in this tcch· nique (intermittent cold and stretch is an option). Joint DysfunctiOlI CO-Clio midccrvical LEFT SEMISPINALIS CERVICUS (Fig. t 3.35) ,~ il .~ LEFT SPLENIUS CAPITUS/CERVICUS Corrective Action Tmin propl:r head on ned postur:.l1 set (i.e .. Ah:xaruJcr technique) Address forward weight-be:'lring pm.Hlre (tight calves. hip nexon;, and pcctur:'lb;,) Facilitall.' ;.Int! strenglhcn glulCll\ ma;ximus anti deep lll.'ck flexors lHRT Stretch. This maneuver is an ul1l;oupled movcment for the cervical spinc. Therefore, if joint pain is provoked. lessen the side bending componcnt. Very gentlc forces should be used ill this technique (ilHcnniltcnt cold and stn:l(;h is an option). i ~ !-----------------------------_.... (;' ii ,'( 1: ~ I GHAeTER 13: MANUAL RESISTANCE AND SELF·STRETCHES FOR IMPROVING FLEXIBILITYIMOBILITY I! Pur,,"' 1'1\1 hl';l\ ~ (If should"'l ClllllPl..'lI:o.:LliHI\ 1\1 short !c~ i "tCII' 273 l,',· tIll" SllI}uhkr "k\·;ali'Hl wilh rl..'spir"li'lil Ellltllitlilal :o.lrl'_~" "\\'ci~ht of th" wurld 011 shouldl'l<' " ()!JS{'t'I'atiflll nf I\\'d~·:o.hnllltkr lin;: ,,'\'lItOUI" i ,.( ;"1111\.'·· ;II'P'::::.: :." Slr:ti;;IHl'llill~ Tri;;;;!..'!· !'ai:!!,,, .\lidhdly, ;llll ... rHlr. Iatl..'ral Emilla/hm for O,'cruC/h';ly Shmtld 110t ahduct wilh excl..'ssj\'C tlppl'f tr;tpaiH;\ ;tt'liYily tIl" l' :rh "',.';Ipular c!cv;ltioll Emilla/ioll jor Shortening Lllcr"Uy hcnd hl'ild .1\\-':1)' and rulal.: hl';lll 1\)\\;11"\1 ;o.id..: III hl'!l·'h'.l. Fig. 13.34. Splenius capiluslcervicus PIR (Iefl). With nl'd; lle,,"'d. push un shoulda, (>nsili\'I..' limling: i.. Itl'" "T rl" .. ilicncy (cumpar... hilaterally), Fig. 13.35. Semispinalis cervicus PIA (left). LEFT MULTIFIDI AND ROTATORS (Fig. 13.36) MRT .r;;trefch. Full nll;l\ioll follom:lI by maximal llexion or the rotated head arc performed. Vcry gCll1lc fol'l.:c,I; should be llsed in thi~ technique (intermittent (old and ~tn.:tch IS ;In Fig. 13,36. Multifidi and rolators PIR (left). option). UPPER TRAPEZIUS (Fig. 13.37) Referred Pain To mastoid along posteri(1/'. btcralncck alld llCcipll! 1(1 forehead Clinical Effect of Shortened Muscle Hl.:i1t1ach('s Neck luin Altered sl"apuluhumcral r11ylhm Aclil'GtiOIl Occup,llitmal slress (flllll slIslaint:<.I shoulder .:,,-·,';lliuII Tclcphl1llC 10 car Chair with ;Inn rcst.~ at \\TOII~ height or ahsell! Desk. typewriter. or key hoard \00 high Compensation to weak low.... r lixators of ~t·~'lllll~lI.' HahiHl;d fllrward pnsiliull \11' shoukkr" Ccr;, ;.... ,i:lllr;lCic kyphosis IU;tdcqu:th' 'Uppllrt fur IW:I\ ~ hn.:a\\\ b Fig. 13.37. Upper lrapezius PIR, ., Fig. 13.38. Upper trapezius self-stretches. ) • Tension releasc shoulder shrugs Jurilll; "'breaks" Proper support br;l wilh wiJcr strap Smaller purse with \\ ida slrap Rc-cdllC MRT Stretch Patient Position Supine Hc.uJ i~ nes-cd. wl;lll:J tuward ;lI1d lillcrally ncxcd away rrtlm sid... or,trelch Arm un illvnlvcLl ,ilk j, n:::laxcd in p ) ,) Doclor Position Stilmling al head of l;lOlc (Ill side of ifl\'olvcmcilt , .} . ,. .... } Fig. 13.39. Levator scapulae PIA. t ~ Joilll Dysfunctional '1 ;,..,J Atlanto-occipital. any mhcr !l<\stcriur cer.... ical joint including lhc cervicothoracic junction , Corrective Actions \...J)< Improve workstation ergonomics Make sure elbows arc properly supported by ~mn rests Correct desk. typewriter. or kcybo;lrd heighl Shoulders relaxed Elbows bent at 90° H'lllds rcla:'l:r;d with wrist ill "neutral posilion" on work surfilce , .> u \ Fig. 13.40. Levator scapulae PIR. ".j" =~:.-'::.'~.::'-..:.'":::.:n-..:.,J:...:.,.::":.:':.:":.-":.:U:.:".::L:...:.".::":.":.::'' :.:.:'A.:.N:.:.:L::":..A:.::.N::U:...::"::"::L::'_'..:"::.'.::H.::":...:.'L:.':.-H::."::"::.'::.r::.U::.H::.::.'::.M_P_R_O,,-V::.I::.N..:G=-:.-F..:L..:E::.X.::I..:B::.'L::'::.T::.Y::.'::.M::.O::..::B_IL:.::.'T_Y ..:275 B A II , II i ,I~~ ----~,~ ,- ,1 (J o~ f' '~ I I ! C Crossed or 1I11lTtlS'Ctl arlll C(llllac( wilh Olll.: h'llld gCnll~ on P;tlknl\. slulllkicr ;lIld other h'lIu.! hchind m:lslnid process "Wind-up" stretch hy laking out slack ill ned llexion ;111(.1 then in genlly side bending ,l\vay alld roliltio/l tllward illvo!n:d side. Finally. take \llH :-.ITOllgcst slack in t1in.:ctiol1 of shoullkr lh.:- pression. Anernpt." III brin£ shouldcr ilH(\ ",!l:v;Jtiot\ toward patient', I.:'IT Common error is for paliclll 10 raise shuulder off l:lbk ralher than dcvaling il hlward car Efron is n:sisll.'d hy doctor 10 kcr.:p corllraclioll as t,:llISC 10 i'<JrJlI,:l- ric as possible Siretclt Aflcr cOlllracling upper Ir.lpaim for appruprialc period. patient is CIlCOUfilgcd t(l "leI £0" or rel;\x Once rcla:<;llion of muscle is fell. uoctOf m;l)' t:.lke lip shIck hy deprcssing shlluldcr ~l~ far as it will ~lIh1W SOllle slm:k 1I1a)' ,l!so be taken (Jut by increasing neck flexion, hut no more in llllCllUplcd side bendin,g away and !'OlatiOll toward musclc Self-Stretches. Excclknt .sclr-strclchc~ ar~ shown in Figure 1.1.~:-\. Sclf·PIR call c:lsil)' be incorporated into other self-treatmcnt methods. I ~ ~ ,t ---_......._---------------------------- ,}j Fig. 13.41. Levator s.:apulae self· stretches. LEVATOR SCAPULAE (Fig, 13,39) Referred 1>ai" Vertebral border Nape lIeck or or scapula ClilliCll1 Effect of Shartt'"ed iHuscle Pain 011 sallle ~ide ;lS palielll lllrn~ hcaJ Torticollis Altered scapulllhllllleral rhYIIl1\l ActiwlliOIl Poslures in \Vlti..:!\ paticHI h;l:, ht,';td lumed li..'f ;';-~'Iullged pcri~ld..;. e.g.. talking 10 somCllllC sillin~ h' the side Excessive Iclphnnc wnrk Working over a desk for pn'!lll11!cl! periods lIt' ;;;,',k Ilexioll ObJen'atioll '11' l",.'...'k line <.lpp,,';lr:o where musde inserts into sl..'apul;l Wilh shortcnint:. I.:onlour ,!:" ;1 duuhle wan: Trigger /,(}i"rs SupcfOlllcdial horder of scapula Push tr"lpczius lataally to palp;lll.' fulllclll=th l'f nlllsdc Periosteal /'oints Later-II surface Ilr SpillllUS Pfll~'l'SS Ill' C2 Eva{UClrimr for Slwr1l'l/illg LaWr<111y hend alld rolal\.." Ik\l'd lk'ad away (rl'::~ 1~'SICd sitk~ ........ " ...... , .......... ,,,''"'' .. u ..... L :\pph ~emk prCSSI:r~ to ipsilah:ral :-I\\Julll\,·1' l'o:-i[j\,e,; lest b lack ill' r..·."ilic11cy wlll'Jl 1'1I~hitl~ 1111 1!' Otha MRT Strctclu:s. PostisolllCll'ic rclaxalioll may also he u~~d with rcsistall':~ lltrough the palicnts elbow (Fig, 13.-W1. :-hl1uhkr Joim Dysfullcti(Jll CI-C2 and C2-C', alw l'CJTinllhur:H.'il' jUIKlillll 5jdf-Strelc/w,\·. St'if-stn.:tch..:s arc shown without PIR 13.4101) and \\'il!l PIR (Fig, [lAth (Fi~. Correcth'c Actiolls Using hc'ldsd ,I Rearr:lIlging C(llllpllh:r turn head Fadli[:lle of slrell~[I\\"ll ilhlJlilHf Imn.:r HI' r\,·:td't1~ lix:llilr~ llIall,.'ri:li .~o 1111 nccd [II SUBOCCIPITALS Rcferretll'ain Ill' :,clpulae Sidl' of he'lt! M liT Slrelcll Path'lIl Posilioll C/illica/l:.1fccts of Shortened Muscle OCl'ipilalllcadadlc S.L111C as fill' Ir'lp..:ziu:., e.'\n::pl hand is IUnh:d palm up and anehllred ,lllthe way ulllkr hack of lhi~h :lIld lIeek is rotaled away Doctor Position AI head of lahh:: Oil side llr involvcment Arm closest ttl p:lIicnt"s head SllpptlrlS hcad while lhe hand COlllaclS p:llicnt\; supcmllledial horder of shoultler hl:lde Outer .Ifln crosses in frOll! of olher arm ~{1 OpCll hand C<.Ill COlll,ll':1 nwstoid prm;ess P;uient\ head lllaXim:llly Ilexed, laterally lIe.'\cd, alltl rulalcd to· w:Jrd siuc opposite of involvl,.'Il\Clll Takc out ~ll slack in din':'lioll of slwult.ter (!I::prcssiun and minimizc forces on hC:ld "Sh~n Ileck"-(;cr\'icncralli~llhYI>cn.::xlcllsion Acti~'alioll SUsl;lincd Ilcxinll r.. 1al;Jdjustcd cycglas:o. (rames RC<.Lding or writing Suslained extension Bil,:y,k riding ~ ~ J1(Jinl.~· Deep to lr..lpaitls and ...t.'nlispinalis CapiltlS Era/uatiun for Shortening ?micnr:{ Actit'(' l~ff(}rl Tries to gently ele"ale shoulder blade Effon is rcsiqcd by doctor \n kcep (;ontf:lclion t) p; !-lou:.c painting Forward-drawn P()stllf~ We,ll.: dl,.'cp neck llc.'\of\ Trigger ,fl· }- ", j ~ -'< Supine patient drilws chin to chest Positive finding if gilp of nn..: or l1ll,lrC linger's brc:ldth remains 'IS close w i"mllt.:t- ric as possible )oi"t I>ysfrmctiotla/ C!J-CI Corrective tlctiolts Stretch Improvc Once palient has fully rclaxcd. dnCl(lr takcs out slack by im:rea:.iog shoulder depression ft1rw~ml-drawn posture '\wmencss trJining of "~hon n~l'k" (i.e .. Alexander leehnique) Book stand or writing w~dge ,, Fig. 13,42, Sternocleidomastoid PIA. --~ ., 277 • CUlllPIll\:I m"IlIlo-r ;,; ~'ul",:d Ikl:lll Il..l..'h;~' nose) Strengthcn \\~';l" ,kcp nc~'" . .., ... ,.. "~ ~ ~ li ... ,Ilh ;111.1 Skqlin~ "II ;\\,. ;'dltlw.. :-ohllrll'n S('\1 1','..lur;1I !ll'rt k~1 ... 111'''0' ' ...·,.mpl·l\s:lti,lll l·nc,IIT..'I'h',1 i""" ;.:~:.::-igIH For,,";!rd h,',:,l r,'~IUn.: Ik\.,\r... MRT StrCfch \\'1';11, \kql Il,'~~, Paricllr Posiriol/ hi :1.' \01':- Shnrh'lh·.! "'\il-.·" q·;I;tl .. Supine OhSC'lTflli1l1l Chin s1i::htl~ lll'\l'd \\'ilh "lh1Ih·lim;. ,; ... ihl~ prllmilh':lIl in..ertioll (II' d:l\·il.'ll1;l1- til' l"'!,'!l llea.!·r"l"\\;ll,; 1',";111'..' Doctor ('os;r;oll Tri~~l'r Al head of lilhk One hand bdlind neck. ilpplying tral.:lllll\ (~Iiglll) Heel of nllH:r h;1I1d 011 forehead \\'ilh till~cr~ ptlillling IOwaI'd I,:hill Anywhen.: I'oint illlll\l,~'k, partil.'ul;lrl~ Em(uariOll hl'IIIW llla:-:lllid pnll:C:-:S for Ow:racf;l'iry 1h.:;ld Ih.:xilln 11.:'1 ...·.1 wilh p;llil'lll 'UpIIW Palicnl ask...'d 1(' ~hl\dy r'li.;<.: Ill,;t..! inll' lIC.\I\ll1 ill :m,,..likl' ra.;hi\'ll At1Clllrl~ In till h..:al! hadw:ml Effon is n.:si"lcJ hy dnctor In kct.'p ,,·olllr:u.:li(lll as duse II' ismll..:l· ric Once p:ltienl h:l" fully rcla.\cd. dOl'wr illcn:ascs {raclion I'uree will1 haml supporting neck Doetor lakes Oul .. 1;lCk wilh heel of hamJ till forehead illl(1 f(Jrward nexioll Ifpatiellt resi\t .. forward flexion. :I,kcd In :u:ti\"dy Itlck chin in ;Illd lhen relax: p:lliclll will havc in .;:-ffcCl t:lkcn oul ~Iack thems..:!\"c,' and ~inHlllalleou ..ly lIsed RI Referred Pain Over eyc. frunt;.J! :m:u. 111aslOltl proct:::-:s Clinical Effect of Shortened Muscle I-Icad:lChc (o\"cr eyes} Ei.tmche Decre:l:-:ed ne;.:k r{llation Actimt;oll l'v1cdl;mic;lllI\ l.:rloiltl (execs"i\{: ilt::ck cxlcnsimll P:liluin~ :1 cl,'iling \V Joint 1JY.'ifullctioll CO·CI ~lIld C~,C: Pillow should be lUcked helwccn \IHlllltkr ;1I1d <:hin. NOT unJa s!ltlllltk'r Correl'l head-hlr" :lrtl !'nslurc (... hnr!cns SCM) LlImh:lr pill{l\\ m::y help rc:-Iorc bOlh Itllllh.u· ;tnd cervical CUI" ..'~ Cum:;:1 Ilc;lr.. igbh:dness Limil ovcrhcad '.\ llrk thai (l\"...:rl(I'ld .. chcckn:in fUllclion of SC\ 1 Rt1und-shoulth:r-.:d po,lUr.., (light pt:t.::t Po.\"irioJl Supine Shuuldcrs al t::J;;c of lahk, ..u head i.. \UPPorl..·d \1111)' al basc Head wlaled ;:\'.")' frolll ill\"lll\"cd \idc and ...Iightly (()ek'~ Ill'" Il,'''l po\iliOll' /)OC(OI" , :\1 h.:ad (If lahle Cephalad hand ih:llld ncah.·.. t III hc;ul.' n;ld\cs h':;Id Olhn haul! pl () j ~ ~ ~ Id Iu ~ I ~ .~~ , Fig. 13.43. Slernocteidmasloid PtA. c) Cl f b ;lll(lWcd Po,\";/irJlf ;~ , \1!.' ,1..... ;.:illUl c.; ); ~ ,uhtll.:l.:il'il;ll, iHRT Relaxatiolt PlIli('Jlf 1:! S or 11l\1\\:IIH.:nl Correcti\'e Actioll.\· Sm!ldr STERNOCLEIDOMASTOID (SCM) (Fig. 13.42) Pn:-:ilivc 1...·'1 iI' ,:hill pH"''::-: dllrill~ inili;llir'lI It I c\l,'nJ MCM/,\DILIIAIIUN Uf THE SPINE: A PRACTITIONER'S MANUAL Correcti"e Adiolls ;\lh.'l1lPI~ In raj~l' Effort is h.. . ad ~Ii~htly. \\ llhllul ally rotatioll n:sisl .... d by dtl~'lllr hI h'~'p ~·(llllra<..·lillil <1:- cl(l~t.' to iSOlll.... l- I~ £'!(I,\'(/ 1iOIl I)oc\flr tl11..'l'I,:I~ .dhl\\" Iwad \Hl'\h:lld a" 1':\1' :,~ i1 w;1l111l ;ts OWII Gra\'it)' i~ .. nl~ f",,:\." rcquirl~d Il' lai-.l' up slal'k :\ lX'rkl'1 ,,~'lr·lll·;llllll"1l1 111~'llhld ;I' \\'l'11 ('nlllr;,indi..:;l1l·d if ;,ny ~i~,,~ tlf \ I.'rt<."hr(lha~ilar il1~llfjk;t.'m:y noted Other 'MilT Strctchc:,\' ((ud Self-Stretches. If the cervical -"pille is irritahk. lh~ SCM Ill"y still be treated by preposi. tinning in Ik'-"iOll. thus 'lvoitling provoc;,t1ive cxtcnsion positiolls (Figs. l.l,-t.l and 13.44). These strctches arc ideal in·ofril~ or self-lfl.:allllclll methods, This ledmiquc is oflcn an ex('dlcllt prL'thrusl rcl'lxation tcchniquc for .1 patient who "guards" c.xL'L':-."i\'t.~ly. SCALENES (FIG. 13.45) ReJern:d Pain Peetor"lis I1lU~(:It;,. :m~a(hing pattern MilT Sfrelc" PlIlk"t Po.\'ilioll ric as IXl"sihk 1 Retrain diaphragmati, Stress m:ln:tgellk'1I1 upper afln, h;lIlJ. :lllli rhurnh(lid~ Possible IIUlllbnc .... or t;ngling ill h:mds and/or fingers Differentia! diilgn('sis Ulnar di~tfiblltion of symptoms frulll the hrachial plexus or subll1Y(lra~cial rcfcrr;11 At hC:l(i of 1;lbk Anterior libers isolated \vith olle hand on mcdial clavicular origin and other hand ju:q ant..:rior to m;lstnid process Medi:1I fihers rcquir..: one h;md on midclavictll;u orig.in and other hand on mastoid process Posterior libcrs rC\luirc unc hand un later-,I c1:tvieul:tr orig.in and other twnd just pmilerior IlIl mastoid process Patielll Ellorl 10 ~idc hend b;lck Inward midline Stretc" Slack I;lken out into grcater 1;lleral l1exioll Anterior tiber Ienglhening \"ilh rotation tow;ml involved "idL' Medial fibc~ require no rot:t1;";j Posterior fiber lengthening with rotation away Activation Forward head pmturc Par"doxi(: breathing pattern (excc ... ~ive upper chest respiration) Anxiety Tension ill nther fix:llors of shoulder girdle Trigger Paims Anywhere within anterior. metlial. or posterior divisions of muscle Palp;\Ie and treat ..calenc~ with c:lution hecause of proximity of extremely sensitive lICllfO ....;lscular li .....uc If the neck is hypersensitive or any vertcbrobasil;'lf symptOms are present. this technique is contraindicatcd. Joint manipulation may be nccessary before using this method to cllsur(' the join.s arc not compressing. especially with respect to the :'1.';1lcne anticus stretch (Fig. 13.4Sa). Gtl,er MRT Stretches. An alternative w,ly to <.lddrc,,~ ::l:a- lene dysfunction involves prcpositioning the patient's ned..: in Joint Dy,\fullctioll Flexion li,x;ttion... of cCl'"ical ~pine First rih blockage Doclor Posiliol/ • Aucmpts Clinical Effects of Shortened Alusete cJ:lvian vein Radial distribution fmm Supinc, lIead Iak'rall)' helll In oppllsite sitle and slightly extcnJeJ i\ntcrillr liher~ lllllSI Ill: strl;'ldll'O with hcatl rot;lled t\lW;mJ invol \'cd sidc Mcdi;L1 libeLS rl.'qllire 11(1 rot,lIion Postcr;or liher:, n:quire h~ad is rlll:ttcll :1\\';1)' (antcri(lr cervical!!! d stretch position and then contacting the origin of thc I1lu:'l'!c over the anterior chest. Resistance to inspiration can be :,ufli· " ~ J Fig. 13.44. Sternocleidomastoid PlR. CHAPTER 13 : MANUAL RESISTANCE AND SELF·STRETCHES FOR IMPROW.~ =LEXIBllITYIMOBllITY 279 B Fig. 13.45. S" ~oe PIA. c cienl to achieve posrcontraclion inhibitioll. SI:Kk call he taken out with the hand over the ante.:rior rcgitm (11' the chest or d~I\·· ide to lengthen the shortellcd musdc. Self-Stretches. S~lf-lr(;atlllcnl is I.'a~y ami ';Ifc. cspl'\':i~lll~ if L'xlCllSion j:, minimized (Fig. 1:\.4(1). Fi~Ul\: 1:;.47 sll AfIllS il1l1:r:l:" Sc.:apula 11...·1.,; ;. :IL._· ';\;:nh J:'m/ualio!l {f)r .r-iltortclJil1g ?ECTORAUS r·.AAJOR (Fig. 13.48) Ann ;Ihdlll·;:.;:: Referred Pain S:tllh' Hill, inn('f .,...·k l>.'ll~ l'erios((,lIl Foillis Rib Iwad or chl:sL bn:'I~1. ~Ill:lk'd :,-1 alld I'n'll':tc.:H:d '/i"iggt'l" IJ(li/If' I\II~ \\ ;"iswncc. Anterior part ahd~_' .11'111. '\Ill.! }iJ' and ,"ll'fIl::!I:. rillall'd \11 l~ll .\hdUt:li'l1l t'llr'':;lrI11 Joiu! /).n{uIH:timl Clillicall:,Jfect oj" 5;/wr(('ued Muscle P;lill similar lu angi11a Bn;asl Ilypcr~cn~ili\'iIY Anterior humer,,1 pt1siliotl liPPlT nb... Corn!",i\"(:. \ctim,... l,;an prolllOh: 11111'l\lVI..' r(lj",'.;~,d Wl'i~111·\'~arjJlg P(l~lllrl..' slwlIldcr impillgc1Il1.:!l1 F:lcililall: i!wj ,'rl:ll~llh.'ll l\lWl:r (Ixalors (If :'l'apulac syndrome ;\c/iJ,'atioll Rlllllld-shoukkrcJ. hl';ld·!",u"\\ ;ml PI):,Illl"l' M RT Slretell I'o.\;li'_,i, 1'1/1it'lIl ObSerntliml RIllilld SI'\I\Jldcr" b - - - - - - - - - --_.__.._. __.•....__. -- Stll'itll' ArIll ahdul',,; !i)' and ,'"ll'rn:lll> nll:tIL,d ...". _ .. _ _ ,- n" II I lu,"c;:n ;:) M,...I\lUJ\L 1 I , i ~,, t Fig. 13.46. Scalene self-stretch. , j ) Fig. 13.47. Scalene self-PIA. Doctur Position C01lcem At head of table on involved side One hand COnl If br~lchial plexus syrnplOrns arc encoun[ered PIR. may be pcrfonned without stretch. Other hand gr..lsps upper ann Self·Stretches. Self-stretching is casy with doorway or comer stretches Parien! S ACli~'e Effort Attempts 10 raise arm Effort is resisted by doclor to keep contraction .IS close 10 isomet- ric as possible Stretch Once paticnt has rclaxed fully. doctor may retract shoulder to new barrier Must firmly stabilize muscle belly over ribs while !,Iking ~!;' Sl;lCk PECTORALIS MINOR (Fig. 13.49) Clinical details arc similar to those for pectoralis major. Application of PIR can CilUSC nerve entrapment related to thoracic outlet syndrome. MRT Slrelch Patie", Positioll • Supine u' "" ,, i •! ' .... " , . ) . 'VI"'~UKL M~~r~ IANCt ANU :;;t:LF·STRETCHES FOA IMPROVING FLEXIBILITY/MOBILlTY 281 ) (") '. ) t, .., !,j ~ .~, ,\ '8 ~ I,., () , i ) I ) I, i R N ;, b ) () I () ) i '. , i, < ..1 ,) 'J:,' t: ; Fig. 13.48. Pectoralis major PIA. ) ~ Ann abducted :':0" ;llId ~x!::rnally rotated I~ ( ) i u f)oC/or J• , ~ ~ SUPRASPINATUS Pariellt \' !\cril'(' .qrorl () ..\llclllp'" ~ ~ \0 rai:...: ,houkkr III l't.:iling (kccpill,g hand lower Ih,lll ;-.Iululdcr Efror! i'i resisted hy dUl:l{'; III keep i:oll(ractj{.n l'l\: 1 "'.'" :l'i dt)~c 1(1 i"ornel- ~ ~ ~ '\ '\.-' ... \, -------------~--~-~-_ '" "" ~ t ~ lJ 't { , Referred l'a;1I Ikhoid rq;iun. I:Ilcral upper afln •...... ;Illt! dhm•.: Cliuical J(c.w/t of S/wrtf!"cd IHu.\"cle Painful ~dxllll'li(\ll (p'lillfu] .i u f; tllli loward Other J\tlllT Strctclw.\". ;\ mollified lc<:hniqlk' for prow; positioning is shown in Figlln.'. 1."50. Caudal hand gra!'ps ann I 'J '! ~ Ouel.: palielH has rda,xed rul1)'. dt1;'°ltlr may lake sbd, lI~W harril:r ny pushing shouldl'r :lway from d P(J,'j;rirm AI head (If '"hk' Oil in\"uh;:d ...ide Ccphal<.td hand I:olllac!'- gkllohtHllcral juint %...,~ t f1 "11 Sfretch H:tmllwnging hl\\'cr thall ,holildcr illl"j ..._._ , ' .-- , ~. ,... rH""' lllIUNt:H ::i MANUAL Trigger Puillis Supra:-pinatus (os-<;;, decp 10 Ira{'\:zius Corrccti,'c Actions Avoid:lllCC of (l\'crhcad work Cross·fihcr m:lss:!gc Impro\'c scapulnhllllicral rhythm '.' MRT Stretch rmkm PO.'ii:ioll • Prone Doctor Position Standing at same side o[ table as involved shoulder Aml extcndcd behind p;llicnt With elbow Oexed 90°. upper. arm :lddllctcd;l$ far ,IS will ~(Il.:\I111 fonably Fig. 13.49. Pectoralis minor PIA. Fig, ,13,51, Infraspinalus PIA. Fig. 13.50. Pecloralis minor PIR. Difficulty rC Activating Factors O\'crhc:td work (i,e .. weight lining. throwing. swimming. Puor :-c:lpu]o!lulTlcral rhythm g ri f; , ~ -~ % ~ \,,'[l.'.) Fig. 13.52. Subscapularis PIA. ._._----_•. _ - - - - - - _ ..... CHAPTER 13 : MANUAL RESISTANCE AND SELF·STRETCHES FOR IMPROVING FLEXIBILITY/MOBILITY 1'1;ln: \Jlll' haml ;lgainsl llr~r arm illid g.rasp patient's wrist with nlh..:r hanll Gl'lHly pu:-hc.; "rp~r ann out into :lhlluctlOU Effort is .1':llil'lll rc~i"h:d i:-ullll'tril"ally .;hotlld follt,w normal orcatbing pror.::cdun: • As paliclH rda\l's. dlll.:lo( takes up slack in adduction 283 COlleem Although this method is simple to perform. care is nceded if the shoulder joint is hypersensitive, Other MRT Stre/cltes. An alternative method that rcduces sirain on the ~houlder joint is accomplished with the aml brought into ful: internal rotation and adduction across the front of the chest. To prevent subacromial impingement, strong traclion is applied to the sh'Juldcr joint. This technique allows for the contraction and stretch to be felt at the scapular attachment rather than the shoulder attachment of the infraspinatus. INFRASPINATUS (Fig. 13.51) Uefirred Paill :\lltcriol' ddtnid-shuuldcr. dowl1 ann to hand Clillical J:.ffect,li of Shortened Mm'cle Paill whcll sleeping Oil either side Diflkulty rc..chillg llChind back to unhook br.l Diflicuhy rcaching b~ICk pocket for wallet Rotator cuff disorders (i.e .. instability syndrome) often result from liglullCSS of external rotators (infraspinatus. teres minor. and supra:-.pinatus) Activatioll NcglCl'lcd shoull.kr overose svndrome :\ltcrcd..scapulohumcral rhythm Trigger Poiuts Infruspinatus. fossa (especiilily supcromedial) Correcth'e Actious Sleep with involvcd side up .md pillow under involvcd mill Improve scapulohunleral rhydlnl MilT Slrelch Patient Positioll Supine Involved shouklcr supported by table SUBSCAPULARIS (Fig. 13.52) Referred Pain Posterior deltoid and posterior ann Clinical Effects of Shortened Muscle Difficulty reaching back as in throwing Involved in "frozen shoulder" Promotes subacromial impingo:ment m~d rotator cuff syndromes Activa/ion Shouldcr ovcruse syndromc Lack of variety of motion in shoulder area Forward·drawn posture. especially tight pectornls Trigger Points Vcntral scapula Joint Dysfunction Glenohumeral joint Correcti.'e Actions When lying on involved side. place pillow between ann and chcst 10 maintJin abduction When lying on uninvolvcd side. place pillow in from to prevent excessi .... e abduction Improve scapulohulllcral rhythm Slrctch peclor MRTStrelch Patient PQJiliofl Docror J>osilioJl Ahduct .Irlll ;Ino flex dbm...· to 90" Allow furearm 10 fall into PatieJ/t:\, Aui\'{, Elfor! {JIIC himo <1Il afln abov.,; c1bO\v and other hand on dorsal aspeci of forearm, gently pushes forearm up or backward toward CX~ tcm,L! rotation Effort isomctric,llIy resisled (.again ensuring shoulder docs not rise orf t.. hle) With Stretch When paticllt has fully relaxed. lake up slack IOward ncw barrier in inwfIlal rotation b Supine • Involved shoulder supported by table DOClor Posilion Facing patient nn same side as involved shoulder Abduct arm and nc~ elbow to 90 Allow forearm 10 f;all into as much external rot ward head) as gmvity will force it Ensure shoulder does not begin to lift off table I'atielll:'i Active Effort With one hand on ,Inn above elbow and olher hnnd on \"Cnlntl nspecl of forearm, gently pushcs their forearm up or forw3rd loward inlemal rotation Effort is isometrically resisted (shoulder should not ri~c sjgnifi~ cami)' uff table) 284 REHAtllLlIAl IUN Vr I HI:: ~I-'INt:: A I-'HAl,; 111IUI\lt:.M';:' IVI ...... I\lUAL Stretch Stretch When patient has fully relaxed. take up slack toward JleW barrier in externul rotation Concern This technique is contraindicated if :mlcrior instability is pr~ senL It also will provoke extreme pain if 2 "frozen shoulder" is the problem. In either casco the functional range for PIR may be limited 10 less than 90° of shoulder abduction. GASTROCNEMIUS (F;g. 13.53) Referred Pai" Calf. posterior knee. and instep Clillical Result of Shortell cd Muscle Forw;lrd wcighl·bcnring posture Achilles tendinitis When pat1cm has fully in ill\kk dllrsilkxioH n:l.n.~',1. take IIJl sku.:k 1\lw;lnl IlI.:W harrier Self-Stretchl's. Sdf-slr.. ·. Il'l,ing tile gilstrocncmius is hest performed with thc s{andil\~ w;tli lean and it:- lllodilll:;ltiollS (Fi!.!.. U5-t). It is csscnti;l! lhat the knl~l~ is eXlcnded ;tlld the hed docs 1101 ri~c up. SOLEUS (Fig. 13.55) Referred Pain Heel. posterior calf Clinical Result of Shortcned l\1uscle foorwilrd weight-bearing. pt1slUre DIfficulty squuning Acli~'ation High hcels Acli~'alioll Exccssi'iC running Scat height too high High heels Too much driving (pushing on ;leedefinor) Trigger Points Superior and inferior musdc belly Evaluation for Shortening Trigger POilllS Medial and lateml border of muscle Prone with knee bent 9W. dor~il1ex. ;tI1k\c: ~h()uIJ have 20" d(lrsi~ flexion Evaluatioll for Shortening Supine dorsiflex ankle without allowing knce to bend. Should have I0° d()r~iflexioll. MRT StreIch Patient Positioll • Prone MRT Stretch Patiell1 Positifm • Supine with legs extcnded Doctor Position Standing at end of table; gmsps heel of foot with halld Passively dorsinexes patient's fOOl by le~Ulillg cephalad Paticnt'!' knee not 'lllowed 10 fle~ Patient imcmpts Standing at side of table, places patient's leg in 90" knee tlc:-.:ion Passively dorsiflexcs patient's foot by pUlling up on hed while pushing down on metatarsals , Resisted Effort y , Attempts 10 plantarflcx fOOl {not toc:-) Effort is isometrically rc~i~tcd Resisted clfort Effort is Doctor Positio1l 10 .f plantmflcx fool (mu toc!') isolllelric~lIy resisled Stretch '....j Whcn patient has fully relaxed, in ankle dorsiflexion t~lke ,) , '> :' Self-Stretch. Self-stretch is accomplished ,IS for the gastrocnemius. except that knee flexion is allowed (Fig. 13.56). ,;"< , ~ Postisometric Relaxation Joint t\.1obilization Procedures HIP JOINT (Fig. 13.57) ~ tf ~ Patiellt Positiou Supine Involved leg flcxed at knee and dr.aped over scaled l!\letnr's shoulder f Doctor Positioll Fig. 13.53. Gastrocnemius PIA. Se;l!cd ;11 s;mlt: sidc or l:.1nk ;IS " .:1< up slack toward lIew barrier 0" "" ..;.$ .~-~ ," ,J d , involvcd hip. (;lcing p;tli...·111 -..v) .... -----_ vnl"\r I 1:;1"\ loj • 1V11"\1-'VI-\L Mt:~I~IANL;t: ANU ~t:U--ti I RETCHES FOR IMPROVING FLEXIBILITY/MOBILITY 285 Fig. 13,54, Gastrocnemius self-stretches, P<.llient's leg draped over doctor·s shoulder Cont<.lct m;'dl.: over p<.lticnt's alUcrio( hip with both hand!> and pull:-: A to P to takl.: out ,Ill available shick in posterior glide LUMBAR SPINE (EXTENSION MOBILIZATION) (F;g. 13.58) Patieltt Positioll Sidl.: lying with hip\ and kth..·~·:, flexed Resisted Effort P<.llient instructed to pull thigh toward abdomcn Errort should be isornctric:llly resisted by doctor Patient and doctor shmlld reel contraclion occurring in anterior hip region Stretch Once paticnt has fully rcl incrcasin~ Doctor Positiolt Facing IUw;m.l patient P]:Jccs lingers ovcr spinous pr~lccssC!'> (one hanJ over thc other) Patient's knees in conlact with duclOr's anterior lhigh Doctor lllust take om nl:;J"lI"1CI'-' IMIIVI'I VI'" I nl:;; .,:)rll'H:. M r-hl-',I.J 1 I I I V I ' l C n " IVIKI'lU ..... L Sdj~Ji·l..'llfl1l('/lf. Sl'lf'lfC , 1l1h:tllllfllrtahk. lh\,.' hal..-k 1.:.'\I\.:nsioll . . lrl...·\l.:h till 11l1' I..'xt,;rcisl: h;111 i,.. all l·fkdil.\' l'.\ll·lIsillll 1llllhilil.;ltillll Sl'll"·(l'l.:allllI.:111 \:-.\'''; I:ig,urc j ..L'i-i ill Chaph..'r I-n. 1 , THORACIC SPINE EXTENSION MOBILIZATION (F;g. 13.60) ! P 1 !, i , ! ! t ) , ? .) (-""), f ) RIB MOBILIZATION PostisOllll'tric rel,nation can be lI~l.'d (0 h~lr mobilize ;111 upper costotr;'lIlsn~rse joint The technique requires that the doctor COIll:!C( the dysfullctional joilll ;ulli reach (he barrier in ,, i :vll.lbilizing [he thnracil' Spillt,; iHlo l''\(l'llsioll is thel1 ;lCC0111plishe.:d hy raising thl' P;ltil'llt'S dhow" while pressing into the spine.: with an oppo~ilTg hand, Self· 'li'CallI/fllt, Thl' lhor;lCic region can easily becollll' kyphotic A simpk slreH:h to incl"ea ....: extension mobility i..; shown in Figure 1.'.61. Fig. 13.55. Soleus PIR. "\ ) ~ ) J ) .~ .< Fig. 13.57. Hip joint posterior glide PIA mobilization. ., j Fig. 13.56. Soleus self-stretch. ,J Resisted Effort Patient attempts 10 push knees inlo doctor's lhigh Kyphosis or patient's spine should result , ~ -" ! Once patient has rull)' relaxed. doctor extends patient's spine by 10 ,) ., Stretch pressing hands anterior i, !, stabilize ~cgmcnl above fixation. while , ~ j pushing with thigh ag'lima patiellt's knees in ;\ tlircction Inward lixctl lumbar SCgllll::.-,1 Fig. 13.58. Lumbar spine extension PIA mobilization. J CHAPTER 13 : MANUAL RESISTANCE AND SELF-STRETCHES FOR IMPROVING FLEXIBILITY/MOBILITY , 287 .~ ., ~ < ,,t I ) IIi '1 ~ g • j I I, ') " f , " .~ ~ J ~ I) ~ ~ • I ) I ,n ~ Fig. 13.59. Lumbar spine extension automobilization. g ! I ,...",\ .J I ex.tcnsion by raising the ipsilatcral elbow. Thc patient is in· structed to push his or her elbow downwnrd. Aflcr resistancc is applied to this movemcnt and the p J~ :1 ,~ LOWER FIXATORS OF THE SCAPULAE (LOWER & MIDDLE TRAPEZIUS) (F;g. '3.63) I ,) Patiellt Positioll Supine ," Doctor Position ""'.7 Standing to side of patient Grasps paticl1l"s arm with both hands iHH.l pull~ ~hollJdcr blmlc into protraclion1 'fi 1'....J, ~ I I Resisted Effort Palicnt pulls should h;\ck towOJrd tJblc ;llld in toward spine. avoilJing hiking shoulder 1(lw;lrd Iheir C;lr or usc of triceps (elbow is secn to bend) • Effort is isometrically resisted by doctor \, / 11 {( Other Facilitatioll Techniques. The PNF DE2 pattern shown in Figure 13.64 is .lIlother excellent way to facilitate .~ , i~ the lowcr fixiltors of Ihe scapulae. ) ,* , ~ i, ,~ A wcll-known PNF technique for the shoulder inyolvcs resisting contractions by the intcrnal and external rotators in various degrees of abduction (Figures 13.65 and 13.66). Facilitation Techniques J I,~{ RHYTHMIC STABILIZATION OF SHOULDER JOINT ...-J <;,.;> b Fig. 13.60. Thoracic spine extension PIA mobilization. n.C."Mt:llLIIAI 'UN UF THE SPINE: A PRACTITIONER'S MANUAL -"J Fig. 13.61. Thoracic spine extension self·stretch. MIDDLE TRAPEZIUS (F;g. 13.67) Palienl I'mi;lioll Pnllle wilh ,lflllS al ... id~·, Ooelor Pm,iliotl SI;llldin~ ;11 side nr 1;lhk' />Cllienl's ,\clil'(,t EJJorl into CX(Cn.. iOll with R;lise~ ,lflllS c.\ICrn;1! rnl.lliOll Auempts 10 pull shouldcr hl.ll,h:s logether without shrllggin~ SIHlUldcrs Rcsist;mcc lIlay he .. ppli~·d (0 mcdial hnnJcr or SL';qllll;u: H,lIllJ wcights mldel1 for pro~ressi\'c training. Fig. 13.62. Upper rib PIR mobilization. Grc<Jtcr challenge will result from performing this same movement with lhe arm~ parLially 'Ibducted. abducted 901>. ;lIld fully 'Ibductcu. A bench or exercise ball may be used. None ofthcse cxerci~es :-hould be performcd. howcver, unless the (laticllt can avoid shoulder shrugging (upper trapezius activation) during thc 1ll0\'Clllcnl. Other Faci/italiol/ Techlliques. This arca llJay also be exercised with the dbows bellt by simply squeezing the shoulder blades logelher (Fig. 13.(8), Rcsistam..'c to the medial horder ()f the sC<.lpul<Jc will facilitate the 11litldlc trapezius (Fig.. IJJ)t). J LOWER FIXATORS OF THE SCAPULAE (LOWER AND MIDDLE TRAPEZIUS) (Fig. 13.70) I'alitilll 1'0.\·;lioll Side lying Involved ,o;idc up Ann fully abducll.:d ) Doclor I'ositioll Silling hchind p:lIicnt PI,ICcs thumh or linger ctmtacl ,It l'atiell/~'i Acti~'e Fig. 13.63. Lower fixators of the scapulae facilitation (contracl· relax), infcf{~mcdi:tl hon!cr uf sC,lpUIa\'" '".oJ/arl Pulls shnulder hbdc h<.lck Inward spine while :I\'t1iding .. ny tcndt:l\cy to shrug shoulul.:f\ CHAPTER 13: MANUAL RESISTANCE AND SELF·STRETCHES FOR IMPROVING FLEXIBILlTY'MOBILlTY Fig. 13.64. DE2 proprioceptive neuromuscular facilitalion paltern. Fig. 13.65. Rhythmic stabilization lor the shoulder. Fig. 13.66. Rhythmic stabilization tor the shoulder (90" obduction) 289 .. _ , ."', ''-'I'' ,-,r 1 nt:: '=It'''INt:,: A PRACTITIONER'S MANUAL ~~1~~]~}-: ;S{J Fig. 13.67. ~,,1jdd'e -.~ trapezius facilitation exercise . • Hand weigh I lllily be added If p;ltiellt Icnt.ls 10 hypcrc.'(tt:nd lhe Illw hack. j1laec.: ;1 pillow unda ;Ihdmnc,~ GLUTEUS MEDIUS FACILITATION (F;g. 13.71) PatieJIt Po.. . itioll Side lying Wilh lower hip ~ltIU knee lk.\l'u Doctor Positioll St;uHJing hchinJ palienl Contacts glutr.:us medius insertion OJlIO gn:;Jter trochanter Grasps p,lticllI'S kg around kllL'l," Facilitation Fig. 13.68, Middle trapezius facilitation exercise (elbows bent). Effort should be isometric,llly n,:si~(cu ny dt}('l Rapid mobilization into abduction \vhilc ;lpplyillg "goading" stitllulation to tendinous insertion Each mobilization should incrementally incn:ase range into hip abduction (may be performed in f.ISI. ratchet)' manner four It) eigllt I!mes) After Illobiliz:ltioll, leg placed inlo abduction. internal rotatiol1. and slight extension: paticnI Iwlds leg. up as doctor suddenly let ... leg drop Muscle should he !-ccn 10 i.(uic.:kiy contract so leg ducs nut dwp ';1;" " , } Fig. 13.69. Middle trapezius contract-relax facilitation. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _----A_ .'> "V '; !PH,) r-Lt:All;11111 Y i....1VOILII Y ·_----=-'- ,•,~ , ~ '~". " ,, Fig. 13.70. Lower and middle trapeZll~s contract-relax facilitation. l ) } Fig. 13.71. Gluteus medius lacilitation. - CONCLUSIOS The MRT arc invaluable lools when sofl tissue lesIons are considered primary or significant in the patient's functional pathology. If chiropractic ~\dju~illt1ents are unsuccessful in relaxin" contracted musculature. MRT should be applied. High velocity adjustments arc still the most potent tool available. especially when;] joint lesion is primary. In patients with significant guarding. however. MRT relax the pJlient and inhibil muscle tension. thereby making the adjustment easier to perform and longer lasting. Generally. tense muscles should be relaxed <:.nd shortened rnyofascial tissue stretched before weak muscles are exercised. Therefore, MRT should be used allhe beginning of any rehabilitation program before initiating a strengthening program. M~lIlual resistance techniques are simple and allow a patient to learn self-treatment. Their usc enhances the doctor· patient relationship, encouraging the patient to become morc tlclively involvcd in their own health carc. Well-prepared patients arc be ncr ablc to manage minor aggravations of their symptoms on their own. Self-treatment docs not replace chiropractic or manual medicine treatmcnt, but it is increasingly valuable in an era of diminishing third~party reimbursement. ACKNOWLEDGEMENTS I thank Joanne Larricq. Jerry Hyman. Vladimir Janda. and Karel Lewit for their suggestions and contributions to th;:~ chapter. REFERENCES 1. Kabot H: Studies on neuromuscular dysfunction. XIII: New concepts and leehniques of neuromuscular reeducation for p-,ralysis. Pcnnanente Found Med Bull 8:121, 1950. 2. Le,'ine MG. Kabat H. Knott M. et 01.1: Relaxation of spa.<;ticity by physiological techniques. Arch Phys Med Rehabil 35:214. 1954. J. Mitchell Jr F. Moran PS. Prouo NA: .m Evaluation of Osteop;Hhic Musclc Energy Procedurcs. Valley Park. Prouo. 1979. 4. GaY'mms E Lewit K: MobiliZ . 7. Guissard N. Duchalc;llI J. Ihinaut K: Mu.~clc strctching .1IId motoncuron excitability. Eur J Appl Ph)'si\ll 58:47. 1988. S. SehieppJti M. Crcntl.1 P: From activity 10 rest: Gating of excil:nor)· 'Ill, togenctic affcrences from the relaxing muscle in m:ln. Exp Brolin Res 56:448. 1984. 9. Willi:tms PE. Goldspink G: Longitudinal growth or striatcd lllusck Ii· brcs. J Cell Sci 9:751. 1971. 10. Tarbal')' Tarhary C. T:lrdicu C. Cl 'II: Physiologic;11 :md structural changes in ca(s soleus lll\lsck due ttl illllllobili7.atiou;lt diffcrellt lengths hy plastcr cam. J Physiol P"ris 224:2:\ I. 1972. II. Williams PE. Catanese T. Luce)' EG. ct al: 11lc illlportam:c strctch and contrnctile activity in thc prevention of conneclive tissue acculllUlalioll in muscle. J All.1t 158:109. 1988. 12. lakei M. Robson LG: lllixotrophie changes in human musclc stiffnl::ss and thc errecL~ of fatigue. Q J Exp Physiol 73:487. 1988. 13. Habarth KE. Hagglund JV. Nordin M. e~ al: Thixotrophic behaviour of human finger flcxor muscles wilh accompanying changes in spindle :md rcflex responses to stretch. J Physiol (Land) 368:323. 1985. 14. Hagbarth KE: Evaluation of and melhods to ch.mge muscle lone. SC;ll1d Je. or J R,habil M,d Suppl 30: 19. 199~. 15. HUllon. RS: Neuromuscularb3.<;is of stretching excrcises. In COllli P (cd): Strength and Powcr in Spon: The Encyclopcdi;L of Sports l\-1cdicillC Scries. London. Blackwell Scientific. 1992.. 16. Voss DE, IOnia MK. Myers BJ: Propriocepti\'e Neuromuscular Facilitation. Pattems and Tcchniques. 3rd Ed. Philadelphia. Harper & Row. 1985. 17. Janda V: Seminar notes. LosAngcles Collegc ofChiropraclic. May 1988. 18. E,'jenth O. Hamberg J: Muscle Strctching in Manual Thcmpy. A C1inic:11 Manual. Vol. I. Alfta Rchab, 1984. 19. Holt LE: Scientific Stretching for Sport. Halifax. D:llhousic Uni"crsity Prcss, 1976. 20. Cailliet R: Shoulder Pain. 2nd Ed. Philadelphia. EA. Da\·is. 198 I. 21. Liebcnson CL: Acti~'e muscle relaxalion techniqucs. Part I: B'1Sic princi· pIes and mcthods. J Manipuhllivc Physio! Ther 12:446, 1989. 22. Liebenson CL: Activc musclc relax:nion techniques. Part II: Clinical application. J Manipulative Physiol Thcr 13:2, 1989. 23. Janda V: Musclc spasm-a proposed procedure for differcntial diagno-sis. J Manual Med 6: 136. 1991. 24. Lewil K. Simons 00: Myofascial pain: Relief by post-isomctric relax· :lIion. Arch Phys Med Reh:lbil 65:452, 1984. 25. Travel! J, Simons 0: Myofa...cial Pain and Dysfunction: Th..: Trigger Point Manual. Vol. 2. Baltimore. Williams & Wilkins. 1992. 26. Grcenm:;1.n PE: PrincipleS of Manual Medicinc. Baltimorc. WilJiall1.~ & Wilkins. 1991. 27. Spilzcr WOo LeBJance It. Dupuis M. el :II: Seienlific arrro;u;h to the :ISsessment and management of acti,·ity·rcl:llcd spinal disorders: A monogr:lph for clinicians. Report of the Quebee Task Forcc Oil Spin:,l DiSQrders. Spinc 12 (SuppI7):SI. 1987. 28. Bigos S. Bowyer O. Bmen G. t:t al: Acute Low Uad: Problems ill Adults. Clinical Practicc Guidclinc. Rockvillc, U.S. Departmcnt of Hcalth and Human Scn·ic!::s. Puhlic HC'llth Servicc. Agl::ncy for Health Cme Policy and Research. Dccembc:r 1994. 29. Lmricq J: Lecture. Los Angeles Collegc of Chiropr-,lctic, April 1994. ----.----. -~ J. 14 Spinal Stabilization Exercise Program JERRY HYMAN and CRAIG lIEBENSON ,, Repetitive strain is the 1110S( <:ommon fl"aSOn pcopic dC\"l:lnp pain. Improving load handling ability is instrumental in preventing chronic or rccurrCll! pain. Ironically, by redirecting the patient's (ocus from chronic pain 10 functional integrity. the pain is more likely to "go aw'ly:· The result of controlJing .~ 1 () "ii, I I I,, ) ) ) ,, I~ l { ~ l !, ':; '/ \i .~ ; '~ i () ,~ } 1 ,, ~ t \ J I 'J >' I1 , I •j: { , .'1 f; 1'c-;] "',' g {; I ~ I ~ , \.~? ) ~ f ~ I~ ~ f) , .,J -I () .~ n 'i ~> loads in .1 more biomcchanically effective manner is less tissue strain 'll1d. therefore. fewer pi.linful.cpisotlcs. StabilizOltion exercises twin a patient to coruml posturally destabilizing forces. These exercises may start by requiring isometric pos· tural slabili7.alion of a key area. such as lh~ lumbopelvic june· lion during trunk or cxtremity movcments. and progressing to involve control of lumbopclvk po~ture during functional ae· tivitics such as sitting. Iifling. ~qll:llting. lunging. etc. Such exercises are Ihf?rapew;c in that they teilch the patient how to maintilin postural control in activities of daily living. By focusing primarily on reducing lumbar overstress during func· tional exercises. the quadriceps. glutci.lls. ~lIld abdominals arc trained without increasing back or hip pain. With this program, it is possible to achieve strength and endurance gains because the back is not stressed. thus the individual can train muscles to the point of exhaustion. Postexercise muscle soreness without symptom eX41cerb.uion is one of the essential stepping stones to returning to full p'lrticipation in the elicit proper responses from the patient. Maintaining proper lurnbopclvic stability requires limiting and controlling exces~ sivr;: or undesired lumbopelvic movelllcnt strategies: e.g., performing a lunge with too much anterior pelvic tilt and resultant lumbar hypcrlordosis. Patient education about the importance of good function for preventing pain recurrencc.s is esscnti;'Jlto motivate the patient to work on creating a healthier back. Explaining that fitter backs have fewer symptoms is helpful. Therefore, it is wise for patients to remediate function r..Hher than just to seek pain relief. Learning to stabilize their back and gain self-rnan.Igement skills i.~ th~ key 10 preventing recurrences. Educating our patients about the importance of this process and seeking a commitment from them is one of our most crucial functions. STAIlILIZATION I'ROGRAM AND OVERALL PATIENT CARE The stabilization program starts by identifying the training or "functional range" in which movement can be performed in a biomechanically correct and painless manner. Staying within this range may initially require performing isometric stabilization exercises by co-contracting (he gluteal and abdominal muscles (i.c;.. posterior pelvic lilt)_ If a patient is asked to hold a posterior pelvic tilt and then move either anns or legs or both ("dead bug"), they find thai holding the pelvic tilt "burns" the abdominals. Kinesthetic awareness. coordination. strength. and endurance are all trained in the process. A simple trunk curl is another example of an exercise that requires proper lumbopelvic control. During a trunk curl. the patient must control the 11<1lural tendency to recruit hip flexors that would tilt the pelvis anteriorly. Floor. pulley. machine. and gymnastic ball roUtines'may all be used 10 increase the stabilizing demands. The stabilization routine can begin in nonweight~bearing positions and thus achieves intense training .effects. such as postexercise muscle soreness in failed back surgery. postsurgical. subacute. and chronic pain patients without causing harm. The main go;)1 of this program is reconditioning key spinal stabilizers through building ~treng(h and endurance while insisting on proper neuromuscular control and coordination. The program also is of value as a mobilization approach that gently shows the path to movement exploration and re·education. In (his case. the de~ircd end result is less a conditioning effcci (postexercise sorencss) and more increa~ iug patient confidence. muscle relaxation. circulation. and 293 nc;nf\DII.. II""IIUN VI- I He ::;PtNE: A PRACTITIONER'S MANUAL f ~" joint movement. In addition, while pcrfomling stabilization exercises, struclUral limitations ~lrc clearly identificd (Le.., inability to pcrfonn a posterior ~iil during a bridge as an indicator of tight anterior hip struclUres) that may require remcdiution thr;ugh stretching tedmiqucs. This exercise progression is oncn facilitated by the "functional rangc" for the particular task at hand. Idt'1l'ij)'ilfg Ihe tmilling rauge is impOrlll1ll for petiorm;".': therapcutic ex· ercise ill (lily part oflhe body. \Vilh resfJccllO spillal prohlems. IWIi'cI'er, Ihe lttmboprll'ic Illolion i... of grealc.<;{ \·allu'. The beaut)' of this exercise approach is that the patient !c..lfIlS lhat it is possible to exercise without p;tin. As a rcsuh the p<.nicnt gains confidcncc that some control over symptoms Gill be achieved with the usc of spccilic sclf·trcatmcilt procedures. I i RULE FOR TRAINING THE "FAILEO"BACK Find the painfree range of mOl ion or functional mnge Identifying the training range involves uncovering postural, movement, and weight-bearing sensitivitics. 7 individuals with postural sensitivities usually must sit or stand a spccific way (Q "void pain. For instance, an individual with a flexion bias is nOI able (0 stand for prolonged periods because of an inability to tolerate lumbar extension. They must preposition their spine in some flexion, c.g.. using a fOOl stool. Patients with mOVfment sensitivities may have pain dur~ ing certain activities. An individual who experiences pain when bending forward to tie shoes or put on pants may have an eXlcnsion bias. The functional range of such a patient may not include flexion of the lumbar spine. A weight-bearing sensitivity or gravity intolerance may be revealed by a history of pain Ihat OCCUfS during sitting or standing and is relievcd when resting. Compression usually aggravatcs these symptOrrlS, as does coughing, sneezing, or any strong muscular con·tractions. This situation is common in patients with acute disk syndromes, who may have no functional range when up· right, but can train effectively whcn recumbent. Another option for the weight-bearing sensitive patient is water cxer· ciscs. Exercise performed in water should not mimic land-based exercises because mO[Qr progwmming may be inappropriately altered by the combined effects of water contact on the skin and reduced weight bcaring. Finding the training range is somewhat like a provocative examination used in the McKenzie system (sec Chapter 12). The goal is 1O detennine what movements and positions rcIieve, aggravate, or ha\'c no effect on symptoms. Those move· melHs and positions in which symptoms arc relieved or arc unchanged can be used as pari of a training program. Activity within (he training. range is best tolerated by the paticnt when attempting repetitive and prolonged exercise training. The pain-free range is nol always one and the same with the most stable or biomechanically·. correct movernenl. For cxample, ~l posterior pelvic tilt during (runk flexion is biomechanically efficient. because ~10 anterior tilt C,IO overstrain the lumbar spine and encourages substitution of the hip ncxor muscles (i.e., iliopsoas) for the abdominal muscles (see Chapters 6 and 18). Many patients, however. report more pilin with this positioning than with the anferior tilt of the pelvis. In cases in which the less stable or biomechanically inefti· cicnt movement is more pain·rree, the joints and related soft tissucs should be analyzed for dysfunction, with ..1 focus on poor mobility or flexibility because of adnpti\'c shortening or poor soft tissue extcnsibility. 1 ') , . J } ~ , }: ) ,~ J ,."'\' ',...ft J I I . ~ 1 , j" vnt\r' I t:t1 14 : ::>t'INAL ~ BI.',::Il1"1.." of the indiYit.luality of ~;\I..'h p~llicnl's fUllctional ranJ;t'.lhIW llHH.:h antcrior nr posterior !ll'h'jc tilt is. feasible will vary (~lr 1..'\-1..'1)'0111..'. hnding the p:linlcs.s range. '1long with asSl..'ssill:: (til" s!l(}I1111tlS(,:k" .llld capsular rt.':'triClions and diagnos.ing slru..:lur;d patho)ol!Y Ii. t •.• spondylolisthesis) will !c.ld tOlh::· IL'rtllillill~ [he functional or training ran,gl' for each palit'll!. Th\.' hl'id~c c.\cl\:is,l' provides :'lllothcr example of whell :11· , ,, , 1 1 ') t ., ~ h.:rl'd IIh:..-h;lI1ics hct.·;llIsc of poor mobility or Ocxibility can n:suit in thl." cxcn:isc being leSs. painful when pcrfomlcd incorr..:t.:II~ Ih~1Il wh..:n il i~ pcrform":d com:clly. Biomechanically. the bridgL'i~ most ~table and efficient when a sufficient posterior lill i~ used. thus r~ducing lumbar stress :ll1d increasing glutcal ;lCti\'ity. If. howcver.)he patient has tight hip flexors, shorh::ning of tile hip joint cap~ulc. andlor tightness of (he lo\\'cr lumbar cr~ctor spinae musclcs. little if any posterior pdviL' till will be wlemted by the patient. This case is one in whit'h muscle relaxation "ltd/or ~tretching and joint mobilization allJJm aujuslillciH would be required before the bridge L'ould he used as a stabilization cxercise. .' ~ j § t' " ! I ;~J J ! I I! I'ROGRESSIVE S1;\BILIZATION EXERCISE TRAINli'\G ) I Exercise therapy should be simple and painless to promoie patient confidence. lnilial rcactinuion c.xcrciscs arc dcsi£ncd spccilically for a paliclll cmcrging from an acule episode or for it p~Hicnt with chronic pain \\"ith fear of movement ("kinesiophobia") and symptom magnificalion (0 allow them 10 exercise \",,'ithout cxacerbating their symptolTls. The pmienr shol/ld leam 10 explore b(lsic IWII!Jope!I'ic IIw\'cmenrs. slu.:h liS IIIl' pc!I'ic lill. lIlUl perform g('",le .wrelches a"d ligltl ca,.diomscular ('xen.:i.'\(:. Weight be~tring or gravity strcss can be minimized by focusing on supint:. prone. and siHing positions during exercise. The stress may be greater during upright activilics of d'lily living. Initial c~erciscs whereil1the patient c~plores movement;:ll the lumbosacral junclion ill a variety of postures demonstratcs the patient's neuromuscular control (or kinesthetic awareness). These exercises also fcn;:ll any structural limitation. Such a Iimiwtion may be prcs~nl as a result of viscoelastic stitTTlt::ss. elevated ncurol11UScul.lr tonc. bony abnonnality. or struclural palhology. When acute pain is ) ~ I I ) (} ,j1 ~ , • I l I• J ~ ~ U I ~ ) u •i, ~ I i ~:; • * ) 1i ., "\.} l'§ 0 ;;: $ S ~ i i ~ t,. -".' L 295 IABILIZATION EXERCISE PROGRAM tiOtI.\". alallg WillI olher additional (1u/{.:ome measures (i.e., lim;Ied range of /1/0(ioll. areas of lel/{I(~mess). should be per- IOl'lI/ctJ. This poslcheck is a crucial step in increasing patient conlidencc abolit the positive benefits of exercise. It can allay fe;lr and .IIlXicly ahout p;'lin and convert Ihe patient from a p;'lin STABILIZATION CONCEI'TS imponant conccpts that pcrtain to this therapeutic exercise philosophy arc defined as follows. TI1C FunctiOlml or training range: P;linfrcc ;lTld stublc joint runge '1f lllOtion (USU:lUy wilh respect to hllnbopclvic motion) and appropriate for the task nt hand Passive prepositioning: Using body position and/or suppons to passively place joints within the functiOilal range (i.e .• lumbar roll to preposition lumbar spine in extension during sining) Active prcpositioning: Patient actively pUiS his or her lumbopclvie joint into (he functional runge nnd holds it isometrically during the course of an exercise (i.e.• postcrior pelVic tilt as a prelude to a "dead bug") Dynamic Slabiliz<.Ilion: Gradual tnovcmcOl of the lumbopclvic junc~ tion into the functional nmgc during c~crcisc (grJ.dually changing a pelvic tilt from squalling to standing) F:lcililation: Process of :l<;tiv3ting ("waking up") Table 14.1. IdentifyIng the TrainIng Range History of static, dynamic and weight·bearing intolerance Identification of the movements thai provoke ar relieve symptoms Identification of the positions that provoke or relieve symptoms ._,.... ", , .. ~ 1"'\ rnl"\v Illlv'''t:n ~ MI\NUAL Staoilil-alion cxcn;isc:-. 'IIC uftcn pi.linful if extcnsibility is Table 14.2. Trunk Stabilization Routine poor. \Vhcn this situalion is identified. it must bc addressed be1. Identify and explore training ~r function~l range. . fore the p::ltiCIH (.111 successfully pcrform stabilization cxer· 2. Train lumbopelvic control dunng dynamic exerCise uSing cise~i. For in.';;(allcc. difficulty in activating the g.luIC:J1 muscles • Passive prepositioning • Active prepositioning is oftcn rcl::ltcd to "lower crossed syndromc" with light anterior • Other facilitation methods . . . hip struclures. Any attcmpt at hip extension exercises typically 3. Automatize coordinated posture and movement In dally skills results in lumbar overstress and It,unstring ;,md cn:ctor spinae ovcractivatiun. In Ihis example. the first line of In~"IlHent would be flexibility training. followed by gluteus maxillltls Table 14.3. Increasing Factors that Progress Training muscle facilitation and then exercise (sec Chapters 2 and IR). Often during therapeutic exercise training. a muscle is Gravitt load Movement complexity hard to activate. The Illuscle Illay not be weak from loss of inBalance requirement nervation. or disuse atrophy, bUI Ill"'y only be inhibited. Rene:\. Repetitions inhibition from related joints and reciprocal inhibition from Resistance antagonist .muscles arc both potential therapeutic targets that should be addressed (sec Chapters 2 and 18):Such relics therapy can facilitate a "donnant" muscle. Oth~r lllet~lOcis to wake vantageous to perform stabilization exercises to a point of exup such an inhibited muscle include (echlllqucs trom the pro· haustion independent of repctitions,~ the end point being prioceptive neuromuscular facilitation philosophy. s~ch. as when the patient can no longer maintain lh~ spine in the funcoptimum patient positioning, verbal cOlllmand. tone 01 vOice. tiunal range during movements. Even then. the palient may be irradiation. and proprioceptive contacts. The value of these instructed to perfonn a similar exercise in an easier position methods in facilitating':In apparemly weak muscle should not ("peel back") so they can continue to exercise thc muscles tobe undercstimatcd. ward greater physiologic exhaustion. Gaining kinesthetic \Vhen the muscle is adequately facilitated so thm percep~ awareness oj the functional range and [hen exercising to fa~ tion or awareness is present, volition alonc can enable the patigue is the best way to deril'e full benefit from this program. tient to train the muscle therapeutically. With practice and It is the quality alld lIot the quantity ofmOl'emell1 tilm is mo.'" repetitions, the muscle can be strengthened and its incl~sion sif!llifiaUlt. in everyday or cven stressful activities can be 3Ulomallzed. ~ Peeling back is an important consideration as a patient Such "reprogramming" is the ultimate goal of FS cxercise~. progresses through a therapeutic exercise program. In this Depending on the level of deconditioning or structural process. an exercise in the patient's training range is identified pai.hology, patients may present with a gravity intolcrilnce. dunn a which the individual can feci a "bum." Aftcr exhaustThese patients can still be trained using non weight-bearing ing th~ muscle over a minimum of 2 minutcs of training, the positions. Gradually, they can move from supine and prone patient then "peels back" to another exercise in which the loading to quadruped and kneeling and eventually to slandfunctional range can be maintained. The end result is a more ing. Slide board or shuttle apparatuses (i.e.. Total Gym) with intense conditioning effcct while maintaining stability of the incremental adjustments from horizontal to vertical can facilspine. itate the transition from nonweight bearing to \veight bearing. Achieving post-exercise muscle soreness requires a cerIndividuals with low motivation often arc noncompliant tain minimum intensity of exercise. From 30 to 40 minutcs or with active care regimens. These patients can be "converled" hundreds of repetitions arc needed to attain such a training efor problems can be avoidcd by determining mutually acceptfect in just a handful of lumbopelvic musclcs (e.g.. abdomiable functional goals and creating simple. painless exercises oals, gluteals, quadriceps, hamstrings). These same exercisc tailored to their individual needs. Additionally, postexercise principles, however, can be used in a lcss intense fashion to checks of functional outcomes provide the palient with evi· help promote better neuromuscular control without actually dence demonstraling the benefits of self-treatment. If they se,e. accomplishing a muscle conditioning effect. Such an applicaprogress. they will be motivated to a greater extent than at tion may be successful for certain pi.Hients. but it may fall asked 10 proceed on the doctor's word alone. short of the mark for a patient with lumbar instability or Treating failed back surgery, lumbar instability. or highly chronic pain. anxious paticnlli represents the most difficult challenge to the physician. These patients have nearly. invisible "f~nctional CLINICAL APPLICATION ranges:' but they may initiate training In the follo\Vmg manner. After identifying and exploring their functional range. Therapeutic intervention with stabilization exercises requires they may begin by performing isometric floor stabilization a clinical problem-solving approach. Typical problems efl~ exercises in the recumbent (nonwcight bearing) position with cmmtered n.·hen progressing patients through a stabilization traction assistance (see Figure 14.56). The patient may routiue are ,mor flexibility, muscle i"I,ibition, weight-bearing progress with or without traclion assist;,mcc to other mo.re dcimolerallce. or low motivation. Addressing these situations as mallJing positions, sut:h as quadruped. se.ned. or standlng. if one encounters [hem is essential. I , 1 I ~ ', .. 'lJ 297 I.;HAe I loti 14 : ~elNAL STABILIZATION EXERCISE PROGRAM Table 14.4. Lunge Test as a Functional Screen • Trunk drills forward during lunge: tight hip flexors. weak gluteal muscles • Increased hyperlordosis during lunge: tight erector spinae, weak , , abdomina Is • Front leg's heelliHs aU floor: tighl soleus • Excessive knee shaking: weak qual'is, poor balance • Front knee in Iront of foot: too short of a stride or torso moves too far for.vard I , I ~ ~ j I I I ) , ..; ~ ~' ;' I ;I I ), ~ , I I I ) j ~ \ ;I j " ',; ,~ I :I ¥ ~ ,) ! .~) ~ '~ }i N Xj ~ ,) I , J ,..J ~ I i ~' ._,1' ~ ti :,' I• lJ j 11 ~ ~ J " ~ i "~;; M ~ :)! ". , \.. } R , ~ f, ~ Ihe p;,lticnt has difficulty mainlaining their function'.l1 range through activc prepositioning. Ihey may usc passivc prcposilioning. For instance, supine hook lying with a cushion under the knees kceps the spine in a posterior pelvic tilt and allows easier stabiliz31ion training with either trunk (sit· up) or extremity movements (respecting any flexion orextcnsion bias). The exact progressions chosen depend on Ihe patient's rc· sponse to training and the individual work or activity demands to which they must return safely. Training c::tn also pr~gress by increasing the movement complexity. For instance, movements may begin in cardinal planes (sagillal or coronal) and advance lO include torsional. coupled, and functional movements. Once a paticnt has learned to explore lumbopclvic motion and to identify their asymptomatic and stable functional range. they can perform various exercises while isometrically holding their spine within this range. Adding extremity movcmcnts to b;'lsie trunk exercises further challenges Ihc palit.:lJl·~ lurnbopclvic control. The goal of FS exercises is 10 perfonn skilled funclional movements with the spine stabilized as the p::ttient moves from one position to another. Examples include moving from sitting to standing, standing to knceling, and quadruped to standing. At limes, the functional range may change during .1 movernc'1l. A classic example of a transitional siabilization exercise is performing a lift from a squat position l() st infonn third pal1y payers of the patient's st • •• _ lIuuugII facilitation lllcthuu,..,. i;ll.::ll pr(1gr~ss to l'xl1allslill~ ~x crciscs and daily hypcr\'igihuu:e (for ahmll 6 \\·cck:,). put it will ultimately fail lInlc~s norlllal 1Il0\ clll~lH p;Hlcrns arlO uot reprogrammed so ,that the illdivitlu;l! "C;lll:!lcs l!lcllbdn:s doing it right.·· The following spc~ifk exercise.. . ;11\.' Jcsi~lled as dirf~I\:l\1 avenues to travd wilh a patient. I-:;Idl palicllt will pnll..·L·cd al i\ different rate. Sessiolls lIl;ly vary fH111I I () minutes HI mOl\''' than I hour depending Illi the ll....eJs (If thl.: patil.:1I1. and Ilol those or the pr.lCtitiona. In gCllcr;l1. each regimen carries the pOlcntinl for patient frustratioll bc(au_,>c a gn.::ll de;1I or coordination is required by thc patiem. Ckar g()als must be laid out and the prilclitioncr must be p,,{icll( and cmp:uhctic. ;\ 6-wcek course of Slabilizatioll session", is often atk::qLlille to begin the process of ··reprogr:.l11uning·· hetter neurolllllS(lIlar control ilnd spinal stability. •• _ t"\ V \..ollIIVl Cn;::. Mr\NUAL Ofril'l..' scssiol1s ShtHdd OCcLlr no more; than three to four times pl.'f week. At IIr'1. {he patient is simply trying 10 led a '"hum" ill the '"bi{' Illu:,eks whik feeling no stfain in lhe; spinal ;11'1..';1:'. EXel\:isl' inlensity is inl.;"rcascd until pos(cxercise SO..l..'llI..·........ is ;\chicn:d \\ ithout s)'mpllllU eX:Kcrbatiou. A few _'C~Si()ll' lIlay he rl.'qllirl..'d 10 lind Ihl..' training range and achiL""c this rcsull. OIll"I.· this lask i., ilCl':lllllplished. the pro· gr;IlH qllit:kly ~:l1hL'r" Ilh)llll..'niUm. :\, Illllg ;IS ;Ul cxcn.:isc r..::tUSI..'", poslexl..'n:ise Il1thL"k sorcllcss. il ,11OUld nO{ bc repented daily. WilhoUllhc il1h:lbily of lraining re4uircd to achiL:\'c this dfcc!. the 1110tor 1.;"0111rol lh;r..:essary to achievc spin:.tl swbility in Jaily lifc is 1l00likcly 10 result. Once a patient is discharged from the prog.ram, intensity and rrcqucnl.·y may be decreased to a IlWimCllallce It;ycl. 1. Floor Slilhllii'.ation Excrdscs A. LUMBOPELVIC FUNCTIONAL RANGE EXPLORATION Lumbopdvic range of lllUlioll terior and ant~rior pel\'ie tilts. i~ ~xplorcd by performing pos- Hmlk lying (f-i!;. I-U I Supin.: Icg~ cxlenlkd I..:n..ure unly millin.I:!1 duwllw;m.l heel pre~· sllre) (Fig. 14.2) I A "" ""-t; f f \ .~ - (...~ , - t 1- '" 1 ~ - --- - • ~I'. I -" B Fig. 14.1. Anlerior Fig, 14.2. Posterior pelvic tilt (supine). ) ., jf -~ Jf I I ! ,} I I • ! f -~ , J I [ A I B f ~ Fig. 14.3. Anterior (a) and posterior (b) pelvic till (sealed). f J.0 --- <;HAPTER 14 : SPINAL STABILIZATION EXERCISE PROGRAM .. 299 1 , j 1 ! 1 l j , ! I ; .1 .., j 0 1 II C) , ~ I, ) I ! ) IJ ) ",. tI I J' A , :. ') } ) j I ) I ) i i s Fig. 14.4. Anterior (a) and posterior (b) pelvic tilt (standing). ~ ~ fl. A B Fig. 14.6. Posterior (a) and anterior (b) pelvic lilt (kneeling with buttocks on heels) . ) " . i, ~ • )l '.) ~ I• } • Scated (Fig. 14.31 • Standing (Fig. 14.4) B .) Quadruped (Fig. 14.5) Kneeling with bUt\UCKs \111 hccb (Fig. 14.6) Kneeling with thighs vcrti("011 (Fig. 14.7) Silting on 110m with feCi \s(llc~) logether (Fig. 14.8J Prone :g .;s li• () •~ •~ u i t ! L) if: >, ,; i ,,,} . c ~ ¥ ,J Fig. 14.5. POSlerior (3), anterior (b), and parti3.1 (c) pelvic till (quadruped). m f ,.. v ~ ,.; r, ~ r 'l'" ~ ~ , 1. Difticulty performing pelvic lilt~ often is <.I result of poor neuromuscular control. Appropriate verbal commands. r~\{:ilip tative cues, passive prepositioning, and n,-, ,"u, .... , ' ' ' ' ' V ' " VI "'I... ..,,- ""I.... " r n ........... I I I I V ' ' ' l : ; n V IVIJ-\'''';UJ-\l. B. "DEAD BUG" TRACK (ABDOMINALS) For each exercise in this track, ensure that the patiellt maintain:-: the posterior pclvic tilt not only at lh~ heginning the movcmcnt, but also to the end of the cxen.:isL'. or I. Hook lying. activc prcpositioll in posterior tilt, rJise one ann at a time ovcrhead 2. Hook lying. active pn:posilioll ill posterior tilt. raisc both arms ovcrhcad 3. Hook lying. activc preposition in postcrior tilt, raise onc foot.\ few inchcs off thc noor at a timc. switching to thc other [oat so as 10 "march" 4. Hook lying. activc preposition in posterior tilt. bring onc knee to chest at a lime. 5. Hook lying. active prcposilion in postcrior tilt. bring one knee to chest at a time while raising opposite arm. return foot 10 noor (Fig. 14.9) 6. Hook lying, activc preposition in posterior tilt, perform alternating kicks without letting feet touch the floor (the lower the legs, the harder the exercise) (Fig. 14.10) 7. Dcud bug (Fig. 14.11) 8. Add ankle and wrist weights A " :1 ; I, ;, .. ~ , ~ ., When a patient has developcd the neuromuscular skill to pcrform exercise 6 properly, then they have an exercise that. if perfoffi1cd repetitively. will bring about the required training effect to condition the muscles. Difficulty with the "dead bug" track is usually associated with poor neuromuscular control or weak abdominals. Shortened psoas and/or erector spinae (hip flexors) muscles may also be a factor. C. BRIDGE TRACK (GLUTEALS AND QUADRICEPS) I. Supine, hook lying. with active prepositioning in posterior Fig. 14.7. Posterior (a) and anterior (b) pelvic tilt (kneeling with thighs vertical). pelvic rilt bridge. slowly raising the pelvis and lumbar spine one segment at a time and then lowering one seglllcnt at a time (keeping kyphosis of lumbar spinc throughout) (Fig. 14.12) 2. Bridge up. alternate hecllifts while holding bridge 3. Pcrfonn bridge. then "march"· with only one foot on the floor (shift weight before marching) (Fig. 14.13) A 8 Fig. 14.8. Posterior (a) and anterior (b) pelvic tilt (sitting with soles together). -----j. CHAPTER 14: SPINAL STABILIZATION EXERCISE PROGRAM 301 Fig. 14.9. Posterior pelvic tilt with opposite arm and leg raised. A Fig. 14.10. Posterior pelvic tilt with alternating leg kicks. B Fig. 14.14. One leg bridge ("dips"). Fig. 14.11. "Dead Bug." Fig. 14.15. Opposite arm and leg raise. 4. Bridge up. extend one knee, keeping both thighs paralic-I. perform one-leg bridges or "dips" (Fig. 14.14) 5. Holding bridge with straight leg. lower and raise leg Fig. 14.12. Bridge. A training effect is possible with application of exercises from exercise 2 on. Difficulty with the bridge track is often associated with a shortened psoas muscle or ovenKlivity in the lumbar erector spinae muscles. The one-leg bridge exercise involves use oflhe gluteal medius, and its difficulty may be associated with piriformis or thigh adductor tighlness/ ovcractivity. Additionally, lumbar segments may have decreased flexion motion. Sacroiliac and thoracolumbar joint dysfunction should also be considered. D. PRONE TRACK (GLUTEAL MAXIMUS) I. Single arm raise with pillow 2. Arm and opposite leg raise wilh pillow (Fig. 14.15) Fig. 14.13. Bridge with "marching." 3. Without pillow ~----------------------- nc.n .... o ..... 1 11"\1 IVI\l Vr- I Nt:. ::».... INt: A PHACTlTIONEH'S MANUAL Diniculty ort~n arises because of decreased spinal and hip lighl psoas (hip flexor) muscle or hip capsule may be il1\'oh·ed. Decreascd lumbi.lr spine mobility in extension (lixed kyphosis) is also a faclor. ~xl~nsihilily. :\ E. QUADRUPED TRACK (GLUTEUS MAXIMUS, MEDIUS) Preposilion in ncutral position anti faise one aflll (Fig. 14.16a) R~lis~ one kg (Fig. 14.lJlb) R"ise oppusilc ann tlIl1J It:g (fig.. 14.1()c) (may add wrist and ankh: wcighbl Add cxterrw] rcsistanc~ with doctor pushes A () () I B ) c :) Fig. 14.16. Quadruped progression. Fig. 14.17. Quadruped with extern~1 resislance. '. ,) ) I !. I 1• II B A Fig. 14.18. Quadruped with trunk rotation (a) and on balance board (b). ___-:-- ,) I I ~ ~- __--i~ <. i' ._. , ,---- ..... ,, , j ! , ~ ~ ,! t ~ 1, " I B A Fig. 14.19. Kneeling hip extension. I, r"",, ,~" c B A ! iI, ) 1 ~ ; i,, ) I, ) I, ) ~ t t, ;Ii tI ) ) I ) I ) I Fig. 14.20. Kneeling to semi· kneeling progression. ~ ~ } ~ Difficulty with the quadruped track is encountered when lhe prone track is not mastered. Also. gluteus medius weakness/inhibition on the supPol1lcg side may be present bCl:l.\uSC of adductor, piriformis tensor fascia 1,.11<.1, or quadratus lUll1bo~ rum hyperactivity/tightness. !-~ " J I l';~ G. ABDOMINALS n F, KNEELING TRACK (QUADRICEPS, GLUTEUS MAXIMUSj -~ iJ{! J !• ,.,1 .~ .~ i t"li ~ 1a. Siuin£ on heels. trunk and hips Ocxed. poslerior pelvic tilt. r;lisc torso by extending hip... (abdominals and gluteus max· imus) (Fig. 14.19) lb. Silting on heels. trunk upright, posterior pelvic tilt. r.:lise IUrsn by extending hips (Fig. 14.20 a illld b) 2. Sallie position as shown in Figure 14.20B with arms raised , \.> (Fig. 14.20e) ',,-J ~ ) f:o ~"") I,, 3. Wilh weights (Fig. 14.21) 4. Hold rOtiscd pnsilic... while Ilcxing ;llld extending 14.21C) ~ -€ ...l...- t ;~ :\ & ~ j; f ~ Kneeling may be difficult beC l j "-,'" { } ;lrlllS (Pig. Crunch with pa:-sivc pn:positiolling (hips ;llld knees positiol1t"u ;11 90" llcxioll a" Oil :1 chair) Crunch wilh ;lclive pr~positi()nin£ (Fig. 1~.22) • Trunk curl (willi knc...·s h~nt ;md partiully ..::\tcndcd) (Figs. I.L~J and 14.24) Posterior pel vic' tilt Keep chin tucked. raise head then uppcr back until should..:r bhtdcs arc off Ooor Feel shnululIlll lift up ~' ;];:; c B A ., I Fig. 14.21. Kneeling to semi-kneeling progression with hand weights. .'" '!t j , ., A Fig. 14.22. "Crunch" abdomina!s (active prepositioning). B Fig. 14.24. Trunk curl with legs extended. Sit back Posterior pelvic tilt and lower trunk one segment ilt a time, then raise back up without lordosis (Fig. 14.25) Lower abdominal hip thrust with back nat and hips and knees ftexed 90' (Fig. 14.26) Oblique Fig. 14.23. Trunk curl with knees bent. Difficulty is often encountered when the erector spinae or hip flexors arc overactive/light. Lumbar spine joint dysfunction may also be prescnt. ... .:;: ----------------- H. LUNGE (OUADRICEPS\ (FIG 1.1 ?7) Fl'l'1 should hl' ~h(ltlltkr width ap;H'l ~I;\illl:lill slight lumhar lordosis lllr')llfhnlli llll\~l' Ik",iol\) (1'1"1111\ knl'l' Slight pllsleri(lf pL'lvic lilt lllay (ll' lll'e,kd Ill';ll' ,' lJ{)" Ill" Difficulty can be encountered when hip flexors (back leg) or hamstrings (front leg) are tight. Observe balance en'ors, in- Fig. 14.25. Sit back. A B Fig. 14.27. Lunge. appropriate neck/shoulder movements (i.e.. chin poke, shoulder shrug), and slllall jerky- transitional movcmcnts. I. B SQUATS With feci shoulder width apart, actively preposition in pal1ial anterior pelvic tilt and pcrfonn partial squat (no more than 90° knee flexion) (Fig. 14.28) Progress to lcaning forward 10 touch noor with hands without losing anterior pelvic lil! Fig. 14.26. Lower abdominal hlp thrust. Difficulty can be encountered if adductors arc shortcned. will lift lip if soleus is tight. I-feels Note: Tllesl' lI\O\,CIllCIHs ;m: Ill\lrl' difficult (lll circular-tuhular (O,llIl Altcrn:lh:ly lifl onc fOOl sli1;llIly \ll'l" l100r (f:i~, 1-l.~9hl Prngrcss tn lJO" hip I1cxitlll Rep-:;ll ,lh(l\'C with anll:' o\'Crhl',1l1 (Fig. J.L29d Repeal ah\I\'\.· with hoth hands ahovc chesl Wi,g. 1~.:!9dl On drdc wcd,ge. hands (11\ t,-hl'sl. onc knec tn l.:ht'~l 2. Styrofoam, ;"ledicine Ball. Stick. Exercise 'nlhil1~ Stahilization Exercises A. ON STYROFOAM Pcrfllrlll posterior pC!\'ic lilt with hands on l1uOf (I/~ l'irch;) (Ii:l'l closcr together is h;mkr) (Fig. 1-l.::!9a) .-1;, B. ISOMETRIC ABOOMINALS (WITH DOCTOR OR THERAPIST) Actin: prep\lsil;Ull ill cnlllch l'klsitjoll wilh loam held bCtW1;'l'lI klh.'t'S Patiellt rt'sists movcmcnt of foam whcn doctor Jlushes or pulls foam (fig. 14.30) Active preposition in cnlllch po~ililln (90/90 hiplkllt'C Ikxjon) with mcdicine b,lll or liglH ohjcct helJ bl.:1WCl.:i\ fecI Doctor Ihrows ball to patienl overhead lFig, I-lJ 1) Al.:lj\·c preposition ill cnlllch PO~ili~\ll wilh hall held helwecn floel ill1d gymna~tic hall un ahdml1cn Pati~nt rc~i~(s movcmcnt (If gymnastic hall hy Ihc uoctor ill diffcrclll Jin:ctiollS ~l(lwl)' ., ,~ 3. Gymnastic Uall Exercises To increase pmicllt confidence. gYl11n~ls(ic h.J11 cxcn.:ise:-o call be done between two chairs for b~lI ..mcc suppon. The ball is or the proper heig.ht if the hips and knees of the patient silting on the ball arc at 90° '-Ingles. '"; , A B " B c Fig. 14.29. Styroloam progression. y J Fig. 14.28. Squat. A. Correct. B. Incorrect. A , .. o ._._._ ... .. _.,_ .. ,~ ~.~- ... ..., .... , ...... ,.. ;;UI ~ I 1," I 1] B A Ii Fig. 14,30. Isometric abdominal "crunch" position with resistance. . l ~ J Be careful that the head docs not shift forward (+ Z) or lhM the chin pokes OUI causing ecrvicocranial hyperextcnsion Scated, posterior tilt. and roll down ball part way until abdOluinals begin "working" (Fig. 14.35) Hold position and slowly lift one fo('~ ~t :~ tim,: {gh!!("us medius) Shoulders on ball, active preposition in posterior pelvic tilt anu bridge up (Fig. 14.36) Hold bridge and fk~ onc leg with knee bent (Fig. 14.37) Keep postcrior till and prcvcnt oppositc hip from f i Ii ) ) I~ I " .~ I I C. ABDQMINALS ) I u II ! I, ~,~ { J ! _--"'J.. ~ 'R i! " , " Middle of back on ball. trunk curls Stall low on b'lll (passively prcpositioned in flexion) :Illd progress higher on ball until exercising ill extended position (Figs. 14.39 nnd 14.40) Middle of back 011 ball. perform partial trunk curl. l·'llCh bnll thrown by doctl1r (Fig. 14.41) Progress to harder positions on ball Middle of b<.lck Oil ball. pcrfoml partiallrUllk curl. ptlll (miley or exercise lubing in rotary directioll (elbow:" should :"lay extended. movement occurs from waist muJ IInl shoulders ()I" ,U"lHS) Progres~ by adding. rcsisl,lI1CC All fOUf!'., front roll (feet off the gnmml) (rig. 14.421 D. HAMSTRINGS With legs extended ,100 feet on b.l!1. bridge up .Illd roll lK11I toward bUllocks by Hcxing knees, then roll ball away (Fig.. 14.43) With hips and knees .It 90/90 nc~i(ln. pCrfUnll bridges (Fig. 14.44) ,) ~ ~ Perform anteriDr and po~\crior pelvic tilt on ball (Fig, 14.32) Active prepOsiliol1, in nculr:ll position, perform single leg raise (Fig. 14.33;1) Sillgle leg raise and rull back (maintain slight lumbar lordosl:-J (Fig. 14..11h) Sealed, perform posterior pelvic lilt and roli down b.llllO bridge (Fig. 14.34) Return to sitting position with pusterior or antcrior tilt (small steps do nUl stup) 1 ~ A. SEATED B. BRIDGE (QUADRICEPS. GLUTEALS) '1 Ij Fig. 14.31. Isometric abdominal "crunch" position wilh medicine ball. _ •.. _ .., , n.-. J" 'v'lIcn .::> IVlf\l\JUJ\L A .-""i Fig. 14.32. Sealed anterior and posterior pelvic lill. i} B Fig. 14.33. Single leg raise and roll back. 309 CHAPTER 14 : SPINAL STABILIZATION EXERCISE PROGRAM B A D c Fig. 14.34. Seated to bridge. Roll ball from extended position (0 kncc flexion position with single leg (Fig. 14.45) 90/90 bridge with single leg (Fig. 14.46) Raising the umlS vertically increases Ihe stabilization dt'mands on the trunk E. SUPERMAN Prone on ball with fc:ct against the wall. perform postcrii.1f pelvic tilt and then extend Ihe trunk by pushing off from w,llI and straightening the back. Make sure to maintain some gltltcal and 'lbdominal co-contmction throughollt movement (Fig. \-t ..P a and h) In extended position. swing one ':lfln up overhead whik holding posterior pelvic tilt tFig. 14.47c) Fig. 14.35. Half sit-up with alternating leg raise (progress to partial bridge). b If this exercise is Jinicult to perform. retrcat to till;.' knceling (rack exercise :,hown in Figun: 1...J..19. MCMROlLiIAllUN Ut- THE SPINE: A PRACTITIONER'S fl.o1ANUAL ----------~==~ 8 A \ ~ ~ \ I, I c Fig. 14.36. Posterior pelvic lilt and bridge up. ~ i Ii 1 \ I I I, A Fig. 14.37. Hold bridge and flex benlleg. ~ ~ I t'·-- - I I I 8 Fig. 14.38. Hold bridge and flex straight leg. Fig. 14.39. Trunk cur! lower on ball (easierl. CHAPTER 14 : SPINAL STABILIZATION EXERCISE PROGRAM 311 , ,, ~ J { ~ j i¥ ; ~ A A B Fig. 14.42. All fours front roll. B Fig. 14.40. Trunk curl higher on ball (harder). , >-~ " A B Fig. 14.41. Trunk curl and catch medicine ball. F. SEE·SAW AllIerior thighs llll 11:111. hands un lloor. active prCp{l~ilitlll in ncutrod pusitiun. r Difficulty c:m be cncoul1(crl.'d if erector spina(' or hip flexors arc light c Fig. 14.43. BridQp. and roll ball in and Oul. A A B B Fig. 14.44. 90190 bddge. Fig. 14.45. One leg bridge with roll. -j ) :'" A B .~) ! Fig. 14.46. One leg bridge 90/90. '--j' ,) J J G ~J C} B ,~'" oJ c Fig. 14.47. Supr;:man progression. CHAtJ I t:H 14 : ::it-'INAL :::i IAt;ILlLA I IUN t:Xt:H\,JI:::it: tJHUl:iHAM jlj G. SQUATS Wall ~lilk wilh !llwL'r b;IL"~ again:-;t wall and :-;ligllt anIL'rill!" pl..'h-iL' lilt (Fig, I--L49) Perform wilh a weight in !Jamb: a:-; legs L'xlellll. gradually rai~L' the wL'ighl overhead When lhe arllls reaeh horizontal. transition rmlll ;Ill ;1I1tcrillr til a p\l~IL'rill!" pelvic till I'l'l'rorlll a ~qllal wilh olle roo! 011 11(1(lr (Fi~~. 1·1.)(}) \(1nl··k~~L·d squab \~ilh the h;llllllay llol he as deep) H. KNEE ON BALL FRONT ROLL Knees on hall 'lIld hand.. . 011 noor, c.:irl'lllllduet plClvis (Fig. 14.51) A A B B Fig. 14.49. Squat. t. Prone on hall back extensioll (Fig. 14.52) Prone on ball upper back CXllCliSioll (Fig. 14.5.'1 :\dJuct :-;hl\ulder hladcs and l1ll'n lift sterTIUllI ll(( b;111 c Kecp chin lud,cd in Fig. 14.48. See-S3\!J progression. 6 OTHER BALL EXERCISES • B; ~k,(rt:tL"1l (111 h,dl (Fi:~, 1·1.:'·1) •.• _ ...... " ,""'......... I I I .... -.I' " .. c. M "'1"11-'0.\..1 1IIIVI\ll::N ~ MANUAL 1f , J i, t ~ I , j ~ Ii A J Fig. 14.50. One leg squat. B Fig. 14.52. Lumbar extension. ) A Fig. 14.51. Knees on ball circumduction. B Fig, 14.53. Dorsal extenSion. 315 CHAPTER 14: SPINAL STABILIZATION EXERCISE PROGRAM B A c Fig. 14.54. Back stretch. Fig. 14.55. Shoulder rotation with trunk stabilization. 4. Pulleys and Bicycle A. TRUNK TWISTS l..,nmelrk slahililalillll with ahd\11llin~:lIgl11tcal co-contraction, perform trunk {wi\! ,-lgainsl resistanti-' (hold elbows in c\lcmlcd po\itioll) (Fi~. 14.55) 8. GRAVITY-ASSISTED PULL DOWNS Pcrl"orm push:rior pdvk lill ag'lin\t rc..,i..,lalKt' while bringing h:lnds hz t(l ;lhdplllcn 'l;.;ainst 1\'sisl,IlKT; Fig. 1,,+.)(1) Fig. 14.56. Pelvic tilt and pull downs with traction. ..•.. _ .. _. I I " . _ _ , ... _ •• , • , . "..... " . , ..... , ... ,. v ,v,nl'lvr-.l.. C. RECUMBENT BICYCLE Supine 011 floor or lay h:l..:k 011 large hall whik riding stational;; bicycle (r:ig. 14.57) REFERENCES 1, l I~ l. Mon.::1Il D: C(lIlC':l't~ in fIllKH''lI;11 tr:lining ;ll1d Jl 2. ~h1H~:1I1 D: $..:rnil1ar. 1.11.';' All":l'k.l Colkgc ofChin1praclic. 1992. J. Sa:II~J:\, Sa:.l IS: Nnllup.:r:lli,..: Ir"::lllll..:nl ,If hl'rni:lk·d lumbar illlc('\·l'rte· br:t1l1i~c wilh r:llliculop;llhy. Spin..: 1... :-01. 1~)H9. J,\: l)~'I1:11llic muscu!;" ,,1:lhili/.:l1iuli in lhe nOIl0pt.:rali\,,: IrC:IIIll.:n1 (If lumll:tr p:tin syndromes. Onllo Rc\' 19:691. 1990. 5. Liebells~111 CL: Rch;jhilil:llioll Oflhc chnlllic had; p:lln patient: FUl1l:llonal r,:sltlraliolllcchni4u,:s. Cal Chir J 16:26. 1991. J.:. Timm KE: A randomilcd·control ~lud)' of acti\'e "nd passh'e IfCa\lllt:nls for chrnnlc low b,lCk p:lin following l:lIllincclomy. J Onhop SportS Phys TII.:r :m:27(1. 11)<)4. 4. S:I;J1 I. ~ A 7. Vollowil/. E: Furniture prcscriptinn for the cOllscr..:ui\'c l1l:IIl;lgclIlcnt of i I I I \\: I, Ii ~ i ! i I~ I I I, I low·had p:Lill. T(I[l/\cUlc Clr..: Traullla Reh:lhil 1: IS, 1988. ACKNOWLEDGMENTS We arc grateful for the example and guidance of Dennis JO.IIlIlC Llrricq in the completion of this ch:lptcr. Morgan and APPENDIX 14.1 Exercise Checklist: B I. FLOOR STAllILiZATION EXERCISES a. Lumbopeh'ic functional range exploration -Flg. 1<1.57. Recumbent bicycle. __ Hook lying _ _ Supine legs extended Scaled _ _ Sl:mding _ _Quadruped _ _ ~neeling with buttocks on heels _ _ Kneeling with thighs verticul _ _ Sitting on floor with fcct (solcs) togcther b. "Dead hug" Track (abdomina Is) _ _ Raise I arm at a lime overhc I knee to chest al a time _ _ Bring I knee to chest at a time while raising opp_ arm _ _ Alternating kicks _ _ Dead bug _ _ Ankle and wrist weights c. Bridge Truck (glutcals and quadriceps) _ _ Bridge _ _ Bridge wI heel lifts _ _ Bridge wI "march" __ I leg bridge _ _ Bridge and lower and raise leg -~ d. Prone Tmck (gluleus maximus) II _ _ Single ..Irm raise wI pillo\v __ Arm/opp. leg raise wI pillow _ _ W/nut pillow e. Quadruped Track (gluteal maximus, medius) Raise I arm _ _ Raise I leg _ _ Raise opposite ann and leg _ _ Wrist and ankle weights External resistance _ _ 1 arm raised perform trunk rotation _ _ Balance board perform trunk rotation f. Kneeling Track (quadriceps, glute.al maxim us) _ _ Silting on heels mise torso _ _ Silting on heels. trunk upright raise torso _ _ Sitting on heels. trunk upright raise torso wI r.liscd arms __WI weights _ _ Flexing and extending arllls g, Abdominals _ _Crunch Trunk curl Sit b.lck _ _ Hip lhrust _ _ Obliques h. Lunge (quadriceps) _ _ Lunge __ WI weight __ WI pulley or exercise tubing Backward lunge _ _ Sideways lunge ~ ~ ;: t7: jj i1 ;: ~ -----------.J~. .... ;. (. .-\hdull1iu:IIs S~i;l:;::. ~_~\'liddh: ~lf " ..,di. Ull _ _ Squal 2. STYIWFOA'I. '1EIHCINE 11,\1.1., STICK. EXERCISE TUIIIN!; ST,\BILIZATlO;-; EXERCISES a. 011 st)THr(l~1ll _" "Pnsll.'ri'll" 1'.:1\ i~· tilt I 1\111.'1.' 111 ,11~'''1 ,.. , i I! ,, ~ dl~'~1 __ On t.:irl"k \\\..Jg~ w/arllls !lamb t1\'l.'l"h~·ad 'III l,:hl·"! I I\lIl.'l' III dll'''l _ _ Crunl,:h plhitiun with f~lalll Ill·\\\l'l.'lI klll.'....s ~hli."h.r I\lcdll:1Il1.' n.lll nl.'t\~I.'Cll 11.:1.'1/ UU(!ur 111nl\\S h,dl _ _ B"11I het\\I.'\.·n fl.'l.'t ano gym hall nn ahdulIh:ll/JIl\.·\or pulls. , h"1I MI.'I..h<.·tlIl.' tJ,llI held hct\\cl.'lI fl.'l't/"tlcb "'"'":!. ~ 3. GYMNASTIC BAI.L EXERCISES ;1 d ) .1. SC::lted _ _ Anterior ~ _ _ Single leg raise and roll back 1 , ) I b, Bridge (quadriceps. SC'-llcd ~) $. .?;I 11 ) _.\ .J I , J ) .~ 11 .~ i !,) , \~ ..... I .) '-...J . , Jl ,,! F *,'," ~ ~ I! \ , < -~ ' ,,,: .... ~ g 1: ] It ,,I , '!-,,) I -" t !, I ~ ,( ~nd ~Iute::llsl rolll.km n h.lll 10 bndge __ Return to sitting position __ Y~ sit up and ··nmn:h'· _ _ Bridge up/down __ Bridge and flex! leg wI knee bent __ Progress 10 only upper b~lck and he.\d ()II ball _ _ Bridge ,lOd flcx I Icg wI knee extl.'llded _ _ Bridgc up ;lnd down wI I leg on noor ") I, ~nJ pnstcriur p\.'I\'ic till __Single kg raisl.' "~ , '<...j ~....... ; I i 1 c, SUI)cnnan . __.SllpCrlll..1Il __ - WI ann . . wing f. Sec-saw Sec-s:!w ({'lise I kg scissor g, Squats Wall slide WI <:omcthtng in h:.lmt<: Isometric St,lhiliz::ltiol1 i~ pu"hcs ur pulls ) I, 90/90 \\1 "mg.!l' kg h. Ismuctric ..\ hdominllts (w/doctor or thcnlJlisl1 \ Ii ___ I I\l1l.'l' III balllnlllk curls and c;Hch ball thrown by dncUlr _ _ l'rugA'SS hI harl.ll,,'r positions on b~ll _ _ Trull" l·url/pulky or exercise tubing in Wl.. tliol) All !"tlur" fnllli rnll d. H:lIlls{rin~s FI,,'l'1 1111 hall hridt:1,,' w/mll in t)O/IJO hIIUgl'''' ~_ Roll 11:111 w/ singk kg ~_Trul\k cml \VI l'Ilr\\.lhi r.\.·II,1 WI I loot on nOOl h. Knec on Imll front roll Front roll i. Other b:lll exercises B'lck extension ___ Uppcr back cxtension Stretch 4. PULLEYS A;-;n IIICYCLE Trunk twists __ Gravity-assisted pull downs I{CCltlllh(,,'llt bicycle ! I I I 1 l I~ ,~, ,'~ ., ') ,) ) ,) ) .;:> ~ II ) ;: ;; II •W~ ~ ~ .f i• I i " ~ <) ,) ) )l }1 ) lJ > :~ "1 ." i~ ~ ~ ~ i I ~ j " 1l ~ i< "t {~ ., .J ,J ~IJ .;) ,J d , .. '-'"~ ~;i f I \j IJ ::,ensory lVlotor ::)ttmulatton VLADIMIR JANDA and MARIE VAVROVA' Tht:rapelllic~lpproaches have (hanged along with our in¥ creasing kllO\\'h:dgc and underslanding of physiology. In the original approach to therapy, we viewed the motor system as an effector only. and did not C:lltlsidcr its rok with the alTcren! system as one functional unit. The conclusion was drawn [hat motor performIll1cc is a result of isolated and separate. although coorJinatcd. activation of individual muscles. The focus of these techniques was activation of individual muscles or llluscle groups in the hope that the new motor pattern would develop automatically. Examples of such thinking arc exercises prescribed according to muscle testing or the progressive resistance exercise program. The next qCP in thc evolution of therapcutic approaches accepted Ihat a movement cannot be accomplished without coordination of the afferent pathways and centers. Along with this knowledge came the realization that the motor system and the afferent system were closely linked, VARIETY OF THERAPEUTIC APPROACHES Kabat developed and introduced into practice the concept of activation of afferent patlmtays as an approach to movement re-education. ' In therapy, this concept is the basis of the Proprioceptive Neuromuscular Facilit':ltion (PNF) technique. This approach. as well as others such as those developed by Temple Fay. the Bobaths, Vojta, and Brunnstrom, systematically stresses muscle coordination and the importance of proprioceptive information. At present, it is understood that the afferent system not only has an informative role. but also par~ ticipates substantially in motor programming and motor system regulation. Therefore. proprioceptive stimulation is stressed more and more. The term proprioception was used for the first time in 1907 by Sherrington to describe the sense of position. posture. and movement.) This term has since been defined in a broader way. and today. although not quite correctly. it is used to describe the function of the entire afferent system. It is now underslOod that to split the function and/or dysfunction of the rnyo-ostco-al1icular system from central regulatory nervous mechanisms is wrong. Both parts function as one inseparable functional unit and cannot be separated. Thus. any lesion or impaired function of any pall of the peripheral motor system leads to adaptive mechanisms in the ccntral nervous system and vice versa. Kurtz was probably thc 11rstto notice, from a clinical point of viev.... the relatiollship betwcen the lesion (injury) of the foot joints and incoordinated muscle function of the lower leg ..' Apart from fundamental experimental work, such as that by Wykc~ and Skoglund,~ it was Freeman and co-workers (1964, 1965, 1967) who, in Ihe clinical selling, systematically considered some aspects of joint traumatology and the importance of impaired afference in the genesis of an unstable ankle joint,(}·R Freeman and colleagues also introduced, in non-neurologic cases, a detailed evaluation of coordination. and stressed the importance of muscle inhibition as an integral part of the clinical picture. Since the publication of this initial report by Freeman and Wyke, interest in tillS problem has increased. One of the most extensive works on this topic is by Hervcou and Messcan.') In 1970. we started to work out our program for clinical use, based to some extent on the published reports just mentioned. To avoid problems in terminology and/or confusion with terms such as PNF, we named our technique "sensory motor stimulation" with the hope of stressi!~g th~ !.!!"'),ity between the afferent and efferent system without implicating any specific structure or function. BASIC CONCEPTS OF MOTOR LEARNING The principle of sensory motor stimulation is based on the concept of two stages of motor learning.l\l The first stage is characterized as an attempt to achieve new movement performance and to work Ollt the basic motor program. The brain cortex (predominantly the frontal and parietal lobes) arc strongly involved in this process. This type of motor regulation has some advantages as well as disadvantages. It enables the individual to achieve new skills, although it is rather slow as it passes several synapses, and it is tiring given [he necessary conscious participation of the cortex. Therefore. the brain tries to minimize the pathways and to simplify the regulatory circuits. This mechanism has been named as the seconel stage of motor learning. It enables a reduction of cortical participation, and thus is less tiring and much faster. If such a motor program has become fixed once. however. it is difficult. if not impossible. to change it. Therefore. in motor reeducation, the goal is to achieve a quality of movement patterns that is as close to normal as possible. To prevent injury. and microinjury in particular. fast reflex muscle contraction is needed to protect lhe joints. The second stage of molOr learning enables such a faster response. which may, in fact, play a decisi\"(:: role in prt:vcntion. Bullock-Saxton and colkagucs" reportcd it is po:,siblc to 319 J..,."__ ". _ . • • • _ ........ ~ ..... ,... rn/"\\.,.l II lVNt:H"ti MANUAL , 1 Fig. 15.1. Rocker board. accelerate muscle contmction approximately twofold with increased propriol:cptivc flow and balance excrciscs. in scnsory motor stimulation. an attempt is made to facilitate the proprioceptive system and those circlIils and pathw<.lys thai play an important role in regulation of equilibrium and posture. From the point of vicw of affercncc. reccptors in Ihe sole of the 1'001. 7 from the neck l~lllSclcs.'~ and in (he sacroiliac arcal.l have the Ill M:lI1Y exercise aids of varioLls types arc llsed. llH.:luoing wobble and rocker boards. rolls from plastic material. bal:llH.:e shoes. various lypes of twisters and trampolines. and the Filter. Wooden wohhlc and rocker boards arc preferable to lhose Ilwue of plasti.. . matcriaL h~causc woou.stimul<.ltes Ihe receptors to a gre:ller extcnL For the s The radills of the wobble board is 35 1.:111 on :m..:ragc ".", (Figs. 15.1 and 15.2). The size of balance shoes (Fig. IS.3) depends 011 the size of the foot. Sand'lls Illust have ;,1 linll. innexiblc ~olc that is modeled and 'HIS metatarsal support: these fe:Hurcs help 10 configure lhe small fool. There should be just one str;'lp O\"(.·r the forefoot and the heel should rem~lin free. again to help III :'Ictiv;ttc the intrir.l:-;ic muscles of the foot. The hemispheres arc of solid mhbcr. 5 10 7 em in diallleler. and arc placed in the center of gravity. The twister enables ~\l.:tivati()n of the trunk .1Ilt! huth.ll..·k mllscles. Exercising before " f Canada (Fig. 15.4). A minitrampoline (Fig. 15.5) is an excellent device f\lr stimulating the proprioceptors of the entire body. Unfollu· nately. the material lIsed for most trampolines is not suffi· ciently resilient. The stimulalory effect is thus redul·cl,.L Springs that arc 15 to 18 e111 in lenglh provide a suilllbly un· stable base: springs of less than 7 em do not provide cllou~h proprioceptive stimulation. Other devices include b:dancc b.dls th.u " i') ,'.J. '-.~ SENSORY MOTOR DEVICES AND AIDS The sensory motor approach is not a rigid program or system. It can be used in all cases .md can be tailored to each p:Jtienl. V;lriolis b "'?;.,), ,. i j.i---~ !~,J I, " i\) Fig. 15.2. Wobble board. IiV '.'''. I I J . --"--'" "''"'' "-'" ,",' "., ............. , ,"-',. Ii Fig. 15.3. Balance shoes. Fig. 15.4. The Fitter. ) Fig. 15.5. Minitrampoline. , J lhcrcforc can be used by individuals with ~Ul "cute low back p~\in syndrome. thus help in prcventing falls. This tcchniquc C~1Ilt10[ be rt:L'olluncndcd. however. for patients with ..tCll{e pain syndromes. INDICATIONS FOR USE METHODOLOGY Sensory motor stimulation is bendlcial when used as a part of any exercise program in that it helps to 'improve muscle coordination and motor programming or regulation and in~ crc..\ses the speed of activation of a muscle. Used originally lO ithprove the unstable ankle after an injury. sensory molor :,timulation C"Ul be of value to individuals with it variety of conditions (Table 15.1). Chronic back pain syndromes reprc:,cnt onc of the most important indications. Better cOlllrol of the (runk. improved activation of the gluteal muscles...md thus better stability of the pelvis arc achieved. There is a broad indic:ltioll for its application for sensory defects of neurologic origin. Carefully (to avoid injury). the method can help to compensate proprioceptivc loss in aged subjecls In this chapler. we describe only th~ main Illl;thodologic prill· ciples. A detailed dcst:riptioll is 'I\'ailablc clscwll(·("c. l ·; One of the most important ~ldvalltagcs or this progr Table 15.1. Indications for Sensory Motor Stimulation • Unstable knee • Sprained or unstable ankle • ldiopalhic scoliosis • Faulty posture • Postural defects in general • Chronic back or neck p · ._ ...•_._..... ticular, the most important motor 'lctivili~s, such 'IS sWllding. i.e., posture and gait. Then.:forc, the most important cxadst:s art~ those performed in lhe upright position. Respecting the appro;lch of motor leanting :.JlHJ motor rq::uhltion, ",,-..:>r ,".c::. ,.... t'tiJ-\\., 1111UNt:.H·:::; MANUAL The tam "smail (shtl!"u 1'001" lhg. 1:'./lJ Is II:-L:'d II' ~Il' snit'll.: Iht: slml1ening and n:lrrowing llf Iht: fll{l( whik till' 11ll'S ;Ire rda\l.'d :IS llHH.. . ll a~ possible. The :-1\1:111 rllllt hdps [\\ in(fC;lSt,; aff..:rent input. mainly from thl' ~ok. h impHl\'l':- lht.' pnsillon Ill' lltt.: hody sl.'gmt:llts and till.' ~[:lbility of tilL:' hlld~ ill lilt.: upright positio1l. and hl'lps ttl illlprmc til... rcquirl·t! spril1~' ing mOWiHl'll( Ill' till' fOOl during walkill~. or I. Currcctlun lJI,;~ill~ ill di"l Excrcbcs an: pcrfonnr.:u in b:lrl' k..:l. \\ hidl incn:;lscs pmpriil' ceplivc Miumlatioll and forces the thcrapi" HI pay attentioll til oeHer cmllrnl. List but nUl least. while u~in~ lhe hal;mcc ;liJ:,. il helps tn decrease [he pOlenti;Jl d:1l1~cr of in.iuries . .". Exercise shuull.i i,~ IlU llll.:all .. 11111\0.....: pain and should IlIlt lead to physic:ll hOIl1:ltil') futiguc. -L From the beginnil1~. lhe aw;m:nt:ss of po,ture W;lffants special ;ltIcll1ion. :;. Excrci~cs SlllHlld hegin Oil st;lhk surf"":,,,. :md lhell pwgrc", In more I"hile ~tJrr;\Ccs. Exercises Gill be divided inw lhosc that focus on training lhe transfer of weighl or the center of gradty Fig. 15.6. The short foOl. Fig. 15.7. Passive modeling of the short loot. .... --------_ ">-.... , '. , ,;: ( ...... m ... r"" I t:.t1 ,~ : :st:N::iUHY MOTOR STIMULATION ! 323 When the patient achieves suffkient skill. similar exercises on the rocker board and later on the wobble board arc "dded. Thc dcmands can be increased by or Fig. 15.8. Short feet and half slep !orward stance. Initially, the formation of the small fOOl is difficult to perform in erect posture. Therefore, it is advisable to sian the fonnation while silting. usually in three steps: (I) sitting. with passive modeling by the therapist: (2) scmiactivc (pas- sive modeling by the therapist in combination with active palient effort): and (3) aClive self-formation (Fig. 15.7). Proprioceptive stimulation can be increased by additional prC5surc applied toward lhe knee ~md thus via the shin to the fool. In standing. Oll~ tf'lining exercise begins with the small feet parallcl and slig.htly apart. Then. the body sways slowly forward and back. the heels remain fixed toward the floor. and (he lower extrcmiti~s and the tfunk arc in alignment. The range of motion must be controlled to prevent falls. The ther· ::lpist controls the ~ways by touching the chest from thc front and the buttocks from the back. In another v'lri:uion the knees arc bellllO 20 to 30°. The hips nrc slightly abducted so that the knees arc slightly apart. Both positions and ,idditional swaying movemClHs help to in· crease the body awareness and the feeling of a well-b~llanccd and controlled posture. The next steps arc body control in a IIalf SIC!, lonvard slaTlce. the corrected stance on both legs. and in one leg stance. To iu(:reasc proprioccptive flow. slow pushes and then even strokes in different directions tow;.m! the pelvis. shouldcrs. and hoth areas arc added by the therapist (Fig. 15.8) • The small feet mus! be. maintained if po!isihlc. Jurill~ Ih..: whole gait cycle. • The subject should Ir)' to control the posture. in particular the po· sition of the pelvis. shoulder g.irdles. ~1I1l1 hem!. • The sleps should be short but quick. • The reel should he held L~lter p:lr~1I1el. ;lnd verliC_11 shirt or the pd .... i:- :-hnuld he a"'oidt'd. G_lil should be trained in place lirst. jf necessary with some support lO avoid inslilhility and falls. At the beginning of the training program, it is advisable 10 control th~ gail in balance shoes hcfore: :I mirror. According to our dini(iI\ cx~ nc:.nr\Oll... I 1"1 IVI" vr I hr;: ::>I""INt: A PHACTITIONER'S MANUAL t. ~ i I ~ s I, ,l i I I~ ! '.~ i I, ) i 1 I ,~i B A t i I! ~;f.t; '/1 -~~-f & I ~ ,~ ~ , ~ •~ ~ ,~ !'t ,~ ~ I~ i1 Ii' :;; Ii Fig. 15.9. Lunges. I*, 'f ~ i ~ ~ is t~ ~ ..,'" ~ jc' :;, ;; - CHAPTER 15 SENSORY MOTOR STIMULATION 325 ~ ~ :fo ; i t, ,,I , , / " J I I i, ) ) i if ~ . " 'B Fig. 15.10. Jumps. ... _. ,. , , .. ,'V',. ' ...... , ..... " .... ",r,,~""'"'''' '(" .~. ~. D E Fig. 15.10. (continued) ) pcricnce. it is more efi.:ctivc 10 walk in the h"lam.:c shoes for a ~hon time. just sc\'e-D.l steps may be ...uflkicnt. (1 10 2 minutes). several times p;:r day. The [\I'iSla help :0 impw\"c the 'Ktivil: .. pinal IlllISdc..... Durillf its usc. it is easy to .::ontrol the !-ynullclry of lhc cxcn:isc. This device is v..J1uablt bccaliSC it help... ('tll"l'CL't ;Isymmctrics that develop in patient:' with hal:k pain as'1 rule ;1Ilt! arc SOIllC· times difficuh to recognize. The twi,ter docs not specilic .) or Fig. 15,11. Therapist pushes. G .. I I \ A Fig. 15.12. Standing on balance shoes. 1- it- Fig. 15.13. Training tile gluteus medius on the Fitter. Fig. 15,14. Walkin9 on a rninilrampoline. B -----------~. I I L , I L ! , i '.--~~ Fig. 15.15. =:;.:r point kneeling on the L~ ~inilr(lmpohne. .l Tht.: IJlillitr:;/II/mlill(' i:-. :t paninllarly lJ~~ful devil.:c. Jogging or jUIH;,ing :u.:ti\";llCS proprioceptors 1110(1.' dTcclivcly l!l;lll il simil:lI' ~·.\~rci.'ic pcrt'Ol"lnl'U on ;J lil"ll1 none In addi· {ion, it prole<.:t, lhe joints l1CGlU.. . C il rlllH:lioll~ ;I" a shock ;Ib· sorhcr. Excrl'j,;.:-, on"l trampolilh..' do lUll nccu lO k performed in ;lll upright position only. Ex~n.:iscs pcrform~J while sitling. afC particularly dTcctive in strengthening the abdominal llHlsclcs.•:ilL! fOllr point kneeling is n.Tolllllh.:ndcu for cIucrly women '.'.-ith kyphosis rd'llcd to ostcnpt,rosis (Figs. 15.1..J.;lIld 15.:"1, CONCLUSIO:\ The sensory motor stilllul;ltioll approadl rcprc~t:nl' all essential p;lrl of till: IhcmpclItic progr.un fur p~lIicnt;" with chronic back pain .1~ "ell as for indi,'idtlals with pO~!llral lkkcl.S. such as idiop~lthic scoliosis or faully poslUre. and for <.Ill situations in which Jde!.:ls in affercncc .Ife presumed. Such a progr;ll11 C:I1l ~d"o be llsed effccii,'c1y to imprn"c the ability of the "hc;lhhy" motor system 10 rc\polld Illore quickly. Givcn that the speed or muscle l:ontraction is one of the most illlport:llll lllean" to protect the joints. it seems propriol:cptive facilililtion can cOl1lribUle substantially to the prevention of recurrences or acule pain. The sensory motor \tilllulation progr , t T REFERENCES 1. Kah:u II: C..:mr;,1 m..:..::hanisl1ls fur r..:co\"cry (If lU:urunlu""'ul:tr rlln~'tl"ll Scicncc J 12:2.'.1950. Shcrril1~lol1 CS: On r<.'..:ipr,x:aJ il111<.'r\':rliol1 of alll;lgo11i:-n AC: B;:~lC Ncurm:dcn..::c.l'hil:l\Jclphi:l. WB S~Ul.Jcrs. 1%-, II, Bu\lu..::k-Sa~\lln JE. Janda V, Bullock "II: Rdkx :u;ti"i1lillll uf ::hlll,';lt llIUSI,.·h:,,, in \,;lIking. Spinc 18:71).1, J91"J~. i:. Ahrahalll' VC: Th.: physilliogy of nCl;k Ulus...-ks. ·nl<.'ir ruh: ill h~·.l,1 1111\\'l'111.:nt and m;:inICn;l1\l;":: of pmlurc. Can J Physilll Jlh;lnnanll 55:.~.'~, 1977. I). Hillllki M. L'"hlll:-':: Lumhllsacral propriu..::cpliw rd1c:o.:c" ill hl'd~ ...·.Iui· lihriulll. Acla Ololaryngol 33()~SupplJ: 197. 1975. I·t Ih:lr.l H, Nak:l~:illla A: Dynamic join! CUllIWllr:lilling fur kn..::<.' li::.llll;.·lll iniurics, Am J Sports t-.kd t4:309. Infl. 15. B~lbalh K, Ihlbalh B: Thl.' f:1CiliWlion of normal postural rC:I(til'Il" ,~nd l\)1l\',;:lIlelll in tr'.:J.lmCIll ()f cercbral p:tlsy. Physil'lh..:rapy 5U:"2-l(>. t'}t~. 16. Umhll1 AK: Trullk musck activity induced hy 1lH">.'1: size" uf wI.ht>k ,ro.ll· anl,'d hO:lrd,. J Onhop Spurts Phy.. Thcr R:70. \98(1. 17, J:llld:l V. V;l"W\:t .\·1: SellS""")' MOlor Slimul:llil'll: i\ Vidcll.l'r<.'s..::l11...·,: t-~ JE B\I!hx:k-S;I.\I~)fl. Brishanc, AU\lr:.dia. Body C\lIIlrol Syslems. 1')':'_\ I .' ~- 16 Postural Disorders of the Body Axis PIERRE-MARIE GAGEY and RENE GENTAZ ) I I i I I I I I ! POWEll OF THE POSTUIlOLOGIST Input into the Fine Postural System \Vhen posturologists undertook the study of postural control. they did not suspect how much power would fall into their hands. I Slowly. year af[er year, they discovered their ability to manipulate muscle tone by manipulating the input into the postural system. Preceding generations of neurologists had conducted studies of muscle lOne and th EXTEROCEPTIVE INPUT plaining. BASIS OF POSTUIlOLOGY -' , ,) - , ) ) \ I Ever since BelP askcd how a pcrson maintains an upright or inclined posture when facing into the wind. physiologists have asked the same difficuh question. Over many years. the contributions of various types of sensory input (0 the control of upright posture were discovered one by one: vision~ and signals from the legs and feet,~ the vestibular apparatus.~ paraspinal muscles,to and oculomotor system.' Not until the concept of (he system appeared w....s it possible to understand hawaII these different senses work together to control posture. Researchers could not observe and record the subtle phenomenon of upright posture!l.~1S adequately until (he resources of clectronics l6 and computers were availablc to allow them to make recordings that do not modify the phenomenon and can be interpreted by signal analysis. Today. after many years of study, Bell's question can be answered in terms of a simple and consistent model of the mechanisms participating in the control of orthostatic posture: the model of the fine postural systcm. The term 5)'slem is used here in accordance with control system theory. i.e.. we do not need a detailed underst To remain upright and slCady in their surroundings. people usc all tbe information about lheir position provided by their st:l1sory org.ans in relation Wilh the surroundings. including the dectromagnctic ficld,~·IfHI" the gravitalional ficld,20-2! and the pressure Hcld underfoot. ~.\A~'Thrcc outwardly directed sensors. or cXlcroceptors-vision. vcstibular apparatus. and baroreceptors from plantar soles-provide information; we do not know of any others apart from these three captors (Fig. 16.1). PROPRIOCEPTIVE INPUTS The cye moyco;, about in the socket. while the vestibular apparatus is enclosed in Retinal. otolithic. ,lOd plantar exteroceptivc information, combined with proprioceptive infonnation from the 12 oculomotor muscles. all the paras pinal muscles. and the muscles of the legs and feet. unite to give the relative positions of skeletal elements from the occiput-atlas to Lisfranc's joint. This combination generates il considerable amount of information that the system must integrate, in real time. if the posture is not to waver. Therefore. problems with the control of orthostatic posture do not necessarily indicate that a sensor has failed. Rather. it may involve faulty integration,:" which may OCf.ur for many reasons. DISORDERS OF INTEGRATION OF VISUAL INPUT Faulty integration of visuJI input is easier to analyze than thilt relating to other types of input. bcc.llIsc it is easy to record a 329 \ .~.. HI=HAt1ILIIAIIUN OF THE ~PINE: A PRACTITIONER'S MANUAL stcildine~s of stance with and withoUI the help of vision. and j to reckon the cOlltribution of the vi:-:llal input using the so-called "Romberg's quoticnt:'-I Postural sway is oneil mea· sured on a stalokincsigram. a record of the successive posi- or tions of the subject':; center gravity projected onto the sur~ face beneath the feet. and Ihe Romberg's quotient is the ratio of the ":In~a" or the slatokillcsigram with the eyes closed to the area with lhe eyes open. llIultiplied by 100. \Vilh this simple [cst, some patients arc roulld to be just as steady with their eyes dosed as w:ilh them open. They miglll as well be blind as fm as their standing posture is concerned. Such "postural blindness" is a frcquclH finding, occurring in association with many disorders. including vcstil!:-il;'lf neuritis (Fig. 16.2);lK strabislllu's."1 and low back pain.~11 Deficicncies of integration of visu;.d input arc so frcquent in clinical pmctkc that \'isual input despite its powerful effect (usually postun!l steadincss is 150% bctlcr whcn thc eycs arc open~l J. seems Fig. 16.2. Histogram of the distribution of Romberg's quotient in 182 patients with vestibular neuritis. The gaussian curve shows the theoretic normal distribution of Romberg's quotient in a normal popUlation. logarithmic scale. 253, mean for normal subjects; 152, mean for patients with vestibular neuritis; CL 95% confidence limits; p < 0.001. Student's Hest. Output of the Fine Postural System: Muscle TOIle Few would argue that maintaining an upright position IS achieved by mcans other than muscle-postural tonc. At lhe beginning of the last cenlury. Bell noted that it is only by the lise of muscles that thc limbs stiffen and the body is firmly balanced and kept upright.) \Vhat is new is the knowlcdge that postural tone is controlled by a postural system. Th~rcJore, hy manipulating the input into the postulJ,l system. one can manipulate postural tone almost at will. Observations Relaling to the Fine Postural System \I\~ Fig. 16.1. The postural man. The most striking fea[urt~ of the control of onhostatic posture is its fineness; every normal person keeps his or her gmvitational axis inside a cyl:nder less than J em! in cross section:u """"" We know that the fine stretching of the neuromuscular spindles is accurately control1ed.t~; that the stretching of oculomotor muscles acts on postural tone only if it is fine 2K ; and that the fineness of poslUral sway is below the lheoretic threshold of the semicircular canals..t/> Clinically. we observe that. standing upright with their eyes closed. paticnts with vcstibular neuritis are as stcildy as normal subjects (Fig. 16.3).3& Only when postural sway becomes abnormally great (area of the st<.ltokincsigram is more than 2000 111m!) do the semicircular canals perceive it. A clear break exists between the neurophysiologic comrol of fine movcments and the control of wider movemcnts. Theoretically. in posturology. this break would be at a slalokincsigram area of about 2000 mm!. and clinical findings confirm [he theory: a group of 800 dizzy patients comprised two subpopulatiol1s. divided al precisely ,hal breaking point (Fig. 16.4)." It is important to _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _~u CHAPTER 16 : POSTURAL DISORDERS OF THE BODY AXIS \ ~ The Postural Patient ; \ subject - r-\ i I ! - i\ : '\e -·1! \: !I I \,\1 I L ; \ 1 I I i \-l I ' , . !\I i! Ill-I 225 31 5 056 Fig. 16.3. Hislogram of the distribution of statokinesigram arEas in 182 patients with vestibular neuritis (eyes closed). The gaussian curve shows the lheoretic normal dislribution 01 the parameler of statokinesigram area in a normal population (eyes closed). Logarithmic scale. CL. 95% confider1ce limits; 225. mean for normal SUbjects: 282. mean for patients with vestibular neuritis. (From Gagey PM. Toupel M: Onhostalic postural control in vestibular neuritis. A stabilometric analysis. Ann Otol Rhinal La , o /1\ 10 subjects ; \ I \ i I \ !I i. 'i , / . ,I / 91 ; 210 493 1691 4024 820J Fig. 16,4. Histogram of the distribution of stalokinesigram areas for 800 unstable patients (eyes open). The gaussian curve (Iefl. heavy line) shows the theorelic distribution 01 this parameter in a normal population. The fine curves have been superimposed merely to emphasize the bimodal aspect of the distribution. Logarilhmic scale. 91. mean lor normal subjects: 210. upper 95% confidence limit. Limit"i of Posturology ~~ To consider thc centml ncrvous system as a "black box" is certainly an 4Ivowal of weakncss. Until ncuroanatomy can ex· plain where and how the multimod'll information ttwt helps people stand upright is integrated. however. we have no other choicc. We cannot prctcnd to know enough abollt the nervous centers and pathways controlling posture to be able to propose a neuroanatomic model useful in clinical practice. The scientific way forward is 10 establish what linb we can obscrve between tlte input of the fine postural system .and its output. .I!( ) ,~ :m :}i " I ~ , § I i I POSTUIlAL DISOIlDEIlS OF THE SPINE II The subject that panicularly interests the therapist is how posturology can help the p~rson for whom standing upright is difficult or painful. I_1 , '- 0 ~ .l ~:. ~ ~ ~ ~ , 331 The person \vhose spine hurts for a postural reason is said to have a functional disorder. Radiographic and laboratory l~sls !l:\ve diminatcd rheumatic disc;.\sc. orthopedic illness. :md ohviotls nucleus pulposus herniation. but pain continues for unknown rc;\sons. Onen. [he patient feels bener after manlIal therapy. hut lhe pain keeps coming b'lck. Such recurrences likdy h;I\'(: a cause that the manual therapy has not ad· dressed. In fact. Olle can obscrve in these patients abnonnal asymmetry of postural tonc. Is this the mysterious cause of the rccurrences'~'} Identifying Postural Tonic Asymmctr:y PHYSIOLOGIC ASYMMETRY A human being docs not have the perfect symmetry of a Greek statue: rather. the statistical norm is postural asymmetry. Not only have we seen asymmetry of orthostatic posture in tens of thousands of "!lonnal" subjects, but also we have established Ihat such asymmetry is not random (I' < O.(XH on the X:! test).~J Therefore, it is reasonable to think that such asymmetry is characterized by laws. The practitioner must not conclude that every type of postural asymmctry is abnom1al. PATHOLOGIC ASYMMETRY To distinguish pathologic from physiologic asymmetry. the gains of neck reflcxes are measurcd during a stepping test. Fukuda-Unterberger Stepping Test. A nonnal subject stepping in place blindfoldcd rotates up to. but not more than, 20°/30° after 50 stcps.~'-"! This finding is easy 10 verify. but several technical points must be considered. Testing conditions should includc no sound or light source that could indicatc a direction. The Ihighs should be raised neither 100 far nor too little at each step (about 45 0 :s right). The pace should be neither too slow nor .too fast (1.4 Hz is goOd).H \Vhen putting on the blindfold. the eyes should be in the "primary position" (looking straight ahcad).~~ The head should be neither rolated nor tilted,~~ and the anns should bc stretched forward. horizontal and parallel.~l.~l Although this simple test, with the head in a neutral position, provides useful information. we prefer a more rigorous test that makes usc of the postural neck reflex. Measuring the Gain of Neck Reflexes. \Vhen a nomml subject keeps his or her head turned to the right. the tone of the extensor muscles of thc right leg increases. and vice versa for the left sidc.~,~7 When a nannal subject pcrfomts (he Fukud fonned with the head facing forward (Fig, 16.5). Thc difference between thcse two angles of rotation is a measure of lhe gain of the right neck rcnex. The sante applics. mutatis mulandis. if the head is turned lefl.~~ The test must be carried out methodically to avoid confusion. The results arc tabulaled, following clearly defined conventions. Angles of rot~ltion are denoted r·+" if rightward ------ HtHAtllLlTATION OF THE SPINE: A PRACTITIONER'S MANUAL 2 .,' '-'- ... /" ~, ~/ .. ~~". .~~>~_ •.; ~---,-",",,",~. , I Fig. 16.5. Fukuda-Unterberger's slepping lest with head rotation. When the subject performs the lest with the head rotaled to the right rather than straight ahead. he or she rotates farther leftward and vice versa. and "-" if leftward; + 10° means the patient had turned 10° to the right al the end of the lest and - 30° means the patient turned 30° to the left), Calculating the absolute value of the gain of the neck renex requires paying attention to the signs: + 10Q and - 30° make 40° of difference. not 20°! It is impor~ tant to adopt new conventions for the gain of the neck rcf1cx~ for inst HA HR RG Predominance +50" -10" +20~ _30" Left 90" HL, +50·: Head turned lelt: the palient rotated 50· rightward. HA, -10·: Head straight: Ihe palient rotated 10· leftward. HR, +20·: Head turned right; the patient rotaled 20· rightward. lG. +60·: The absolute value of the gain of the left neck re!lex is 60·. noted wilh a + sign, because it is in the normal direction. AG. - 30·: Tho absolute value oltha gain ollhe right neck reflex ;s 30', noted -. because it is not in the normal dircclion_ Lell predominance 90': The best gain is the gain of the left neck reflex because it is in tho normat direclion; and the dillercnco between the two gains is 90'. (II both gains are in the normal diroction. the larger is considered best. il neither gain is in the norma! direction, the smaller is considered best). HO.,,", to Manipulate Input into lhe Fine Postural System If the patient shows abnomlal asymmetry of postural tone, the posturologist must try to restore symmetry by modifying the input into the syslem that controls orthostatic posture. The system is dclicme. however. ::tIld must be manipulated carefully. with gC1H1e stimulations: otherwise. it does not rcspond_:j;. Three types of input arc accessible tu the clinician: spinal. oculomotor, and plantar. SPINAL INPUT Manual therapy of the spine is well known. and for the pa~ tients considered in this chapter, it is assumed that clinical success is only temporary. That assumption does not always apply to other postural patients. such as those labeled unstable and the squinter. The practitioner should consider the possibility of acting on the fine postural system through this sensory roule. OCULOMOTOR INPUT Oculomotor (and possibly viSUitl) input can be manipulated by putting a weak prism. of I to 4 prism diopters. in front of the patient's eyc.~~ An optical prism de .... iates light rays toward its base. For pedagogic purposes. think of a weak prism put in from of a normal eye as moving t'le eyeball by e.liciting the fusion re·flex opposing diplopia_ This movement stretches various oculomotor muscles in accordance with the various positions of the base of the prism. (In fact. this cannot be the true explanation of the action of such prisms because they act even in the absence of binocular vision.) Conventiolls of Notatioll, Imagine an optical prism. base down in front of a subject's eye and with one of its dioptric faces perpendicular to the subjcct's visual axis. If the prism is rotated around this axis. its base describes successive tangents on a trigonometric circle centered on the subject's visual axis. By convention. degrees on this circle are counted counterclockwise from the observer's viewpoint. Regarding the subject's left eye. 0° is tOward the subject's temple. 90° at the zenith. and 180° toward the nose. where<.ls for the subjccl's right eye. 0° is toward the nose. 90° at the zenith. and so on. (Fig. 16.6). Strabismologists consider that each of the six oculomotor muscles has a main direction of action (ar 0°. 55°. 125°. 180:". 235<>. or 3050).~9 Because a prism deviates light rays toward its base, the main oculomotor muscle it forces to work is the one with the main direclion of action thm is opposite the base of the prism (sec Fig. 16.6). Table 16.2 illuslrates 'he correlations between prism positioning and activation of oculomotor muscles. The formula RLR 3 refers to a prism of 3 diopters. in front of the right eye. base tangent at OQ, activating the right lateral rectus. lAw oftlJe Semicircular Calla/s. Even when considering only the main direction of action of each oculomotor muscle. ",re =_" ) J -, ,y ,,==..OO~ ~"."" ="=' o"~.~ .._------- lCHAt>IER 16: POSTURAL DISORDERS OFTHE BODY AXIS 55' 0' Fig. 16.6. Main directions of action 01 the oculomotor muscles and positions of prism bases. Table 16.2. Relations Between the Positions of the Base of Prism and Oculomotor Muscles Stlelched Muscle Base 01 Prism At Right Eye loti Eye 0' 55' 125" 180" 235' 305" RLR RIR ROS RMR ROI RSR LMR LOS L1R LLR LSR LOI LA: lalctal r{!Clus; MR: medial rectus; IR: in/crior ractus; SA: superior reclus; SO: superior obliquus: 10: inferior obUquus. Six oculomotor muscles increase the gain of the left neck rc~ flex. and the other six increase that of the right neck reflex. It is bcucr to decide in advance which oculomotor muscles may bring about better balance of the muscle tone than to proceed solely by trial and error. The law of the semicircutar canals can help in the decision. According to the law of the semicircular canals (Table 16.3). deviation of light rays away from the main direction of aC'ion of an oculomotor muscle acts on the tone of the c;lttensor muscles of the legs in the same way as deviation of the endolymph stimulating the cupula of the semicircular canal governing the rencx activity of this oculomotor musclc.«)...(,4 If you know on which side you wish to increase the gain of the neck reflc;lt. six oculomotor muscles can be eliminated' immediately by referring to law summarized in Table 16.3. 333 po.se new tenninology to describe these new plantar orthoses. Any construction crossing the foot transversally is called a bar. and any marc circumscribed constnaction is called a Spot. The front-to-back position of bars can be designated as follows: Infracapilal. under thc metJtarsal heads Amerior. behind the metatarsal hC:lds M~Jial1. allh,~ kvd or the sC:Jphoid and cuboid bOlles Posterior. under the distal pan of the calcaneus Infratubcrous. under lhe calcancallubcrosity For spots. side-to-side positioning is also specified: Medial infracapital and lateral infracapital. under the heads of. respectively. the first and second and the fourth and finh metalarsals • Anlcrornedial and anterolatcral, behind the he:Jds of tht: corresponding metatarsals: and so forth (1l1ediomcdial. rncdiol:Ueral: posteromedial. postcrol;]teral; and medial and latcr.ll infratubcrous) Any CO!1struct:C!1 must be positioned in accordance with the podographic footprint. with due attention to dysmorphisms of the fect. The footprint can be achieved by using a light layer of ink under the foot and then having the subject place that foot onto white paper. Fool Paiu. The effectiveness of these exteroceptive stimulntions mny be limited by any pain in the foot of which the patient r:nay not even be aware. ~herefore. we recommend both questioning the patient and pressing with the thumb on various regions of the soles to discover any painful area that the patient had not not;ced. In such cases. antalgic elements should be provided in addition to the element for postural stimulation. Proprioceptive Disorders of the Legs alld Feet. \Vhcn free movement of the joints of the legs and feet is impaired to 'he extent that proprioception is affected greatly. plantar postural stimulntions are less effective. Such disorders must be, corrected before stimulatory wedges arc used. Identifying the Right Input In principle. Ihe therapist can modify ;Jny input discusscd in this chapler. In practice. however. there may be only one thnt PLANTAR INPUT Plantar input can be modified with microwedges under the soles. The mcchanorcceplors of thc sales are accurate to within I g.. and the wedges used to stimulate them must be correspondingly thin (about 1 mOl in thickness). Thick wedges do not alter postural-tone. Microwedges act on plantar baroreceptors. They may also stimulate deeper proprioceptive sensors. such as capsular or ligamentous Pacini's and Ruffini's corpuscles. Golgi tendon organs, and neuromuscular spindles. Microwedges placed under cenain regions of the sole modify the sensory input into the fine postural system. Because the technology of conventional orthopedic shoes does not correspond to that for postural stimulation. we pro~ ! I ~ ,. f....... -~ • j " Table 16.3. Law of the Semicircular Canals Increases the gain of the neck rellex ~ ~ "0 ~ ~ E 0 >~ Z a:'" 1ii ~ 0 ~ " 0 >- '" ~ -' Righi Left RMR RSR RIR RLR RIO RSO LLR L10 LSO LMR LSR L1R LA: lateral rectus; MR: medial reclUS; IA: inlerior rectus; SA: superior recluS: SO: superior obliquus: 10: inferior obliquus. I-'.>-'.•.• } ----,-------------------_. REHABILITATION OF THE SPINE: A PRACTITIONER'S MANUAL I .1 will cffcC'tively alter the patient's postural tone, and the prac- "I titioner must look for it Then, the quickest and most adaptable clinical test is the rotators test. ROTATORS TEST OUf tcam has lIsed this clinic'.li tcst of tht.: tone of the hip ro- ~ I I i g f, I , Ii I I I I I~ ,. I I , I ~ ~ I I '¥ I tator muscles since the work of Conslantincsco and Autct."~ This lest has the great advantage that the patient is lying down and does not gCllircd. and that the effectiveness of each Illa· nipulation is known within seconds. Seen for the first time, it looks like a conjuring trick, so before explaining how to do it, we explain the underlying ideas. Clinical Investigation of Muscle TOile. Clinical investi· galion of muscle IOIlC is a delicate subjcc~ indeed. Despite the longstanding agreement, going back to Galen, 10 define "tonc" as muscular activity that does not bring about any movement, most authorities agree that the tenn is ambiguolls. The idea of "light tcnsion thal any muscle at rest is usually. subject to," or som~ :~uch usual definition confuses the effects of the viscoelastic properties of muscle tissue with the effects of contractile processes originating in the nervous system.(o(> Therefore, tone is a trap, representing one of those words the meaning of which may unconsciously be distorted, to the great detriment of clarity of discussion. Because the concept of tonc is so elusivc. criteria for its clinical investigation must be all the marc rigorous. This need is panicularly great when we manipulate tone to test it. for what is observed then is not "tone." but ruther certain tonic reactions to ccnain changes imposed by the clinician. In the unavoidilble "action-reaction" pair. [he reaction will have epi· stemologic value only insofar as [he action is known. \Ve must know what we are doing before we can understand what we arc observing. Sherrington led the way in the rigorous study of muscle tone by quantifying the lone of a muscle by its resistance to passive stretching in tcnus of the physical quanti tics Icngth. time, and force applied. It is reasonable to continue strctching muscles to tcst their resistance to stretching. and thus their "tone:' but each maneuver must be defined in physical tcons. Regarding stretching movement. the amplitude. speed. acceleration. time elapsed since the prcvious movement. and applied force must be specificd. Each parametcr matters: ampli· tude for the properties of elasticity and for secondary spindle endings: speed for the properties of viscosity: speed and acceleration for primary spindle endings: nnd time elapsed be· tween two successive strctchings for muscular Ihixotropy.('7 We cannot adequately stress the limitations of the clinical examination of tone. In such a moving world, the posturologist must be wary and accept only those excitation-reaction sequences that are repeatable and uncontaminated. Performing the Test. The subject is supine. in a strictly controlled posture: arms lying loosely bcside the body. head facing straight up, eyes in the primary position, jaw relaxed (lhe teeth should not touch). Sland at the end of lhe lable, facing the patient's feet, and take the heels in your palms. with your hypothenar eminences and linlc fingers resting at the edge of the soks wilhout touching them. and the mcdial edge of your thenar eminenccs pressing 011 the anterior edge or the pnticnt's external malleoli (Fig. 16.7). Lift the subject's (eel JUS! 2 or 3 cm from the wbh::: your ;,nns should be extended and your body should be s!raiglll and leaning slightly back. so that you arc pulling gClltly 011 thL' patient's Icgs. With the subjc,.:1 relaxed with feet slightly ;!rart. pl'rftmll llvc or six succcssivc medial rotations of both feet at once to tcst the p;\ssivc rCSiSl ~ ~ i I () Fig. 16.7. Rotators lest. ~-----,--------------------------------- ~ 3 , jG 335 """... , oK 16 : POSTURAL DISORDERS OF THE BODY AXIS -, ; f MANDIBULAR INTERFERENCE Why or how m;,mdibular disorders can change lhe rules of lhe galllt:: of postural lone is unknown. This still mysterious phenomenon must be borne in mind from the outset when examining any postur..11 patient. for experience has taught us tll;]t it ;s a wash: of time to put prisms in front of the eyes or minowctlgcs under the feel of a palicnl whose pos(ur..Il lone is altcn.:d hy a mandibular disorder. Only after Ilwntlibu1:.lf uis- ) , J orders have been cured. so that they no longer interfere with postural tone. is it reasonable to usc prisms or microwcdgcs. if the palien! still needs them. The back teelh-molars and premolars-have protrusions or cusps that engage the cusps of the opposite teeth during closing movements or occlusion of the jaw. for instance. during swallowing. The positioning of cusps makes great demands on precision, with which occlusodontists are famil~ iar. The posturologist need know only how to be sure that some modiliciltion of lhis "imercuspidation" is not ahcring postural tone. Testing Procedure. The principle of lhe lest ior imcricrencc by rnillocclusion is simple: the tone of the rotators must not alter when the intercuspidation is modified. To begin. tcst the rot:HorS with lhe subject's teeth in lhe usual intercuspidation position. Ask the patient to swallow spittle and keep the teeth in contact-the usual intercuspidation position; now. test the rotators. Next. put a small piece of Bristolboard. cc~ to :.:zc, b~ twecn the back tecth and have thc patient walk around and swallow spittle several times before testing the rotators again. with the modified intercuspidation. If the results of lhe two tests are not the same. modification of the intercuspidation has altered the tone. To verify this finding. use other tests (such as the Fukuda-Umerbcrger stepping test or the thumbs test) and refer the patient to an ocdusodontist. The bitc planes can be more sophisticated and more effective than the piece of BrislOlboard rccommended here. but how to make them and fit [hem is beyond the scope of this c!wp[cr. Even if bctter options arc not 3vailable. this crude method is useful. After establishing that mandibular input is not playing havoc with the patient's postural tone. the practitioner then considers which of two types of input into the fine postural system to modify to effect treatmcnt. adapt to the new visual surrou!\ding::: by IUming his or her eyes to look around in all directions.) If one or two muscles bring about tonic reactions, this information is noted for a possible prescription. If none of them produces ~\ response. we recommend testing the other six Illuscks anyway before going on to the next stcp~ the practitioner need not be a slave of the law of the canals. LOOKING FOR AN EFFECTIVE PLANTAR AREA Manipulating plantar input is easy: tcst the rotators in thc standard conditions. stimulate the sole at a particular spot. and immediately test rotators again. The stimulation is done simply by applying light pressure with a finger. just enough to stimulate the baroreccplOrs in ttle soles-2oo g at most. If the resuhs of lhese IWO leslS differ. the plantar spot stimulated may be able to modify postural tone, and is wonh keeping in mind for a possible prescription. The entire area of both soles. onc after the other and spot by spot. may be tested, but spots under the scaphoid at the top of the arch and under the cuboid at the lateral edge of the foot should be tested firsl. followed by spots in bars under and just behind the heads of the metatarsal bones and then spots in bars under the anterior part of calcaneum. Prescribing Tonicitj' is such an elusive phenomenon that measuring the gains of neck reflexes and testing rolators is. not sufficient to ensure that the correct manipulation has been identified. Faced with 'his uncertainty. the practitioner has various choices. depending on the circumstances. If the piltient can be re-examined promptly. c.g.• within a fortnight. it is acceptable to lry lhe simplest and most efficient modification (a press-on prism aflixed to the- patient's glasses or wedges made quickly). A therapeutic trial is one way of making de.lr determinations. If. however. the patient cannot be rc-e.x:lmincd soon. the prescription must be based on the convergence of several tests. From the billtCry of possible tests-po5-turologic. chiropractic. osteopathic. kincsiologic-each pra.:ritioncr chooses lhe ones with which he or she is most comf~)nable. Nonnally. we usc the stepping test and the test of Ba.rrFs vcrtical (sec subsequent discussion). \vhich we consider fairly reliable. and LOOKING FOR AN EFFECTIVE PRISM Measuring the gains of the neck reflex reveals which side has the stronger tone. left or right; the law of the semicircuh\r canals identifies which of six oculomotor muscles have the best chance of modifying postural tone in the desired direction. The next step is to test those six muscles. one after the other, using the rotators test. The patient puts on trial spccta~ des with a 4 dioptcr prism. \Vith the base of the prism positioned successively at each of the six orientations associated with these muscles, the rotators arc tested for altered tone. (Before testing the tone of the rotators. the patient should Fig. 16.8. Device for Barre's test. Heels are 2 em apart and blocked behind. Feet are fanned out at 30°. REHABILITATION OF THE SPINE: A PRACTITIONER'S MANUAL the thumbs' tcst (see following section), which is sensitive. None of these tests, howevcr. is absolutely necessary. \Vhat is necessary is (0 base the prescription on morc than one tcsl. BARRE'S TEST For this test, Barre observed his patients in relation to a vcrti· cal plane, the intcrmallcolar median sagiual pbnc. Each adjective matters. The unclothed pmicllt is posilloncd between two motionless plumb tines that arc aligned with the main medial axis of his or her suppon basco Positioning the feel is accomplished most easily by using a simple arrangement such as a block behind the heels and a block with a 30' angle between the feet, with the heels 2 em apan for the sake of steadiness (Fig, 16.8), The subject must stand still, relaxed,looking forward at eye level, with the arms hanging beside the body. The observer, behind the patient. aligns his or her eye with the two plumb lines and notcs the me;J1l positions, at the midpoint of postural oscillations, of the glUlcal cleft. the spinal processes of L3 and C7. and the vertex relative to the plumb lines. The observation is repeated with and without the corrective device-the prism or plantar insert-that is being evaluated (Fig. 16.9)63. Often, the result of this tcst 1S not immediately altered by a manipulation thnt later proves to be effective. Therefore, we consider the tcst to be fairly reliable. T: tUMOS TEST The patient stands upright, with feet apan by the width of the pelvis. The practitioner, from behind. puts his or her thumbs gently on the patient's skin. without pressing (<1 pressure of about 10 g is appropriate), making sure they are positioned symmctrically relative to the patient's body axis, starting at the level of the posterior superior iliac spine. The patient is then asked to roll downward slowly, i.e.. to start by dropping A B c o E -, Fig. 16.9. Barre's test. A. Try the plantar input first. B. Try the oculomotor input first C. Try both of them. D, Be careful. do not try either oculomotor input or plantar input without looking at the spine, the mandible, and joints of the feel. E, A whiplash injury is a possibility. (From Guillaume P: L'Examen clinique postural. Agressologie 29:687,1988.) fig. 16.10. Thumbs test. the head completely. then letting lhe.shoulders fall. and tin~l!ly the trunk. as if attempting to touch the fect with the hands. without bending the knees (Fig 16.10)."" The practitioner. meanwhile. notes whether his or her thumbs arc dragged symmetrically. or if one is dragged higher than the other. The tcst is rcpeated with the thumbs al variolls levels of the spine. for instancc L3, 012, D7. D4. C7. ~lnd the occiput. The rcsuhs obtained with ;md without manipul~lting an input into the system arc written in a table for comparison. Using a test thc mechanism of which is not fully understood has its dangers. but with this reservation. we can say that the thumbs test is sensitive. revealing slight differences that other tests miss-the results of the thumbs test arc altered by a change of only one diopter of the prism. This sensitivity is the reason we include it in our battery of tests. Just which tests are used-Barre's venic;.I!. the thumbs test, or some other test-maners less than the need (0 prescribe on the basis of a group of converging arguments. so that on each test. the prescribed corrective device ;"lters the result in the desired direction. Treatment Follow~up Within I or 2 months aftcr the !'itart of trcatmcnt. the p,Hiclll must be seen again. Within this time, a prism can induce all iatrogenic postural hypertonicity contmlatcral to thc original hypertonicity. The patienl then merely stops wearing lhe prism. After 2 weeks, an area of plantar stimulation may ha\"t~ lost its effectiveness. If the patient's pain has nOI been fully relieved, another plantur area may be better-the change in postural tone having changed the distribution of pressun::s under the feet. For this reason, we prefer treating by prism insofar as possible. because postural tone docs not change con~ tinuously. as it tends to do in response to plantar stimulations. Prisms must be used with caution, howcver. Small prisms an:: powerful; they can modify nn ant;'llgic posture. and one can imagine the effect on the patient's suffering. if,) :) . _" I ",....l... ul~uH.Ut::H::i U~ 1HE BODY AXIS Contribution of Stabilomctry _. " Although we have mentioned only clinical examination. a noteworthy means In record the functioning of the fine postural system is the ~Iandardizcd cmnputcrizcd platform for clinical stabitomclry.'° The reason for nOllllcntioning this ap~ paralUs previously is simple: in effect. the platform reduces the subject (0 a single point, the center of grdvity...md ,maly1.c~ the stahility of thi5- point rc!nti,,!= t':' the surroundings. II is difficult for a clinician to accept such a reduction of patienls. Nevertheless. stabilomctry remains a basic tool. because it provides much needed certainty regarding the elusive phenomenon of muscle lone. It provides documentary evidence useful for treatment follow-up and also for COI11piling statistics on groups of patients, making it possible to sce beyond the random variability encountered in everyday clinical practice. In addition, stabilometry is indispensable to the clinician, because disorders of the rcgulation of onhostatic posture often arc not clinically apparent and are manifcsted only in patients' complaints a:'ld abnomlal sta~ilnmctrk parametcrs. Without its stabilomctric underpinnings, posturology would not have the certainties It has at present. ROMBERG'S QUOTIENT AND LOW BACK PAIN The first objective indicmion that low back pain is improving is a stabilol11ctric criterion: a :-hift of Romberg's quOticnl to':..:::.i"d :::. :o.armal value. From 600 patieols with low back pain who had been followed using stabilometry, Guillamon and co-workers40 selected 125 for statistical analysis because thcy showed no other impairment, they had received thc same treatment, and they had not received any other treutment thut could have modified their postumltonc. Scvcnty-one subjects of this group benefited from the treatmenl. and of these. 63 , I ~ r,' .~ i~ ~ !t 11 • .." ) ~ i •t u 250 showed a shift of the Romberg's quotient toward normal (Fig. 16,11). The condition of 54 subjects. howevcr. wa:o; no( improvcd by treatment; of these, only 10 showed a shift of the Romberg's quoticntlOW 0-h· --=;:::f=:::;--;::==::::;--(8) Because oculomotricity plays a major role in th~ tine postural s}'stem. knowing how well patients' eyes arc functioning is as important as knowing how well their vestibular apparatus is functioning. Postllrologists cannot work effectively without collaboration with ncuro-ophthalmologists as well as neuroolOlogists. Neuro-oplllh • ii 100 Fig. 16.12. Changes in Romberg's Quotients at patients whose condition did not improve. Each arrow represents changes in Romberg's q'uotient 01 one patient tram the start to the end of follow-up. 250, normal value: 100. limit lor postural blindness. A, 54 patients whose condition did not improve and whose Romberg's quotients move away Irom normal. e, 10 patients whose condition did not improve and whose Romberg's quotients shifted toward normal.·o Contribution of Postural Orthoptics 81, .~ cs:;-~ ( 10 ) o A i 337 100 250 • Fig. 16.11. Changes in Romberg's quolients of patients whose condition improved. Each arrow represents changes in Romberg's quotient for one patient, tram the beginning to the end of followup. 250, normal Romberg's quotient; lOa, limit for postural blind· ness. A, 71 patients whose condition and Romberg's quotients both improved. B. 8 patients whose condition improved but whose Romberg's quotient moved away from the normal mean.~o 1 1------,------------------------- .- .... Postural Training Platform PoslUr.l1 rehabilitation can he accelerated hy the use of :l wobbly platform. similar to that dcscrihc~ by FfC~l1lal1 el aF' but adapted to the fine postural system. The dOI1l~ on wllkh the platform re~ts has .1 large radius of cur\',lture and the platform construction limits its mean range of movement to -l nr 50 (thc normal mngc of hody sway in (HlhoSI:ltic posturl' thal is conLrollcd by the linc postural systcm). Therc! Psychologic Aspect How reductive it would be if the posturologist considered a standing person as merely an assemblage of eXleroceptors and proprioceptors. the infonnation from which is integrated to produce the reactions needed for stabilization in his or her surroundings. To stand upright means much more. To stand on one's feet means to have the hands free to act and the joy ~c I i i I ~~~\ l-=? /1 tj I ... ~,,, of (011tro1 tWL'r 01l~':, hody. Phyl(lg~l1('tically speaking. humankind is Ih~ OUh.'\ll1l(' or this impulse toward more freedolll. morc control. more powcr, To reduce the standing per.. . on W posturologic lCflns is to condemn ourselves to lllisulldcrsiand the "lnis-"{~llldillg" person. ~n longcr lX'ing ahk 10 sl,md lIprigJ1t is sh,uning. the opposite or being. upright and proud of it: to lose this ability is III he powcrkss ;lIld dqll'lhklil. Wilh ,I postural p'llicnt, there· f\lre, wc IllUS! asse~s lh(' pSydlOlogi..: aspect of this dison.h.:r 011 his or hcr behalf. for the patient will not be ",ware of the extent this break. We arc then faced with a difficult sitlla~ lion, because the ~igl1ilil.::'ll1ec of psychologic disorders that '\CCOlllp..m)' poslUral disorders is dOllblc·sidcd: the individual 1ll:'IY havc experienced ;I'profound \\~()und to the bodily ego that is expressed ;IS depression and anguish. or the paticnl may feel depression or anguish thal is being ex.pressed in bocl· ily language. Some postural disordcrs can bc ameliorated with purely psychiatric trcalment. All pfilctitioncrs musl rc~ membcr thm a purely posll1rologic point of view docs not rc· ncct the entire person, () or CONCLUSION Everything said about the control or orthostatic posture seems obvious, but we must l10t forgct Ih:'11 nn "obvious fact" may We thank Susan Millcr for her help with lhe English tr 2. 3. 4, _L-_~::-__' - ~ ! ...... ', ....... _, ...... " ... REI'ERENCES I. Gagc), PM. {broil HI, C..hio N: lnlmduction , 10 , cd=L ,,, 5. 6, \ ----- I 1<0 7. I"" !:t, ~--=----tU._j Fig. 16.13. Postural training platform. 9. 10. II. a la poslUrologic diniquc. Agresso1ogie 20E: lit). l'lxfJ. Thomas A, de I\juria~ucrra J: L':IXC Corporel. ~hISl.:ul;lluh: ct lnncrvaliOIl. P;.ris. M:t~:-on. 19-18. rr H-38. Bell C: '111e (-land.. lis \lcchanislll and Vila1 Ellviwtllllcnl. 4lh Ed. London, V. 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Ribol E: E: W M;1nh','hi r W"her U. Ga~cy P/,..1. .:1 al: \l.Jl:.lr;lliOl1 :Hld cvolutioll of R(llll~l<.. r~·Jo quulil'nl: Inllu.:ncl' l)f abnmm;.lt,,:ulomolt1r equilihriulIl. In l\mhlOl,,1 B. BerI1l\11. A. CI:lrJC F (I,.'ds): P\l~ltlrl.'" ;lIld (;;\il: D,:,·clojlmcllI. Adaplali,m and E\'ollllinn. Amstcrdam. EIsl.'"\ll:r. [9~\l). pp i'>:'-9:!. .w. Guilbllll1fl JL. Genl,ll R. lkludry J: The 1'()~tur:11 DiSlIlrh;lI\cL's Im.lm:cd hy I.ll\\' Il:K'k I'aiu. Hhh !Illernaliollal S~ 1Il1,,1'iiullI IItI l)isHnkr.' of I'uslun' :11111 Gait. ~liillil.'"~L S",ph.:mocr 1990. "'1. Nnnnc.' S5.l l uhliJohcd hy Ihc :\.\SllCi;llioll Fr;ll~\':I1'c dL' p,"lllrultl~iC'.·1. :I\·cnue ,k Corl~r.L. 7.)U\~ P:lris. 19H5. ·12. lIir;t..o,a\\:I Y: StUll)" Ull human standing :lhllll~. A!!-r":Jo~...,hl;:ll· I-lc.n. 197.'. 4~. Guilleni G: Slabi[(ll1l~'lri:t clinic;!. Istilutn di dil1il-a Ohlrim'!aringni:ltrt...·a lid!" uni\'ersita di Modcna. [989. 44. Suganll B. T;lkcy;. T. 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Pail1 i ---c--------------------------- ·.. _.•••• ,r'>...... ,. ,.... u 67 \\i~!~:!~ ~:G. ~'.'r.f::;: C'.'./: I\l~tur;ll Ihixlllfllpy ;11 til.: human hip. Q 1 hj' Phy!\iol 73:369. 1988. 68. Guillalumc P: L\:x;lmcn djniqu~' I'IISlllral. A~r~'~:-\'l,'pl,' 29:6S7. !IJSS. 69. B'l.~~anj B: Lcs SCillliqucs .:t b ~-cncbrulh~rapi~·. P;".:cdings tlr the 5th Symposiulll "journcc!\ d' A~'urum'\IIre 1,'1 de \,I,'n~'t-wlhcrapic:' Vidl~ 1965. tic BU$s:!c Clcollond·FaTJlld. dc Bms;I,·. l<1N'.I'P .'i7~(d. 70. Bi ....1.0 G. Guillci N. !lal;1l .-\. (1 :1.1: Sp\:cili~·;tli\ln., (,': t>:lildio;; :1 "cflic:! force pJatroflll dcsigncJ ror dmi,';11 Sl;lhiltllll.:lry. \k,l Billl Eng CI'llll'll! 2J:474. II)S~. ...... ~ 'V'M.'''UM.L 71. Fcrr..:y G. G:l~ey JIM: Le syndrome sUbjcclif ct les lrouhlcs psychiqucs dcs lr:IIII11:1.II'':' du crtmc. En.:yd ~tcd Chir (I'ans). Psychialric. 37520 A Itl. II)~S. 72. Manlcchi C. Fouche 13: /\gro:ssIlIO~I" ~~:16l). 7._. AI1ll:-l~\lpie profolltlc ct prislIlcs I\oslurau.". 11)91. Frl'l~Ill;lII ~1 ..\R. \},,:all 1o.IRE. Ibnh:lIll IWF: 'Illc ctiology ,\lid prevclllion (If hll1,"I\II1::! In_~I;lhililY Ilflhl" i''Clt. J BllllC loim Stlrg IBr!47:(17S. 1(6). 7J. (;;Igo:y 1'.\1: L.I plalo:-l"\lflll,' Ik rc":du<.:alillll l'0stur:lk. "nil Kil\e.~ilhcr. 20: .... 1.1\19:. ~ ! I:1 I~ •~ i .~ I I ~~ ~ I-----~--------------! i, ! ;; I $ _ _ _ _ _. ..-I""'Ii· . . '. 1( Lumbar Spine Injury in the Athlete ROBERT G_ WATKINS ! ': ~ -,~ § , , ~ :;; -~ .~ i !"" I ) I~ \ -~ '~ ,', ;1 ~: ) ~j ~~ :\." ~ ~ ~ i •,• ! ~ ,, I I .J ~ "li~- '. ) -1' (} ~! :": t g ii I• "I ~ -f ~ I• I I < -r.' .'" ~ Low back pain has b~cn a significant factor in many differenl types of athlctic activity. Thc ~evcrilY ~\lld extent of back pain oftcn dctcrmincs the aClUal abilil)' to compete ;lnd is i\ worry (() the athlete. the family, coaches. trainers, and those persons responsiblc for p::lying the bills. TrCallIlCn{ of thc athlete with a lumbar spine injury involves an lInderstanding of basic anatomy mId biol1lcchanic'll function of the spine. the diag~ nosi$ of conditions ,lffecting (he lumbar spine. proper usc of diagno~tic ~tudics. and a syslcnmtizcd. all-inclusive history and physical exmnination. We must also recognize somc factors that predisposc the athlcte to lumbar spine problems. as well as training Predisposing f'lcwrs to back pain in athlelcs include increased trunk length and sliff lower extrcmities.f , There is an increased prevalence of occulta spina bifida in patients who dcvelop lower lumbar spondolytic dcfects. 7 The study of exercise and back pain in athletics and in the average populalion demonstrated no higher incidence of back pain in athletes participating in orgnnilcd sports relative to regular students. fairbank ct al found that back pain was more cOlllmon in studcnls who avoided sports than in those who participated. Fisk ct aP- found that prolonged sitting was the important factor in the pathogenesis of Schcurmann's disc.lsc as opposed to athletes lifting weights. undergoing comprc~ sive stresses. or doing hcavy lifting and part-time work. This study involving 500 17- and 18·ycar-old students showed that 56% of young men ~md 30% of young women had some mdi- ographic evidence of chnnges similar 10 Scheunnann's discasc.'~ Keene ct HI" found that 80% of back injuries occurred during practice, 6"fcJ dliring competition, and 14% during preseason conditioning. Of thosc who sustained injury, 8% were men mid 6% women. which was of no statistical signifiC;Ulce. The n:lturc of injury usually was acute (59%)~ 12% \Vcre related to overuse and 29% involved aggravation of a pre-existing condition. ANATOMY The vertebral column is a series of linked intervcrtebral joints. The join! consists of the intervertebral disk, its two facet joints. concomitant ligaments. vessels. and ncrves. referred to as a neuromotion scgment. A neuromotion scgment is considered as onc of the basic units of spine an ,.) _ . itsdf would be insunicicllt to pn~tlllce proper spine strength withom rhe additional supporl provided through (he trunk Illusculature anti IUlllbodorsal f:ISl:ia. :V1usdc control of lhe lumbodorsal fascia allows gn.':il1cr n:sistal1ce to bcnding anti IO~lding stresses. The: rok of 111111!wsacral fasci,l Illi.ly be com· p . In dClermining the exact ctiology of lumbar spinc pain in mhletes. age-is i.1ll important fi.1ClOf. l'ounger athletes arc more likcly to havc slr~ss fractures and congenital predispositions to slress fractures. Diseases that affect growing cartilage are more common in young athletes. such as Schcurmann's dis· easc. In the m.Hurc athlete. radiologic assessment often in· volvcs distinguishing between age-related, asymptomatic changes '¥ " i ~ i ~ I '-' I i i J .'i: :i ~o~ .~ -B 'I i { S 'pondylolysis and Spondylolisthesis ~ 1i ~ M :1 jj i Age is important in the natural history of thcse conditions. An incidencl: of 4.4% ,J( age 6 years increases to 6% by ..dult· hood. It is unusua-' for children to presellt with spondylolysis beforc the <.\ge of 5 years or with severe spondylolisthesis. grade III or IV. Most symptoms appear in adolescence. Fonun:.llcly. however. but the risk of progression after adoles· cencc is low (about 15%). Symptoms cannot be correlatcd wilh the degree of slip. Rapid progrcssion to spondylopt.osis is more common in 9 to II year aids and in children with occult spina bilida and doming of S I. Children with high degree slips may present with dcfonnily and minimal pain" Many times, it is (he pain of an injury that leads to the identification Of:'1 signif1cant spondylolisthesis. . ~.~.; i! i.1 ~ ~ i ~ .• , , •• , ¥' \:;. M t"'t11\L; Isthmic spondylolisthesis most commonly develops as a fracture. A hereditary predisposition to dt:vcloping the stress fractur~ is likely, and there is certainly the predisposition in conditions in which the bone of lhe pars inarticularis is nO( sunicicrll to withstand normal stresses. Also, certain mechanical activilies thaI expose the p scan. we routinely prescribe a bracc and restrict activit)' for 3 mOnlhs. At the end of lhis period, if the bone scan is fl.> peated and the results are negative. sufficient h~aling has OL'· curred to allow the patient to begin a rehabiliwtiol1 program. If the findings of the bone scan arc still positivc. and the .nhlete is asymptomatic. it may be difficult to decide whcther III begin the rehabilitation program or to continue further r~striclion. \"Ie usually initiate the rehabilitation progr'llll and observe carefully for any return of symptoms. If lhe patieIH i~ 1 c) asymptomatic in a full, rigorous, trunk stabilization (level II Back Class) and aerobic conditioning program. w t : J allow lheir return to their sport and conlinue the rehabilitation \ program. progr~lIn I I· ~ ....) J t ' I" IUNt:.r"n;j MANUAL I'· C; L \ . ' > $ ----------------------------------------------~ ~ ·~i % t ~ t 1 -.,} CHAPTER 17 : LUMBAR SPINE INJURY IN THE ATHLETE Pal kills wilh unilateral "hoI" h,Iill..' scans. wilh or wil1lOU( demonstrated fr:\I.:llIfc. have a rC:I'llllably high illL"iJL'llCC 01" healing. and adnk,(cllt allllcl..:s ill ~l'l1cral should be (reilted with the idea o( hl'aling Ihe defec!. Bil:l\cral sln:s.", fractures afC less likely to hL';11 c.kspitc l'olllj'n..·hL"n",ivl..' IltHhlpcr:lIivc !i !, 111cr:lpy. Ir the hom: . . ..,-an lindings ,If\.' 11:.''::;lti\·l~ ill a palil'!H \~'i[h a spondylitiL' tkt'c(1. lhl.' In:atmclH pLtn should be IikL' [hal for :lll)' patient wilh lllt.:l.:hanic:1I lnw h:h.:k paill. Tilis plan usually involves a progl'cssi\"c1y vigorou" lfunk stahility rL'ilabilit.\lion program. We put no rennan~nt r~stril.:lions on .ultk(cs \\lith spondylolysis or srondylolisth~..is. Ckarly. p;'li~ms \\lith grade III to IV spondylolisthesis ar~ less likely (0 b.: able to partil.:ip:Jtc in vigorous sports ;ll.:li\'ili~s without pain and oisl.:omfort. Thcy should probably :l\"(lid lhe hC;l\·Y.. strength sports. such as fO{.ltb;.tll. wcighl lifting. etc. The lm;idcm:c of spondylolysi~ ::md grade I sp()l\dylolis~ Ihesis in sports participants is high, In the long term. this condition is not considered lo be a significant factor in an athklC's ability to pl~l)'. ~ ~ ! ,, $ ! I, ~ , .. I, } I ")1 I ) I § BIOMECHANICS j .~ , ) .~ i Ii TI i I I l ! I I .J oft ,, d ! B .k j I ) " I• z. > I " .f ~ j \1 \;, ~j .~, <; I I , iI I ~ m ).> , .,, '"' ~ ! ; j , , 1 . - The understanding of the basic biomechanics of Ihe lumbrar spine begins with ~n understanding of the forces ilnd stresses 'Ipplied to the spine as rclalCd to its normal curvaturcs. Because of the lordotic shape of the spine. lhe results of vce· toral force 011 the spine usually consist of a vertical axial loading compressive force perpendicul;:lr to the surface of the disk and one horizontal to the disk. producing 343 SOllie injuries fesult from direct blows. Certainly. sports slIch as football arc associated wilh muscle contusions, musdt.: stn:tchcs.•md lears of fascia. ligaments. and. occasionally. muscle. Lumhar fractures can occur as a result of direct blows to tltl..' hack wilh fracture of the spinous process or twisting injuries that avulse the tnlllSVCrSl: process. Vertebral body cndplate fracture from axial compression load on the disk is a rclati\·t.:!y common source of compft::ssivc disk injury. The allIlU· Ius is morc likely injured in rotation. The end-plate is morc vulnerable to compression than the annulus. Axial loading compression injuries can result from jarring injuries in motor sports or boating. Flexion rotation fracture dislocations of lhe ccrvic;::tl and lumb;'lr spine arc certainly possible. In any sport in which one athlele falls on another. the mechanism is simiI"r to that of the coal face injury with the rock falling on the coal miner while on all fours. An athlete can suffer an asymmetric loading. rotational injury to the thoracolumbar spine. The intervertebral disk is injured predominantly through rotation and shear. which produce circumferential and radial lears. Initially. the layers may aClUally separate or lhe inner layers break. As the inner layers weaken and arc lOm, added Slress is placed on the outer layers. This increase can produce a radial tear of the intervertebral disk. \Vith the outer layers lOrn, the inner layers of annulus break off and. with portions of the nu~ deus. \ I Conclusion of these faeLs indicah:: that mOl ion docs have an effect on the nerves and Lhe Ilcuromorion segments of an i injured ..rca. For example. in the presence of a spinill obstructive problem. such .IS spinal stenosis. extension exercises can funhcr COlllprcss lhe neurologic slructun.::s ami make them worse. I n the presence of a nerve root tension problem. such as disk herniatioll, fkxioll can produce incrc:Iscd tension in;1Il already ten"e nerve alld im:rc.. lsc symptoms. IlISTOIlY ANIlI'HYSICAL IeXAMINATION The key 10 a proper history and physical examination is to hayc a swndardi7.cd format that accomplishes the needed spe- dlle objectives. I. QuullIil Pinpoint the pathophysiology causing the syndrome. Important dClcnnin The physical examination should address: I. 1l1C prcsencc of sciatic strctch signs 2. The neurologic deficit 3. Back .lIld lower c;(trcmit)' stiffness and loss of rungc of motion 4. The C;('let lociltinl\ of lcndcmc~s and r:ldiation of pain or pares· tht:sias 5. Mallcuvcrs during tile cx'lmination th.ll reproduce the pain Thc history dClennincs \\'hethcr it is an axial (back pain) or extremity (leg pain) problem. \Vhat is the exact percentage of baek versus leg pain? Is the pain made worse by the mechaniC'11 activity or is it a constant resting pain? Docs the pain worsen with maneuvers thar increase intradiskal or intraspinal pressure? Is there significant night pain? Do maneuvers thal decrease spinal diametcr increase the pain? Do maneuvers that incrcase nerve root tcnsion increase the pain? Cla'\sic radiculopalhy is radicular pain radiating into a specific dermatomal pattern. with paresis. muscle weakness. loss of sensation. and reflex loss. The radicular pattern of the pain and neurologic examination detcmlincs the nerve involved. The cl~ssic hi£tory for radiculopathy resulting from a disk herniation is back pain that progresses to predominantly leg pain. It is made worse by increases in intraspinal pressure such as coughing. sneezing. and silting. Physical examinalion shows positive nerve stretch signs. A derrnatomal distribution of leg pain is made worse by straight leg raising. sitting .or supine; leg-straight foot dorsal flexion; neck flexion; jugular comprcssion~ and direct palpation of the politeal nerve or sci~ atie notch is characteristic of r.adiculopathy. A source of radicular pain not found in this description is that caused by spinal stenosis. Spinal stenosis usually lacks positive nerve stretch signs, but has the characteristic history of neurogenic claudication (i.e., leg and calf pain produced by ambulation). Pain that docs not go away immediatcly on stopping is made worse wilh spinal extension and is relieved by flexion. The pain pro~ grcsses from proximal to distal. The pain drawing. completed by each patient. is a major help in accomplishing the objectives of the physical cX j ~ I~------------------------h ~ ••. _ .• _ _ .__._.....J "HA~ I 345 I cH 17 : LUMBAR SPINE INJURY IN THE ATHLETE \\ ithil1 thi~ g.nmping ~Ire several different syndromes. First is :111 ;ll\lIular h~;lr of Ihe intervcnebral disk, usually a loaded tion program to correct them requires a great deal of skill on the part of the lihysician. ~'l\11lpre~~in~ rotatory injury to the lumbar spine producing sc· h;lI.:k ~pasl11 ,lI1d pain. The pain is usu<1l1y ,,\)r~L" ill Ikxion with coughing. sneezing. straining. upright 1'(I~lUn..·. siHing, ::i·ld ...) NONOPF:RATIVE CARE The nonopcmtive treatmcnt plan consists of sc\'cral basie rules. I. 2, 3. 4. S. 6. SlOP the inl1:l\ullliltion Restore stn.:ngth Ri..'Slorc Ocxibility Restore aerobic conditioniuf. R~(ore balance "nd coordination Adapt the reh3bilitution progmm to sports-specific training and exercises 7. Sian slowly back into the sport 8. Return to full function Rest and/or immobilization arc often required to stop inflammation of thc spine in an injured athletc. We tf)' to keep the period of rest and immobilization to :'1 minimum. Bed rest produces stiffness and weakness, which cause the pain to persist. Stiffness and weakness arc the antithesis of the body fune· tions necessary for athletic performance. Every day of rest and immobilization may produce weeks of rehabilitation before the athlete is able to return to performance. As in motion lrcatment of lower extremity injuries, i.c .. fracture bracing and postoperative continuous motion machincs. rapid rehabilitation of lumbar injuries in athletes requires effective means of mobilizing the patien~. 1kd il3st fOi" longa than 3 to 5 days is not of any bencfit in the natural history of the diseasc. Rapid mobilization requires thc use of strong anti·inflammatory medications, ranging from epidural steroids. oral Medm! Dose pak. and Indocin SR to other nonsteroidal antiinflammatory agents and aspirin; icc: a TENS unit; and rnobili7...ation with casts, corsets, and braces. Corsets and braces are used for only limited periods of time. Strengthening tech~ niques begin whcn the brace is applied so brnccs can be rc· moved as soon as possible. Bmces in themselves can cause a significant amount of stiffness anu weakness. Exact timetables arc difficult. but determinations should be based on infommtion obtained during the history and physical examination. As a gencral rule. our patients with acute disk herniation are treated with 3 to 5 days of bed rcst: scc the physical therapist within 7 days; usc a corset for nQ longer than 10 to 14 days; receivc Indocin. occasionally Medrol. and less commonly. epidural injections. The therapist b<:gins the neutral position. isometric trunk strengthening progr..un thaI. depending on the response of thc patient. evolves into rc· sislive strengthening, motion, and ._._ thought out, balanced biomechanical approach. Common questions are whl;;lher to do extension, nexioo, or twisting exercises. what type of aerobic exercising should be done. when can someone lift wcights. what role docs Nautilus beautification exerciscs have in rehabilitation of the athlete. and what type of nonoperative rehabilitation is bcst for the individual athletc's spon? A COllllTlon concern is the risk of producing or increasing a neurologic deficit through Ilonop.:rativc care. So often. nonoperative care. in lhe face of a neurologic deficit, Ili:Is COIlsisted of no carc. A shon pt.;riull uf bell rest is tlte usual. initial stage of treatment of the athle[c with a disk hcmiation and neurologic delicil. Bed rest is thought to protect the patient from increasing injury to the spine and therefore increasing neurologic delicit. Unfortunately, bed rCst also produces profound weakness and loss of biomechanical function, which actually increases the risk of injury. If the purpose of bed rest is to decrease inflammation. the logical substitute is aggressive anti-innalllI1latory medication. If the objective of bed rest is to prevent lIlotion, braces and casts can be substituted. If the objective of bed rest is to prevent abnormal motion that could injure the spine. it is with Lhe understanding that cenain mechanical functions have to take place. Patients get on and off of bed pans. they get up to go to the bathroom. They roll over in bed. They cough, they sneeze. and eventually have to walk. it seems logical that if we could design an exercise system that would prevent abnofiDa1 motion while restoring strength and flexibility in a biomechanically sound fashion. we could protect the spine from the abnonnal motion that produces injury. and possibly enhance healing. This enhancement takes place through normal biomcchanical motion in the injured pan through increasing strength and flexibility in the adjacent portions of the body that Can ~lbsorb the stress potentially directed to the injured pan and in preventing the atrophy, weakness, and stiffness caused by inactivity. Lumbar spine injuries in athletes demand prevention of atrophy and stiffness and restoration to maximum function as early as possible. It follows that if this restoration can be achieved in athletes. il can function jusl as effectively in steel· workers. sccrctaries! weekend athletes, and housewives. The key to the program. obviously. lies in safety and effectiveness. If you could summarize an overall basis to our preferred rehabilitation program. it would tie in thc concept of neutral posilion isometric strengthening for the spine. This program is derived from work by Jeff Saal, M.D.. Arthur White, M.D.. and others illclluJiflg Celeste Randolph. AUJI Robiuson. Clire Brewster and others at the Kerlan lobe Orthopedic Clillic. Trunk Stretching and Strengthening Program This exercise program concentrates on trunk strength and (runk mobility. balance. coordination. and aerobic condition~ng. A practical app~i~ation of the .usc of trunk strcngthcni'1£ In back trcaUllcnl, IIlJury prevention. and improved perro\'. manc~ i~ :lthletes. ~ ,- OM " v l ' i c n . : ) MMI'lUI-\L,. It appean- th:H the place to bc;;in t:,c id;ab:!i~::.ti~~:~ i'::-:;· gram in an injured lumbar spine. with or without neurologic deficit. neutral po"ition isometric !'trengthening. Th~ b:lsis of the trunk st:lbility program is to havc the patient tind a neutral. painfrcc position while supinc with the knees lkxed and feet on the ground. Not only is this beginning to rehabilitation a.~ nomraum:ltic ;1" possible. but abu it forms the h:lsis ur :tn imponant concept in tcrms of b01h athletic fUllction and :1\..•• uvuics of <.Jaily !Inng for cveryone. We retrain muscles to work to support tk spine while the patienl is using his or her anllS and legs. It b nOl only theoretically ideal. but also practically possible. Teaching muscle control with tight. rigid contraction of th~ muscles, controlling the spine through the lumbodorsal fascia. with the gluteus maximus, oblique abdominals, latissimus dorsi, not only produces protection of the lumbar spine. but also Can improve athletic pcrform <.;HAPTER 17 : LUMBAR SPINE INJURY IN THE ATHLETE j I ( Fig. 17.1. Begin identification of the neutral position with dead-bug exercises. The patient is supine with the knees flexed and feet on the floor. With assistance from the trainer or therapist, the patient pushes the lumbar spine toward the mat until a mod~ erale amount of painless force is exerted on the examiner's hand. The patient then maintains this same amount of force through abdominal contraction while: 1. Raising one foot: 2. Raising the Olher foot; 3. Raising one arm; 4. Raising the other arm; 5. Raising one leg; 6. Raising the other leg; 7. Doing a leg flexion and extension with one fool; 8. Doing a leg flexion and extension with the other foot. These same exercises can be performed with weights on arms or legs. player pushes the lumbar spine toward the mat until a moderale amount of painless force. not exaggerated, back flattening. extreme force, is exerted on the examiner's hand. The player then learns to maintain this same amount of force through abdominal and trunk muscle contraction while: J. Raising one fool. 2. Raising the other foot. 3. Raising olle arm. 4. Raising the olher arm. S. R 347 The next stage for torque transfer athletes is resistance to rotation, first supine, then sitting. then standing. in which the player maintains the neutral spine control position while resisting rotation of the upper body on the lower body. The player resists (he rotational activity exerted by the therapist or trainer. III the next stage. the player maintains trunk control while actively rotating through a shon range of motion ag.ainst tlie trainer's resistancc. 1l1is mancuver is done in numerous positions to teach trunk control rcgardlcss of the positions assumed by the patient (Fig. 17.2). Beach ball exercises can also be of bencfit. A ball that is 4 fect in diameter can be used to do partial sit-ups while maintaining control of thc ball. \Vilh the trunk in neutral position. the sit-ups and resistive sit-ups are done on the ball (Figs. 17.3 and 17.4). Lower extremity, tnmk. and upper extremity strengtl1cning must bc donc with conccmration on maintaining thc neutral trunk control position. It must be taught away from the sport, without a bat or ball, on thc training table or floor. A routine is established for the player: think trunk control-neuIml position-tense contractions. Trunk control is incorporated into throwing or batting. This control will ultimately produce;] more efficient transfer of torque from the lower to the upper extremities. i.c.. better bat control for a hitter .1Od better endurance and ball control for a pitcher. An additional valuable benefit can be prevention of spine injuries and spinal pain 'assoclated with the athletic activity. After cstablishing neutral position isometric control of the spine, extremity strengthening can begin. Probably the most important muscles needed 10 protect (he spine ilself are the quadraceps. The ability to return to work after a back injury is directly related to quadraceps strength. _Yet. qlladracep strengthening should not be done in the standard. sitting. full knee extension position in a patient with severe lower back pain. The goal is to accomplish quadraccp strengthening without irritating the lumbar spine mechanical pain. Also. the ability to move a weight from 90° to zero may not relat<: as specifically to lumbar spine function as quadmceps strength obtained through funclionul strcngthening. Functional strengthening initially involvcs wall slides-sliding down the wall, holding the position for 10 seconds and back up at varying depths of slide. We begin this exercise immedimely after surgery for our patients. Throwing the medicine ball in a flexed knee position. Exercise that involves the use of such devices as a Versiclimbcr or stationary cycle as well as other techniques arc used to teach quadraceps function while maintaining trunk control and during sports-related (I<.·tivity. Gluteal and hip extensor strengthening is important. but must be done without inadvertently hypercxtending the lumbar spine. Exercise bands that provide rcsist;;mcc to hip extension without mllch spine extension arc optimal. as are other techniques that de·emphasize spine motion while producing isometric extensor strength. Weight machines. with a safe. protected range of Illation. can be of value in extremity sm:ngthenillg. The key to Ihe •. _." .~._•• , ,. ,...... ~...... •• ''- ..,. , "~L;.. M r-n..... V II I lUl'it:1"1 ;::, MANUAL 8 n Fig. 17.2. The patient maintains trunk control while aclively rotating through a short range of motion against the trainer's resistance. This maneuver is performed in numerous positions to teach trunk control regardless of the position oflhe patient. sliccessful usc of thcse machines is good isomctric trunk control in a painfrec neutral position. By first establishing trunk control. it is possiblc to dctcnnine a safe. protected range of motion and a good position for the spine. 1l1crefore. military presses as well as lats, ann, and lower extremity leg strength· cning with machines can be of benefit white protecting the spine. Spine strength testing machines have been shown to be of benefit in predicting return to work. The ability to pcrfornl flexion extension exercises or resistance rotational exercises on a machine, however. may not translate to functional spine :.lctivity during athletics. We have not recommended a specific back machine for treatment of lumbar injuries: we greatly prefer the trunk stabiliz:ltion program. Stretching exercises are an important part of any rehabilitation program. The more flexible the legs. arms. and upper body. the more likely the proportional decrease of motion stress on the injured lumbar spine. If tnmk muscle control is established flrst through the strengthening program. then the spine can be held in a stable position while stretching of the extremities takes place. It is important (Q nOle that hamstring stretching too often is takcn to the extcnt that produces abnormal lumbar spine motion. Stretching the leg pasl the point of pelvic motion only strains the spine and docs not increase hamstring looseness. Too often. lumbar spine conditions are irritated because of excessive lum· bar motion during h of motion is the CAT/COW position on all fours. for example. a position in which muscle control can be easily maintained. The streIch exercises arc a critical component of the program. Stretching increases the functional range of motion of the trunk and legs. which in tum decreases the likelihood or lumbar spine injury 'Juring lhe strenglhening program during: play. Most low back injuries occur when the player exceeds (he strength of the spine and its range of motion. The stretching progr311l provides a greater area of painfrec and injury-Free function. For example, if a player who is stiff. having 100 of spine extension and 20 0 of spine rotation. suddenly reachcs' for a ball producing 25 0 of extension and 400 of rOlation. injury to the bi:lck can occur through tearing stiff tissue. If mobility exerciscs produce a functional range of motion of 40;:' of extension i:lIld jOO of rotation. injury is less likely to occur. This is a protective range of motion. The chief findings in our ball players with back pain an~ weak abdominal musculature, loss of spine extcnsion. loss of rotation (usu~llIy more in one direction). and poor mechanics in rotation. Once the back pain starts. the weakness nnd contractions increa..e, This progrnm is designed for perform,t1h':~ enham:cmcnt and injury prevention, as well as treatment of back pain. Aerobic Conditioning ~UI11CrOllS mcthods arc available for aerobic conditioning. Often \\:e see athletes who prefer a specific techniquc. stich _______.Jaa~ ~ < 349 'CHAPTER 17: LUMBAR SPINE INJURY IN THE ATHLETE Cross-training is critically important in recovering from aerouic exercise-induced injury. Not only docs the runner with an injured back have [0 do the stretching and strengthening rehabilitation progrnm. but also they must learn crosstraining for ) Fig. 17.4. Extension exercises on the exercise ball while maintaining control ollhe ball and the lrunk in the neutral position. injury, including lumbar spine injury. Therefore. aerobic cnl1~ ditiol1ing is an important pan of every spine rchabilit;\ti'on program. Restore Balance and Coordination Restoration of balance and coordination is vitullO an effective return to full activity and spans. Incorporation of balancing techniques into the strength program as is done in the Spine Stabili1...1.tion Rehabilitation Program. begins the process of retraining muscles to lire at the right time with lhe proper strength. Balance and coordination are the key to friction~frec pcrfonnance~ it is safer and more effective. Coordination is the key to $winging the golf club, throwing a baseball. or even lifting weights. Using the S\\'iss exercise ball, balance beam. standing positions for resistive exercises. exercises bands. and techniques such as one leg squats while resisting an exercise band pulling on the waist uses balance with strengthening exercises. Therefore, it is important to incorporate balance and coordination into all strengthening. stretching.. and aerobic conditioning aspecls of a rehabilitation program. Sport-Spccific Exercise ) o I Fig. 17.3. Partial sit-ups on the exercise ball while maintaining control of the ball and the trunk in the neulral position can be of benefit ;l~ After relief of inflammation and pain: rcstoralion of str~ngth. flexibility, conditioning. and coordination; and establishing the rehabilitation exercises. the physical therapist. trainer. physician. and coach come together in the rehabilitation program to incorporate these techniques into the sport. Much will be lost and injury will likely reoccur if this application docs not take place properly. Nc\\.· exercises are added that morc closely simulate the sport. Proprioceptive neuromuscular fucilitalion-type techniques of resistive rotation and others blend in with techniques used by the athlete normally to prc~ pare for the sport. The coach may be able to change cCI1ain techniques such as slight external rowtion of the lead foot in golf. or a different foot plant in baseball. All athletes should srart slowly back into the sport. The return is comparable to spring training all over again. They must take the time to test out the new techniques and the new awareness of trunk muscle function <1Ild body alignment. Too fast a reLUrn is too fast back into tho: same old rut that often _ have been emphasizcd: keep the pelvis stable, keep the ex~ tension of the spine sYlllllletric over aHIevels of the spine. and obtain good extension through the hip jointsY Ballet involves lhe lifting of dancers. especially lifting in awkward positions. The outstretched hand produces trclllCIldous level-ann stresses across the spine of the lifting partner. Off-balancc bending and lifting is a hallmark of back problcms in industrial workers. and yet ballet, although a sport of balance. ohen involves some of the most difficult lifts. Male dancers follow the body weight of their female partners very dusely. Spondylolysis and spondylolisthesis playa critical role in dancers and may often produce severe mechanical back dysfunction. WATER SPORTS In addition to injuries to the wrist and cervical spine. diving is associated with added strain to the lumbar spine that results from rapid flexion/extension changes and severe back arching ~tfter (:i"itering the water. Although swimming and water exercises are a major part of any back rehabilitation program. cer~ tain kicks, such as the butterfly. produce vigorous flexion/extension of the lumbar spine. especially in young swimmers. The swimmer must learn good abdominal tone and strength in order to protect his or her back during a vigorous kicking motion. Thoracic pain and round back defomlities in young female hreast-strokers (:an be a problem because of the repeated round shoulder-type stroke motion. POLE VAULTING Pole vaulting is another sport that involves maximum flexion/extension and muscle contraction. The range of motion of the lumbar spine has been documentcd with high specd photography from 40 0 of extension to 130 0 of flexion in 0.65 seconds. One can imagine the tremendous forces generated across the spinc with these functional demands.~~ WEIGHT LIFTING Moving from the motion Spol1s-those sports that require tremendous flexibility and strength and involve large degrees of changes in range of motion. we go to the "heavier"-those that require strength, lifting. and high body weight. The most common such sport is \veight lifting. The incidcnce of lower back pain and problems in weightlifters is estimated to be 40%.1~ The tremendous forces exerted on the lumbar spine by lifting weights over the head produces trcmcndous levcr arm effects and compressive injury to the spine. Weight lifting begins with the spine in tight rigid position of llexion. and the lifter lifts with the legs. Tremendous extension force is exerted at the hips and knees with the spine in a rigidly stable position. Success in this por~ tion of the lift requires the body to generate tremendous rigid immobilization of the spine in lhe power position of slight flexion. i T~1 p;':i·form FOOTBALL Football players lift weights. It is part of the sport. For most ~thletes involved in the sport. football requires trcmendous upper body forces and leg strength. Some football players rely on great agility and jumping ability. throwing ability. and eye-hand contact. but strength is the backbone of football. Every year, professional teams need heavier. s.trongcr athletes, especially for the offensive line. Players go through their period of mechanical back pain as training c::nnp begins. it is difficult to prepare an athlete in the off-season for the tremendous, rapid back extension against weight necessary for blocking in the offensive line. Extension jamming of the spine produces facet joint pain. spondylolysis. and spondylolisthesis. The effect is similar to the weight-lifting position of weight over the head. except that it must be generated with forward leg motion, off-balance resistance to the weight while trying to carry out specific maneuvers such as blocking a man in a specific direction. Lumbar spine problems in these athletcs requircs specific training in back strengthening exerciscs to prevent injuriesy,2x Safety in weight lifting is an important part of football. Having a promising football player injured in the weightroorn is a relatively common occurrence. It has been eSlimated that more injuries occur in training than cOl11pclition.~<) This situation can be avoided by using proper weight-lifting tcch~ niques. In addition lo extcnsion lifting-type forces. football in'.'olves sudden off-b:~lancc rotation. which may produce trans- ------------------------ verse process fractures, IOrsion Another SpOrL that produces stiffncss is running. Distance runners must cross-train with f1::xib:!ity to prevent injury. Running involves mailllcnance of a specific poslUrc with trcmendous muscle exertion oyer a long pcriod of timc. Low bnck pain as well as interscapular .md shoulder and neck pain are commonly reported by runners. The majority of runncrs with mechanical low back pain arc "cured" with stretching exercises. Runners also have a natural tendency to develop isolated abdominal weakness. Running docs not naturally involve constriction of abdominal and spine-stabilizing musculature. A significant inbalance is often noted between flexor and extensor muscles. not only in the legs but also in the trunk. Inlrascapular and back pain also results from abnormal posture during running. As statcd previously, the key to posture is good isometric trunk strength that holds the body in an upright chest out position. Treatment for runners with low back pain should include the following: I. Vigorous stretching program thaI stretches trunk as well as lower extremilies 2. Cross-training and lTlu:-c1e strengthening Eedmiques lhal also strengthen the antagonist muscles. such as hip extensors and knee eXlensors. 3. Abdominal strengthening. using isometric trunk st:.lbility exercises to enhance abdominal control 4. Chest-out strengthening exercises. beginning with abdominal strengthening and adding upper body :-houldcr shrugs, arms behind the bilek-type exercises 10 emphasize chest-out posturing :llld tight abdominal cQmro!. The basis of bOlek pain prevcnlion in runllers is stretching exercises. 5. Proper fOOl\Ve:lr for cushioning .md enhancement of foot functillll. ROTATIONAL AND TORSIONAL SPORTS Rot;Jtional and torsional spans have ccnain charactcri$tics in common despite the exact span itself. Baseball. golf, and the javelin all require rotation and have distinctly different de· mands Oil the spine, jQl'eliu Throw. The ja"clin throw requires an athlete to gcnCr..1h:: .1 tr~m~lldous 'Huoum of force to go from a h)'p~rex Icnded po:\ilion to .1 full lkxion forward through position. Athletes do nnt throw il j3vclin 200 fcct with their ) .. ----._----------------- painfii:e. Prem~i;ure..~ymjitoni,ltic UC'::Clll.:r (y)(,:;, 1. t~nnis (219C l. and badmiltoll (20S~'). It has been reportcO thaI 3~W(1 of professional tenni::. players have missed tourn:.nllcnts because of back pain. Trunk strengthening should ~ a major part of the tennis player's regimen.-II Tennis involves spt:'cd. rotation. and extremes of llexiotl. later:d ;~lldillg.. and extension, as well as the pO\ver aspects or tile (l\ ~'rhead serve-lhe effect of lfunk strength on shoulder t'UllCtl( l i1-many of the aspects brought out in other sports. The rn~ht consistent ami important factor in protecting the spinc m lennis is bending. the knees. Leg strength. quadricep strcll~th. and the ability to play in a bent-knee. hip-flexed position \\ hile protecting the back is the key to prevention of back p:.tlll. In the servc. trllnk strength in proc,!:cding from the back c\tended to the follow-through positioil requires strong abdOll1lnal control. Ciluteal latissimus dorsi, abdominal obliquc~. and rectus abdominus- strength control the lumhodor<:l fascia and deliver the power neccssary through the legs up into the ann. The b:~ '.; to proper management of lumbar spine problems for athlcte:,: I. tvt:.k.: <.l comprehensive diagnosis. 2. Prcn ide aggrcssive. effectivc nonopcralive care. 3. Pinpoint operations thai do as lillIe dam'lge tisst.::: but correct the pathologic lesion. :lS possible to normal REFERE."CES I. Ket~;~ 15: LI1\\" h'u.:k pain in thl: ;llhlc!c from sptlildylogenic injury durin t ;~;:realilln (lr competition. Postgr'ld Med 74:2t}9. 19~G. 2. Sp<:,,~::r CW. Jackson DW: B,lCk injurics in the athletc. Clin Sports t-.-kd 2:1'Ji. 1983. 3. C>l~::::orin. ED. Hochh>luser, L. PClro. GR: Lumbar thoracic spinc pain in the ::::hlctc: Radiographic C\'aluatillli. Clin Sports r.. l cd 6:767.1987. 4. Mi.::h-:li U: Back injuries in gymn:lstlcs. C1in Sports Med 4:8S, t985. 5. P'lp::.nicolaou N. Wilkinson RH. Emans JB. ct al: Bone scintigraphy and radiography in young o. 7. 8. 9. 10. 11. 12. 13. TENNIS 14. When reporting on racquet sport injuries. Chard and Lachmann·1o separated inciden-.:c data according to squash 15. !'lek injuries in collcge aLhletes. 1 Spinal Dis 2: 190, I\)% Light HG: I-krnia of the infcrim lumbar ,pace. A causc of back paill. Areh Surg 118:1077. 1983. Keene J5, Drummond DS: Mcchanical back in lhc athlete. COl1lpr Thcr II :i. 1985. Sdmebcl BE. Simmons lW. Chowning J, ct al: A digitizing tcchniquc for the qudy of movcment of intradisl.:al dye ill respollsc l\) llexion and cxlen j----_._--_. 1(" brIan HF: Muscular lII'·':-:..llIi~llI tIl" [hI; htlllt-Jf 'rilll' ;lud Ihe rn~illt\ll uf (low~r and cfficicllc..·. Cniwp Clin NUrlh Am (.: 1.;5. 1975. 17, F;lrf:11J !"IF: The bio;ll... .:h.~:~i,;l1 .1l1~-;11\Ia;:~· ,It" l\'r,h\~i~ and hip nlO:lIsillll fllr upright 'll':livily. Spine' .~.~.j6. ItJ7S. IX. Walkins RG. J).:.:nis S. Dillin WII. ..'I ;11: ll~n;llllk EhlG ;1ll:lly"i" of IOlquc Ir:Hll'fa in r~,';·.:"illll;\1 h:hd'.lll ru.:ho:rs. Spilll' IJ;JIW, 19~9. RG. Buhkr II, L,'\~·m\.:k 1': Thc" \\';Il~'r Worlw\1t R..:~',\\·.:ry Pwgrarn. Chic:l';;'''_ C"n:,,' ;,;,,'r;U) Bnob. P.l,".:" 20. Sicm;lIl Rl.. SI':III!:=kr D Ti,..: "i!-=llili'":lIlrl' of tUlIIhar spOllllyl{lly,j, in collcg.: (oolh;11I playa.... S;'inc 6:17·1. 19~1. 21. Schnook GA: Jlljuric., in \\\)J\lcI1's g)'I1lIl:l\II(\: ..\ Ii\'c YC;lr study. Aml SpurtS ~kd 7:1..\::!. 1971), 22. (iarric:k lG. Ih'qua RK: ErlJcrniulo~y Ill' \\\,nh.:I1\ gylllll,lSlics injurics. AI111 Sll\Irb ~lcd S:1(d. 19S0. 23. l-hlWS~' A1G: ()rth\lpcdht'~ ;:iJ h;llkl. CORR S9:;'i~. )'171. 19. ,i ! I I :~ I, \Valbll~ 2..\. G halllincnlCIt. j Silurts ~kd 2:63. 1974. ::!lJ. D:I\'ies m: "11,,:;- spine in sf'>ons injuries. prcvention :lntl In':;llll1ent. Br J Sruns Mcd j·UlL 19$0. JO. Ch:trd MD. bellm'lIlll SM: Racquct sports - rattcms of injury pre~llt jng 10;1 SJ'Xlrts injury dinie. Br 1 Sports Mcd 21: 150. 1987. .11. ~'Iarks MR. Haa.~ 5S. Wcisel S\V: Low b:lck pain in the competitivc Icnnis pl:tycr. Clin Spons :""1cd 7:277.1988. J! , :} I I I I ! i I! 1 i I, i, , >': :~ ~ I, ;; 'v, !i " •~ i! il t ii ~j !\ ,~ 11 '.> ~, i f,"' ,, c,' (} I tj ACtIVe KehabllltatlOD protocOls CRAIG L1EBENSON ----------- ---- -----_._._-----_. . _-_._--- Symptomatic treatments for pain relief Not every patient is a candidate for functional restora- should be used to promote active rehabilitation rather than as lion. Some patie!H~':~with pain have conditions that require cmcrgency mcdical attention or urgent referral. which are tient with a chronic problem. but its carly usc can also prevent cd led H:JI pags (sec Table 18.1). I.~ dccondilioning and disability." Rehabilitation focuses on Patients presenting \vith low back pain initially should be cbssilkd into one of three categories u (Table 18.2) (see PaticlH Classi lication. p. 3(1). As stated previously. those with red flags identified by a medical history and physical examination should be referred to the appropriate specialist (emergency room. oncologist. rheumatologist. etc.). Simple backache accounts for the major.ity of patients who seck care. Their prognosis for recovery is good: 80 to 90'!c of these in~ dividuals recover spontaneously within 4 to 6 weeks. Spinal manipulation is advocated because it hastens this process. Other pain-relieving approaches. such as activity modification. over-the-counter pain medication, light aerobic exercise. and reassurance arc recommended for usc within the acute stage. Unfortunately. the recurrence rate is high. Therefore. active rehabilitation principles arc important to improve the quality of care. 2 Persons with signs of nerve root compromise also have a high rate of resolution (80%).1.2 For these individuals. hmveva. bed rest as many as 7 days and stronger pain medication may be required until the severe pain or impainnent abates. Management strategies similar to that for nonspecific back pain arc recommended. but progress is usually slower. Highvelocity thrust manipulation is lIsed with caution in these patients. Patients whose recovery progresses rapidly (within :2 to 4 weeks) do not need a sophisticated rehabilitation approach. Patients with chronic or recurrent pain. those considered of subacute status but \vith significant symptomatology after 2 to 4 weeks. and postsurgical patients. however. are ideal candidates for aggressive. active rehabilitation. Rehabilitation involves a functional and biopsychosocial approach. Functional testing to identify \'alid retumto-work or activity outcomes is important. Other functional tests that can direct the choice of therapcutic intervcntion. such as identification of specific mcchanical sensitivities or functional pathologies, arc also necessary. A biobchavioral approach is stressed. because the longer the patient surfers. the greater the likelihood that illness bchavior will become entrenched. This approach involves patient reassurance, education. and promotion of self- functional restoration and reducing illness behavior. not tilL" promotion of son tissue healing. The goal of rehabilitation is to control ralher than clire symptoms. This changes the doctor's role from one of heakr 10 helper. Functional restoration takes place within a biopsychosocial context, in contrast to the pathoanatomic model. which emphasizes treatment of injured tissucs. Most spinal pain syndromcs arc nonspecilic conditions that may become disabling because of physical and psychologic deconditioning. The FUNDAMENTALS OF REHAIIILlTATING THE MOTOR SYSTEM Identifying Appropriate Candidates for Rehabilitation J Patient selection is crucial to successful functional restoration. Those paticnts with serious pathology (spinal or nonspinal) should be referred to the appropriate specialist. individuals with traumatic injuries should be stabilized before functional restoration is attempted. Patients with nerve root conditions also require aggressive conservative care to reduce their nervc tension signs before rehabilitation can be pursued. in gencral. once the status of a patient is subacutc. restoring l ft_'"_C_l_i,_'"_C_"_"_,_II_,,_I_S_h_O_II_I'_I_b_C_C_O_"_'C_'_I_hc_._p_r_il_"_,,_r_,_g_'_"_t1_'_'f_C_-'_If_C_- rC_.I_i<:_"_JC_.C_.- 3_5_5_ _ Table 18.1. Red Flags'" Fracture Trauma Strain in osteoporotic individual Medical pathology Infection Tumor InUammatory Cauda equina syndrome Table 18.2. Low Back Classifications U Simple backache Nerve root pain «5'%) Se,ious spinal pathology «1%) Functional Testing Functional testing is the first step down a rehabilitatioll pathway. Functional testing secks to uncover various functional pathologies and mechanical sensitivities (Table 18.3). fuJ\t.:tional testing performs two basic functions. First. it provides i.I bi.lsclinc level of functional capacity, Second. it idcmifks targets for functional 'restoration, The baseline functional deficits me objective. quantifiable. and measurable. Thus. they arc ideal outcome assessment [Dais. The most valid tests relate specifically to relevant job trailS. They do not. however. usually tell us what dysfunction in the motor system is causally related to the patient's symptoms or "pain generators:' Such information is obtained through a rigorous analysis of bioll1cchanical and neuromuscular links in the ilrthrokincm mechanically or kinesiologically re/ared to the symptomatic area. Unfol1unmcly. the results of these tests are often "soft" and only qualifiable. Because many outcomcs related to return la work al.'c valid. they often arc mislakcnly considered <.1n aid to the clinician in decision making. This infonnation docs provide a quality check for the clinician. but the practitiOiler "in the trenches" with the patient must have the freedom to use tcsts of a "softer" variety if they can change the course of lreatment. The utility of a functional test is bascd on :.tn overview of its safety. validity. and reliability. Rissanen found that "nondynametric tests correlated beller with disability than did dynametric tcsts."~ If rcliability overshadows validity as a criterion for a good functional tcst, then we may falsely conclude that nothing is wrong with many of our patlcnts (false negative result). Grabiner addreSsed this point when he found abnormal asymmetric muscle activity during bilateral clcctrom)'ographic (EMG) assessment of trunk extension on patiellts who passed Cybex dynametric extension c"alllalions.~ The Cybcx lest proved to have poor sensitivity (high false-ncgative ratc). Limiting ourselvcs to only quantitative examinations may result in mismanagement and an ovcrdiagoasis of psychogenic disorders as a result of the low sensitivity of lhese tcsts to truly idemifying meaningful functional pathology. CompHcating Factors of Recovery Complicating factors may interfere with patient rccovery. Our history and examination should uncovcr these factors to allow us to form an accurate prognosis. No one has a crystal b:.\ll for seeing when a patient will rccover. but various clues can help to identify who might take longer to do so. Such factors are helpful in making projections. which are increasingly important in the utilization rc.... ic\'.,· process associated whh managed care. Table 18.4 summarizes the Mercy. Agency for ... Table 18.3. Functional Testing Evaluates Joint mobility Muscle flexibility Muscle strength/endurance Movement coordination Static and dynamic balance Posture and gait Lift capadty Weight-bearing sensitivity Movement sensitivity {I.e., flexion or eXlension bias} Postural sensitivity (i.e.• sitting intolerance) Table 18.4. Complicating Factors History/consultation Previous history of low back pain~ More _than 4 episodes" Total work loss in past 12 months" Heavy smoking? Personal problems: alcohol, marital. financial 2 Adversarial medicolegal problemsi' Longer than 1 week of symptoms belore presenting 10 doctor.:. Low education attainmenF' Heavy physical occupation?Questionnaires/pain drawings or scales Radiating leg pain (pain diagram)'-H Severe pain intensity" Low job satisfactioni' 0:. Psychologic distress and depressive symptomsl.:'~·l> Examination Pre·existing structural pathology or skeletal anomaly (Le .• spondylolisthesis) directly related to new injury or conditionl> Reduced straight leg raisingl.Z Signs of nerve root involvemenl 1. l Reduced trunk strength and endurance" Poor physical fitness (aerobic capacity)2 Disproportionate illness behavior (Waddell's signs)l.i',1i 'Only sJighlly increase ·ite risk or chronicity, but significantly increase the dillicullyof rehabiiil ., .,j Hl"ahh Care Pt\li.... y and Rcscan:h (AHCPR). and British Guiddilll"S t"Olh:lu.;ioIlS with respect 10 this yit;ll issue in C<1SC 1ll:lllagl"lllClll. Findin~ the Rl'~;lrdkss if:IL"Ll. h.t·Y Link of till' ,Irucwral diagnosis or "pain generator" that ) " ) ; \' I Alter prolonged standing linked [0 lhe w aSSCS.\llh,,'tll. Functional improvement is diflicuh if not impossible to achieve unless inappropriately handled extemal demands arc identilied. f-or example. any <.lctivity. sport. or work demand that is unusually repetitious involves great external load. Of requires a biolllcchanically improper movement (i.e., bending and twisting) must be tlushed out. Such factors can be uncovered during the hi.Hory by asking the patient in what activities they arc involved. whcn they typically get their symptoms. and what aggravates the p ; <., '. Un(ovcring key functional pathologies HISTORY ) i~, f Pain-provoking activities C[l:.). patient's symptoms is the goal of func ! tional l' High risk activities Prolonged sitting Driving Heavy lifting Repetitious bending and lilting Torsional sports (tennis, hockey, baseball) rehabilitation im'olvcs the cn~ myot'asl.,j;!I. disk. IiI'\.' !1ll'Pllllllor ~Y~h.·l1l. Table 18.5. Prognostic Factors After prolonged silting After prolonged walking With bending In the moming When changing positions With weight bearing PHYSICAL EXAMINATION Once a fimClional evalualiOll Iw.'O becn pc/formed. it is essen· rial to attempt to differentiate rhe key functional pathologies from those that are secondary. Lewit said we must not mistake the pain for the problem, but ~nstead identify and then treat the dysfunction responsible for the pain.' First. we must tap the patient's hislory for all relevant information. Pain location and what aggravates it often helps make the diagnosis before any testing is performed at aiL Therefore, this information is the crucial starting point. The next step includes various tests to localize the source of the pain (palpatar)' and mechanical). It is validating for the patient to have lhc;ir examiner find their pain cither through palpation or spccilic provocative testing. To be able to provoke the patient's pain experience is to hit "pay dirt," This information gives the doctor and patient a baseline or ideal outcome assessment tool that can serve as a "barometer" of the success of our interventions. It also helps the examiner "zero in" on what tissues arc involved. Although trigger point palpation or McKenzie or Cyriax provoca~ive testing is not as reliable as an anesthesiologist's needle. such an assessment can be useful in day-to· day practice. Provocative tests. whether static (e.g.. prolonged sitting). dynamic (e.g., lumbar flexion), or palpatory (e.g.. trigger point identification). are invaluable as signs of irritability or dysfunction'~'')These results, however. should not be mistaken for the dysfunction itself or its cause. Once a pain gencrawr is found. the all-important job of hleJllifying why that lissue is irritated ("the perpetuating factors ") begins. 9•10 For instance, if a patient has buttock pain and a triggcr point is found in the quadratus lumborum that refers to the region of the primary complaint, we may have found the "irritable focus" of pain. but we have not necessarily found the "problem" or source. To find the key link. we must discovef what could be responsible for the quadratus lumborum becoming an "irritable focus," Evaluating gait and movement patterns may help to identify this patient -----------------------------------~---------------- I l i ~ I I I! I I! II II I i 1 up should be evaluated with the goal of finding the joint or muscle dysfunction that is "upstn:::am" of the "irritable focus," This t'lssessment is the only way in which we can separate the adaptive compensations of the locomotor system from the true source of functional pathology. To nile OUI the chances of a shorHcml dfcct. treatment may be rcpc<1tcd over a period of 2 (0 6 weeks to change nClI· romuscular paHcming. If long·tasting results prove diffkuh to .achieve. it is best 10 perform functional rc·cvalualion for other key links .lIld to rcinvcstig~\lc complicating f:lctors (i.e., psy· chosocial or high external demand). CASE MANAGEMENT General Principles According to recent American and British back pain guidelines, patient rca~5urance, pain-relief methods. and exercise should be included in case management. I~ Patient reassurance is required to allay fcars of back pain resulting from a serious disease. It also helps 1O inform patients .. bOtl! a favorable prognosis if back pain is managed properly. Pain-relieving methods such as time·limited passive care (i.e., manipulation). pain medication. avoidance of biomechanically delete· rious activities. and reactivation with light exercises arc ap· propriate. Exercise or active rehabilitation gains in impor· tance us the acute pain phase subsides. Exercises should be aimed at restoration of function and prevention of dcconditianing. In particular. trunk strength, cndu'rance, flexibility and cardiovascular fitness should all be addre.c;sed. Treatment aimed at pain relief should not be the only gOlll of care. Even if a primary pain generator is identified. it is important to restore function in the locomotor system to reduce the likelihood of painful recurrences. Rehabilitation has two primary goals: (I) through education. ergonomics. or training in load handling. to Jecrease extrinsic mechanical stress (i.e.. sudden or repetitive overload) on the painful area; and (2) by functional restoration to improve the intrinsic functional capacity of the spine or its stability. Patient education helps to decrease mechanic..1 stress plilced on a painful region. The combination of manipulation and exercise restores function in the locomotor system. thus improving thc ability of a painful region to adapt to increascd mechanical stress. Essentilll inerediel1ts in achievin~ a successful outcome are finding the key sources of tissue ~verlo3d and identifying the key functional pathologies to address. Key Link It is casy to become overwhelmed when attempting to separate important from trivial function..1 pathologies or deficits. .So many sfr/u:lIlral and jUfIf.:tiollal pmh%gies are preselll ill as)'mpro!JIatic individuals rlwlthey may /lol be clinically significant whe" secII ill symptomatic patients. Lc\Vit and Jandu outlined a biomechanical and kinesiologic appro<.lch that "culls out the wheat from the chaff:· 7. 11 The primary goal of assessment is finding tht: t..t::)' functional pathologies of the motor systcm. the associated dysfunction of \;:hich can !:.:ad ~~) mechanical ovcrload aI a distanc~ throughout a kinetic chain of a particular posture or movcment. \Vc 1l111~l cardully analyze historical data ;lite! observc the mOlor system of our patients in ,Ictian to identify the kcy function,,1 pathology. Thi~ approach enables us Lo find .1 relevant dysfunction that can significantly alter the trC:ltmCl1l program. Pathokillcsiology that results in tissue overload and thus pllin can be identil1~d by evaluating posture. gail. and k.c)' stcreotypic movement pattcms.7.Il The impli<.:atiolls of Lhis analysis for chiropractors and those involved in manualmcdicine is that specific muscle imbalances (tight and weak musclcs) that ;.lfe functionally relatcd to the painful area can be.:: identified. Thus. wc can fonn a prescription of which muscle nceds to be stretched or rclllxcd. those that need to be strengthened or facilitatcd. and the joints th:l! nced to be .it!justcd. By finding the specific patllOkinc.'iio!ogy reilltcd to (/ pain/ul area. (III exercise prescriptiolJ (:(1U be ratio1/ally linked to lhe mallipulable lesion. Pathokinesiology in' a kinctic chain can be nushed out through posLural and movemcnt analysis.II.I~ Posture. gait. skills analysis. and key movement patterns all pill)' a part in cv,alulltioll of the motor system. Low back pain m4.lY h.we arisen afler an overstrain. On examin4.ltion. a paraspinal trigger point may be discovered. Trcating thc local functional pathologies mllY be all that is necessary. If the condition pCI'· sists. however. further evaluation of the locomotor system will be required. The problem may be found in a dysfunctional chain of C\'enlS involving a biomechanical foot faull. shortened iliopsoas. gluteal inhibition. and lumbosllcral joint dysfunction with accompanying trigger points. Finding the chain reaction is CruCi~lllo removing key perpetuating factors for motor system disorders. A further and more difficult situation arises when longslantlin~ abnorm4l1 posture and movemcnl patterns ha\'c been learned by the cerebellum. This situation requires treatment of not only periphcral tissues but also the central nervous system {e.g.. proprioscnsory retraining).'·' Each stcreotypical movement pllltCm is important for its rcl.nionship to basic skills performed many Limes each day.' These skills include l:ait, sitti"!: postft1'(,. ",randing posture, prehension. respiratiOIl, I1lll.'iticatioll. {//ul lijiillJ.: or bClldill~ (T.able 18.6). For instance. hip extension {psoas, hamstring! gluteus mllximus muscle imbalance> rdates to gllit (toe olT and forward propulsion). stllnding posture.•lOd lifting. Hip abduction (tensor fascia latae ITFL). adductors. quadratus lumborum IQLI. pirifonnis/gluteus mcdi'llS muscle il1\b~lI~ ance) r~latcs to foot strike and stance phasc of gait (pelvic stability). Trunk flexion (erector spinac. hip Hexor/rectus abdominus muscle imbalance) relatcs to lifting and trunk stability in general (during carrying. reaching. pushing. and pulling). Shoulder 3bduclion (upper and lower fixmOfs of (he scapulae muscle imbalance) relates to prehension. reaching. gr'lsping. and holding 4.lctivities. Trunk lowering frulll a push. up (pectorals/serratus anterior muscle imbalance) rcli.lte~ to pushing and pulling activities. Head/neck ncxion (stcrnoclci· dornaslOid (SCM I. sliboccipiwlldeep neck llexors muscle im- -------------- J lIb.· ·....3 Table 18.6. Chain Reactions in the Locomotor System ] i,, 5;';111 Movement Pallern Gait/loe off. lilting. and standing posture GaiFslance Hip eKlension . Lifling and trunk sla- Trunk flexion bilily Prehension. reaching. grasping Pushing/pulling i ~ i .~ Maslicalion and siUing poslule Respiration I i iI , ~ I i I Shoulder abduction Trunk lowering from a push-up Head/neck Ilexion Respiration Weak or Inhibited Muscles Stiff Joints Hypermobile Joints Psoas, hamstring. erector spinae TFL. QL. adductors. pirirormis' Psoas, erector spinae Gluteus maximus Hip joint Lumbar Gluteus medius Hip joint $1 joint and LS joint Rectus abdominus Lumbar flexion Lumbar extension Upper trapezius, levatar scapulae Pectoralis majorl minor, subscapularis SCM, suboccipitals Lower and middle trapezius Serratus anterior CfT junction, SIC joint CS-C6. GfH joint CIT junction. mid- GJH joint Scalenes hal'IIKe) , ) ) ,I ,, 1 I to sitting and mastication. Rcspiration relates to breathing. Other important ~lcli\'ities pcrforlllt:d include squatting. stooping, crouching, overhead reaching. 'and the like. depending on the particular work or SP0rl ,lctivity in which a person is engaged. Weaknesses of spt:cific muscles, such as quadriceps i:lnd crcelOr spinae. that occur with dccondilioning arc also key links to c\'aluate as arC<1S of high risk during activities like lifting or squ<1lting. Oncc lhe mechanical relationship between certain postures. activities. muscles, joints. or kinetic chains and the patient·s symptoms has been revealed. a treatment program can be outlined, Intcr\'cntion involves three levels of care, Advice (patient education about biomechanics and ergonomics), manipulation (manU'll or reflex therapy), and exercise (Table 18.7). In general. advice is the easiest intervention followed by m'lnipulalion and lhen exercisc_ Chiropractors have thrived on the powcr of m " I rdate~ (s<:.il~nes/di~lphragmJ '~ i ) ~ ~ •• ; , exercise). I ~; .;t, I• . I ~ I <) --_ Complicating Factors Encountered \Vith Exercise Trnining ' Such f.lctors include low mOlivation. poor flexibility. incoordination, or a mechanic,tl scnsitivity (postural, movcment. or weight-bearingJ. Motivational problems arc addressed through appropriale goal selling. gradual conversion of the patient from .1 pain avoider to a pain manager. explaining lhe i •• ,~ t ''-; ~ ~ ,? \ * Deep neck flexors crr junclian in lIexion, Diaphragm TMJ Rib cage. lower cervical-spine CS·C6 j p .~ upper Ihoracics ·TFL. tensor lascia lalae: OL. quadratus lumborum: 51, sacroiliac; LS. lumbosacral; GfH, gleno·humorJI: err, ccrvicothoracic; SCM, sternocleidomastoid: TMJ, tcmporomandlbular join!. SIC stcrnoclaviculJr. 'i I I Hip abduction Tight or Overactive Muscle I I ~ Table 18.7. Trealment of Key Functional Pathologies Advice (patient education) Head set for neck pain in receptionist Ice and 90190 rest position for acute pain from lumbar strain Lifting advice for recurrent low back pain sufferer Ergonomic workstation modilication lor carpat tunnel syndrome patient Manipulation Trigger point therapy 10 upper trapezius muscle for neck pain Adjustment to lumbar spine lor back pain Manual resistance techniques OlrecteO at scalenes or pectoralis minor (or thoracic outlet syndrome Adjustment 01 foot far low back pain Exercise Strenglhening abdominals for low back pain Improving muscle imbalance between hip flexors/exlensors and paraspinal muscles for back pain Propriosensory retraining for chronic back pain Trunk stabilization program for chronic back pain Improving scapulohumeral rhythm for rolator cuff syndrome Improving laleral pelvic stability by restoring muscle balance to gluteus medius, tensor fascia latae. and quadratus lumborum Table 18.8. Addressing Functional Pathology in the Kinetic Chain Relax/stretch overactive/tight muscles Mobilize/adjust stiff joints Facilitale/strengthen weak muscles Re-educate movement pallerns on reflex, subcortical basis difference between hurt und hann. and. if ll~ccss<:lry. refcrral to a pain psychologist. Flexibility deficits arc Table 18.9 Case Management for Nonspecific Back Pain and Sciatica'.... (see Fig. 2.24 a-b) Conservalive Care Rehabilitation (Active Carol BiopsyChosociill Assessmcnl Diagnostic triage • Simple backache • Nerve root pain • Serious spinal pathology Rule out red flags • Trauma (fracture. instability) • Medical pathology (tumor, infection, etc.) Functional assessment • Quantifiable. outcomes • Functional pathology Exercise (temporary increase in pain acceptable) Stretching • Strengthening (not within the first 2 weeks) • Propriosensory Special studies (biologic) • Radiography > urgent referral «3 weeks) • Rheumatologiclinflammalory > urgent referral «3 weeks) • Major neurologic compromise (cauda equina syndrome) > emergcmcy referral Diagnose nerve root compromise • Molar. sensory, reflex testing • Nerve tension tests (Le., SLR) Evaluate for complicating factors • Abnormal illness behavior (distress, depression) • Job dissatisfaction • Past history of more than 4 episodes Preconsultation duration 01 symptoms> 1 week • Severe pain intensity • New conditionlinjury related to pre·existing structural pathology or sketetal anomaly Aggressive, conser:vative care (~i'mplom control) (6 weeks)" • Rest «2 days. unless sciatica <7 days) • Manipulation (ioint dysfunction, soft tissue dysfunction, and/or trigger points) (Maximum of two different 2-week trials if no progress documented) Advice (reassurance, earty activation, activity modification) Exercise (light aerobic activity, McKenzie. gentle stretches) (increase over time) Physical agents and methods (decrease over time) Medication (NSAlDs, acetaminophen) (more import~nt if nerve root pain) After 6 weeks • Active care> Passive Care • Consider alternative symptomatic measures ff unresponsive after 6 weeks, a biopsychosocial assessment is indicated. • CSC, ESR Bone scan MRI or CT if tests indicate specific nerve root compromise Psychologic assessment • Fear avoidance beliefs • Distress, depression • IItness behavior Social assessment • Family attitudes or reinforcement • Job satisfaction • f:lhysical demands 01 job • Other lactors rclating to missed work If unresponsive afler '2 to 16 weeks Disability management • Job modification • '!'hrk hardening • Vocational re-education Pain management • Multidisciplinary approach If unresponsive, a more active approach may start within the first 2 weeks, but no later than 4 weeks. "If nerve root compromise progress is slower and treatment less aggressive. Thrust manipulation is avoided with severC."lr progressive neurologic dehcit. muscle balance, correcting 3nicular dysfunctions, and facili!aling enhanced perception of the "weak link" will contribute to improved coordination. A mechanical sensilivity, like gravity or weighl bearing inlOlerance, is no bar to exercise therapy. Non-weightbearing exercises can be performed on {he floor. All major muscle groups can be challenged before gmdual reintroduction of gravity forces is ullcmptcd. A person with a pos{Ural sensitivity, such as to silting, can exercise while upright or recumbent. Another common sensitivity is to movement in a ccnain direction. A paticnt with pain on flexion that is relieved with extension (extension "bias") is a classic McKenzie pillieot (see Chaptcr 12). Othcr patients who have pain with trunk extension, but relief in the slump posture can be trained to identify their "neutral rangc" and to learn 10 stilbilize their back from potenti31 harm. They also may havc a common altered movement pattern-hip extension, in which they extend their thigh Releasing Patients to a Private Health Club Much has been said about chiropractors working with priv:lt~ health club facilities. Although this praclice is certainly good, a few points are worth mentioning. Proper spinal posture must be l~lUghl NautilwHypc machine!> arc open kinetic chain and thus uo nOI tr.tin rcOex control Nautilus-type machines and Olhcr health club exercises often cncou(;.\ge "frick" movements. Be on the lookout for the fol- lowing: SubslilUt~ng for the :lbdominals ....:.....Lumbar hyperextension during hamstring curls. tensions. and stairclimbcr -Hip flexors seated leg ex· -Slumping during. bent·over rows, lunges, st.tirclimhcr. inclin\.' Ircadmill. or bicycle -Chin poking during pull downs. bench press, abdominal excrcisco bicycle, or squats -Shoulder shrugging durin~ ovcrhcild lifting. arm exercises. tlr rowing Free wcights arc preferable but require spcciric instructions -Lunges should be performed with proper lumbosacral siabilil.;l· lion ("ncUlml position") " -1 I ! , -) vV' -Avoid shouldl.:r shrugging with biceps curls -Avoid excessive shouldl:l .:xtemal rotiltion during bench press Aerobic exercise is I:xccllcnl, but wilh certain exceptions -Slaircli11lbing is ddelerious if paticnt has wC:.lkness of gluteus m:lxilll\ls or gluteus medius or o\,cr i,, i II i I! ~ FUNCTIONAL RESTORATION OFTHE LOCOMOTOR SYSTEM ,I l i, ~ I ! ,l• I I m ; ') I •~ Table 18.10. Typical Postural Faults and Clinical Consequences that Result from Improper Exercise Programs ~j I i ~i I ~( ~ i Different classification schemes for back pain patiems have been proposed. Those dealing with pathoanatomic diagnosis were rejected for lack of proof. The Quebec Task Force proposed the following classification ~cheme for spinal disorders (T<.lble 18.11 ).I~ This c1as~ification has been simplified by recent British and American guidelines (sec Table 18.2).1.2 Most patients (70 to 90%) fall into the back pain category.l.:! This nonspecific label replaces pathophysiologic hypOlhcsis such as facet syndrome. sacroiliac (51) syndrome. myofascial syndrome. or radiogr.lphic diagnosis such as disk or joint degeneration. Usc of lhi~ iavd uut:~ nut mean that most low back pain has no cause. just that the cause is not yct known. Recent evidence suggests that some of these causes are becoming clearer. Using a double anesthestic injection technique (one is a control block), it is possible to identify thc primary pain generator in more than 50% of both chronic neck and back pain patients.IS.IC.-I" Sacroiliac joints arc pain generators in 13%. zygaphophyscal joints in 15%. and disks in 39% of patients presenting to specialized spine centers. IS.I:t.19 Unfortunately, no physical signs Imve ~- ~ Posiurai Faulls Clinical Resull Overactive slernocleidomastoid in women performing sit-ups incorrectly Rounded shoulders in men doing 100 much pectoralis work without working their upper back CeNicocranial syndrome and headaches Shrugged shoulders from too much upper trapezius work and not enough lower trapezius strength Mililary posture (anterior pelvic tilt with chest Slicking out) Irom abdominal and gluteal work without lumbosacral stabilization (poste· rior pelvic Iill) Thoracic outlet syndrome, shoulder impingement syndrome. cervicocranial syndrome Headaches and shoulder impingement syndrome Low back pain Table 16.11. Quebec Task Force Classification oi Spinal Disorders Pain without radiation Pain + radiation to extremity. proximally Pain + radialion to extremity. distally Pain + radialion 10 exlremity + neurologic signs Confirmed neNC rool compression (advanced imaging or clec!rodiagnosis) Spinal stenosis Postsurgic~1 status 6 months Chronic pain syndrome Other diagMsis (tumor. infeclion, fracture. rheumatologic disease. etc.) been corrcl.ltcd with anesthctic relief of p.lin.I~.I(..I~.l'l Ho~ fully. anesthetic block techniques will be used .lS a gold standard to adjudicate less expensive physical examination procedures as diagnostic lests for specific spinal syn· dromes. Moffroid "and colleagues subdivided group~ of patients with nonspecific back pain into discrete functional Cale· gorics. 21l These authors arc studying the effects of stretching: versus strengthening exercises on both flexible and innexible patients. ~, The Quebec Task Force also classified patients according to the duration of symptoms. Acute was defined as less than 7 days; subacute as 7 days to 7 weeks; and chronic Cl..'\ greater than 7 weeks. TIley also recommended classification by working status-working or idle. An important development in the classification of spinal syndromes was revealed by Dclino and Erhard. 22.23 who found that nonspecific back pain could be subclao;,siflcd into a few catcgories that rcsulted in improvcd treatment outcomc. An extension and an Sl category were identificd by specific provocative movcment and functional tcsting. respectively. Cntegorization and customized treatment resulted in improved results over gencric trcatrnem for all patients with nonspecific low back pain. Using reliable tests, they showed lhat they could subclassify cases of nonspecific back with pre~criptive validity. 11lc Qucbec Task Force recently published a promising classification scheme for whiplash·rclated disordcrs_1~ Neck complainls were divided into four categorie.o; as follows: C;,llegory I: neck complaint without musculoskeletal signs ti.c.. mobility tenderness); catcgory II: with musculoskclctnl signs: category Ill: involves neurologic. signs; category IV: invo!\'cs a fracture or dislocation. Spinal St.<'lbilily, PathokincsioIogy, and the Importance of Muscular Imbalances Spinal stability depends on three intact clements uf the locomotor system. 2S First is the centrul nervous system. in particular the cerebellum. which conlrols posture and movement. Second is the articular and ligamentous structures. which are the major passivc structures involved in the locomolor sys- 0 I •,, ~ h ~ -----,-------------------- ! t t I, tem. And Lhird is the muscular system. whkh n::prcsI.:!l!S !h" active part of the motor system. This system is under the direct control of our will during conscious activities. but it is also responsible for rene;.;, subconscious Ud'lptations to irritations or injuries. Any internal structural pathology or excessive external biomcchanic I,• " 1 ~ ical cvidcm:c :-ubstantiah.:s this mood fur pres(.·ribing. exercises (T:'lbks t S.I:? and t S.l.'!. The grouping of muscle imbahlllcrs described by Jallda arc not isol;lt~d dinical phenomena. Patienls Iypically //(/\'(' "wlly./i'llefitllld /'atlln/ogie.\" alld .\"(J!l'iflg tll(' mysrclY (~r ('(lch !'min/{ \ illtli·.-idl/o/ .lil/Wliollo/ I'(lt/wlng." 1"('(Juil"(,s .IiI/ding (l eltaill r('(/('Ii(ll/ in lite moto,. .\".'".\r('l/1. Ul1lh:rsl imb ! Chain n.cactions in the Locomotor S.ystcm LOWER CROSSED SYNDROME One of the mo~t clinic'llly relevant patterns of muscle dysfunction is (hc lower crossed syndrome. which is typified by Ihe following pain: of tight and we"k muscles Crable nU-l-). Awareness or lhis pattcrn is important for low back and pdviL' conditions related to abnormal sitting. standing postun:. g"it. bending. or twiiiting <.lctivilies. Table 18.15 shows the signs related to various dysfunctions associated with the lower crossed syndrome. The combined result of this posture is that tilt:' tUIllbosacwl. thoracolumb'lr. 51. hip. and knees joints arc :'111 o\'er~ stressed. Joint dysfunction ,HId trigger points naturally result from lhesc Illu:\c!e imbalances. accompanied by low ba<.:k pain. buttock pain. pseudo-sciatica. and knee disorders.;,lIAI .. I~ Each of the threc muscle imbalances that contribute to the lower crossed syndrome are discussed in the context of the .) Table 18_12. Clinical Evidence for Muscle Imbalances FOlWard head posture and decreased isometric sltenglh and en· durance of neck flexors correlated with headache patients~~ Upper cervical joint dysfunction, weak neck flexors. and tight suboccipitals correlated with postconcussional headache patients:;Cerebral lesions result in poor descending control of tonic pos· tural reflexes'" Most reflexes involve reciprocal inhibition~8 Hypertonia with antagonist paresis is the norm u Table 18.13. Scientific Evidence for Muscle Imbalance Increased tension or tightness Relative type I muscle fiber hypertrophy on symptomatic side in chronic low back pain (LBP)29.30 Prolonged nociceptive bombardment can lead to flexion reflex from excessive contraction 01 skeletal muscles in the vicinity of the nociceptors 31 ,n Fibroblastic proliferation occurs in injured tissues if inflammatory stage is prolonged33 Muscle inhibition, weakness. or atrophy: Reflex inhibition of vastus medialis oblique aller knee inllammationlinjuryJ.l.-3G Unilateral, segmental lype II muscle fiber atrophy aller acute onset 01 LBP): Bilateral. type II muscle fiber atrophy in chronic LBP~!U" Atrophy of type II muscle fibers in multifidus patients wilh herniated disks)l)"'o ,---------------------------ti ~ ~ , "'1. d a Table 18.14. Lower Crossed Syndrome (See Fig. 2.22) Imbalance in the following pairs of muscles: Weak gluteus maximus and short hip flexors Weak abdominals and short lumbar erector spinae Weak gluteus medius and short TFL and QL· Seen commonly with gait. lifting. sitting. kneeling, crouching, pushing. pulling. ele. I j "TFL. tensor fascia lata.. ; QL, quadratus lumborum. ~ Table 18.15. Postural Signs of Lower Crossed Syndrome , I, ~ I Postural Finding Dysfunction Lumbar hyperlordosis Anterior pelvic lilt Protruding abdomen Foot turned Oul Hypertrophy of thoracolumbar Shortened erector spinae Weak gluteus maximus Weak abdominals Shortened piriformis Hypermobile lumbosacral junction Groove in iliotibial band junction Shortened lensor fascia lalae 1, .j key movement pauem that is affected-hip extension, hip ab: duct ion," and trunk llexioo. I I Altered Hip Ex/ellsioll (Table 18.16)',11,1) Hip extension is important for its relationship to the propulsive phase of gait. lifting. and the standing posture. I i I Weak agonist: gluteus maximus Overactive antagonist: psoas. rectus fem"ris Overactive stabilizer: erector spinae Overactive synergist: hamstrings II Trigger Poillls Gluteus Jlluximus • Coccyx Iliopso;ls Erl'ctor spinac (onlrable-raJ uprx:r trapczius and/ur k\';l!or sCapUI;IC Mo!)iliry (j oim [).",~rltllcJi(J/IJ • Hip joint • Lumbosacr~ll (US) junction • Thoracolumbar (Tn~) junction Contrnlalcral ccrvical spinc Altered Hip Abductiou (Table 18.17Y·II.0 Hip abduction is !Illportant for its rdationship to the stance phase of gait and any balancing activity. \Vcak agonist: gluteus medius Ovcractive antagonist: adducLors Ovcractive synergist tensor fascia latac (TfL) Overactive stabilizcr: quadratus lumborum (QL) Overac.:tivc neutralizcr: piriformis SympJomJ (ue Figs. /0.10. 10./1. {/wIIO.13J Lew back or buHock pain (51 or myufascial syndrollld Pseudo-sciatica (m)'ofascial syndromc) Lateral knce pain (knee cxtensor disorder) Postural Analysis • Prominence of the iliotibial tr.1Ct Lateral prominence of patella • Turned Qut foot (sec Fig. 6.11 a) Symptoms Low back or buttock pain (facet or myofasciill syndrome) (sec Figs. 18.1 .nd 18.2) Coccyalgia Recurrent hamstring pulls Recurrent or chronic neck pain • II Poslltral Analysis Forward-drawn posture (sec Fig.. 18.3) Anterior pelvic tilt Hypertrophic erector spimle (sec Fig. 18.4) Hypotonic gluteus maximus ~: I.) Gait Analysis Decreased hip hyperextension ,~1 • Compensatory incre I Muscle Lenglh Tests I ) M I,-' \ I I 11 , Shortened hip flexors (sec Fig. 18.5) Shortened hamstrings (sec Fig.. 18.6) Shortened erector spinae (sec Fig. 18.7) Conlralateral upper trapezius and/or lcvu(or scapulae £\'aluarioll oj Key Movcmelll Pallems Altered activation sequence during hip hyperextension (sec Fig. 18.9) Gait Analysis Hip hiking gait • Asymmetric pelvic rotation (blocked SI joint) A-Illscle Length Tesls Shone ned hip flcxors (sec Fig. 18.5) Shonened QL (sec Fig. 6.12) Shoncncd adductors (sec Figs. 6.IOa and b) Shoncned TFL (sec Fig. 6.7) Table 18.16. Treatment Approach for Altered Hip Extension Relax/stretch ipsilateral hip flexors Relax/streich overacLive erector spinae Relax/stretch overactive hamstrings Adjustlmobilize tow back and hip Facilitate/strengthen gluteus maximus (bridges, squats. leg raises) AbdominaVgluteat stabilization exercises and biomechanicaV ergonomic advice 10 correct lumbopelvic posture Table 18.17. Treatment Approach for Altered Hip Abduction Relax/stretch thigh adductors Relax/stretch tensor fascia latae and quadratus lumborum Relax/stretch piriformis Relax/stretch hip flexors Adjust/mobilize sacroiliac joint, low back. and hip Facilitate/strengthen gluteus medius (1 leg bridge, P·S retraining) -~----------------------------- S~ I ~ ~ £ , 1: s ~ • ;, EVlIJUlll;OIl oj Key MOl'cme,,' Plltl<:nl.'" • Altered coordin,llion during hip ahduction (~l;C Fig.. 6.17) Trigger Points Gluteus I1 I ~ I$ I tJlcditl~ GltllCUS Illinimll~ Pirifonnis QL • TFL Mobility (laim Dy.t!/tJU:lioll) • 51 • Hip internal rotillion II is important to I\\~ntion lhe psoas paradox. According to Janda and Schmidt. the iliorsoa~ normally lkxes Ihe hllllh,ll" ~pinc:I.\ If. h()\\"('\cr. thl.: erector spinae ;.Irc shortened. the psoas wil! instead :i-Upport the rc~ultant hyperlordo~is. The hyp...· rlord(llk spine Clll he lifted up hy lhe PSOi.IS without lhe dTol"l or the abdl11llinals (i.e.. polio). The tighta lhe Cl"l..... lOf spinae. llle l11\lrl' the pSO,lS pawdox is ill clTe<:!. Thu:,. if the crc<:wrs ;lrt..' tiflll. it is llec...·s~;lry t() strctch them as well as perform .1 p'-... 'Ierior pdvil' lilt before anempting. trunk cLlrl cxcrcisc~ IN the abdominals. Abdominal cxcr· cisc:, thai I I' I !"(lITCS ..I·1 TIL ilnd L2/L3 Altered Trullk Flexioll (Table IS. IS!""'" Trunk Oexion is important for its rdationship to lifting. trunk st;]bility. standing posture, and spinal statics. \Vcak agonist: reClus abdominus Overactive antagonist: erector spinae Overactive synergist: iliopsoas Symptoms Low back or bUllock pain (facet syndrome. inslability) (sec Fig. 18,1) Neck pain Postural Analysis Increased lumbar lordosis Protruding abdomen Gail Allalysis: • Increased lordosis l~fllsde Length Tests Shortened lumbar erector spinae (see Fig. 18.7) Shortened hip flexors (sec Fig. IS.5) Evallllllioll of Key Mm'emclIf Pallertl5 • Ahercd coordinalion during trunk flexion (sec Fig. 6.18) Trigger Poillts • Erector spinae (sec Fig. 18.2) UPPER CROSSED SYNDROME Muscle imbalances alY~ct the neck i.lnd upper extremity just as deleteriously .IS they do the low b --~ ; I 1°I j} Table 18.19. Upper Crossed Syndrome Imbalance in the following pairs of muscles: Weak lower and middle trapezius and short upper trapezius and levalor scapulae Weak deep neck llexors and short sUboccipitals and sternocleidomasloid Weak serratus anterior and short pectoralis major MobWly (JO;1I1 Dy,'ifIlIlCt;OIl) Table 18.20. Postural Signs of Upper Crossed Syndrome • Lumbar-spine Table 18.18. Treatment Approach for Altered Trunk Flexion Relax/streich erector spinae Relax/stretch iliopsoas AdjusVmobilize low back Facilitate/strengthen abdominals (dead bugs. trunk curls, sit backs) POSlur31 Finding Dysfunction Round shoulders FOTward-drawn head CO·C 1 hyperextension Elevation 01 shoulders Shor1ened peclorals Kyphoti(: upper thoracic spine Shor1ened suboccipilals Shortened upper trapezius and levator scapulae and weak lower and middle trapezius Weak serratus anterior Winging 01 scapUlae -' ,, -~,y - - - - - - - - - - - - - - - - _...... \.., -.. _._ ... Altered Scapulotlzoracic alld S'capuloJrumcral RIlJtll111 (Table 18,2/)"-',"''' The scapoluhumcral rhythm is impol1ant for its n::I:Hion* ship to prehension. rcaching. grasping. and carf),jng aCli\'itics, 365 Taole 18.21. Treatment Approach for Altered Scapulohumeral Rhythm Facilitate/strengthen lower and middle trapezius Relax/stretch upper trapezius and levator scapulae Relax/stretch subscapularis ':"dj\.tsVmobilize cervicothoracic junction and slernoclavicu· lar joint 3 r eathing correction and ergonomic advice Weak ;\gonist: lower and middle trapezius Overactive synergist: upper tmpc.zius. levator sCilpula\..'. and rholnboids , Sympto/1/s (see ,,, ~ J0.6. 10.7, (II/(/ 10./4) Table 18.22. Treatment Approach for Altered Neck Flexion Neck pain " ,~" I Fi.~s. Relax/stretch sternocleidomastoid Relax/streich suboccipitals AdiusVmobilize CO-C 1 and cervicothoracic junclion Facilitate/slrengthen deep neck flexors Correct poor sitting pos!ure Lumbopclvic stabilization exercises HC:ldachcs Rotalor cuff syndromes (i.e .. impingement syndrome) Shoulder blade pain ~ Postural Allalysis 1 ~ • Gothic shoulders (sec Fig. 6.25) • Upward rOtillioll of the scapulae ) i ~ 1::l'alum;(JIl of Key Movement Pall em..,; Gaif Atwly:..i.c I • Altcr~d·;.trlll SWillg • Shoulder de-vatian \'::th aml flexion " ~ Muscle Lengt" Tesl.5 , • Shortened upper trapczius 'Hui Iev,Hor scapulae (sec Figs, 6,1 :< ~ ;;md 6,2) ~ ) ; 1 l' I, ; ~ z, \ , £valllarion of Key MOI'cmcllt Pallems i • Ahcrcd sC ~ Trigger Points ;~ I Upper. middle. and lower tr I Lcv:.JIor sc;;spulac Subscapularis. Mastoid process. C2 and C3 aHachmenl points ~ I,< i. Mobility (Joint Dysjimcfioll) ~ 'i ~ Upper cervical spin~ Ccrvicothor.acic (Crr) junction Altered Head/Neck Flexioll (Table 18.22Y7,,~,~Ii,!7,.J,' Head/neck flexion is imponant for its relationship to • Altered (oordilwlioll dllril~g lied flexion (see Fig. IS.34) '/i'iggl!r Paims SCM Suboccipitals Middle trapC7.ius Maslicalof)' muscles Mastoid process MobiliTy (joilll D)'sjtmclirm) CO-CI and err junction Lower cervi cui spine TMJ Altered Scapular Fixation during Trunk Lowerillg from a Push-up ITable 18,23)'-',1','" Scapular fixation is import'lIlt for carrying. pushing. mu.l pulling activities, \Vcak agonist: serratus anterior Ovcr;]cti\'~ ~mtagonist: rhomboids OvcrJ,cti\'e synergist: upper tmpczius. Icvator st:apl1\;;!e. and pectoralis major. minor standing or siuing posture and mastication, Symptoms Weak agonist: deep neck flexors Overactive antagonist: suboccipitals Overactive synergist: sternocleidomastoid (SCM) Neck and shoulder blade pain • Rotator cuff syndromes • Ccrvicobruchiul syndrome Symptoms (see Fig.\'. /8.29 alld /8.3/) Postural AfWlys{\' Head'lClte Neck and shoulder bludc pain Round \houlders (see Fig, 10.20) Winged ~c;;splliac (sec Fig. 6.24) TMJ Postural AlUllysis • Head-forward posturc (sec Fig. I S.l2) • Prominence of SCM (sec Fig. 6.4) Muscle Length Tests Shortened SCM (sec Fig, 18.33) Shortened suboccipilals I Table 18.23. Treatment Approach (or Altered Trunk lowering from a Push-Up Facilitate/strengthen serratus anterior Relax/stretch pectoralis major and minor Relax/stretch upper Irapezius Adjust/mobilize upper thoracic spine Postural re-educalion f< '1 1'c -~ , ...,.. _ CLINICAL APPLICATION OF REHABIl.IT.HION PROCEDURES Gail Allalyxis • Winged :;capulae with ;Ifill JlhnCllIClll Differential Diagnosis of J\·tyofasdal Trigger Points and Joint Dysfunction Muscle Lel/gth Ti'xts SI,OrlClled pt:cloralis lIl;\jm {... ~'\.' Fi::. (1.31 Shortcned upper It";lpCJ;ill .. ;llid k\,:llor scapula\.' t .. \.,\.· I':i,t:s. (l.J and 6.21 Ewtfuluhm (~,. f..('y Mm'ctl/cllt !'afferl/.,· Altcrcd scapul'lr li.\:llillll (!'ce Fi~. 6.19) duril\~ trunk 100vcrill~ (wm a push·up Trigger Poi",.\" Pcctmalis lIl;lj{lf Upper trapezius levator ~l:apul;lt: Pel'toralis minor Mobility (Joilll Oys/wlClio,,) DCCrl.':t!'cd uppcr thoracic !'pilk' c:\tClIsiml Respiration (AbNQrmal or /Jarad(JXiclll Uespiratiol/) (Table /8.24) Agonist: diaphragm Overactive ~yncrgist: scalcllcs. imcrcostals, upper trapezius Symptoms (xee Figs. 10.6 aI/(/ !O.S' Neck p"in and headaches Chest wull pain Thoracic outlet syndromc iVl)'ofascial Pain Syndromes If an active trigger point (TP) is found (taut band. twitch response, + jump sign, referred pain to larget area). lhe approach is as follows 6 '''l\: Posrtlml Analy:iis • Round shoulders Evaluation of Key Movement Patterns t I 1.,. prcdomillate~ o\'cr abdo- Trigga Points • SC~llenes Mobilily (Joi"t Oy.\/WlClioll) Decreased laleral bcnding and extcnsion of lower cervical spine Del.:reased lateral excursion of the rib cage Table 18.24. Treatment Approach for Altered Respiration Relax/stretch scalenes Relax/stretch upper trapezius Facilitate/train diaphragmatic breathing Adjust/mobilize lower cervicals and thoracic spine Postural re-education ), \ i) -.j i \.) I. Assess for muscular imbalance 2. Assess for joint dysfunction 1 Identify work or lifestyle factors 4. Aim trclltrncnt ai restoring muscle balance and rcmcdi:lting joint • Forward-dmwn head • Thoi..lcic kyphosis P:lradoxical breathing (chesl bre:llhing. minal breathing) II is dt=ar Ihal l1HISC!t= ;IlKl joint dysfunction are imer-twined, If you take IlIl' \l-=w th;lt muscles ,Ire responsible for reflex COIllpensations 10 joint Of disk stress, then evcrylhing possible should be done to feduce joi;H stress before addressing trigger points. In g~ncral. triggcr points require little directtreatmcnt (needling. isch~mic compression) if joints are treated first. Oftell, howcwr the muscle imbalances must be addressed to prevent joint slress. The proof ~f the success of the therapeutic intervcntion is disappearance of the jump sign on posttreatment checks. It is still important to be able to differentially diagnosc Illyofascial from articular sources of palpable tenderness. Bogduk .1I1d Simons discussed this issue.'" Trigger points sari.\!\' lite lo/lOll"i1l8 (:rilaia: (I) a palpable band with :1 local twitch response (+ jump sign); (2) reproduction of pain on palpation of the trigger point: and (3) relief with trigger point ther'lpy. If a joint is cOl1sidered tlte .WJ1lrc,~ of!Jain, the followillg ,:,-ileria apply: (I) abnormal passive movement, especially of cnd-fecl: (2) reproduction of pain when moving the joint: and (31 relief with joint anesthesia or manipulation. It is not possible to differcntiate betwcen joint and muscle sources on the b3Sis of the location of the pain. Both muscles and joints can cause local or referred pnin. L dysfunction 5. If treatment fails to eliminate TP use Ischemic compression (5 to 10 second!' of sufficienl pressure to recrcate referred pain) Postisometric relax'ltion Nutritional or metabolic factors m and Sacroiliac Syndromes Manv of Ion back dISorders of the 80% presently labeled nonspecific are undoubtedly related to problems of the facet or SI joints. The 51 syndrome is prescnt in 1010 30CJc of patients with chronic low back pain.'~ Unfortunately. anesthetic blocking technique is the only known way to make the diagnosis. and it has not been correlated with any physical tests. Similarly. zygaphophyseal joints have been proven 10 be rc~ sponsible for low back puin in at least 15% of pati~nts, al- {] i: ~ "! ~ e :", "'1I. U "01 " .' Fig. 16.1. Facet pain. (From McCalllW, Park WM, O'Brien JP: Induced pain referrallrom posterior lumbar elements in normal subjects. Spine 4:441. 1979.) i ~ ! ) I I I ) J, ! ?I it I \. Ii ! ) ) ., ..J L) S i ill I ~ W •~ ( ~; ) ji I, I ,) I 1~~ '",'" \' though no physical signs have been correlated with anesthetic relief of pain."·l~ Two goals when constructing an appropriate rehabilitation program for a patient with pain arc as follows: (1) to reduce stress at 111<11 tissue site. and (2) to improve the ubility of til.1t tissue to handle stress. Facet syndromes arc likely to correlate with pathokincsiology involving altered hip extension and (funk nexioo. Improper loading in the sagitlal plane. especially in a hypcrlordotic individual. would be the probable pathomcchanics of a facet syndrome. Predictable functional pathologies affect the hamstrings. hip flexors. and erector spinac (tightness). erector spinae (poor endurance). glutcus Illi.lximus. rectus abdominus (weakness), hip joints (hypomobile), and lumbar spine (hypcnllobile). Pain provocation of the hypcrmobile joints and trigger points (in both the tight and weak muscles) will be present. Typical flndings include a for\V Fig. 18.2. Erector spinae trigger points. (From Travel! JG. Simons DG: Myofascial Pain and Dysfunction: The Trigger Point Manual. Vol. 1. Ballimore. Williams & Wilkins. 1983.) ---~------------------------------ Rd'lx/ lrl·'..:h ill\'ul\"cd crl'l'lnr spinae (Fig. I~.171 Rd".\I lr~·l~'h involved !l;l111Slrings (Fig. IS.;·S) Thl.' k('~ i:-: to lind a spc.:t:ilic manipul'lbh:: lesion which reduces pain l'fOvot:.uion (lendcr point or movcmcnt) ~lItd/or fal"ilil;IIC", Ihe "wt:ak lill"" {glutt:us m;lxilllllsl. EX-':fl.'.";'·" fnr illlpn)\"in~ slrt:nglh. endurance. ;:Ind Ikxihilily should .:1 .. \1 h-.: t.:onsidl'f-.:d: Sdl·-str...' kh (or liglll iliop."~las iFig. IS.19) Sdf·:-lro..' h'h f(lr li~ht cn:ctur spinal.' (Fig, 1};..201 Self-slreldl fllr light h;lI11strings lpig. IX.21 ) Slrcng.lhl'n ~llllCliS Ill:lximus (Figs. 11';'~210 IS.25) Squ;lIs :lnd Iungr.:s involving altered trunk ncxiQI1 al~o the L51S 1 joints because of poor IUlllbopclvic sl.,biliziltion, Trunk S1 Fig. 18.3. For\'lard·drawn posture, ,, ,) , ! /) () i ') h'lmslrings, and crt.:c1(lr spinac may ht.: prcs~nt (Fi~s. 13.5 to IS.?). Trunk cxtension should be: rcstc:t1 for lack of elH.1urance ..." J Il\~tnlclioll aboul tl\'l.'rhe'KJ ;telivilics and e"rrying (avuid lumbar hYP~'n:xtensiul1 by pcrforming ,I poslcri(1r pch'ic till (Fig, '8.1(.11 Instruction ahoul the liSt: or a fOOl SlOt)1 during typical '1('li\,illc., of ~I:lil~' li\'in~ (fig. Is. II) ,-\'·oid.mee of Ihe 1~'lll.kIlCY 10 hYrer~'_\.II.'.u.l the.: o:.ll:k Ull(illg l1lall~ \.·l'IllIllUn hcahh club o:crt:i",e.:~, such ,IS lhe ",tairclilllbr.:r. sit-lip'" ",t,lllding hip m'l<.:hilll:. l,lIer,11 pull·dowll. step :lemhics. hamstring curls. ;l1ld Cllhcrs er:i~. 18.121 ~\'I~l11ipul J Ci\-rr lumbar spine ~h)hilizchip(rig. IS.I.1) 1vlvbilize libular head lFig. 11$.14) Rl'1;tx/slrclt.·h iJ1\"lll\-...' d hip rk.'. IS. IS <.lrllJ l}i.lfl) t ._~ __ ._~, Fig. 16.4. Erector spinae hypertrophy. ... 369 '., ) I I I ,\ I , I I ,I Fig. 18.5. Test for shortened hip flexors. lesions in the talocalcancona\~icular region. Evaluation of the lower extremity kinetic chain is esscntiallo solving the riddle of many 51 and [ function and reduce pathokincsiology acts as a catalyst for reducing nerve root compression. C plex. McKenzie techniques have been l'hown to quickly Disk Syndromes Regardless of the C t ,¥ ~ \._~ Table 18.25. Disk Protocol Conservative care until nerve tension signs disappear Nonweight·bearing exercise Aerobic exercise Spinal extension mobility Quadriceps strength/endurance Traction assistance nonweight·bearing exercise Isometric trunk slabilization Quadruped, kneeling, ball. standing stabilization exercises Address muscular imbalances Seated exercises nific;lIltly more oftcn in pOSICol1cussional headache patient..; than in norillal indi\"iduals.~i Patients who experience morc ~c\"cre hc:ul;lI:hcs (usually women). ()(;c:lsion.al mig.rainc sufferas. ;md thnsc wilh forehead and eye pain OflCIl ha\'c weakness of their dcep neck ncxors and loss of lower ccrviGL! extension. Such lilldil1g~ certainly help us g.i\"t.~ affeclcd paticnts;l realistic goal. Result" arc oft.;n not illllllt'di;\lc. hut:ls he;\{.1 and neck l1exioll coordi· n:Hion ~ll1d lowcr ccn'i:.::t1 c.';I::n~:i\~:l :11(1hlll[j" impro\·c. Ilh..' heOldachcs will likely occn::;lse. Any P:lticllt can c1carly SCl,,' the Lonlleclion between not heing. able to hold their hl:ad up against gra .... ity with their head nexing too far forward ami the development of illlractahic headaches. This information is better received th , or Fig. 18.6. Test for shortened hamstrings. centralize symptoms relatcd to nervc root compression (sec Chapter 12). Head"che The variety of types of hC or or Fig. 18.7. Test for shortened erector spinae. I: I """<; < ,t-.- - - - - - - - - - - - - - - - - - - - -. . . . j ....iI I !I ~, ;,< , ~ i ! B A ! Fig. 18.8. Test lor trunk extensor endurance. ~ I I Fig. 18.9. Hip hyperextension test. i I, ~ I i \ ~ ") ~! II \ ) I ) ~ ~ ') ii ) 1, W Ii i ) I 1! B I• ;; ) ~ B A Iu Fig. 18.10. a, Incorrect overhead reaching with back hyperextended. b. Correct overhead reaching with posterior pelvic till. ~ ~ ) .~ § • ~ ~ ~ '~ •t < ~ '~ \.., ) ; J B 1 A Fig. 18.11. a, Typical ironing position. b, Use of a fool stool to re~ duce lumbar lordosis. I 1 I I ~ Fig. 18.12. Harmful hamstring exercise. Fig. 18.13. Post-isometric mobilization of hip joint. Fig. 18.14. Mobilize fibular head. :~ , y Fig. 18.15. Post·isometric relaxation rectus femoris. Fig. 18.16. Post· isometric relaxation iliopsoas. " .. _~ , 4_ 1 I \ - ,, ) i Fig. 18.17. Post-isometric relaxation erector spinae. Fig. 18.18. Post·isometric relaxation hamstrings. ) ) Fig. 18.19. Self-streIch for light iliopsoas. Fig. 18.20. Self-streIch for light erector spinae. }jf!. \-.,) Fig. 18.21. Sell-streIch for light hamstrings. I l I~ ~ ------------------------------------------ ) Fig. 18.22. Basic bridge. Fig. 18.23. One-leg bri'j:;~-; ("'dipS"). .J Fig. 18.24. Bridge on the ball. Fig. 18.25. Superman () ..". 'j . "11, ) o C) (J Fig. 18.26. Squat. Fig. 18.27. Lunge. \,.1 Fucilitate/slrengthcn lower .. au ;:lidd1e 10 ,, ~rap;.,'/.i(;:-; ;Fib'.~. I ::.~..; t8.42) Remcmber. it is time saving to find lhe "key link" which if manipulated can affect improvement in provocative tests of the inhibilcd muscle (deep neck ncxors). 'nlc following exercises arc recommended (0 improve posture ,lIld promote strength, endurnnec. and ncxibilily: ,~ I I 1 Ii c~ercise for the deep neck flexors (Fig. IR.43) • Strength/endurance exercise for deep neck Ilcxors and lo\vcr scapulae stabilizcrs (Fig. 18.44) • Strenglhen lower and middle tr.\pczius (Fig. 18.45) • Lumbopclvic stabi1il.ation exercises (Figs. 18.4610 18.48) • Upper b"ck cat (Fig. 18.49) • Upper lhor.\cic spine eXlcnsion l:trclch (Fig. 18.50) • Postural Fig. ~ 8.28. Back extensor exercise. I! i ~ ,r: I I I I I \, i i I C5-6) is affected by the flattening of the lower cervical curve and resultant biomcchanical change in the spinal stability of the cervical spine. Patients experience typical pain referral from trigger points in the SCM and suboccipitals (Figs. 18.29 and 18.30). Joint sources of referred pain may also overlap with common referred pain patterns from muscles (Fig. 18.31 ):(1 Some patients may have a head-forward posture and prominence of the SCM (Figs. 18.32 and 18.33). as well as tightness of the suboccipitals. pectorals, upper trapezius. and levator scapulae (sec Chnptcr 6). The neck flexion movement pattern may be ahered (Fig. 18.34). Rehabilitation management includes advice. manipulation. and exercise (sec Table 18,7). For a typical headache syndrome. the paticm is advi~ed !c: !.!s!= :: hcad~et if on lhe lclcphone for prolonged periods, make available an ergonomic computer workstation (sec Table 10.2). and correct poor sitting posture (Fig. 18.35). Manipulalion (adjustments, mobilizalion, manual resistance techniques) involvc the following potcnlial functional pathologies: • CMT ccrvicocranial and ccrvicothor.lcic junctions • Relax/stretch SCM (Fig. 18,36) • Relax/stretch suboccipit.l1s (Fig. 18.37) Manuallraction cervical spine (fig. 18.38) When the scapulohumeral rhythm (SHR) is ahnorm,,1, any reaching or grasping movement can trigger ~\ he~\(lachc. Prolonged static overstrain from keyboard or writing work is also a common culprit. Muscular imbalance involving ovcractivity of the upper trapezius and Icvator scapulae and inhibitcd lower and middle trapezius arc usually responsible. Upper cervical and cranial ::lttuchmcnts for the upper trapezius and levator scapulae can become hypersensitive and Iheir joints become hypcrmobilc. These headache patients sense most of their pain in the back of the head. but occasionally they describe pain over the eyes. Advice about an ergonomic warkst.uion helps immeasurably to improvc SHR. One intcrvention involvcs the usc of ann rests. which allow the arm to rcst in a relaxed position, Secondly. the writing surface. typewriter. or keyboard should be at a height at which the wrists function in their neutral rnnge. the elbow is flcxed 900 • and the shoulder girdle is relaxed (sec Table 10.2). Manipulation should focus on relaxing the upper trapezius and levator scapulae. Specific joints in the ccrvicocranial or ccrvicotharacic areas may need adjustment. Exercises to strengthen the lower fixators of the scapulae are necessary to avoid further ovcr.activity in the clcvmors of the shoulder girdle. , '----' .,:~ Fig, 18.29. StArnocleidamastoid trigger points. (From Travell JG, Simons DG: Myolascial Pain and Dysfunction: The Trigger Point Manual, Vol. 1. Baltimore, Williams & Wilkins, 1983.) 1-:----- ._ Fig. 18.30. SUboccipital trigger poinls. (From Traveli JG, Simons DG: Myolascial Pain a~d Dysfunction: The Trigger Point Manual. Vol. 1. Baltimore. Williams & Wilkins, 1983.) ") ) I I) I II'" ~,y 1--' I '" h I } Fig. 18.31. Referred pain from celVical spine joints. (From Dwyer A, April C. Boyduk N: Cervical zygapophyseal joint pain pattems: A study in normal volunteers. Spine 15:453, 1990.) Fig. 18.32. Head forward posture. Abnormal "respiration should also be evaluated in all headache pntients. Those patients with weakness of the deep neck flexors and upper thoracic kyphosis may have an aggravation of their pain if we adjust their necks too aggressively or too frequently. As the upper thoracic spine extends more (and the lumbopelvic junction stabilizes), neck adjustments will be more successful. downward shift of the ccrvicOlhoracic junction:I'J·~1l f\ccording to Janda. the ceryicothof:.lcic junction can move as low as T3n·4. This positioning is not biolllcch'lllic.llly sound, and certainly is unattracliye. Unfortunatcly, such posture certainly can lead to the lho· racie outlet syndrome (TOS) from scalene anticus or peclOf<Jlis minor entrapment. easily verified by lhe AER (abduction. external rotation, lest of Roos.SI.S~ M:.my "authorities" say TOS is an example of a psychogenic disorder. yel the dysthcsia is so prcdictil.bly on the pinky and not the thumb sid\? and is reliably reproduced by the AER test. Indced. its origin is neurogenic .md not vascul Thoracic Outlet and Cervicobrachial Syndromes Shoulder blade pain. chest pain, ccrvicobrachial syndromcs. :.md headaches can all come from a forwan.l·drawn head and · .. _ ..• _ ·._......... ' ... "I"\I'V'~ 377 r-nvlul.-VL:> Fig. 18.33. Screening test lor sternocleidomastolCl Fig. 18.34. Altered coordina:ion during neck flexion. A B ~--------- c , .~ l l B A Fig. 18.35. Corree! poor sitting posture. 1 ••< ., .. .) Fig. 1&.36. Post· isometric relaxation sternocleidomastoid. Advice would include avoiding slumping. cspcci.l!ly when silting. Manipulative treatment may sian with the pcc~ toralis minor and scalenes, but progresses often to include middle and lower trapezius raciliwlion. Exercises to improve posture. strengthen the lo\\'er fixators of the scapulae. stretch the pectorals and hip ncxors. and stabilize the lumbopclvic region may be necessary. Improved rC\piralion. hC"lcVncck flexion coordination. and lower cervical extension mobility are also esscnti:.l1. Overly cilgcr fleck adjusting may aggr,lvate lhe complaint. especially if the patient has a cervical rib or \\'eak deep neck flexors. The soundest principle to follow in TOS involves stabilizing the b.ISC of the spine and improving the mobility of the upper thoracic spine. Cen'icaJ Acceleration-Deceleration Syndrome P.;ui~nls who havc suffered Illotor \'chiclc accidents autoIllaticnlly must be considered difTerently from those with other neck or back complaints. Trauma involves inflammation. and a~ such, treatment follows a slower coursc/' Rchabilit.ltion C<1Il1101 begin until the "chemical" signs of ill¥ fiamm"ltion decline and thc pain becomes morc "mechani- ca'" (sec Tables 2.15 and 2.16). The usc of physical agents (ultrasound. electrical muscle stimulation. heat. icc. etc.) may be required until completion of the inflammatory ph,lsc of soft tissue healing. Both muscles <.lod joints have becn identified .IS sources of chronic pain after whiplash injury or concussion. 1(,.~7 From 50 to 70% of patients with chronic ncck pain havc been shown to have posterior zygapophyseal joint syndrome, If> Typical muscle imbalances invQlving weakness of deep neck flexors and tightness of the suboccipitais have been identified in postconcm.sional hcadache paticntsY In patients who arc victims of trnuma, it is imporwnt to be alert to psychosocial problcms that could intcrfere with a full rcco\:"cry.~-· A biobchavioral approach is a nlll:-i. ) ; I Fig. 18.37. Post·isometric relaxation suboccipilals. Fig. 18.38. Post-isometric traction cervical spine. ,, Overemphasis of the usc of passive means (physical agclUs) 10 treat pain and promote soft tissue healing promote illness behavior. especially patient dependency. A rch'lbilitation ap· proach should begin as soon as mechanical symptoms pre· dominate over chemical signs of inflammation (radicular complaint subsides and relief positions other than rest an: present). The goal of patient education and advice is to reassure the patient aboullhcir overall positive prognosis and Ihe benefits i1nd safety of carly mobilization and activity. \Vhen the inflammatory phase is subsiding, within I week in cases of mild 10 moderate truuma (sec Tables 18.26 and 2.20). aClivc rch<.lbilil<.ltion may proceed. Manipulation may stan wilh gentle musclc relaxation tlnd joint traction or mobilization procedures. Typical functional pathologies targeted include overactivity of scalcncs, SCM. upper trapezius, levator scapulac, suboccipitals, and the pectorals. Early rehabilitation efforts should bc directed toward preventing the "programming" of any of these typical muscle imbalances. Gentle PIR (no strelching) 10 the overactive muscles helps in thb regard. Gentle mobilizntion, adhering to McKenzie princi- pies of p~lin ccntT;Jlization. ~lids in restoring the cervical lordosis. Early exercises may address the glutcalhlbdominal mu~ des to help maintain the imegrity of lumbopclvic junction. Stability in this region is crucial because poor trunk stability or a forward weight-be:.Ifing position inevitably le~l(.Js to cervical overstress. Calf strctching and dorsal cxtension l1exibility exercises (cats, doorway, ball stretches) and strengthening exercises (back extension on the ball, supenmms) also arc tolerated well in the subacute stage, and should reduce cervical ovcrstress. For paticnts in whom excessive muscular guarding is maintained for more than 2 to 3 weeks, regaining lower ccrvical extension becomes a key to improving o\'erall function. Adjustments, joint mobilil I ! 1, Fig. 18.39. Facilitation 01 the lower fixalors of tile scapulae. Fig. 18.40. Facilitation of the middle trapezius. --~ .•. . } ~ Fig. 18.41, Facililation of the middle trapezius. Rotator CulT (Impingement) Syndrome Imping.:mcnl syndromes in the shoulder represent one of (he more iruriguing rehabilitation probk:ms. The shoulder girdle functions as pan of a kinetic chain linking the neck to the hand. ~lany mus(,;1cs in this region.mach 10 the ccrvic.;;al spine and thorax: thll .... addn..'ssing the shoul(kr is crucial to many spin.1I disordl:rs. The shoulder is an inherently lHlstablc joilll-·;l large h Fig. 18.42. Facilitation of the lower and middle trapezius. The SHR is the pancrn of joint and muscular aClivity occurring during shoulder 'lbduction and nexion. Its purpos~ is to kecp the glenoid fossa in a biol11cchanically optimal position !O receive the humeral head. If the ann is internally rotated (impingemcllt test). abduction will be limited by tile grc,ller tubercle striking the acromion process and l,'or;lcoacrolllial ligamcnt. Total abduction is 1800 • The gkllllhumeral contribution i... 120(.1 :.md the scapulothm:.u.:ic c{)lltrinutioll is 6()o. Thus. there :'Ire two degrees or glcllohulll..:r~11 nHHion r(lr evcry one degree of scaplllolhoracic IlH'lioll. In tllC first 30(' to 60 0 -thc .selling phase-virtually all mOVC1ll\.':l1t is glcllo!lulllcml. Afler that ph'lsc. 'lb<.luction occurs roughly equally hctween the two functional joints. Two other j~lints also participate in this .symphony 01" motion. tmmcly. til,,' sl..:r1UH.:1'lvicular ;In<.l i,l(;romioclavicular joints. i\S lhe arm moves into ahduclioll. thc scapula rotalc" upwardly (inferior/medial bordcr 11l0VL:~ iater:.lIly) 10 p()sitipl1 "i1 rl ..... ' .~, 'L..I' IV ........... I I ! i ! ~ ,I \ ! I ! " Fig. 18.43, Proper postural sel of head and neck. H I ~ the glenoid fossa at the proper angle to receive the humeral head. The serratus anterior. upper trapezius. and lower trape· j'jus help to achieve this movement. Downward rOlation is promoted by the rhomboid major and lcvalor scapulae. For the prime abductors of the shoulder-the deltoid and supraspinatus-to operate near capacity. the trapezius and serratus anterior must act synergistically. The upward rotation of the scapulae allows the deltoid and supraspinatus to keep a proper IcngtlHcnsion rcl:.ltionship. so they do not lose their strength. t ~ ! ~• ~,i,' il . F: I 381 v .... ncnM,OILIIA IIUi\l t"HU I V\,;UL:::i Exccssiv(' dC"iltion of the shoulder girdle caused by too much upper trapezius. levator scapulae. and rhomboid activ~ it)'. along with 100 little lower trapezius and latissimus dorsi activity, GIU:\t.:S impingemellt. TIlC rchahilitation of shoulder disorders is complex but n;\\';mling bCI'~llISC of the v the rehabilitation. The role of a tight subscapularis (internal rotator) is still import;.tnt. but typically this problem is of greater concern when assessing the stubborn "frozen shoulder." Two new developments in shoulder rehabilitation are worth noting, The first is the inclusion of proprioscnsory exercises for this !lon·weiglll·bc<.lringjoinI.J<-·~.l\Yall pushes may be lead to exercises on all fours. The practitioner should \.....ltch for proper scapular fixation. Patients may then progress tn tripod positioning and. eventually. the hand may be placcd on a balance board or other labile surfacc. The second dcvclopment is the usc of medicinc balls and a rebounder to plyometrically train the shoulder gir~ dlc.~ Throwing and catching is a simple. fun activity that can be varied to reintegrate the muscles into a coordinated. stable functioning. The main advantage is that eccentric and concentric actions are combined in this powerful approach. I j a ( ~ 1 ,~ j: ~ " E ~ i" j I ~ ~ ~~ l ) § f'l ~ .~ ~ :% • ~ ':..~. #. , t ~ i ~ ~~~ :,:' '< -~ ,. .. { z; ~ 1 Fig. 18.44. Strengthening exercise lor deep neck flexors and lower scapula stabilizers. 1- - - - - - - - - - - - - - Hand wt.:'i!!hl~ ,mtl t:abks .Ire m'linst Extensor i'vlechanism Disnrc!t'rs of the Knl'e Knce disonlt.:rs su..: h ;I.... qu'ldrit.:cps (rullllcr"s !\1h..'C) or palell;l1· (jllillpa's kncc) h:mlinilis ,Ire 1.:UlllmUIl .1I1l! t.:\'t':l1tl1i1l1y wind lip in the surgeon"~ parkir. fI.'losl tr;,u.:!\ing disorders arc CUlllmonly thoughl 10 restlll from an imhalancc bctween the quadriceps ,\lid the hamstrings. ~:lost likely, Ihc)' also lIlay hc attributed to btt:rallr;ll.:king 01" the patclla causcd by an overilctivc TFL sllbstilUting for a weak glutcus mcdius. Comlllon muscular problems asso<.:iated \\'ith knee problems indudc .~ .....i \r\'--: , \ -,-,,--". <)i~ B Fig. 18.45. Home exercise for middle and lower trapezius. Fig. 18.46. Posterior and anterior pelvic lilt while Kneeling (butlocks on heels). ,...,;I Fig. 18.47. "Dead bug." Fig. 18.48. Ouadrapcd opposite arm and leg raise. lighlnl..'sS of Ihe TFL. hip flexors, gastrosolcus, hamstrings. If th~ glulcu\ I1K'dius is wC~lk, the TFL will only hl..'l..'ol11c tighler. Ikfon: an iliolihi.d hand friction syndrome de\·d(lpS. km.:e pain can occur. Re:,1. icc, and the usc 1Il1llslcrllidai adductor:-. ,lIld gluteus mcdius. Proprioscnsory and other bioll1cchanical faults from the ,"ecl ,Ire also prohlcllwlic. Lumbar spine, as well :I:' Sl. IalpUufal. ,lilt! hip joint dysfunctions must also bc ;tdllrcssL'll. or arui-in!l,11lll11"t\ory :lgCllts arc nol Ihe solution. Along ",ilh looking til the fecI. .Iss('ssing lhc glllll..·IlS medius for In\\'cr lilllh 1..'I\1I1rol durin.:; olll..'-k.:; weight he•• rill~ is e:-.selliial (the '''1 !~~ db (' ~.-" \"onJ-u- I t:.H 10 : J4.L. J I Vt: Ht:HAtilllTATION PROTOCOLS 383 , I j ': ,~ J ,f, !,, :; 11 i.i Fig. 18.49. Upper back cal. !, ,,, hip abduction \~S( is an casy screen). The key is not to wait unlil cartilagt: or meniscus damage occurs or for the surgeon to pri.IClicc Ihdl' l,ltcr'll rclc~lsc pro<.:cdurc. Lilllih.:d r.mgc squats and lunges can be Streich out the light mllscles. sran pro· prioscnsory balalll.:c training. and facilil<.llC the gluteus medius. Then. rclUrn (0 squ..us 'lIlU lunges ,tIld gradually increase the depth of knee flexion. The training or functional range should quickly expand. '; ".' ~ I, j ~ ,i I ~ y I ,~ i Dizziness l ~lIld Bal.anl·c Disordcrs The mOlor ~y"lcm lk'pClld~ Oil appropri,lIc inpul from somalosensory, \·cstihul;'lf. ;'lIld \"i:..ual pcripheral alTcrcfll s)'slems.~~·~s Without one of these sy.. tcm..... sud\ a!'o in bli·iluncss. b;,i1:.mce ;'IllU equilibrium arc not ..acriliceu. In the event of a l:onllict belwccn two of the sy~lcms, howcycr. a problem will cnsue. Classic examples ;'Ire the nausea that dc\"e1ops on a boat whell lht: vestibule notes the motion hut the fcct I , I j Fig. 18.50, Upper thoracic spine extension stretch. .J... matoscnsory affercm system depends on the soles of the feet. the neck. and the lumbar spine for input. Lewit studied the rclutionship between ccrvicocr:lI1inl joint dysfunction and equilibrium problcms,w HalHant"s leSl is an cssentiul screening tool for finding the cervical dysfunc. lion and then treating thc related muscles or joints. Postwhiplash injury dizziness is most likely ccrvic;,11 in origin as well. 6 I.l'! Gugey developed a systematic way of studying the. connection between the poslural system and the balance system. 5'> Differentiating between primary feCI. lumbar. and cervical disorders is crucial. Vestibular dysfunction is known to be related to poor motor development in children. Children with vcstibular deficits cannol stand in a darkened room (you need two of three afferent systems to maintain motor function). Longstanding vestibular exercises for the trerltInent of dizzin~ss include thc usc of hammocks and gyill balls lO help train th~ labyrinth <.lnd tracking exercises for the eyes while the hC>1d is moving. The visual "'ystcm C;,1I1 be an interesting area in\'oh'cd in dizzincss or neck pain. Optokinetic reflexes can be trained (e.g.. lighter pilots and figure skaters). Gagey found that a mapping error of visual fields often results in increased tension in the upper lr:lpezius. 5') Following correction with special prism;,nic lenses_ the trigger points dissoln~ :-pOIlWneousl)'. Brandt found that eldcrly indi\'iduals wilh al<.lxia \,.'..\11 b~ Ircateu succc!'.",fully with balance training. I '! Brandt rcponed th;lt 2 weeks of training led to signitic'll11 impron:mt:nl 9 months later \.'. ithout :'lo)' home maintenance program. Thick foam is lIsed on the 110m to deprive lhe feet of sensory feedback and the eyes are closed. thus forcing the vcstibuk- and som:Hosen.. . ory systems to train hard. Similarly. it is possible to train the eye" and feet by le,lving the eyes open. bll! lipping the he _ ••• _ problem involving the. cervical spine plays a role in improv- ing standing postllwl dysfunctions.'oO Corrcdion involved PIR to the SCM or masticatory muscles or the CO·C I joint. ETHICAL OFFICE PROCEDURES Soap Notcs At the initinl examination, be sure 10 rc('ord the: presence. of any rcd flags. Then. perform the necessary tests to identify nerve rool or inflammatory conditions. Fimlily. review all po· tential complicating factors (sec Table 18.4). Thc hislOry, physical examination, and sholl form questionnaires arc all that is needed to identify these complicating factors. The use of expensive pathophysiologic diagnostic testing equipmcnt or seeking special psychologic expertise arc unnecessary. i ~~ Our SOAP noles for each paticn! should rcflcci Ihal our i ~ I i i I I I I ~ ~ n II ~ i ~ I I I it management strategy is rehabilitativc rather than traditional. To 'Iccomplish thi!'i t Billing procedures should also renect the use of active approaches. Therapeutic e::ercise (97110) and thel'dpeutic activities (97530). arc excellent examples. Medicolegal repoTts should clearly state the positive results of orthopedic or neurologic tests along with findings of functional assessment. It is improper to assume that long-tenn care is Ilccess "i! l----~------------G 1 , i _. ". __ , ....... " , ............ " " ..... n .... " ....... , ..................... est error in the treatment of paticnts suffering motor vchide :lccidents is the a.~sumption of a moderate to severe injury when in facl the injury is only mild to modcrate.~·' It is diflicult to differentiate between a mild and a moderate injury/'7 Without proper documentation. a mild or mild to moderate injury must be assumed .\ltd. with it. the appropriate type and duration of carc (TJble 18.26). [f an insur.mce adjuster or auomey questions your servicc codes. SOAP noles. or neccssity for active carc. sevcral points can be raised to legally defend your treatmcnts. Standards of care or guidelines have emcrged in neuTOl11usculoskclctal medicine, and this political hot potato has not been a welcome sight to many practitioners. Guidelines, however, arc an accurate representation of the state of science if not the state of the art. As such, they arc not meant to be applied \Vilhout exceptions. but to serve as guidelines. These guidelines for care have been established as a result of review of scientific evidence and. where evidence is !:Icking, expert consensu!'i opin~ ion. Many practitioners arc s.urprised to realizc just how help· ful guidelines can be. In the past, reviewers could SlOp payment on an insurance claim without good reason. Now, you can defend your practice and quote the guidelines. There arc no longer any secrets. which can only work to the advantage of the honest. ethical doctor. Quality assurance is a go"ll of managed carc. Thus, providers practicing to the highest standards will be sought. The Mercy Ccnler Conference was an example in which such a guideline process occurred.6 Active care wa.'\ dislinguished from passive care in several ways. First. they addressed stages of treatment and their goals (p. 120): Passive Care Report Writing i ~ •• I. Acute intervention Active Care I. Rcm()biliwtion 2. Rehabilitation a. Re~toring slrength and cndurance b. Incrc"lsing phy<,ical work capacity 3. Lifc:'lylc ~ldapla(iuns Second. thcy clearly sWlcd lhat aClive carc was essential (p 110). ··It is beneficial (0 proceed to rehabililation plmse ~IS rapidly as possible. and to minimize dependency upon passive forms of trcatJnentfcarc." Again (p 125). "AII cpi!'iodcs of symptoms that remain un<,:hanged for 2-3 weeks should be c\'aluatcd for risk factors of pending chronici.ty. Patients at risk for becoming chronic should have treatment plans altered to de-cmph:lsizc passivc "arc and rcfocus on active care approaches." Table 18.26. Grading Injury Severitr ' Mild Pain on stress 01 tissue, local tenderness. mild swelling. no gross instabilily Moderate = Pain on stress of tissue. generalized and marked tenderness and swelling, mild laxity, no gross instability Severe = Gross instability. generalized swelling, disruption ollis· sue, sometimes minimal pain =: ',,) 385 ; Th~ British St;mdarus Advisory Group for Back Pain sim~ llarly slalcd thm , or phasis physical therapy fOf back pain is on symptomatic relief or pain. despite e\'idence thallll ) treatment. to the provision of active rehabilitation and patient education... The American guidelines from AHCPR were emphatic in their criticism of physical agents: "Physical modalities such as massage. diathermy. ultrasound. biofeedback. and tr~tnscutaneous electrical nerve stimulati~n (TENS) also have nu pruvell efficacy in the treatment of acute low back symptoms. COIl\'illcing scientific evidence is beginning to emerge ahollt the usc of active c~rc before the chronic stage. Refer to Chilptcr I for a full revicw, including the topic of chronic carc. Linton dcmonstrated that carly aggressive treatment (p'l~ ·Iienl education. exercise instruction. physical therapy) WOlS superior to traditional treatment approaches (rest and analgesics without physical therapy for 3 months). "Properly ad~ ministered Eurl)' Activc Intervention may therefore decrease sick leavc and prevent chronic problems. thus saving considerable rcsourccs.·· hS This study is particularly powerful in lhat the risk of dcvcloping chronic pain was eight times lower in the early active intervention group than in the traditional group. In a comparative study of passive physical therapy versus rehabilitmion. Mitchell found. "Active exercises to provide mobility. muscle strengthening. and work conditioning lUIS shown superior results ... substantial saviofs have been real~ izcd in the number of days absent from work .md savings in the dollars expended for compensation benefits. There WaS an initial incrca~c in health care costs resulting fromlhc intensity of the treatment. but these costs were morc than offsct by savings in wage loss CO;-;.."/I.I Lindstrom ct al compared a group of patients trealed with exercises and education to a marc traditionally treated control group itatian is esscntial for all palients, including those considered candidates for surgery. Saal and Saal said, "Failure of passive nonopcrarive treatment is not sufficient for the decision to 01'crmc:' In it randomized, controlled trial looking at exercise and passive care in failed back surgeI)' patients. Tim1l1 found that 100\·-tcchnologic exercises (stabiliz'ltion and McKclli'.ie) were of greater benefit thiln were high-tcchnologil.: exercises (Cybcx). physicalmcthods. or joint mobilization. 7-4 CONCLUSION Rehabililation is .m exciting new way to practice. This paradigm allows us to evaluate regional conditions in light of dysfunction in lhe entire locomotor system. It is also a highly ethical way 10 practice because it reduces patient dependency on passivc. pain-relieving approaches while leaching patients the sclf-treHtlllent techniques needed to develop control over their symptoms. By focusing on functional restoration (instead of promotion of tissue healing). we can achieve quicker and more lasting results with spinal adjuslments. b~'cause we are :ldd... ::~:-.:ng tl1:: underlying cause of most pain syndrornc~. Future neuromusculoskeletal specialists will not only bc expens in manipulation. but also know how to transition from passivc to active care. and evaluate the biobch;l\'ioral component of musculoskelet'll illness. Improved results in our practices and accompanying cost savings in the health care system will be rcalized by the improved managcmelll afforded by the new rehabilitation paradigm. REFERE~CE••' i I. Bigos S. BowycrO. Braeo G.C( al: Aculc Low Bad, Problems in Adul!!'. Clinical Pmelice Guideline. Rockville. MD. U.S. Depanmenl of Hcallh and Hum,1ll Servicc:s, Public Health Service. Agency for HC li\'ity-rclalcd spinal disorders: A monograph [or clinicians. Spino.: 12(SuppI7):SI.1987. 15. Schwaner AC. April eN'. Bogduk N: 1111,: s;lcroili;lc joint in "hronic Illw back pain. Spine 20:31. 1995. 16. Bamslcy L. Lord SM. Wallis IlJ. et 011: The pre\'3Ielll"C of chronic cer\'icalzygaphophysc..11 joint p"in ;.ftcr whip1:lsh. Spine 20:20. 1995. 17. Jackson RP: TIle [acet syndronh.:-lvlyth or realllY? Clin Orthllp Rel Res 279: 110. 1992. 18. Schwar£cr AC. April CN. Ocrh)' R. CI al: Clinical features ()f paticnts with paill :.,cmnliii£ from :hc 1:J::lbr ... j't;:r:~~\r:!:j':O:::~! ;c:ltts. SrillC 19:1132.199-'19. SchwarLcr AC. April eN. Dcrby R. et al: 111c relative contributions ~lr t:'c disc amll.yf,OIj>ophyscal joim in chronic low back {Xlin. Spine 29:l'iOI. 1994. 20. Moffroid MT. Haugh LO. Hcnry SM. cl OIl: Dislinguishable groups of museuloskeklal low back pain patients :l.nd asymptonlatie control suhjects based on phYSlc:l1 lIIeasurcs of tht: NIOSH low b:lck atlas. Spinc 12:1350.1994_ 11. Mo[froid MT. Haugh LO: Prospl:ctive mndomi1.L-d excrcist: trial in two p;:l\icnl groups wilh LUll. V~nnonl Rehabilitation Engincerins and Rcs~arch Centcr. 1994-1998. 22. Deliuo A. Cibulka MT. Erhard RE. et ill: Evidence for usc of ;Ill extension-mobilization category in acule low bilck 5yndrome: A prescriplivc \'alidation pilol study. Phys TIler 73:216. 1993. 23. Erhard RE. Oeliuo A: Relali...c erfecti\·cl\c:-~ of an cxtension prog(;llU and a combined program of manipulation anti nt::(ioll :lnd ex lens ion C.'(erciscs in patients with acme low !:l;lck syndflllllc. Phys 111cr 74: 109:'1. 1994. 24. Spitzer WOo Sko\'rom ML. S.:Ilmi LR. et .:II: Scicntific monograph of Ihe Quebec T:lsk Force on whiplash-rel;lIed "whiplash" and its management. Spine 20:8S. 25. Pilnj.:lbi MM: 111C slabilizing !'ys(em of lhe ~r~fl1n<:tion, ad disordt:rs: Redefining 1995. spine. Pan I: FUll"tion. J Spinal Oi:-ord 5:383. 1992. 26. Watson Oli. Trott .PH: Cervic;ll heatJ:1che: An investigation of Ilalur.ll head posture :lnd upper cervir,: 1992. 31. Dahl JB_ Eridl!oCn CJ. Fu~Is.1.ng-f:rcderibenA. cl 011: Pain !iensatiOIl alld nociceplive rcllc.>: excitahility in l'urgic:11 paticlltl' and human voluntccrs. 13r J Anacslh 69:1 17. 19l)~. 32. Woolf CJ: Long Icrm ahef:lliolls in lhe e~cilability of lhe f1e~ion rcncx produccd by peripheral tisslle injury in lhe chronic decerebrale ral. Pain IS:32S. 19S..L 33. Lchto M. Jarvinen M. Nclilllarkka 0: Sl;:lr ftmnatiol1 after skclelallll~s elc injur)". Arch Orthop Trauma Surg 1(}';:366. 1986. 34. Dt:Andrade JR. Granl C. Di~on ASJ: Joint dislen!>ion and rene.'<. muscle inhibition in the knee. J Done Juint Surg IAmI47:313. 1965. 35. Brucini M. 1)1I101nli R. Galleti R. et al: l';tin lhresholds and electrolll)'ognphic katures of periarticular muscles in palients with oSleoarthritis of the knee. P:.in 10:57. 19~1. 36. Spencer JI). Hayes KC. A!ex'lIlder 11: Knee joinl t:ffusion ~8_ M;,;;II;I::. ~I~r.:...: ~:_ .-'.::1,::::::: ~!. :: ;:~: ~;r:;:..: 11 :731. 19SCI. 39. Lehto M. Hum,.: ~1. ..\lar~lI\t or 11 :6. 1988. 50. Manhews 11.1: The T.+ ~yndrollle. AilS! J Physiother 32: 123. 19~('. 51. Ribbc EB. Lindfrcn SHS: Clinic;.1 diagnosi!' (If "l"OS. l\1;tIluclle Mo.'J 2:82. 1986. 52. Roos DB: I\e\\ conct:pts ofTQS th~t cxpl"in c\iolo~y. !')'mptotlls. di:.~· nosis. and trC:ltml:nt. Vase Surg 13:313.1979. 53. Tarola G: Whipla...h: Contempowry considcr;ltions in "sscs.~ntcnt. manascmenl. trealm;:nl and prognosis. JNMS .:1: 156, 199;\. 54. Wilk KE. Arrigo C: An integmled appro:lch to upper c~trel11ity c.'(ercis\'s. Onhop Ph),!. Thcr C1in Nonh Am u.n, 1992. 55. SOllltller HM: P:llcllar chonJropathy illld ;lpidti". and musclc jmhalam·c.s of Ihe lower c'trcmitic.~ in competitivc sports. Sports Med 5:386. 19S5. 56. lippel SR: Clo~ed ehain c:\crcisc:. Oohop Ph)'s TIler C1ill Nurth Am 1:253. 1992. 57. SchiabJc HG. Grubb BD: Afferent and ~pinaIIllCch;lIlislllsof jllilll p;lin. Pain 55:5, 1'J4.~ 58. Proske U. Schi:lolc HG. Schmidt RF: J(,lint rel'cl11ors amI kirwcsth,,~i: •. Exp Brain Re- i~:219. 19:-:8. 59. Gagc)' Pr-.·1; PO"lllf,,-1 disordcrs among workcrs Oil huilllill~ sill'S. In Bks W. Orandt T h.-d,': Disordcrs of Posture and Gait. New York. Els\.'vicr Science.. 1%6 60. LCW!1 K: Dj,tud:...:d balafl~'e Jlle If,) 1c_~ilJll.' or the cr;miol'ervical jllll"'li"lll. J Onhop r-.·lcd 3::'8. 1988. 61. Odk\'isl I. Odb i~t LM: Phys;othcrJpy in \·cni!=\l. Ael3 Otolaryn,;:t1\ Suppl (Stockh! ":55:74. 1985. 62. B(lf:UCI J. 1\-'loofe :So B()i,~l1larc F. et al: Vertigo ill Pos!·concu.~.~i()nal :llIti llIigr;linl' p:Jticnb: llllplie;ltioll of thc autonomic Ilcrvous S)"SI~·Ill. Aggrcssologie ~J:2)5. 198J. 63. Brandt T. Krufczyk S. Malshcndend I: I'o\lural imto"l:lIlcc wilh he:ld \.\tension: ImpRlH:ment by tr.linillt " .. a model fllr ataxia therapy. Alln;,\Y Acad Sci :636. 1\18 t. 64. G;*cy I'M: :"on·\-eslibul:lr diaillcs~ ;md "Ialit: postumgraph)'..·\\·Ia O\(lrhillolar~n{J1 Belg 45:335. 1991. 65_ Shekel Ie PG...\d;Jffis AU, Ch;l... ~in MR. el al: Spin:.l Illanipulalinn f\lr kl\v-back p~ill ...\nn Intern Metl 117:59IJ, 1992. 66. Shekcllc PG: Spine updale: Spill:11 manipul fiX. Linlon 51. Hellsillg, AL, Andersson D: A controlled study of the effects or an early intervention Oil 71. Fordyce WE, Fowler RS, Lehmann JF. et al: Operant c0!:ditioni;:;; in :~:~ treatment of chronic pain, Arch Phys rvlcd Rehabil 54:399. 1973. 72. W,lddell G: A new clinical model for the treatlllellt of lOW-hack pain. Spine 12:634. 1987. ." 73. Sa,ll JA. Saal JS: Nonoperative treatment of herniated lumbar intervertebral disc with radiculopathy, Spine 14:431, 1989. 74. Tillltl\ KE: A ralldomilcd-colllrol sltldy of activc :llld passive trc;ltnl\.'nts for chronit: low bJck p:lin rollowing L5, :.' t Ii"' '.! ~ .~ it ') J I } l! ) ~ ~ ~ " .;;1 t )1 tii ,0 ~ '-, " N ':.-:. ,,','"ji I I ," " j ~ " } , ~i ->:1 J J ~ ~ .~ 1" •~ '1 ,> ~ $J " Ii;! ~ "" " J I 1 ) ~ .~ # 1; ! '-" ~ ~ ~ ~ "0:' ?: i: i -........ v , , , t (, ~ ~ ~ PSYCHOSOCIAL AND SOCIOPOLITICAL ASPECTS OF REHABILITATION ~ I . ~ t ) ~ ~ \. I ) I , ._---------_ _ •. ..... _ ...•.•....... '1\ ~ ; ~ ," ~- , ~ ~j • ~ 'i " t'f" .. ) 1 '< " !i :~ i ;. ~ () !! li ."} ~ I • I 'j ~ l ~ ') !." ;~ J 0,- ~ -",- .J :., ';;:" :" :t ~ f ~ ~ .,"\ , ,.~1' .", \J: ~ ') ~ .., i • •i ~ .? ., ~ ..,J ~ , • :~.. .,! ;:; i.. :,~ , i1 .J :j • ~.. ~ ~ ~ J! ., \ J J , II , J '" I I ,.; ~ ~ :~ • ,,' 19 Psychosocial Factors in Chronic Pain I GEORGE E. BECKER ! ( Il ----------------------------_._-Psychological .md physical ["clors arc incxlricably involved anti imcrrdatcd in virtually every case of chronic back pain.' The art of healing begins with recognition of the se\'eral dc· tcrminants of chronic back pain, and 1Il1dcrst :-;OTllC of the terms helpful in describing alld understand· ing the patient with a chronic back pain syndrome 10 describe those charilclcrislics lhilt will alert the clinician and en· able COlrl)' recognition of tht prohkm'lIic patient 10 review \ I I I i I ~ i ! ~ ~;;. ~1 ! I I ~ ~ -~ ~ _\._..1.--,.- The notion of a mutual intcraction bctween mind and body in health ..IS well as in illness is not ncw. It is likely that some of the miraculous cures ascribed to the man Jesus in the New Testament <.Illest to his charisma .lIld the empowcnncnt transmitted through him to the unheahhy believer. (Clearly all healers possess the ability 10 empower patients with whom they have established a healing relationship or therapeutic working alliance.) In the seventeenth century. Sydenham recognized and described syndromes [hat. despite the outward appearance of physical maladies. in reality were related 10 identifiable, heavily emotionally charged life event.s and circumstances_ He described but did not name sOl1latiwtitm. which is the experience and expression of psychological stress and connict in physic;:i1 rather than in emOtional terms. Bunon latcr described the physical (somatic) and hypochondriacal preoccupation that today is a recognized concomitant of mood and anxiety disorders. Almost a half century ago. and long beforc the popularization of the holh;· tic approach to h~alth and illness. Alexander: wrote: "Onc~ Th::...e characleristic.. inclmk: (I) ,-ague history, confused (·hronology. or illtfOUlH.::tioll of matcrial ostensihly h;n-ing nothing to lIn ",ith the injury and SYlllptOIll!«: (2) ~:fpressiol1 of OpCIl or veiled rcsclltlllCIl! low.lIll Gll\'~I DISABILITY AND CHRONIC PAIN The problem of chronic pain and uis;.Jbility. which is gro\\"il1~ ...t an a"!fIning r.ltc, has rc"ched gargantu'lI1 proportions and i:, ;lssoci:.ucd with aSlronomical costs for health l'ar~, Work~r=, Compensation, and physical injury_ in 19S5. r:rymoycr lind Gordon~ wrotc that low back pain disabkd 5.4 millil'll Amcric'llls each year and cost at least S I (1 billion annually. {n 1992, Ford·\ reported th.1t .It least \o(iO 01" :.l1lmcdical·'surgh:;11 patients have /10 objective t'\'ide/lce of phy:dcal disease_ {The ,lUthor's cxp~ricncc suggests (hm 10% is a low cstill1at~"1 Lipowski l • described an evcn higher percelltage of functional illness. especially depression. among patients prescllling ((I primary carc providers with physical, nol psychological. ('Olllplaints. The messagc is clear: depresscd ami otherwise p=,y. chologically unwell pcrsons frequcntly de,) nOI rccognil_c Ihe psychological nature of their problem. In f _ • cates thal somclhim! is wrong wilh our appro,ldl lO cllnmic pain. Misdiagnosis ~f lhe ~oll1atiz~r is thi,; ineviwble precursor to prolonged and ineffectivc tn:allllcni. and frequclltly to lllultiple and inappropriate chcmical. elcctrical. and imaging studies: inappropri:Hc mcdic ..llions. induding ll<.lfcotics (which frequcntly compound the prohlem); or. worse yet. to invasive procedurc$. including surgical intervcntion. After (lvcr 40 ye:lrs of experience caring for bac.:k pain. it is dear to this author that ,mrgay i,\" rarely i/ldicmccl. ~,tost ''failed backs" arc found in unfortunate indi\"iduals who should never have hud surgery in the first place. or who, necding sllrgery. did not have the right procedure at the right timc and ;,It lhc righllevel. Frymoyer 1 states thut the "failed surg.ical back" is usually the result of poor surgical judgmenl. TIle purpose of this chapter is to .describe and dclinc the dynamic and psychosocial issues involved wjth ;'lntl frc~ quently fueling chronic pain syndromes, to rC\'icw Iho:-oc presenting signs and symptoms that should alert the astute clioician to the issue of functional o\'erlay, (0 outline bricny" comprehensive hislory format. to review the adjunctive usc of psychological testing, and to describe management stmtcgies for this frustrating and often passivc. rcsistant. and noncompliant group of paticnts. Typically, many of thcse patients simultaneously proclaim ardently how much they wanl to get better while conveying, with their mixcd~message behavior. that they really are going to (and unconsciously wish to) remain disabled. Timely recognition and appropriate treatment of the chronic back pain patient not only is cost effective, but also ultimately benefits the doctor spiritually and ma~ terially. In the highly scrutinized health care environment of today. the practitioner must cSlablish a reputation for the kind of comprehensive treatment protocol that gets !J0lieflfs back to work (am/to life ill full) and keep.,· them there. .~ ,...... I I ' ' ,,,~. ,.., r-nf\,\", 1IIIUI"lt::;n ~ MANUAL bcing dis.ahk'J. On..' doL'S nOl1k'cd;1 proks:-oional tkgrcc to understand thaI ;~ i~l'r.;()n :-ouing ror an illjury-rclatcd disahility willles:-o likely pr\~lit linallcially it"lhc disability rcsol\'es. Thi:-o ~itt1atinn kilds n:ltur~llIy 10 a cOI\~idL"r,llinn of gain (scc suhsl.> ljUCI\! section). \111 COll1pliallrt· Some patient:- f~lil hI ((,Imply wilh trc,lll1lt,'llt regilll(lls tksiglled for their r.;:lh:liL This f;tilufl: may hest he ulHkrstood as an illlpeuilllelli h_~ or as UlKolhL'ious fesistallo: 10 healing.. These lInfor1Ullat~ sOllls. for reasons they themselvcs ran:ly understand :md llf which they usually arc un:lW:lrc. Il('('t! to he in pain. /1('c'(/ 10 ~\IITa. /1('('(( to rccllikc powcr1css victims. i111tL ~ Il('rd to he cared for \\';111(",1 foxing fact'. Olhers. a smaller subsct. arc at k~l ... t partially ;\\\';11\' or their motivcs: They exhibit pain behavior fllClcl.l by anger. n:sclltl1l..;llI, or ;1 wi:-;ll 10 rcwhate. Denial Individu::i1s who !'onwlize typic;lIly deny that they ;Ire cxpcri~ cncing signific<.Jnl emotional or psychological stress. much as an alcoholic dcnic:s having a problem with Depression Several terms and concepts frequently encountered in the chronic pain vocabulary arc defincd or discusscd in the following section. Many persons who arc deprcs:-ocd neilher look nor feel depressed. If <.IS ked <.Jbout their mood. thc)' will deny <.Ieprcssion. Instead. they exhibit chronic pain Alexithymia Dreams TERMS AND CONCEPTS Sifneoss coined this tcrm to describc those individuals who (literally) have no words for their feelings. Lex is the Greek r~ meaning word. ~he thymus is the g'-Iand thought by the vnclcnts to he the seal' of the emotions. hence Ihymia. Persons troubled by aICXilh)lliia. i.ither than recognizing their innermost feelings. bury and deny them only to have them surface as physical symptoms that seem to. but do not. have ::1 physical basis. Compensation and Litigation If the benefits (or potential benefits in fantasy) derived from staying ill outweigh the bencfits of regaining health, the p'lricllt will not Iikcly gct well. It is gcncmlly recognized in the healing professions that some patients seem clearly (0 thrive -~ ~- ) Dreams havc been described as-:tilC to,",,,/ mad to the lCIl('CJ1/sciou.... ,o.:ccrtainly. thc dreams ~)f patients oftcn rev~al ('in their sYmbolism) conflicts. fears. and wi:-ohes tiwI lie buried outside of conscious'-a\varcncss. They Illay crard). issues <:011stitutiilg'b::uTIers to recovery. Fear At a conscious Ic\"cl, fe;.Ir fre<.]uently bespeaks a wish at all llllconscious level. particul<.trly in th~. p~!!i~J}J .. \..Y.h.Q~.ejl~.til.l!lS-;llld words signalj~JlQUbk..Quamn!£~.l!lL!~::~" Functional Overlay This vcnerable tcrm in the 1l11.:dical vernacular is not part of official mcdical nomcndalUre. Nonetheless. it is useful in _____________________________________________..ci. .J .... , ,,·w I eM 1::1 : .... ::iY(.;HOSOC1AL 393 FACTORS IN CHRONIC PAIN describing (hose nonphysical (i.c., psychological and emo· Lional) f3clors lhat color th~ way in which patients present thcl11sch"es. It is also accurate bCC walll and nCL'd til be carcd foro-or lovcd. Thus. the double Illcssa,::e Ihat iJcmilics the: ~oJ11tltil.er. These patients. in their passiyit~. :Irc oftcn misllnderstood as poorly motiYilted. The dinician "h\\uld remain mindful thilt ;\Ctions speak louder thall \\'\\rd:-.. :tnJ underst:llId that what appcar~ 10 bL: poor 1110tivatil'l1 11l~IY in n.:ality he a powerful (uncollscious) cOlllliclo Guin For pr;u":li(al pllrposcs. gain can be thought of as primary. Se'C' ol/tlm:\', and Tl'I'Tiary. ! )I ~ , R t I, PRIMARY GAIN Primary gain addresses psychological needs: bcin2 taken care of while feeling independent. Primary gain is entirely within the individual. and involves self image and self esteem. Il allows the disabled person to deny passivc dependency. because the illncss (i.e., the back condition) is forcing the dependency and, bUl for it, the patient would be an independent and rcsponsible member of society. The person unablc to work because of dis~bi1ity can see him- or herself as absolved of responsibility by the illness, which is not their fault. SECONDARY GAIN This term describes those material benclits (special attenLion. care taking. sick leave. relicf from some if not all responsibilities to others such as alimony or child support payments. compensation payments. awards. ongoing payments from dis· ability carriers. and the like) derived from oUlside the individual. The ministrations of othcrs to one who is disablcd arc secGildary gains. Although sccondary gain figures prominently in chronic pain syndromes. it is often not 41S potent :.l force as primary gain. TERTIARY GAIN This relatively new teml describes those material and psy· chological gains enjoyed by those caring for the disabled onc. The spouse may have a need to be a caretaker. the I.\wyer may havc a need to kcep the patient disabled and out of work (0 maximize winnings. a doctor may need to keep the patient dependcnt on ongoing care and manipulation (in more than one sense) rathcr than to teach the patient self-sufficiency. and the psychiatrist may nurture ongoing passive dcpendcncy for considerations that have liule to do with the welfare of the patient. Tertiary gain usually involves a conflict of interest. all issue that behooves all hcalLh care and legal providers to self· monilor. Motivation Vinually all patients state that they want nothing more than to get belter. Most of them do want to gct bettc; and most of thcm do get better. The rcmaining fe~v. however. with their ongoing complaints of polin and their problematic behavior. bespeak a conflict of which they havc littlc if any 'lwarencss: consciollsly, they wanl to get bctter. but ,,,,consciollsly. they Parallel History The parallcl history is th~ r~( ord or important psychosocial evcnts and circumstanccs e perienced during and bcfore tho~e lypically indutlctl in the history of present condition. II When vic\\'cd against the b;lckdrop ,-)f the formativc YC;lrs. th~ parallel history often makes clear the C\'Cllls and circumstances that may bc fucling ;1 chronic pain syndrome ill the vulncmblc persoll. Somati7.ation Somatization is lhe expression of unconscious feelings and emotions in physical rather than emotional terms. The somatizing patient. believing \vith a conviction of delusional proportion that his or her symptoms arc solcly and totally of physical origin. typic;;l1ly seeks medical rather than ps)'chi.uric carc.'~ Unfonunatcly this con\'iction often leads the unsuspecting doctor to inappropriate and rather far-nung diagnoses and equally in'lppropriule and unsuccessful treatment. Somatization Diathesis C~rtain individuals. clllotiorwlly sh()l1~changcd or scarred during their formative years. evidence a proclivity to somalize in the face of strcssful urltow;lrd events or circumstances of adult lifc. espccially onc~ that awaken fc~lings buried in the unconscious and rooted in the p.\st. These individuals ;'Ire said to harbor a JOII!(lt;z.atio/l dial//('...;s. I RECOCi\ITIOi\ It is proverbially true that if one chinks of the right diagnosis. onc willlikcly make the right diagnosis. Nowhere is this morc apt than in the recognition of back pain complicated and col· orcd by ps)'chologicol1 factors. Unfortunately. even tOday. ill.lIlY textbooks fail to include a discussion of psychological faclOrs as the)' apply to chronic musculoskelctal symptoms. including neck. shoulder. and back pain. The aim of this section is to spotlight the characteristics of this group of r~·HicIlIS; to olltline an interview format helpful in identifying the 111. and to review the use of the Pain Drawing. the Minnesow Multi Phasicz, and other select psychologic:lI tests. Red Flags The following listing of reel JllIg.,·-signs. symplol1b-. and other clucs that alert lhe clinician lO the likelihood (hal psychological and emotional factors ligurc significantly in the clinical prescntationl-arc 'lrrangcd in groups relkeling his- Ht:.nl-l.OILI 11-1.1 IUI'l u r Inc "ru'lt:.: H. r'HH.l,.. 1IIIUI'lt:.H v tory, psychosocial issucs. disturballCl:S 01 mood. and l:xamination findings. RED FLAGS I (HISTORY) Vague, inconsistellL and implausibh,' history of illjur~. (l(lell lIll· witnessed Symptoms that pwlifcratc from (Inc body arca (ll' SY:;ll'!ll \II :;cveral, often culminating in tolal botly pain Highly emotionally charged pain descriptors: torturing, .;ufrocating, cutting, wrelched, blinding, exhausting, scaring . .;caltlin);. stabbing, wrenching, punishing, gruding. cruel, vicious. I~elletrat ing, piercing, terrifying, fearful. crushing, gnawing. !lnunding., beating, and the like Obvious hyperbole in history: "... I couldn't ll111ve .. ,my kg:; collapsed ... I was numb all over . . I couldn't or can't dn anything ..." Obvious discrepancies during evaluation: the patient \\ 110 reports an inability to sit for more than 10 minutes but sits for an hour or more relating the history A lengthy history of life-long hard work and responsibility with a professed desire to return to work. which, unfortunalely. is llOW precluded by pain Marked passivity, inappropriate activity curtailment. fr~quelltly with concomitant weight gain illid marked physical deconJilioning Accept•.H1CC of disabled status: "l'vc just 1cmned to accqll m), limitations." History that only narcotics afford pain relief. with gradually esca" lating narcotic usc RED FLAGS II (PSYCHOSOCIAL ISSUES) Externalizing responsibility or blame for occupational. r~lation ship, mood, or financial problcms Emotional constriction: keeping feelings inside Tearfulness or weeping during interview Denial that the manifest somatic problem is in any way related to life events and circumstances, except to blame life failures on the purported physical illness: (e.g., "but for my back pain. cvcrything would be A-okay") A verbalized fear of ongoing disability. Such aiNu' frequently represents un unconscious wish to be taken cure of. especially in persons emotionally short-changed in their youth. RED FLAGS III (DISTURBANCES OF MOOD) Dissatisfaction or frustration with job or anger at a boss or doctars frequently represents unrecognized (displaced) anger at parcnting ligures, which mllY culminatc in verbalized resentment at the way the claim is handled, the way a disability is (not) accommodated, ar the way treatment is rendered Failure of reasonable treatments, in the face of which patients lIlay report worsening symptoms. Such failures may reflect resentment at authority figurcs displaced from parents or supervisors onlo the unsuspecting and often bewildered doctor. The doctor begins to sense his {)f her own anger directed at the pa+ tien!. This "countcrtransference" frequciltly signals thc passive-aggressive behavior of a smiling, manifestly compliant. but latemly angry ar enmged person. TIle challenge for the doctor is then to rccognize his or hcr feelings to bettcr control behavior. It is :I grievous error for the doctor!o return in kind tbe anger of passiveaggressive patients. IV1H.I'lU/-\L \'i:;itillg Cl1\erg~lll:Y r,"lms ror narcotics. escalating drug needs, inakohul ;lbu'L'. Ill' gaining weight may represellt a thinly \eikd elliotillnal hun;a and neediness in concert \vith ~TL'asing R::D FLAGS IV (EXAr.Pi,...T10N FINDINGS) Tht,'alricl! ]lI'<.'s\·nl;1111 ,1 walkin~, wilh all llhvio\1sly Ulllll:ccss;lry I.·allc (often carried in lhl' \\T\ln~ hand), a strange limp, or main\,lining a bizarrc po"turl' \'\)(lanatolllic sens\'r~ lindings. such as glove~slOckillg or half· nndy bypesthesia \'\lnanatolllic lI\otur tilldings, such :is giveway weakness on musde h:sting or Ol1lOe llr hed walking, or oh~vio\1sly suboptimal grip alleillpts Significant diffen:rKt: bet\vcell observed and formally tested r;lI1ges of motion Significant difference >d\veell straight-leg raising ill sitting versus recumbent postures Inappropriate ccrvio.l compression lest (e.g.. causing low back pain or causing legs 10 give way) Inappropriate \vithdrawal {)f exagger:.ned tenderness response on gentle palpation or percllssion, especially if the paliellt grabs thl: (',aminer's hand in th~'atrical fashion 1 :"lone of this information is n::ally new. In 1940. Fctlennanl,l identified symptoms. including dramatic pain descriptors. preoccupation with pain, fcar of increasing helplessness, and lhe utility (i.e .. secondary gain) of the symptoms. that have a "neurotic ring." More recently, WaddcIP-l·I.~ described physical signs and symptoms that bespeak functional overlay. In essence. when the examiner encounters any of these red flags, he or she should document them and make an anempt to account for them. All too often. they arc mentioned in a medical report. only to be ignored in the discussion of findings. En',-yt!tillg in a comprehensive evaluation has meaning. Depression Eighty percent of persons suffering from depression art? evaluated by primary care providers: chiropractors, ram~ ily physicians, intcrnists.(' These patients usually do not realize that they _._. ., ..... -a ~ ..... , .... , I l.." 1>3 • ,... V I VI IVvV\.;I .... L rKv 1 un,;:) 11'1 \.;nnVI\llv ,...... 11\1 ~[':lli/l'd pain (including pscudo-JilmllllY(llgia or filnomyosi- tis l. It i:-; axiolll;lIic that no person should be givcn a diagnosis()t" chrol/it, jtU;gl/c syndrome'. jil)J'olllya(t:ia. or jibrol1l)'o.'ii/is wilhout 'Ill ~"alll'l1i(ln lhat includes C;\fl:flll psychodia~lh)Slic .ISSl'SSllI.:1lI hy a profession.1I who lllldCl'SI~lnds lhat d1l'Ollic p;tin alltUm chronic fatigue may be (and not infl'l'qUl'lltly ;lrd lh~ initial manifcswtions of an occult and c1inic;.II, il1:1PI);ll'\"nt th.'pression. S(llll:tlizil1g/dcpr~sscd individuals (who are usually highly r6i .. t;llIt 10 psydl{llogic;jl interpretations of their symptoms) llfh.'u arc so cOI1\'inccd thai their problem is physicnl, nnd offly physical. that they persuade their doctors of their delusional misconception. Because th~sc pOltknts have a mood (i.e., psyL'hologiL'al) disorder, thC)' do not get better in response to Ir~:lll11~1lt dirccteu at a I,hysical problcm, Typically, thcy re· (jllL'SI and rccci\'c t.:.\lcnsion aftcr extcnsion of their disability. One: ..hnuld beware of the patients who st"lte: "The doctors jllstl,:an'llind out what's wrong with me," They rrustr;,lte their ~h':lOr~ who, nol recognizing or cven suspecting that they are dcpr.:~~cd, unwittingly colludc with them. seeking consultalion~ and diagno!'tic tests directcd at discovering a physical explanation for tilC pain. The astUlc doctor, howevcr, may rec01.!IlIZC carlyon that these patients will remain disabled. They d~li\'cr a double message: mouthing words about their inde~ pendence, their lolcran~e of pain, ;nd their frustration with their physical problem. their pussivc. dependent behavior be~ speaks emotional need and dependence, intolerance of and in~ capacitation by pain, and complacency in accepting the invalid status. The double message of the somatizer is as foHows. Their words S;'IY: 'i f I started working at an carly age and I have worked hard all my life, I havc ~dw:lYs been very indcpcndenl. I (,'an Ii.Ikc a lot of pain. , , rm nOI one to complain (deni:ll), I jU~1 want 10 £el better so I C whilc their behaviors say: Becausc I had to fend for myself a~ a youngslcr. I W,lIlt the care I didn't get (In'". My p:Jin forces IIlC to be pa.<;sivc and dependent II(JII' '·alidisl11). 1am a victim. disabled and helpless in the face artltis terrible pain. I need (0 remain disabkd because now I am being laken carc or. I don't W~lIH to go back-to work, , , (maybe) ... I want Ihc educational opportunity (vocational n:habilililtionl I forfcited when I dropped oul of school. Blumer • Worked at hard jobs a long time before becoming dbablcd by pain • Family role model for pain ;Illdlor di.':.lbilit)' (idcntilicalion) • Often school drop·out These authors cxplain lhat, "by virtue of providing for others .lHd 110t being fully able to depend on their own parelHs as children __ .Ihc)' Imd postponed gr;'\Iilic.. ~tioll of such needs unlil a minor injury provid<::d a mtional and socially acceptable means of depcnding on othcr!' for emotional ,u1d economic suppon:' Chronic (back) pain, in stich inst Pain (emotional) begets Pain (physical i.e. psychogenic) Because the pain-prone patient is one who seeks and usually receives endless nnd costly studies or imenninablc treatmcnt and doe.'lllot get beller, it is important to recognize the dingnosis of somatization early. In 1959, Engel't> outlined his understanding of psychogenic pain and its relationship to depression: ",' ,a common error by the physician is to assume lhat lhe patient is depres~~d bcc:!use he has pain. Investigalion will usually make clear that lhe experience of pain serves to atlenuate the guilt and shame of the depression .. :' PsychogclJ.iL(or somatofonn or idiopathic) pai.n.Jather than being a cause is more frequently a manifestation of depression. This IS to say that pa· tiefi1s whose psychogenIC pain represents depression do not fe~ch, if3!!Y' depres~~~, Instca~.. they ~x~erience pain. Engel also recognized that narcoHc addictIOn frequently complicates the management of these patients. Unfortunately, some well-intentioned but ill-informed lawyers will object to psychological examination of the chronic pain patient (in accident-related litigation) on the grounds that the client is making no claim for psychological injury. Whenever chronic pnin is a manifestation of an unrccognizcti (i.e.. unconscious) depression or other mood -disturbance, the patieoJ ..9OCSJlOL_c¥cn-_kuQW of the mo~-(fl.'iturbancc,__Thc Illost effective way to prevent and obfuscate 'accu~;(C diagnosis and impede optimal trc3tm~nt is t~ preclude pSy"chqLogi~ilt inycstigation of chronic pain that has failed to improve in response to treatment directed at a physical disorder. Substance Abuse The chronic pain patient frequcntly dcmands, and th~n receivcs, prescription after prescription for narcotic analg~sics. reporting that nothing else relieves the pain, Such p~Hi~nts arc at risk for drug dl:pl:lldency and iatrogenic addiction. The addicted patient invariably denies such addiction. asserting, "I only lake the narcotic for my pain. _. I only take i( when I reall)' need it ... nothing else (but the narcotic) helps, .." This lil r~aJ. but tilt: sufferer ha~ Illl way of kIH1wing whether il is physical or psycIJOlo:.:.il"ol Of hoth. Pain is pain. POlin rcprcsCIllS a final C()I1l11Hlll p:lthw ALCOHOLISM The child of an ::tlcohoJic parent is. at the- very least, cmotion~ ally shon·changcd. not only by the emotional unavailability of the parcnt (le.wing residu::tl neediness within the child), hut also by Ihe negative role model that alcoholic behavior pn;sc.:nts. SURGICAL OUTCOME Ii I i I~ ti ~ I Som:ltizatiol1 Diathesis Becker ' identified a .'ilJllltl1i~(;riml diatll('.'.is in those individu· als who, in one significant way or another. wac cmotion t Factors Predicting Disability ABANDONMENT t I I M I N Ii I I I I ~ I ; Schofferl1l~m Ab Abu~c takes several forms. £motiol1al abuse can occur in the form of name-caHing or ridi.culing or subjccling the child to a const;lllt state of ::mxicly in the face of parental fighting. yelling. screaming.•HId inappropriate favoritism. Abusc. how· ever. can also be physical, involving inappropriatc or frequclll corporal punishment. beating. or actual haltcring. Lastly. abuse can be sexual. either as a single episode or on an ongoing basis. Adults who were abused as children commonly harbor both unconscious guilt and unconscious rage. either or both of which can fuel nOl only abusive and rebellious behavior. but also a chronic pain syndrome. Low back pain typically is a self-limiting symplom. MOSI patients with acute low back pain respond promptly to appropriate treatment and are back at work in short ·order. In a subset of paticnts, however, pain becomes chronic. The tcnn chronic back pain was used in the past to describe pain of more than 6 months duration. but FrymoyerJ redefined chronic back pain as pain of more thafl 3 mOfllhs duratiofl. Becker ' commented that. in most cases. chronic back pain can be identified in even less than 12 weeks. Frymoycr identified several factors that arc important in predicting prolonged disability after back injury. They includc the duration of the current disability; a history of previous disability; psychosocial factors; occupation::tl requirements; job dissatisfaction; ::tnd whether or not the patient has retained a lawyer. Other factors idcntif'Jed with back pain and/or symptom:llic disk disease that frequcnlly prolong disability or serve as barriers to recovery include obesity. inactivity. deconditioning. lack of aerobic fitness, smoking and other substance (alcohol. marijuana. cocaine. legal or illegal narcotic) ::tbuse. exposure to vehicular vibration, and a troubled family situation (e.g., children leaving the nest. illness. de.uh. marital discord, divorce. or other losses). A shan period of employment before ::tn olHhe-job injury often bodes ill in terms of prognosis. -..... i) , } .~ ..J Examination Format The cornerstone of evaluation of an injured persoll is an ac~ curate description of the person and of his or her work. Such a description is possible only aftcr mcdic,,1 and other relevant ,~ '~I i1 \I; i 1 ---- _ ~ "'''' nX\lrd", ilrc rc"icw..:J. and the individual is inlcrvicwed and cxamill~d. , . Al lim~:-. il is necessary 10 interview a spouse or other family mcmha. The procc~s or c\" ,i ;Illd pn=~cl1(cd dm'lllologiGilly. This process may take the form Ill' handwriuL'l) notes, but a lllOre.: dficicl1l I11CilllS is lhn)ufh dil:l:ltioll lor subsequent word processor input. A dnonolngic rC"lc\l,: of the records "ffords the hc.<>1 opponunity to ull{krSlalld sOllh.'thing of lhe backdrop ~lgainst which an injured PCf:-:OIl Illusl be viewed. Record review is the task or a d~\(':lOr and should not be delegated. Sometimes extrcmdy sulHk medical record entries provide vitally important Chl#CS to the comprehensive understanding of an illness and disability. A ("(1/II/Jl'elwlISirf history is the foundation on which an lllltlcr:-'l;lIlding of an injured person rests. It is important to establish r;'ppaTt with the individual being examined as quickly as po:-.siblc. The good doctor is first and foremost a good listener. The HISk of eliciting a good history is both a challenge 10 and ;lrl opportunity for the examiner. Imcr\'ic\\'ing is ll. skill. Almost all persons coming for an initii.11 examinatiolf after an injury (and virtually all those t.:omil1£ for ;, medicolegal e\'aluation) arc anxious. A gentle. reassuring. kindly approach helps to calm them. Some injured person~ .Ire angry. It is particularly important that the doctor not respond (0 them in kind. Frequently. if the doctor simply listens quietly. the anger dissipates and patients are better able to talk abollt thcir problems. Many patients, particularly chronic pain patients. have gone through life viewing every human being with whom they come in contact as an adversary, These individuals have a way of "setting up" the doctor The history format cncomp:'lsses material appropriate for bOlh chiropraclic as wcll as mcdical or psychosocial evaluation. All areas are imponam for a comprehensive understanding of the individual being examined. J. Ideuti!.villg Data Namc of patienl. ilddrcss. marilal status. age. occupation. and em· ployer a D:lle of evaluation Dale of injury. ;f relevant Job description. inclUding physical demands Employcr and dale of hirc Hislory of prcvious Worke~' Compensation claims or personal injury litigation Time periods mil of work. current income source (ascertain income while working versus income while disabled) Nole any job or work hid changes bcfore injury Ask about rumored layofrs or plant closings A~k aboul an}' suspensions. or censures for unsatisfactory work pcrfonnanc'~ Reason for evalu II. Present Condition List all symptoms attributed to injury-their onset. frequency. and sevcrity. Note symptoms present before injury of focus. Chronologie history of prescnt condition. inclUding all prcvious IrCiltment methods and responses. If an injury is involved. a detailed hislory of that injury is needed. with particular attenlion paid to discovering and understanding the probable mcch.anism (in tenns of biomcchilnic:J1 forces) of injury. Othcf\visc. as dctililcd as possible 3. history or onset of symptoms should be documented. ll/. Pas/ Medical His/ory Describe prcvious accidents or injuries. ope,.uions. medical conditions. hospitalizations. and any pre.cxisting disabilit)'. 1\ole current usc of medications. appliances. :md physical therapy or similar lechJljques .. :~'\ ~v~!! :\~ dini(' IV. Review of Systems and Psychological Symptom Inventory Ask about general heahh and pose approprii,\t~ly focused que:,lions pertaining 10 the hC J,\'lldromc. Ask spccificail y about depression. sleep problems. crying. difliculty with concentration or memory. loss of energy. casy fatigability. irritability. temper outbursts. physical viL'Ilellce. social withdrawal. dre~Hns. self-esteem. sense of guilt pill' bias. panic attacks. bypcrventil;ltion. fainling. dizziness. lremors. (,'xccss swe;i1il1~. childhood bedwelting. history or shoplifting \lr stealing or gam· bling problems. and hallucinations. V. Chronologie, Educational, alld Work Histor)'. Ineluding Military Experience Note schools attendcd. interests. performance. \,·,\tracurricular :Ii.,'tivitics. disciplinary problems. diplomas andlL'r lkgrccs. If schO\'I1 drop-out. i1sccrtain why. NOll' .tll major johs. wnrk d:lll'S. jnh s;Llisfm:tioll. and n:asOIl for leaving. Ask :.p..·..:ilir.:;tlly ahoul ...· xll'n ~ ploymcrll. COlllprdll'lIsi\"l' desr.:riptiol1 of til\.' w\lrk pl;\Cc and duties, ;IS well as qualitr of relationships with employers. supervisurs. and Jc' <:o-workers. Ask spccilic;tlly about jllil satisl':lCli(ln. Specifically d(JclLlll~'nl allY work lash pn:dtldcd by till: physic.L1 or psydm·lllgic:ll (.:ondili\ll\ of Iii..• individual. wilh rr.::.ISOl1S for sm:h precilisillil. I , i I, I I \!I. Personal History Note composiliollufhmlsdtolJ. any rCl'Cllt or illlpending changes, alld rCI:CII! <.bllhs or scri.ous illness in family or fricnds. Assess changes jn ;md stability uf living arr..lllgcmel1ls. Ask about i1H:r~asing l..k hIS. financial problems, and b;mkruptcy. Check inICrpCrs()Jlal relationships: marit;tl or spousal: childrcn. es· pecially l.:hildrcll by (llhcr marriages: parents: in-laws: and siblings. Obl"in hi~tory or invC:~lig'Hions and :UTeS(S (including driving while intoxicated), ;\llc.l notc any periods of incarccration. ~ ~' I t I ~ Vll, Family History J t! ~ I I I Note signi(ic~nt medic'll or emotional problems. specilically depression, ner,'OllS breakdown, ~lcoholism. suicide. psychialric hospilalizmion. or disability involving f~mily m~Jllbcrs. Vlli. Biographical In/ormation Developmental history. nOling quality of bond to parents, siblings. step-parcnls. or othcr~. Ask specifically aboul harsh or unusual punishment. physicJI or sexual :Ibusc. Ask person 10 describe lJIother ... fOllta. Asscss quality of bond to siblings. parcnls, and other family members. Determine whcn the individuallcft home and why. Obtain affectional rclatio·nship history (inclUding history of abuse) to assess :loy difficul1y in mainl:lining stable and malun.~ intimatc relationships. If divorce ha~ been invulved, inquire about alimony and/or childsupport paymenls. ,1; ~ i " iI i I, «'" I! IX. Social and Recreational History NOle r•.lUgc of interests. hobbies. pursuit of sports. rccrcatiomtl activities Wilh fril.:llds and family. Specifically dO<:lllllClll any ;;IClivilics Ih'lt the Il:tlienl fecls arc preduded because of physkal or psychological conditions ;Ind the reasons for such preclusion. Specific;llly ;;Isk about and Iry to delerminc in dClail Ihe paticnt's physic:d fitness progr.un, if any. Assess the patient'S initiative, mOlivation. and pen;cvcr.mcc in maintaining a comprchcn~ :-ivc fitness or physical rehabilitation program. X. Mental Status Examination: Bricny describe the following: appearance during Ihe inlcrview. ..ulitudc. attention. eye conlacl. posture. now of speech, ·content of speech, unusual manncrisms. mo....ements or behavior, and observed as well as reported r makc rcasonable judgmcnts. ;.tnd recent and remote memory. ~re partiCUlarly import::tnt in elderly persons who may. because of mcmory difficulties, be unable to comply with complic;\tcd treatment routines. M:tny of these functions Xl. Physical Examination The format for the physical examination is beyond the scope of this chapter. It is clear, however, that thc corncrstone of a thorough cvalualion of a person with chronic spinal pain is a comprehensivc history (which does not neglect the psychosocial arena). and a careful physical and mcntal statliS examination, Psychological Tcsts Just as radiography and other imaging studies are diagnostic tools that work in concert with the history ) .--~ j 1, 'f ;: I ,.)" ',J 1---------------------------- ... ,., • • • _, . . . . . . . I V I V, , ..... V ..... V, " ... 1-,... ...... un~ 11'1 ...... IOUI'I' ..... r,...ll'l Hyplll.:honoriasis (Hsl: ahnormal concern over bodily health Dcprc:-sioll (D): dy:-phoria. won·y. discoumgcmcnt, low ::~lfHystl'ria (1-1)'): inappropriate happy :lcccptance of ndversc or qn:ssful cvents or t'irCllll1st:IIlCcs in general (deni<:t1) l)s~'dl(IP;llhic dcvi;lIc (Pd): moodiness. resenttncnt. mal er.. Thes~ descriptors arc simplistic and not intendcd to cncour- ) :i 1: 5 l' !i ~ "f age the i.llllalcur interprclalion of MMPI-2 profiles. The interpretation of the MMPI-2 requires an extremely broad understanding of that specific (cst instrument. Normally, the MMPI-2 and other psychological test measures are interpreted by a clinical psychologist with special tr.lining 'and specific expertise in the area of psychological test adminislmtion and interpretation. Validity scales are built into the MMPI. Lees-Haley" devised a fake-bad seale for the MMPI2. which has proven useful in identifying patients who may bc consciously misrepresenting fact or even frankly malingcritlg.~l Full-blown malingering is. in my experience, infrequcnt. A more common situation is unconscious or to some dcgree cOllscious embellishment of symptoms wherein the hyperbole is part of the patient's theatrical (i.e., hysterical) character style. At thc other end of tile continuum is pure som~ ariz-arion. which is almost as uncommon as purc malingering. Most chronic pain patients represent a mix of somatization plus underlying organic pathology plus somc symptomatic cmbellishmcnt, not necessarily in any ccnscious aucmpl to bc deceitful. ~ I PAIN DRAWING ~ ers2~ described a means of evaluation in which the patient -~ ~ I ~ draws. on the front and back of a body outline. the precise location of pain, specifically using symbols to indicatc numbness, burtling, pills and needles. and stabbing. The pain drawing is remarkable in its correlation wilh the history. cspecially the p,lralle! history. and the MMPI-2. Brown~·' concluded that the pain drawing (along with mugnetic resonance imuging) is especially useful '1S a diagnoslic adjunct in cases of back and lower cxtremily pain. I CHRONIC PAIN TEST BATTERY i• j ~ ~ ~ • i;: < ,~ ,f:, ~ ~ t } I3eckcr and Smilh',} outline a sm.11I psychological lest useful in chronic pain evalumion. including: (;.t) an gence assessment (it is imp{)nant to know if .. Back home - - - • \Vhal ;.. nnvy:- m..: - - • A mother - .. .. My greatest fem - - .. When I was ~I child - - .. The future - - What pains me - - - My father - - Use of appropriately seleclcd psychological tesling de- rives several benefits. including. revealing evidcnce of depression. factual misrepresentation. and the psychological asscts and liabilities of a patient. In terms of the clinical prognosis. thcse tests demonstratc the ability of the inol\'idualto benefit from psyehothernpy or counscling and the likelihood of eompliance with exercise regimens or of persevering in functional restoration or vocational reh;lbilitation progr:.lm~. The markctplace is repletc with so~called "self-report" test me:'lsurcs. In general, lhese arc not tests that look bene.nh the surface. but rather they indicate how the patient wishes 10 be perceived. They have, therefore. limited usefulness. Becker ~nd Smith1\l point out that although psychological tests can be scored blindly (e.g.. by a computer or a psychologist who has not interviewed or even seen the patient), the conclusions are most accuratc when the interprcting psychologist has performed a screening interview and a mental status examination to provide a backdrop against which the hard tcst data nrc best interpretcd. The chiropractor who wishes to use psychological testing for chronic spine pain patients should establish a rclationship with a clinical psychologist who is knowledgeable about chronic pain. somatization. depression. symptom embellishment. malin2cring. and the like and thcn work with that individual on rcg-ular basis. This working relationship is panicularly cfkctiv~ v,,'hen the chiropr.lctor and (he psychologist confer to fonnulate appro~ priatc management strategies for each patient with chronic pain. Patients, particularly those who may harbor a somatization diathesis. are frequently resistanl to undergoing psychological evaluation. They tend to dislort the mC~\Iling and V~lll~ -. of such testing with interprctations such as "tltt: doctor thinks it's all in my hcad," "the doctor doesn't bdicvc me," or "the doctor thinks I'm cr<1zy." Explaining to the patient thaI hc or she is to undergo a chronic paill f!wduafioll is less threatcning to an cmmionally fragile and rigidly dcfended person than is a psychological et'a!tullioll or. worse yet. a pS)'chiatric evaluatioll. MOSI paticllls readily ad.:nowledge chronic pOlin. and most can accept lhe rCillity that chronic pain and mood and behavior arc rdalcd. It is often helpful to review with the chronic p;'lill pmiclll his or her :1 A piclUre is worth a thousand words. Mooney and co-work- , istering an MMPI-2); (b) self-report measures, such as the pain drawing; (c) a personality test, such as the MMPI-2; and (d) projective tests. such as the Rotter Incom~ plete Sentences tesl, in which the patient completes a rull sentence. given only one or two words. Examples from this test include: batlcry intelliis literadmin- R ~---- --_._---_.__.._ ..__._ ••..... __ ...._.... _...._- failure to reg~in health despite reasonable {re~tlllenl, and to poilll OU! that a chronic pain cvalumion mOlY yield findings that suggest additional m:atment stralegies. Using patience, underst::lndim~. and 1.11:1. Ihe doctor C'lIl usu:'llly persuade the rc~istalJt pcr;OIl to undergo a compn.:hcllsivc chronic pain c"aluathHl. The usc of psydlOlogic;11 tcsting as a diagnostic adjunct in the evaluation of chronic p:lin is :'lcccpled as standard practice. Failure to consider 'psychologic:il evaluation (in~ eluding. testing) in the face of a rcfraclmy chronic pain syn~ drol11c. particularly before perfonlling inv:lsive proccdurcs. is llcgligcm" TREATMENT CONSIDERATIONS The carc of many paticnts with chronic back pain can be satisfactorily managed by the treating chiropractor, e:thcr alonc. or if mcdicmion is indicated, in concert with a physician, Chronic back pain, especially the kind that lingers or smolders. w:'lxing viduals arc less susceptible to incapacitating chronic pain syr.Jromes.oI Chiropractor as Thcrapistffeachcr Psychothempy is the praclice of listening to the patient talk in supportivc, underslanding. and appropriatcly interactive way that leads to a doctor/patient bond within which healing can be facilitated .md nurtured. It has been around sil\CC recorded time, antedating Sigmund Freud by several millen· Ilia, For m.IllY pain palients, especially those who remain pro· duetive. the doclOr may be able to serve effecti\'ely in lieu of :.1 therapist. Living with a degree of chronic pain means fo· cw:;illg increasingly on the resumption of as many activities of daily occupational, family. social, and recrcational function· ing as possible. Simply because an exercise or activity (done by a deconditioned individual) causes an inCrC3s.c in pain is no reason to stop the activity. Indeed, unless the chronic p:'lin patient pushes on with an appropriate functional resloration program. despite some pain. little if ;;I Le I I i ,~ ;; ~ L, l~ I, ) I~ I; L, I..) 'J " ",, .T .. I ." """\ >" "") ,} ___________________-4 '-' ..... ' " " ' .... ', ';' .... v, ..... "V..,)v..... I .... L rJ·H.... luM~ ll~ p;tin :,... :\ \h.:pn.:~si(ll1 cqll;\'~I~n!. or if the patient complains \11' in:-'llillnia 1X'~aLJ~~ or pain. a trial of ,ll1tidcpressant I11cdicaliun is \\'arr;lI11~d. Dctaib of '\Heh (hentpy :.IfC he)'ond the scope of thi . . ,,:hapler. hut lh.:~ have been outlined by Becker' loll' and othL'l".'i. i\llllllll~h lllallY patil.'llls who somatii',c can be s;uisracto- rily 11l,11l:1~\:d t,y the chiwpr:lt"Wf or by ;l chiropr;lctorJf.lI11ily practiti(llil:J" h:;Il11. some f,lillO make progress. They should be rdcrn..:d for P'~ chmliagllo~liL' c\'aluatiul\ lind. if indil::HCd. for smgi!.:al L'\';l!llalion ;IS well. The ('riteri" for sJtisfactory man· agelHem illl-lude: Pn1gn:ss in llll.: r~~urn~nl '1r~lchillgf;.,lr~'Il;;thl.:nilig/li\lli;SS "t:lh~kks ~ltld l.:lltll~ss progralll withollt date ex- r~tllrn'lO-work h;llsions I'rH~rc:\:. in r~;t(hin~ f:'lch1ry maillkn;uKc it pcrnl~lll'lH and or th,,1 "l;.itll\ 401 \.;nHUNIL; PAIN slatiollary status and salis- Eith~r rl.:lurning (0 work on a \u,wined hasis or entcring and com;1 nl>::.llional r..:habililaliol1 pru~nllll. finding appropriOltc l;ilinful cmplnYlllclll pn:.Hr;tining. ;lIld sustaining work perfllrnl;ll'l"\.' Disl:ol1linUilli\ln Ill' Ilarcolil.' anall!csil:s. Only in rarc instances an: n;lfl"Oli(, indil:(ltl.'d in l.:h.ronil" bal.'k pain management. A small SUbSCI (\f paliel11S funnion more salisfaclorily willi it low Ic\'eI of mailllen"nce narl.'Qtic th~ln willtout the narcotic. klclHilicati<1n of such patient' n:4uircs considcmble skill and expcrience in assess me 111 and mana£Clllcnl of chronic pain syndromes and is bcsi Ilnd::naken hy it physici;m skilled in algs. stamin:t, and endurance! and ... /ton-rclllg(' 1;(1(11... {progressive learning of a homc cxc["(:i~~ and fitness prngr;lfH; acquisilion of skills to enable a high dcgrcl:: (If self-sufficiency wilh infrequent monitoring: deprcswcaning fmm rdi~ltlcc Olll1arCOlic ;lllalgcsics: treatment sion ur pain a, a depression cquh·"lcnl. if present; progress in gellcral phy~ical aCli\"ity Ic\'c1 withnul recurrent sctbilcks. which indicalc Ihal mllrc spcci;llized Ircatlllclil is indicaled), should be established \\ Ilh t:lrgel date" to avoid endless prolong~ltion of disability. Ab(llil 99t}- of all back p:tin patients should reco\'cr promptly. Wh.:n Ihcy do not. S\llllClhing Illay be seriollsly wrong. and thaI something may escape definition if the psychological dmnain is nOl included among thc uifferclllial di:lgnosli..- cOIl,idcrali\llls. ACUPUNCTURE Acupuncture hi:ls been used by Chinese practitioners for CCl1lOnes. Recent work suggests it may have some value in chronic pi:lin syndromes,2 4 BEHAVIORAL THERAPY This type of therapy is rooted in the pioneering work of Skinner, who recognized that behavior is shaped by its conSt;' qucnccs. Stembach:2~ describes an approach that identifies: (I) undesirable (maladaptive) pain beh:wiors that interfere with the patient's life and constitute barriers to recovery; (2) desirable (adaptive) behaviors that the patient has but fails to usc; (3) working with family, reinforcers that encourage the desirable behaviors (2) and strategies to discourage, if not to eXlinguish. the undesirable behaviors (I). COGNITIVE THERAPY pJ..:lin~ or i This fonn of Iherapy is based on the work of Beck and colleagues.~(, Cognitive thcr-apy helps .he patient to recognize the cognitive distortions characteristic of the thinking of deM pressed persons, and to acquire the inner resourcefulness to overcome passive dependency and the "viclim complex." RELAXATION THERAPY, BIOFEEDBACK AND HYPNOSIS Alone or in combination. these methods have shown limited success. Those patients who mallifc:-.i iilt;: l:ydc illustrated in Figure 19, I, a fonn of tension myalgia, may respond to a treatment approach that involves the therapist teaching and the patient JcaTlling skills that culminate in a high degree of patient self-sufficiency. Relaxation. accomplished through medication, biofcedbnck, or selfMhypnosis may increase a motivated patient's sense of self-sufficiency and control while PAIN or I , :~ I I MORE MUSCLE SPASM MUSCLE SPASM Ps)'chiatric, Psychological, and Supportive Treatment j\ lcthods I An in-depth description of lrcallncnt mcthods is bcyond the scope of this chapter: however. several are identified brieny. The actual choice of treatment may v:.try with the community resources that ;Irc ilvail'lblc. ;i\ ~ ~ MORE PAIN Fig. 19.1, Pain· muscle spasm cycle. I ~ I', ~ 1_"_-'... :',: '~ , ! i ~' I ;;; \ l _ diminishing or extinguishing maladaptive thoughts of hclplessness and victimization. FAMILY THERAPY Rowat and Jcans:.!7 st,He Ihat "learning 10 live with pain is a family affair." Certainly. when a major wage curner or provider becomcs dis~lblcd for an extended period oflime.lh~ impact on thc family Illay be devastating. In the worst casc scenario. the passivc/dependcnt patient can become a virtually helpless invalid. indeed. some chronic pain patients arc as much of a demand on families as is a newborn infant. Additionally. most chronic pain patients manifest depressive spectrum symptoms. including insomnia. irritability, fatigability. lack of motivation. diminishcd selC-es(cem. social with· drawnl. and diminished libido. It is not unusual for families to collapse and marriages to fail when an overworked spouse cannot shoulder yct another cx(ra burden. Frequently. Illounting bills lead to bankruptcy and somctimes homes arc lost. Family therapy can sometimes help the family understand the underpiilOings of the chronic pain syndrome and to learn strategies that may avert disaster. The family that learns to encourage and reinforce the patient's active lh'illg and to extinguish Ihe patient's passive sufferillg has a greater chance of survival. PHARMACOTHERAPY The chiropractor should discover what medications the patient is taking. Narcotics, except under special circumstances. are inappropriate for chronic pain patients and may only diminish energy and motivation. Patients with chronic pain syndromes are at risk for developing iatrogenic substance abuse disorders. They frequently seek narcotic prescriptions from several providers. Appropriate team management of such patients designates only one provider to prescribe and manage pain medications. Ongoing regular usc of narcotics diminishes endorphin production. thereby robbing the palient of a biologic mechanism intended to help cope with physical pain. Aspirin is one of the best analgesics in the entire pharmacopoeia. The practice of taking aspirin with a full glass of water effcctively minimil.cs gastric irritmion in most individuals. The use of (lllxiol.vtics and sedative-hypnotics (benzodiazepincs. barbiturates) is inappropriate in most cases of chronic pain syndrome. Especially in the presence of dependent 'lOdlor somatil.ing. dynamics. these agcnls lend to diminish energy levels and motivation. lhereby effectively sabotaging recovery cffons. Like marijuana. when used regularly. they may be associated with the ltmotil'atiollal sy"drome. a serious barrier to active recovery. Amideprcs.mlll medications arc among the most useful in chronic pain syndromes. Insomnia attributed to pain by the patient often signals an unrecognized depression. Therefore. in this group of patients. antidepressants are more effective than sedative-hypnotic medications. Newer antidepressant agents. including fluoxet::lc. :;~:1ra:iae. <;,,,c i~~~:-~~;:;lil~:::. !~:~\'c nOI yet been ~(Udied extensively in the trcalmenl or chronic pain syndromes. but they may prove effective ;.Igainsl pain that is a depression equivalent. These newcr medications ;ap. pear to hav~ J more favorable side effect profile lhan the lra· ditional tricyclic compounds. Mu.w:h' r('laXllfl!S may help whcn idcmiliablc and ongoing muscle spasm is .\ P:Ul or the (.'lillie:ll picture. This c!;ISS of medication IS Illost apl)ropriatt.: in acute cases and when uscd regularly. like sedative hypnotics. may diminish cllcrgy. motivation. nnd initiative. TIlc efficacy of these drugs has bl:cn questioned. Carisoprodol has acquired .1 repul Street Drugs. Nutrition, Alcohol. and Tobacco At[arijllalla has an effect similar to the benzodi'lzcpincs. \Vhen used regularly. it is a'isociatcd with the af1lOliw"iollOI syndrome. Alcohol abuse signals a self-destructive behavior pattern that may effectively undennine the best-intended effofts of the caregiver. M;my chronic pain paticnts are overweight. It behooves the chiropractor to teach these individuals somcthing abollt nUlrition. including lowering intake of dielary fal, and illcreasing intake of fiber, grains. fruits. and vegetables. Telling a patient simply 10 lose weight is usually ineffeclivc. Teaching a patient the basics of nutrition in Ihe light of CUfrent knowledge sometimes helps. Refractory patients may have success wilh a fonnal weight reduction program. The role of diet in conjunction with exercise in a weight loss program must be instillf'd. Many patients with chronic back pain have never been infonncd about Ihe relationship between smoking. back pain. and disk degeneration." Pan of a comprehensive attack (Le.. educational program) on chronic back pain should always invoh·c encouraging the patient 10 stop smoking. Indced. lhe patient's willingness or resistance (0 do so will serve as an excellent index of moth·"tion. Ultimately. of course. patients do what they \Vant to do and what they arc motivatcd to do. Functional Restoration Many persons with chronic pain syndrome arc not at all psychologically insighlful and their care is beSI manag.ed with (l func~tional restoration approach as described by Polatin.~11 Such an approach involves careful assessment of the paticlll's clinical condition. particularly with rcgard {() flexibility. strength. and aerobic conditioning. The injured worker with chronic back pain usually has restcd for ::l long period and has becomc incrcasingly out of condition with each day of passivity and rcst. The patient mU5t be taught to recognize decolldirioning. and to addrcss that state. rather than pain. as Ihe focus of concern. A functional restoration progwm is most effective when led by a temn. which im:ludcs the prin~ary provider (dliro- Ih 4U;;S pr:h.:lnr. family physician. or internist), the physical and oc1.:Up:ttiOll:11 1Ill..·rapi:,t. and the psychologist. Optimal Illan~ agl.'ll1Clll prL'Sllll1l.':\ ongoing tcam conferences, at least by h:kphollC. Th(: important ph;lscs of a functional restoration progr.tl11 aflL'r illiti;,l ill-depth evaluation include stretching. progrcs~i\'\,' fl'sisl;lIlCC l'\t,.'rciscs. work simulation :a."ks. and aaohics. TIl\,' p:llil:lll kant .. wlwt In do on his or her own (without f , j .~ j I I, ,,, ~ j I, § ~ cOl\:"ists or four phases: ,~ ,I 1 I. EvaltJillion and tklaiJcd physical asscssment. including and strength measurement. Ph:lse II C! [(l nwaks). Supervised stretching. TIle focus is on im· prnvil1~ ;llIY lll Phas~ r;lllg~ of llIo1i(ln i i I I i I ~ I I !, ~ I i I I r! I fl i ~ ~ ~ ~" i ~ ~, • ," ~ ~i , 'f, •! , 'i I -, ploymcnt ~cHing. , Timely identification of those individuals who arc vulnerable 10 develop chronic pain syndromcs. and working with them to tt:ach and CllCOur;lgC them aboul thc importance of thcir active in\'oh'cmcnt in and responsibility for Iheir recovery. \viU result in more clTcctivc and faster physical rchabiliunion. Impediments and !'itlllTlbling blocks to rccovt:ry should be idcl1litkd early on .md CONCLUSIONS It is imponant for the practicing chiropractor to recognize. evaluatc. {cst. and trcat patients with chronic b:tck pain in whom psychological .md emotional factors arc adversely coloring the clinical presentation. thereby constituting barriers to reco\'C:'y. Prompt recognition and comprehcnsive suppon· lye and aggr~~sivc treatmcnt of these Iroub!l.:d indi"iduals is of ~ign:d imp0rtn!1C"c if they arc to relinquish p;l"i\'cl dcpcndcl\cy ;md Ill nEFERENCf:"~ I. Becker GE: Chronic Pain. Depression. ,,"d lhe Injured Worker. Psychia!r 2. Ann 21:1. 1991. Ah:xand~'r F: PS)'chosomatic ~·Icdicinc. New York, WW S"onon. 1950. :t Brown T. \"cmi;lh Jc. Barr JS. Cl al: I'sychological (aclors in low rad.: pain. N Er.fl J Med 251:12~. 1954. 4. FrYlllu~'\.'r lW. Gordon SL (cds): New Perspectivcs in Low B;]~:" Pain. Ameri'an A.;adel1ly of Onhopaedic Surgeons. Workshop. Airlie. \"A. 1988. 5. Ford CV: The 1992. 6. Lip(lw~1.;1 7.J: 1990. 7. Frymoycr JW: it Sifneos PE: role of somali7.;]\ion in medical pr.lctice. Spine 17:S:-38. Som:lti7.;\lion and depression. Ps.ychosom.nie:, ~ I: I~. BilCk p;lin :llId sciati::;t. N Engl J Mcd 318:291. 19$$. Shon Term Psychotherapy and Ellloti'lnal Cri:,i:,. Calilbrid~::. Hal"'.ard Univcrsily Press. 1972. f). mume~ D. Heilhronn ;'1.1; Chronic pain a,. a \';triant of dcpresslw Ji~~·a..'e, J Ncr.' ~1::::t Di:- 170:381. 1981. 10. Freud S: Strachey J. Frcud A (cd!'): Thc Standard Edition ~,( ~h<.': Compktt: P;;,yehologic;ll Works. London. 111e Hogarth Pre$~. 1..:):'~. p60S. 11. S;mdlcr JL Bed;cr GE: t\ddres"ing the rd:!lionship octWCl.'1l b;:.:k r:!in ilnd diwe'" in your pali~nts. J Musculmkd l\lcd 10:26. 1993. 12. Lipow:-ki ZJ: Somalizali\lIl: The conccpl and its clinical applic~ni('ln...\m J Psychi;)'lr 1-45:13%. 198ft. 13. Feucnnill'1 JL: Vcnebralncuroscs. Psychos-om ~'lcd 2:265. 1940. 14. W;lddcll G. ?'o1cCulloch Gt\. Klllnmcl. ct ;II: NOllorganic physic:11 $i::r'I~ in low b:u:f: ;:.::in. Spine 5: t t i. !()SO. t5. Waddell G. Pilowsky J. Bond ~'1: Clini{'at ;\s-s-cssment anu im"i1'r~' 131i0l1 01 ::bnonnal illness- hcha\'ior in 1\\\\' hack Jl;lin. P.lin •• 0:.1 I. 1989. 16. EllJ;c1 (;1. "Ps)"ch{l~:l.'ni~·" pain ;md thc p;lin·rronc palicill. Am J ~kd 26:899. ! ~,~'j. 17. Schofferm::.:'! L Antl.... Po'l.ll I). Hinc' R. cl ;11: Chiklhuod ps-y~·h\'I,'::i~·;11 lr;J.uma C'.:7::1atcs with unsuccc...... rul IUlllb~lr spine surgery. Spin,,· 17 \Sllprl,:S:::~. 1992. IS. Soulh" l~;. 5\1. While A'\: 'Illt: u"e of pS.ydl\llogicilllcsts in llk' <,'\;11113tion of k:··bad; p"in. 1 rhlllc Joint Surg lAmI65:560. 19S.'. 19. Becker GE. Smith RB: P...ycholugical fa~·ltlrs ill h;ll:k I'~lill. III Kirk;lIu:.-·Xillis WH. BUrlll1l CV led... ): Mall:l;:ing Low B;I~'k P.IlU. :"<,'w Ytlrk. C::.~~hilll.i\'ill:,>hUle. 1992. 10. Wih.. . c LL Rflcdlilll'D: I'rcllpcr:.l\i\·c p~ydH,111~icallesls as rr\'Ji,'h'r~ Ill' sun·c...... I.: ~hcllll)lIudcolysi .. in the lrcallllelll \'1' lilc low·b:lCk "~II,lr\'I\l~'_ J 0011(; J:.;~;; Sur,.: IAml 57:479. 197:;. 21. l.ecs·H;.:!~:. PR: A fake bad \(;;.:1.: on lht: ;'I.1~tPI-2 for l't:rs"ful Ill.iury dailll;lIlt· P,yt.:hlll Rl.'p 6S:203. I'NI. '" Cairns D. R\.hefl'llll J: ;\ sysk'm f\.r c\"alua(in~ ;IlIJ lr<,·.!Iill~ dmmic ::-::.~~: Ji.":;lhililY. We...l J ~kd 124::nO. 1976. 2;\. Brown.V The P;)lhtlrh~'sinlogy :Illd Di;I~lIt,~is til' I.ow Ibek P.m~ :md Sciali(":J ';mcril;;lll .·\\.';ukmy 24. Dcyo RA: Non-opcrnti\'c Irc.;Ilmen! of low oack di~ordcr~. In FrYnlo)'cr JW (cd): The Adult Spine: Principlo.:s alld PraClicc. No:w York. Raven Press. 1991. 25. Sh:mbach R: Behavior therapy. tn Wall P, t-.ldnd, R (cds): TC.'l:lh(\ok of Pain. 2nd Ed. Edinbursh. Churchill Uvlnsslonc. 1989. 26. Beck AT. Rush ,\J. $h;\w OF, cl :11: Co~nili\·.:' Tlu:mpy of lkl'rcssion. New York. Guilford Prc!\s. 1979. 27. Rowa: KM. l;:a...~ :.11:.. \ ,:o::::~·.;;:;;;;·. .: io;....:,: "I' can.:: 1':lliO:III. f;llllilv. and health profcs::ion:.tk In Wall 1'. ~kl~;ld R lc~h): Text!>,,,.,, tll" 1':li;1. 211d Ed. Etlinburgh. Chur..:hill LivingslIllh:. 1%9, 2X. Pllblin PH: The rlllH:liNUI rcslw;llillll appa':lo:h to d1f',}Ilj,,: In\\ h;ld. pain. J ~l\lscu[(\s~d }o.kJ 7:17. 1990. -.~ 1) I II t " I ,~ ) I,) I10 i ''y ! ~"' ,~ !<"y I"" ..,~ v Q i i.-J () Ed LU PatIent/Doctor interactIOn WILLIAM H. KIRKALDY-WILLIS SCOI'I-: OF OLR RELATIONSHIPS The interaction between medical doctor and patient. chiropmctor and patient. and medical doctor and chiropractor leads to an integration, a oneness that embraces these three and their environment. The resultant combinations arc addressed throughout Ihis chapter. Relationships matter morc than noy individual factors. "'n the rcalm of science. lhe unbiased observer record!> tlCIS from the world around us __ . In the field of ..n. the observer is involved in 3 pcrsunai assessment of the objects studied ... III Ihe sphere of religion. two or more people arc im'olvcd in personal intcr;,.ction:' These words of Macmurryl.2 define the scope of human relationships. In the work of any health care professional, all three areas of study-science, art, Hnd religion-arc impor~ t~UH. Chiropractic embraces all three ,Jrcas, which is why it IIns so much iO offer. THE INDIVIDUAL Each person i" made of four differellt. yet interconnccted, parts: the physical, the cognitive (logical), thc emotional, and the spiritual. This image can be illustrated simply by drawing a circle that represents the individu:ll. dividing it into four quadrants. and imt.lgining t.l door bet\veen each division to illustr:lle the conncction between the parts (Fig. 20.1). A pr"lctical application follows: E"1Ch (lilt' (l:'lh~ four p:lrts innuellcc~ lhe others. A hig dillercllcc is nOlc.:d !Y.:IWccn a disk hernialioll ill a person who is in good mClllal. cm(,rional. and spirilual heallh .llld one ill .Ill individual who h;\~ m::nlal or emotional problelll:'. A complete diagnm.is includes th:: other Ihree component:' ;IS well as the physical lindings. The same different parts of the ellvironlllellt. A simple practical The wise physician. chiropractor, or physical therapist sees the patient as someone with four parts to their make-up living in a four-part ellvironment. Practitioners cannot help every patient with all possible aspects of their problem, but they may need to approach the problem in greater detail sometimes. Often it is helpful to allow the patient time to tell all he or she wants to say about hil1l- or herself. \Ve should be 405 PHYSICAL MENTAL llfti,.:.... r is IHIt llH.·rd~ ~l\It1t:Ollt: who c.m manage a prohkm. hut l'lllt' who 111:lirll;lil1~ ({'111m] \\'hell (oping \Vilh a ·'mess." Fn1l11 Ihi:- di:--l·U.."j\ll1 of the inui\'idu:'11 anti the cll\'ironllI\,.'IU. il is easy hl ~I..''''' thl' common ground between the busi· lIt'" l'XLTllli\'l' ;lll{! Ill.: kallh em; professional. In helping his {\r Ii '" pal iClih. Illl' ph~ ,il'iall or \.:hiropral:10r IIllist he prcpah.:U III d ';d ",ilh tlli ... "1lIt'''''' frl.'qlh•.'lllly. T'l rcali!."" thaI physil.."j;lllp:ltit'lll "ilU;lIitlll' 1)111.:11 arc fr:tU~hl with'lhis kind (\1' diflkulty i... III minilllizc lh.... ,tl'l.', ... c.xpcri .... lll'l.:d by tIll': th .... rapist. [11 additinn. it .... n:lhk:-. him or her 10 ullth..'rsland llHlrc easily the 1IHlugIHS. fcdill~S. ;Illd altitudes of the p;ILiclll. It is curiolls thaI \\'1..' human hcing.s havc two opposing f:ll'Ct:-. within tl:-., On Ihc {lilt.' hand, we \\'Olnl «~ bc different. ~1~ll1d out among our fdlows-hrilliam roolh"n player. top of Ihe d ..lss. c;lrly promotion: 011 lhe other hano. \\11..' wallt to Illl'rgc wilh the I.'rowd·-havc the siilllc ideas and habits and we;lr the same dothc ..... Tht.'sc w..ming faclors make lhe EMOTIONAL SPIRITUAL Fig. 20.1. Four aspects of personality. "11)1..':-<' more l"lHllpk'.x, or the many \\'ay~ to dcal witllthis ··mess." the Ill()!'l valllThis attitude is etwnging. however. Many of us now feel at ease when talking about our world. our universe. and our Creator. The approach of many. p~lrticularly younger people. to this subject is often one that differs from tellr.:ts once considered orlhodox. As physici..ms. we need (0 keep open minds with respect to different ide..ls and beliefs. The good physici"ll1 sits beside the patient prepared 10 listen. rather than standing over the patient or sitting behind the desk. prepared to make: pronouncements about the individual's health. MANAGING SEVERAL PROBLEMS AT THE SAME TIME Although a great deal of our work helping people back to health is quite straightforward. it often can be difficult ancll:lX our capacities to the limit. Ackhoff. an expert adviser ..md writer on the subject of business and industrial m..magcment. commcllled. as quoted by Dixon.~ Ihal problems in these. areas rarely occur in isolation. In :,blc is l'-'llghter. H'i," and nol against someone else. often about something rirJindolls. Wt.'. can ~it beside our paticllts. chauing naturally, gClling them 10 l<.lugh. laughing \\lith thcm. ~(llllctil1lcS wlH:n llcl.'cssary bt.'ing oursc!n;s the butt of the joke 10 enhance the intr.:raetioll. . '.,~ ) liAWTllORNE EFFECT'-'- Mal1 -., HOME AND FAMILY •t HOBBIES (INTERESTS) Fig. 20.2. The individual and the en· vironmenl. • • @ tt WORKPLACE • • SOCIAL (CLUBS, CHURCH) .... __ ..• _ ........ "",., , ~ ( ,,~, c:nl"\v 407 IIVI\( feeling that both m:,magcmcnt and the (cam of sociologists were interested in their welfare. In commellting 011 the Hawthorne effect, Dixon nOlcs that the scientist. in designing experiments, docs his or her best to minimize or eliminate this phenomenon, which is one kind of placebo effect. Dixon thinks thaI using this effect forms the bOlSis of a good deal of his practice and is a central feature of family medicine. The author concurs in regard to his pwcticc as well. OUTAINING THE PATIENT'S CONFIDENCE The effecI of putting the preceding principles into practice in our office and clinics is to build up a patient's confidence in him or herself as well us in the physician or chiropractor. Our interaction with each patient should begin with a friendly greeting. a handshake. walking with him or her from the waiting room to the office. sitting beside him or her and not behind our desk. These things arc little but very important. and represent the invaluable combinati(;n formed when Pc.liir.;ilt and therapist work together. Legend has it that in teaching his apprcmices. Hippocrates stressed the value of obtaining the patient's confidence. It is reported that he went so far as lO say that evcn in cases of the direst of diseases. the comentment engendered by the patient's conviction of the real concern of the physician could be the main factor responsible for a curC. Chiropraclors have all advantage in that their particular skill requires them to lay hands on their patients. This action itself induces confidcnce. The rest of us should share this ad· vantage. by touching the patiem with our hands during the examination and placing a reassuring hand on his or her shoulder when saying goodbye. In referring to a specialist, onc patient said. "He never laid a hand on me 10 examine mc. He came into the room. greeted me brieOy and them asked his resident to tell him what he had found. Then he (old mc i would need a CT scan. a myelogram.•1I1d an operation. I was nOI satisfied. 1 said 1 would think it over. I didn't go back to sec him ag'lin." HOLISTIC DIMENSION Obtaining Ihc paticnt's conlldcncc stems from our regarding him or her as an entire. integrated being. a unilY. somcone of valuc-the physical, mCIHaJ. emotion.d. and spiritual working in combination. The tem1 draws attcntion to an imponant fact. already considered to some extent: 'IS we look on our patients, set Ollt to diagnose their ills. and attempt to treat thcm. we must think of them. '1l1thc time. as a whole man or woman in their own p::lrticular environment. In so doing. we try to get alongside the paticnt. with or almost ;1 p"lrt of him or hcr. 10 help solvc the problem. HOW SYMUOLS AND METAI'HORS WORK The use of symbols :md mClaphors has a powerful effect on the patient. They help the patient overcome the feelings of ios:. of wl&ulctlr.::-:' ;'IIIU unelh';~:-, iv:-:-. ,,;' ... ouirol. vulnerabililY, and isol::uion from friends. relatives, ::JIll! colkagucs. Symbols and mctaphors ..II'<:: vcry pcrsonal. E~ICIl illdi\"idu sc~ h~r fcel happy. free frolll cmbarrolSSmCnl, .llld al case again . • The praclitioner can put him- or hersclf in the p'lticnr's Shl'C:'. ~:IY· ing "Yes, if that happencd to me I would be really mad." The practitioner can say. "After what you have told mc. i \\-l'uld be reluctant 10 undcr£o cystoscopy. I r.:all illlilginc h\l\\ YllU fclt... Another paticnl s'lid. "Once I had" catheter passr.:d by a r\lufh. inexpericnced a..sislal1L It WilS vcry painful. In my C I \\il;iL' ~hln<..lill~ ill l"r\l111 ,Ii" j;, . . ,'I' ~i.\ 1ll1'1l seemed to be ~njoyin); my pn.:l.!il.'allll.:I1I.'· ami \\'(1111\.'11. Tlwy All of these silllllliolls sound ridil,:ulously Silllpk·. Till' reader mav think thaI the\" an.': IHH 1\l..'II'l'u1. I hclil:\'c llh'~ :11\.' cxtrCl1lcly· irnpOrt Ih~rollghly: and wc"lring dCOIli tll1tlcrw\'ar. PREVEl'TION: I'!W\IOTING IIEAl.T11 The most important mcasurcs for the flHurc ..In: ill thl.." 1'1.':11111 ofprcvcnlion. Fortunately. individuals now invol\'ed in 11I"~llth care arc concerned with the promotion of active he'llth ;1I1tl 110t jusl with the <.:orrcction of a disease process. This n\~l.'l1t lesson has been lcarned mostly in the lieltl or sports 1llcdil,,:illC. The resl of us owe a debt of gratitude 10 the pioncers in lhis field_ Our mono should be "health through activity'" Thc 100is and resourccs nccded for disease prevention are well known. \Vc need now to reline ::Ind develop lhl.'lll. ChiropraCIOr5 and medical practilioners teaming to \'.. or" 10gether in harmony is probably the most signili<.:alll advancl.' in [he field of musculoskeletal illncss and tre::Jtmenl. These professionals havc diffcrent yet complemcntary skills and allitudes. For the last 25 years of practice. my work in incrc:t:,ing cooperation with chiropractors has turned oul to be of great benefit to chiropractor. physician. and palient. and W3' of great assistance in teachim! and in resc'Jrch_ Whcn chiroprac;or and physician work together. almost in symbiosis. the rcsuit is something of far greater power than the sum of the two working alone. An analogy can be helpful. The power re:;uhing from fusion of interests on the spiritual pl:.mc is comparable to that relcased by the fusion of hydrogen :.Homs on the Fitnl'ss Cl'ntcr I:\"\.·n sm;lll Nonh Am;.'ri.:an citi~s ha\'l' on~ or t\\"o litness ;lnd large ci,ll..''' have many. Thb type or vcnture is lIsu;dly fUll by a lr;lill:..'d tlH:rapisl or exercise physiologist. Thl'ywl·rl.· startl.'d fnr Ill-.' henclit IIH\~C cngaged in o.Itlllctit: ;ll.·ti\,itil.·.. Ill' :.11 kiml-.. ;,' hoth prnm(ltc litl1ess and help the rl.·Stl!1l1i\11l or minDr l11tl'l'llh\~kcklal illjuric~. The dielll ;1l1L'Il(b ;11 his or hl.·r ,'\\ 11 Qllitiol1. docs his or her own work-oul. ;Illd ;lsb 1'(11 hdp alld ;td\'ice as I1cce:-.sary_ iviany dliropr;ll'{\lrS :Ind Slllll:..' physiL'ians usc thc litllcss center tIl Suppkl11Cnl wh;lt thl..'~ GIll do for the patient in their or~ li(~ :lnd wh;lt lhe pali;.'1ll can do .11 homr.:. They refer the p;tticlll 10 lhe lhcr;lpi~t in.':harg.r.:. bcing careful to kt tile lalll.:!' know by pholle or wrillell IH)\e the nawre of the prohlem. with l)Crhap~ "Ollie sugg.estions as to the type of L'xl.'rcis(' li!,dy 10 bL' u,cful. The therapist has free rein to dirl.:<.:t and advise the pJticnt and to control his or her activity. While the patient i~ allcnding a litness centcr. the health care practitioncr ~lIld IherJpist C.1Il have frequent dis<.:ussions about lhe progress made. The chiropractor or physi<.:ian sees the patient at regular intt:fv.lls. Somctimes. thc professional personally attends the .,amc fitness center. \vhich provides <10dilion;J! \';dLJablc <.:011l Cl.'llll.·r~. or ) physical. Sometimcs the chiropractor takes the lead nod sometimes it is the physician. Each should leam from the other. Th~ chiropractor can help lhe physician by making treatment simpler and more cost effectivc. Quick. almost immedi:.ne intcf\ ention by thc physician makes things bcltcr for both paticnt ~l1ld chiropwctor if somelhing suddenly gocs wrong in the management of a disk herniation or spinal stenosis. or sudden de\'e!opmclll of cauda CqUilHi syndrome. Back School The availability of Ihis f:.lcility is essential. The physician or chiropr:'lctor should be EIOlstic Uodysuit The ratiol1;.J!c for wearing an clastic bodysuit for the prevention and tre.llment of 10\1. back pain is similar III thai Pllt forward by athlctes eng.tged in many different kind:-: or sporting ;lctivitics: downhill lind cross country skiing: bt'bsledding; water skiing: and sl:uba diving. among other things: c1:'lstic trunks or suits arc often worn by footb;.tll. tcnni~. and baskethall players i .. ~ ,.:J. I .. · ,? I , ). _ v •• r\, ASCENT OF TI II', SI'lkITlJ,\L 1\ series , j ~ I ! Il Religiun and Healing Abdul Baha writes. "Religion and Science arc the two \\ ings Oil which man's intcl1igctlcc can soar to Ihe heights. It if. not possible 10 fly with one wing alone. With the wing of religion ! 'llooc an individual \\!ould fall into the quagmire of supcrsti~ I ,i i , ! or steps lead upward from what might be cOl1~id~r~d the purely physical (if such .1 stale cxi~{~d) to lhe COlllpkh:ly spiritual (something 1101 seen in this "-orld). In our w()rk as hc"hh can: pracliliona5.. we arc conccrnt:d with the sp:.'(trum Ihal Iic:'\ bctwccn these 1\\"0 extremes. i ,1, )I I 409 ' · v v ' - ' I v n 11'lII:HI-I.L.IIUN lion. \Vitlt the wing of science nlonc he or she would 1'.. 11 inw the despairing slough of materialism."" Edison patented 1093 invcntiolls Olnd turned the iJl\'cnlions of others into a success. In 1879. after many unsuccessful attempls. he made the first electric light bulb. His tenm produced latex from Goldcn Rod aftcr examining hundreds of plants. When asked whcrc his ideas C41me from, he used to smile and point 10 the sky. Quite ordinary men and women like ourselves belie\"(:: in the existence of a God who is all powerful and prepared under certain conditions to intervene in our affairs. provided thi~ intervention docs not compromise our frce will. We seek this help through what we call "pw)'cr:' It i~ wise to do thi~ lllorC often than we do. l\k.iI:alirm. r('!a.wtiol1. am! ;IIWgf''-Y ("1Il be a part of H;\ck Sdllml or they call be taught individually. both with gl"l.';II b:..'ndil. An illlcgral pari of thi:, proCI.'SS is how to t1l;U1a~1.' :'Ircss. This subject is discus:,ed at length by Z'lhollTl'k. t,· l.;'.\/' (.r the ilJlOgil/Clrio" should h~ cuhi\·all.'d. Sanford" tdb 11(\\, .:.hl.' was able w help a SlH,lll boy with a ':'l.'riol1s heaft condition. She lIiscon:red that he· \Va:' fascinated hy foothall. Sh:..· ,aid. "Let's pl;l)' Puhlications Either/Or: Both/And ) ,! ,II 1 )1 ,' ! I Somcthing is lacking in the way we think. Perhaps it has always been that \\'~IY. In most situations. we think in terms of either/or. The ehiropraclOr or osteopath thinks in h::rms of manual thcrapy. thc physician in terms of medic.lIion or surgery. In S;'lskatoon. the process of chiropractors and orthopedic surgeons learning to work logcthcr \Vas at lirs! p~inful for both sides. Out of lhis elTon c"me a "both/and" tlpproach resulting in a synthesis of both disciplines. something new for us. to thc benefit of bOlh ourselves and our patients. Turning to consideration of the physical and the spirilUal. we encountcr the same difficulty. r\'1~ny spiritually minded health care professionals sec no need for anything other lhan physical and material methods of treatment. Priests and ministers who have ;,\ concern for healing often tend to lhink in spirilucli tenns onl)'. The best approach is a synthesis of the two. Intermediate steps on the journey from the Phy~ic ...1 to the Spiritual contain clements ofholh, <.lnd are mentioned only briefly. Othcr Rcsources /Jack sc.://Ool. already mentioned. deals not only \vith material facts but also with the interaction of instructors and clients .1I1d with the \vhole group ill the class. Discussion of their problems dming breaks is as important as Siegel \\TOIC of lessons learned about sclf-healin~ from a Sllr~ geo;'s cxpcricnct: \!"'ith exceptional p;,llicnts. ' : Hi:, approach combines orthodox medicine with Ihe spiritual. The Americ Power or Prayer M;'II1Y of liS believe that the natural indwdhng defenscs a"ainq forcil'll c invaders and disease, incllldill~ Ibc immune s;slcm. wcre giycn LO us by God as part of our ~makc-up: lhat our CIl\"iro111l1cnt contain~ many resources for hl.'aling. sllb~ stal1c.:c~ like pcnkillill and digitalis: and thai h~;l!th care professionab ;lIld (lthers have their source of tr;lining directly from Him-it is no accident that hospitals :lnd dilli,s had their origin in lhe mona~tcric:' of the Middk .-\;;e=" h is not too !.'!.r~at;l strell'l1 pf the i1llagillatinn to believe in the existence of~lI1 all~po\\'errlJl king, prepared uncler certain circulllstances to intcrvcnl' ill \)\ll' ;tllail's. Again. wc seck this help through prayer. It is l':l'~ to ignore thl' l..'.'\istcllcC of a power "reater than ourse!\'l', \\ hell till' Still j, .;hining. Thl'n our bomfmav• well bl' -~{)Ir. nur ':l\'ior the computer. Ol:r illSpi. ration gained from though!" (It" "<..'.'\. Wlll'll ill health and disaster loom ahL'ad, \n,' ;1I"t~ lllPrl' indillClf!o h\\l]..: above and hl'yond oursch'L" for help. hlrlllllate is !hc man or woman. health care pwrl'" .. ional or p;l1il'l\!. who seck, lO take advantage both of the natural pro\'isilltls for health :\Ill! well ness and of those from lhl' supernatural realm. One exalllpk makes the POllll morc dear. '~hc people involved were lOugh sturdy lishermell. The c.iptain and four members of the crew of a sm:dl craft Iivcd for II days without food in a rubkr rart after their ::r9-llleter fishing boat sank. They werc evclHually rescucd. When ljuesti(\I1ed later. one of the crew said. "We did a lot or praying. I Jclinitdy belicyc that God was watching ovcr us. Every timc \~'e made a stupid mistakc or something went \\Tong wc would just slump our heads and stan praying hcavily·-and bingo something would happcll. Wc did a lot or soul searching and now I think wc'rc going to cnjoy the simpler things in lifc. Inswad of shootiJ'lg for the stars we'rc going to sit down and smell thc flowers." The samc sort of rcyclation can occur when somcone is suffering from severe low back pain. at a time when both patient and doctor are at wit's end. A priest in the Episcopal Church developed severc back and leg pain of sudden onset. He contacted a friend who in !Urn called his friend. an ortho· pedic surgeon. The surgcon examincd the man and thought he had an acute L4-5 disk herniation. This suspicion was confinned by a CT scan. Members of the priest's church prayed for him that night. On his next visit, the surgeon prayed for him as well. with some reluctance (surgeons do not usually pray for priests!). In the middle of that night. thc patient' woke up and realized all his pain had gonc. From that point, he had a rapid and unevcntful recovery. Thc priest later said that he had experienced two miracles: the first, that a surgeon had visited him in his own home, and the second. the healing of his back. SUMMARY Interaction betwecn physician. chiropractor. and patient is both fundamental and complex. The resulting relationships arc the phenomena of most importance. They depend on something more than science alone. The raw materials of which they arc built come from a variety of sources: A careful study of science and its br:lllchcs humanities Philosophy Mylh, lhc story with a meaning' Behavior, symbol and Illclaphor TI1C The combination or these sources with the grcatest significance arc those with a strong symbolic content. GOOD' rela~ tions stem from our seeking the best for onc another. The search Illay involve us in efforts to understand aspects of a person's psychc thaI range from slight differences in dress to grasping the nature or an individual's reaction to a situatioll of life and death. At timcs, it is not difllcult for the discerning physician to empathize with the distress felt by a patient. sh'lring the symbolic contt~llt and the behavioral aspects of the situation. The practitioncr must shift from time to tillle from close identity on the stage to standing back in the wings. In lhe process of travelling with a client from a state of distress to one of complete well-being, we should be prepared 10 seek help from other sources. Complete rapport between the physician and the chiropractor is of greatest significance and also is rewarding. The convergence of ideas and beliefs held by students and teachers from two different backgrounds produces within them the stimulation required to conquer new areas in the spectrulll of musculoskeletal illness. Given the large a nUlllberof different approaches to spiritual healing. it is essential to respect beliefs that arc different from our own. It is good to be aware of the presence and in- . volvement of the Creator in any and every scenario in which client and helper seek health and wholeness. This statement docs not imply that we arc always talking about such awareness. \Vhen we ourselves do not have access to the "throne of grace:' we should feel free to refer the client to someone clse who has. The One who sits on the throne is able to come "alongside" us just as we arc taught to come alongside our clients in their need. REFERENCES I. t\1anllurry 1: Re;mm ;ll11d Emolion. London. Faber and Faber. 1935. 2. Macmurry J: Cre;l(ivc SocielY. London, Faber and F:lbcr, 1935. ~. Blanchard K: Listening::1 Basic Business Skill. In.side Guide. Nc\\"s1eller for C\I1;ldian Plus. Toronto, Grant N.R. Gcall. June, July and August. 1992. 4. Dixon 1": TIle philosophies of family medicine (editorial) Can Fam Physici;lll 35:743, 1989. 5. Chapman-Smith D: Rdleclions on the Hawlhome cffccl. Chiropractic Rcport (editorial). Vol 4. 1989, P I. 6. Dix(\1I T: In praisc of lhe Hawlhorne Effecl (cditorial). Can Fam Physician 35:703. 1989. 7. Coulchan L: The lre;lllllet\{ act: All analysis of the clinical art in chimpr:lctic. J l\-Ianipulali\'e Physiol Ther 14: I. 1990. 8, KirLlIdy· Willi" \VH: Energy stored for aClion: The clastic lwdysltil. In KirLlldy·Willis WH, Burton CV (cds): Mmlaging Low B:lek Pain. New York. Churchill Livingstolle. 1992. 9. Abdul Baha: P;lris talks. London. Baha'i Puhlic Trust. 1973. r 14.'. 10. Zahourck R: Relaxalion and Imagery. Philadelphia, WB Saunder.s. 1988. ! l. S,mfonl A: The Healing Light. New York. B"llanline Books. 19S.l. 12. Sil.'gcl US: Love. ~kdkil\e and 1'vliraek.s. New York, Harper & Row, 19S(I. 1.1. Simonton OC. Mall!ll.'wS S. Creighton J1.: Gelling Well Again. Nt,\\, York. Bantam Books. t980. * Ll Place ot Active Care in Disability Prevention VERT MOONEY The difliculty of defining and treating a sort tissu!.: in.iury to the back is well known. Nonetheless, the.: primary thcr;lIk~Ulil: focus is now changing from relieving pain to rcswring function. The ability (0 measure fum:lional capacit)'. cspct:i;dly for the returning worker. becomes im.:rcasingly illlpOrWIll. MEASlRING FUNCTIONAL CAPACITY Most back injuries. whether industrial or n,:crcational. occur withom :t verifiable sile of injury. No rcpcal;:tblc. valid lest is available to pinpoint the location of the painful soft tbsue in· jury. It must indeed be ror injurics, No matter where the soft tissue injury--disk, facet joints. Iigamcnts. or muscle tendon junction-progressive exercises Sllould be of I]enefit. Anolher importtlnt concept is that when ex.ercises an~ ·used as the Ill or PERFORMANCE LEVELS Objective measurement ufo function is accomplished fairly easily in thc rcalm of sports testing. Performance 1c\'e1s in the athlete arc measurable. and norms against \vhich to asscss performance can be readily cstablished. Athletic pcrformance is a summation of many physical charactcristics. including: strength. endurance. neuromotor control. R~HlgC of Motion Earl)' in the analysis of performance. range of Illotion was recognized as a measurable entity. and the 'lbscncc of normal range was llsed as a possihle predictor of delicicm performance. Range of morion of the extrcmities is nicely measured by goniomctcrs (lnd thus became a standard of physical thcr"py assesslllent of extremity fUllction; the validity nf such measurcment can be verified in the opposite limb. For the back. however. r.mge of motion of the hips l1:1d to be separated rrolll that of the lumbar spine. Thus. in the bte 1960s. sped lie discrimination of IUlllb~lr range W Fig. 21.1. Aerobic lesting using bicycle ergomelers is a relatively inexpensive measure of pertormance. Consistency of elfort and attilude toward physicallunction can olten be detellTlined by evaluating aerobic perlormance. now standard. ~ccordillg 10 the AMA Guidelines for Impainnclll."' In facl. the delineation of lumbar r.mgc is the only objective measuremcnt of function for thc assessment of spin'll impainncnl in these guidelines. This measurement does not give a tolal picture. but no other functional capacity tests for the spine have been judgcd reliable C1nd valid by consensus. Also. some clinicians believe they can recognize intersegmental vari~tions in motion. but such a finding is not Illcasurabh.:. 1• Rang.e testing is insufficient to evaluate the functional cap'Kity of the cxtremilies. A signilicant innovation in the late 1960s was thc dcn~lorlllcnl oftMe capacity locontrollhc vari~ uble of speed in muscle function.] This isokinctic testing <.II~ lo\vcd an individu<J1 (t) cre'He as much torque as feasible. while allowing forcc to be mcasurcd throughoul the range by controlling velocity. This type of measurement proved to be an excellent guide for sports medicine physicians trying to evaluate the rdmi\"c strcngth of ncxors and extensors and status of rehabilitalion after injuries to various joints. The lise of isokinctic dcvicc~ ..\S tr;tining/cxcrcisc tools has come into question. howcver. because the incompletcly controllable imp;tct forces may cause ""Idditional injury. Not until tlu.: early 19S0s WilS the conccpt of isokinetic testing .applied 10 the b'lck. Using converted extremity equipment and normal subjects. the first study was conducted in Japan in 1980." Although the invcstigators did not have a mcthod ef normalizing the torque curves. and the equipment required that subjects he recumbent for testing. several points ~lI1ergcd that arc cuntinned by current studies. In normal subjects, the extensors are s.tronger thun the flexors of thc buck. ~llId the differencc is more signific'll1t in mcn than in women. ~ Age definitely innucnces the strength of trunk muscles: older subjects arc notably weaker than' younger individuals. The relative strengths of extensors and ncxors, however. remain the same during the aging process. Smidt el al (also using convcl1ed equipment) took measuremcnts while subjects were sitting.;'1 more realistic posture in terms 01" o;lck performance.') TIle results conrmn~d th'lt men are sig.nilic~mtly stronger in torso muscul .. ltur~ 111<111 women, :ll1d that the cxh::nsors in normal individu'lls an: signitkmllly stronger than the ncxors. As in most of th~ early studies. the number of subjects was small. Furthennore. factors such as fitness and patient size were not considered. Nonetheless, the sitting posture could be of use in isolating trunk musculature from hip musculature. Mayer ct al lO performed the first major study using equipment specifically designed 10 test b.tck performance isokinc(ically. This group compared significant numbers of subjects (125 normal and 286 chronic back pain patients). The patients were tested while standing, which probably permits a more realistic cv'lluation of lifting performance. The investig I-------~--------------------------- II \ '"~ ) ... _ ..• ~''''''.''''''''''' ",'-v ..... ','-'·v 413 operating at the same lime, comparison from one day to alloth~r and from onc individual to 3nGther is morc difficult 111;111 with isokinctic equipment. Nonetheless, norlllal Icvcl~ of function have been rcponcdY Once again. women have luwer torque and velocity measures than men. One of the most ill1port:lIH contributions from studies w~ing lhi~ equip· lllcllt is that speed of perfonnance is a major discriminator be· {ween individuals \O,:ilh back pain.l-l Investigators lIsing (hi:- . equipment have also observed that with increasing fa~iguc. muscle substitution and greater deviat.ion in the arc of mol ion occur. Fig. 21.2. Example 01 a strengthening circuit manufactured by Cybex. In the far rig f)! corner is the lumbar testing machine for evaluating sagi,Wlllexion and exlension isokinetic lorque. Ih-.: lap,ing of SOIllt: Cybt:.x p;ltcn1s. which h.ls led to a virtual L'xplo~ioll ill lht: lllark\:'ling or l'unL'lional testing equipment. In addition. mallY manufacturers supply exercise eqllip~ 11lt:1\l modeled 011 tht: origin Such evaluation of lateral bending and rotation simultaneollsly with llcxion and extension is a unique property of this equipI11cnt.l~ The point is that different systems of measurcment can provide alternative perspectives on human performance. It Hlso underscores the emerging awareness that onc specilk me.lsure cannol totally summarize or diagnose with certainty the incapacity resulting from soft tissue injury in the back. Various other methods can be used to evaluate free lifting. The subjects arc tested in such a way' that they can lin or lower Isodynamiclisolllctric Testing An alternative !o isokillctic tt:sling is a computt:rii'ed system l'lbcled isodynalllic. Manufaclllrcd by Isotcchnologies (Hillsborough. NC). this constant~load device simultancously measures change ill torque and vdocity in all three planes of molion (silgilt;ll. frolltal. and tralls\'t~rsc). With ~o many variabks Fig. 21.3. Device manufactured by the Lordan Company with an adjustable platform allows testing while sitting or standing. Unfortunately. stabilization of the pelvis cannot be fully achieved. Also, intense. variable resistance concentric and eccentric exer· cise is not available. With these design characteristics, the equipment has proh,~11 to be extremely reliable and repeatable in testing lumbar strength (Fig. 21.4).20 This equipment can also be used for ex· ercise training. Because of the intcnsity of the variable resistance exercise, full potential for strenglhening C~lI1 be reached with only one or two sessions per week. in 3ddition. strength· ening correlates significantly with dilllinish~d pain complaint.:!1 f, PAIN TREATMENT Fig. 21.4. Design of this equipment completely stabilizes the pelvis so that testing accurately documents lumbar extensor mus· cular strength. Also, variable resistance concentric and eccentric strength training is provided to the lumbar extensor muscles. This equipment provides the most significant am\?unt of isolation. and thus. specific training of any device currently available. time. For safety and to avoid overexertion. limits on perfor· mallCc can be identified. For instance. in the Pile tcst, 5- or lO-lb weights arc added ill 30·second intervals. and the sub· jeet lifts and lowers the weights four limes in 30 scconds. If> This lype of tcst provides an alternative to methoJ:i icquiring expensive equipment. Normal standards and comparisons of the performance of back pain patients against such standards for thesc tcsts have been recorded. An improved weights in a box test, known as Epic, has been developed that defines deficit rclative to normal ability.17 Allhough isomctric testing was the first functional tcst mcthod with which to assess lumbar performance and thcn compare it with the expected performance of worker. this single-dimension'method has not maintained its primacy .in lum· bar assessment. l~ In simple. unconstrained isometric testing. the posture of the tesl.subjcct is difficult to cOOlra!. In addition. the significant weak link cannot be easily identifiedunconstrained isometric testing depends on arm strength. trunk strength, and leg strength, but standard test methods cannot readily separate the contribution of each of these factors. Another isometric lumbar test. the Sorenson test, requires th~ subject to hold the trunk parallel to the floor while the torso is unsupported. In industrial populations in Denmark, the inability to hold such a pO!'tufe for a minute or more cor· rdated with an increased incidence of back injury. I') This find· ing implies that strength has something to do with back pain. New equipment has been developed, however. that speed'· iCi.llly segregates lumbar isometric performance from that of the arms and legs. This equipment. made by MedX (Ocala, FL). identifies isometric perfofllwncc at spccilic equidistant points in lumbar range from full flexion to full extension. The thoracolumbar spine is totally !s~b!ed from all other an Given our improved ability to measure strength. we must recognize our inability to locate specifically the soft tissue site of injury in back pain. Quantitative assessment of func· lion secms (0 be the only way to obtain objective data. This concept is not totally accepted. Hasson and Wise criticizcd earlier investigators for not dividing patient groups into diag· nostie categories; howcver. the diagnostic catcgorics they suggested arc non verifiable. Le., ~acroiliac strain versus facet syndrome versus disk pathol.ogy.1~ This problem is identical to that which plagucs the treatment of chronic back pain: most of the sourccs of pain arc non verifiable. Pain in the back usu· ally is withoUl representation of specific nerve root dysfunc· lion. The role of deconditioning-the impairmcnt of physical capacity that may result from prolonged pain~limited bell..1 \'· ior--eannot easily be evaluatcd with a simple physicJI examination. Such barriers to undcrstanding have led to the deve!· opmcnt ef pain clinics with .1 focus on the perception of pain f'lthcr than on the sources of pain. Behavioral control of pain has been the project in these centers. but restoration of functional capacity and return to work have not been mC:i.lsured goals. The focus on treating the pain alone has led to a general suspicion. particularly among third-party payers. that rchabil· itation for chronic pain may be ineffective and in fact m:.lOY be no beHer than a placebo in attaining specific societal goals. such :-lS return to work.~·1 Fordyce and colleagues noted that pain clinics tend to treat the experience ofp<.lin but not the disability associated with pain behavior. Pain often is associated with the deconditioning syndromc. and technology now allows us to measure this extent of deconditioning. III the case of the back. objective lumbar function testing has been of gre One 01" the most imponant areas of community knowledge has emerged from the availability of widespread observ'ltion of sporting evenls. With lelevision covewge. man)' more people wilness injuries suslained during various professional ) ~ptlns. Tk~ abo obsern:: the rapid r~lum of this athlctc to acwithin -'L'veral day.. . or wecks after ~ignificant injury. Thus. thl.' rr..,;t1ily or cl"kcti,'c can.: in SP0l1~ medicine is rcacl~ ily t.,:\·idenl h1 the publ;t.' 'II large. What ;1;"(' lhe priuciples of SpOilS Illl.'dicinc'! Put simply. pm~fL'~S in tre;\(lllCIiI is b:ls~d on measurcd chanu.cs in fUllction. Thl..· ;Hhktt.,: vicws discomfort as im:!c,"ant in~'crms of reltlrn "ur hlll..:tlUIl. Moreover. Ihe c ,; f .~ t; t 1• i, 1"'! ~ I, I, I ~ I ) ) < QUEBEC TASK FORCE: PRINCIPLES FOR EVALUATION AND TREATMENT ~ dr~ssed -~ I ~ -; ~ I$. t "'-¥, t Certainly. the back injury problem is one that has been adby many experienced c1inici.lOs and scientists. A wide ~lfra)' of concepts and various areas of cmph.lsis havc becn reponed. A:-. mentioncd previously. a consensus of these COI1CCPIS is now availablc. In 1987. a document was publishcd stoning tho~e principles dcemed most appropriate for the ev..lu:ltioll and treatment of back injuries. The projcci was initi- aled by the Canadian Inslitule for Workers Health and Safely. Thus, the Quebec T~ck Force on Spinal Disorders was convcned. Included in this task force wcre a wide arTay of experts in mcdicine, law, and therapy.2s This extcnsive consensus report identified various factors that would increase costs, e.g.• exccssive, unnecessary diagnostic testing. such as magnetic resonance imaging. CT. and c1cctromyogrJphy withoUl clinical justification. Surgical in(ervclllion with lillie c1inic31 justificalion also was .. oted. Oneof the most important factors in increasing costs was the usc of ineffective physical thcrapy techniques, such as ultrasound. The usc of the therapies was "hit or miss" in large part because few objective data wcre used to support the benefits of .my type of treatment program. Finally, the report noted that cmployers often arc reluctant to allow an employee \\'ho is still having pain to rcturn to work. This siluation led to prolonged treatment .1I1d. of course. cnhanced legal costs. Delay in receiving effective care ,vas also noted as a factOr in driving up costs. What is effective care? This repon revealed that most complaints were nonspecific in that no anatomic ..:au~c \,.uuld Ix: identified (0 explain the patient's complaint. Even though thc source of the probIcm was unexpl A relatively simple exercise progm.n1 was documented by Choler ct aPR At this acUlc· and subacute phase. some methods in the form ofhcat or cold likely arc useful: however. the literature includes no justification. as supported by the Quebec Task Force Study. that other techniqucs such ;;'s diathermy, massage. and repeated hot packs offer any benefit to enhance the rate of recovery. It must be emphasized that treatment is to a nonspecific problem. and the only definition of improvement in the McKenzie concept is centralization of the pain to the mid-low back. I r the pain progresses funher in a peripheral manner. the therapist must recognize that thc exercise program proposed is inappropriate. The exercise may be extension. nexion. or side·shifting based on what happens ~' 1 to the pain. At least, this type of program has the benefit of some relatively objective measurement of progress. Indeed, a method to measure progress should bi! at the core of (Ill eDident. efJecri\'e rreatmtllf plans. PROVIDING CARE IN TODAY'S HEALTH CARE ENVIRONMENT· I I II t{ iI ~ I The reason for interest in the sports medicine approach. i.e.. measurement of progress by some objective maneuver. is the mattcr of reimbursement. As the health care system begins to look for greater efficiencies, it is apparent that more docllment:.1tion as to the levcl of dysfunction is the basis on which reimbursement is more likely to be provided. The system responds more specifically to paynlclH for IIlcuit.:;,11 care that is focused on documenting how (he parient is functioning beuer. rather than how they might be feeling better. Il is apparent to the providers that even though the patient may feel better briefly. no benefit has been served in tcrms of reimburscmcnt for medical ClIrc without long-tem change in function. Documentation of progress is lhe essence on which billings are reimhurscd. Lack of measurable progress is the documentation on which lIseful medical care for soft tissue injuries has ccased. This is essentially a sports medicine approach. It is unlikely that the future health carc dollar will pay for maintenance level care for benign. nondestructive disease. A plan of care that reflects this attitude is noted in Table 21.1. This treatment guideline has been accepted by scveral preferred provider org,lIlizations in the SOllthern California area. It speaks specifically toward documeIHalion of function. In indu!'trial back injuries. experience shows that the patient seldom arrives at an appropriately oriented trcatmcnt program wilhin thc first scver;;l1 weeks. In those patients for whom treatment is delaycd. somc dcconditioning occurs. In this group of patients. and those that have not improved in the McKenzie type of program. one may expect Table 21.1. Treatment of Medical Bac;<, Prot~cm::; • A program 01 progressive ex:ercise should be initiated after no more than 2 to 3 days of bed rest. Passive melhods (either ice or hot packs) are only useful as an adjunct to exercise, Other tech· niques are not appropriate. • An objective, reproducible functional assessment should occur if more tpan 2 weeks of treatment are required. • Most patients need instruction on appropriate exercise but do not need a lormal program of physicallherapy. When physical therapy is indicated, rll)r~linn ~holJlrl nol exceed 6 weeks and frequency should not exceed three treatments weekly. • Diagnostic radiographs are seldom appropriate initially and, with rare exceptions. are not appropriate at intervals during lrealment. • Unless neurologic function has deteriorated or progressive exercise has failed. specific diagnostic techniques (e.g.. CT scan. magnetic resonance imaging, bone scan, EMG, nerve conduction studies) are not appropriate. • More than 75% of employed patients with medical back problems relum to work within 4 weeks of.on581. Careful re-evaluation of the treatment plan is warranted it the patient has nol progressed significanUy in 4 weeks. • If treatment lasts 6 weeks, the patient should be evaluated by an appropriate medical specialist. The evaluation should include objective measurement of funclional status. reassessment 01 treatment goals. and confirmation of appropriateness of treatment. • If the patient has not return":!d to work within 3 months. the patient shOuld be referred to a specialized center for computerized reassessment and care planning. \ ) of treatment by objective testing is justified. These tools were described previously. SUMMARY Active excrcise programs arc effective in disabilit)' prevention. It is important to separate the concepts of impairment and disability. Impairment is the physical we~lk link(s) that limit function. If we can isolate anatomy suffkiently. we should be able to test thc deficit ;;.lOd evaluatc progress and treatment by further testing. Disability, on the other hand, refers to thc limits that prevent retum to thc previous level of function. In addition to lhe ··weak link" is an array of personal and human factors thm create disability. including age. sex. educ;.uion. secondary gain. and overall attitude. Some factors of disability may involve acquiring b;'ld habits such as substance abuse, obesity. marital and family upheavJI. and anxiety and depression. All of these f () ."..". ,~ . J HEFERENCE.,,) wo, LcBl:lIlc FE, Dupuis 1\'1: Scicnlilic ;'rpmach Hllne assl.'ss· lIlelll :md lIlan:lgcmCllI of ;u:li\'ily-rclalcd spinal dis(lrdcrs. Spine I ~:S t. 19K? 1. Sril7,cr (J --------------~--------_..... + ......; ll:thklll;l1\ S. Phillips RB: 111e spinal manipulati\'c theory ill the man;1~':11I<':11l ~lr low hack pain. In Ft)'llIoycr JW (1.':0): "lC Adult Spine: I'rjll~'jpk~ and Practice. New York. Raven Press. 1991, pp 1581··1605. Lamh I.. Johnsull RL. Sl. Jens PM: CanliO\':lscubr conditioning during ~'h;,i .. r..:.'1. ,.\..:mspat'c r.·lcJ 35:646. 1964. !.od-j w: ~k;lsurCUlcnts (If spinal poslure and f:l.llj;C in spinal nnm:1II~·nl'. :\la J Illlys ~kd IkhahiI9:IOJ. 1967. En~dha;: :\L h.-d): Guides-Io the E\'"luatioll of Pcrlllallcm lmp;,irIllCIlI. "HI Ed. Chi(";,~tI. Americ.m Medical A!'i:sociatiOIl. 1988. ;1IIl! I'r.n.:licc of Chiropr.tclic. New York. API)!clnn Century Crufl ... 11)l\t1. l11isloc H, Hislop HJ. MofTord M, CI al: lsokinetic contraction: A new CllllCCpl of resistivc exercise. Arch Phys Med Rehabil 48:279. 1967. Ilasue M. Fujiw:lr:I M. Kikuchi S: A new mcthod of 'lu:llltit:lti\'c measuremenl of :lbdomin:ll :lfl(l b:lck Illu~clc ~lrength. Spine 5:143,1980. Smidl G. et :l1: Muscle strength :11 the (nmk. J Onhop Spons Ph)'5 Ther 1:165.19S0. :o.1:l)'cr T. Smilh S. Keele)' J. et :II: Quantification of lumbar function. !'an 2: Sagiu:11 rhine trunk strenglh in chronic low·b;lck p;,in patienls. Spine 10:765. 1985. ~h)w T. Slllilh 55. Kundrd- " ) ) " ) 16. Mayer T. Kishing ND. Nichols G. ct :II; Progressive isoincl1\'ll llfling evaluation. L A standardized prolocol ,\lid nonnalive dalaba...e. Spine 13:993. 1988. 17. Alpert J, M:llhesOll L. Beam W. et ill: 'nle reliahililY allli v,!Iidil}' or two new leSCli of maximum lifting cap:lcity. J Occup Rehahil I: 13. 1991. IR. Chaffin DU. 1);lrd; KS: A longitudin:ll study {If low h;lt:k (uill :IS ;Issud· "Ill 1990. 21. Gr.wcs JE. Pollnd ML, FOSler D. ct ill; Effcct of training frcquency :lnU spccilicily on isometric lumbar c:\tcnsion strength. Spinc \5:504. 1990. 22. Ha....son SM. Wisc D1): Instrumcnted teluing of thc back. Surg Rounds Onhop 10:28, 1989. 23. Fordycc W. Roherls A. Slcrnbach R: 111e bcha\'lorJ.\ managcmcnt of chronic pain: A response to critics. Pain 22:113. 1985. 24. M:I)"crT. G:Hchell RJ. Kishino N. el :II: A prospcclivc shon-Icnn study {In chronic low b:lc\.: pOlin p:ltiencs utilil.illg no\'c1 objt.~tivc (uncCioR:d mca.<;urelllenl. Pain 25:.53. 1986. . 25. Spill.Cr UO: Thc scienlilic apprc,xlch 10 lhe a. ;I ~ -? f '\ ~ , ~ ,~ '". ~ C) ~ l, I -...,.~ -' I, .:~) •f .... -~~ ~ t "J: ~ I ~" () ,o- j § tt\ ;: iJ :,.: '{i B t: \! \, ~ ~ 1;s ,- ....j,' ~ t -I " i•• • 1i f: G I• ~ ~ ~ Ir, ~ ~ i ••! J .~ > , '-,? {-~ "',j (} , <-' f-" "o,} /--~ ~,,".J (] :n ;;; f ~ t!:i f 1 \J I Index \ I i , , Abdominals exercises crunch, JO'; lkad but; description. 300. JOI illuslratiun, 347, 382 isolllclrk. 306, JOi SI:lbiJi~\ioll, 303-304, 304-305 gymnastic: tM11. 307, JIO-11 I ohliquc. wcal.:llCss cV:llualions. lOY, 110 Abnoflll;ll illncss bch;wior chronicity 'lOd. :!5 l1eltncd. () cffcCI on ncurolllusl.:ular system, 18 indicalions fur, 6 nonorganic ",i~I)"', 6\) pain and, 17 Waddell's si);lls, 73 Abuse cmotional, 396 sC."U lhig.h illhih;led. eV;llll:lIillll \If, IOi-: muscle ilTlh;ll.~es, locomotor syslem. 48 Aerobic tcstin£. fur p:rforl1lam.:c Ic\'c1 d~tcr11lin:I' lions, 411~11, -112 Arf~rcllt libcrs mech Allodyn;:l dclined, B symjlWIll". 23 mo\'emcnt p:Utcms chronic p:lin and. 25-26 erfcc( on mowr S)·st~lIi. 30 lJ)usl.:ul"r imbal;ll'Ices :mu. J I IrCal1ncnt for. 31 Amotivational s)"lIdrom.: . .\02 An:lcrubic capacil)', cffl'cl on lifting c Alla~d ,\RCON ST. /-17 Afln "b<.Im;tloli. ill p;ltil'nt with shor1ellcd upper lrapczius. 135. 135 Aniculol1luscular :llllJllitllde. (SC(' Flc.'(ibilily) Asymlllctry. pOSluwl llllli.... id~ntirying. 3:\1-.'.': '. palholo,gj(,.·. 331 physiologic, :n I Athleles. (St·t·III.WI Sptln~l lum!l:lr spine injurk,. :lcruhil.: (,.:"tJlldititll\ill~. 3.\X-341J :Igc·rdated facl(lr~. J.\:! ll:tl ,,"'9 ht:d 1\:'1. J.I{. . . \)/1111\(111 'ymlrtllll...·,.. J..15 comdin:ltilill. ~'\I) diagno,i:-. 3'11 injury JlIech:mislll~. J·12 lI1:lnagelllcnt guiddincs, .]:.:> Illl11opcrati\'e care. 3~5-3~6 patient history, 3-1..\ physical c;.;amination, 34.\-3·15 predisposing f;H:IOr.~. 341 rehabilitalion prosr(llilS. 3.48 spmltl)'lolisthcsh tx:curn:llC~. J·e spondylolysis OCC\lrrCllce. 3..l:! t01ll1.: sll\:lIgthening pro!!r:lIJ1s..U6-J-li ATI'. ISt'c' Adclllisine triphosph:u':J U;lh~ l.: skill. 200 flllll;lion,. 19IJ ,un lissue p..in S~lldHlllle:,. :tl.: prolei,'lin~ 419 ..I. Ba~cball, lumbar ~pinc injuries, 353 Bcd, gcning in and out of, propcr fonn, 188 Bcd rcst di$advantagc~, 346 low back pain allcviation, 345 Bchavioral t~crap)', chronic pain trcatm<:nt, 401 Biarticular mu~c1e~, tr.lining specificity for, 51-52 Bias sourccs, 011 pain mcasurell1CIl! quc:>liollnaircs, 59 Biccp~ fcmoris, (St'" also Hamslring) functional an'ltomy, 120 gcncral charactcristics, 120 postisometric rclaxation. 259. 260 shortcned body contour changes. 122. 122 body statics impairmcnt. 120. 121 disturbcd motor pattcm~. 122./22 Biochemical mediation, (See Infiammation) Biofcedback. chronic pain trcatment. 401-402 Biomcchanical coupling. effect on lift-Iowcr tasks. 144 Body contours changcs in shortcning biccps fcmoris, 122. 122 piriformis, 124.127 quadratus lumborum. 128. 130 stcrnocleidomaslOid. 137, 137 tcnsor fasciae latae, 124. 124 upper trapezius, 134. 135 weakening glutcus maximus, 120. 120 rectus abdominus. 133, 133 inspection of, 113 Body oUllines. (See Body contour~) Body static~ abnonnal. 116. 197 case study back view. 140, 141 di~turbed statics. 142 front view. 138, 138 sidc vicw, 138-139,139 diagnostic critcria. 117 disturbed description. 116.217-218 in musclc dysfunction. 116 pelvic di~tortion. 221 normal, diagram.~ of. 115 visllal impeetion, 113-114 back "icw. 113-114, 1/4 front view, 1/5 side view, 114. 1/4. 116 view from above. 115 Bone, immobilization effects. 15 Bone scan indications for, 342 low back pain diagnosis. 341 Borg verbal r.lIing pain ~eale dcscription.61 illustration. 63 Bradykinin. releasc Juring ischemia. 19 Briuge e:>;ercise, 295. 374 description. 300-301. 301 Bnl.~hing teeth. improper and proper posturc. 186 Cardiopulmonary sy.~tem. immobilization crfen~. 15 Care standards low hack pOlin, 34-36. l61J reimburselllent for. 37 C'lrpaltunncl s)'1Idl'Olllc. IhnJ,t Illanipllla1iI1l1'. 215.216 Ctrr)"ing. corrcct posturc. }."'',I C.lse management gencr.l1 principles. 3;;S for nonspecilic back pain. 3M) pain and disability quc,tionn;lirc usc. (II). 69 Cat cxercise. 187. 383 Ccntral controllllcchanislll. tScc Fecdhlrward mcchanism) Ccntral intcgration exteroceptivc infonllation. 329 visual input disorders. 329-331 Ccntralization fl?spomc, in derangcmcnt syndrome,247-248 Cerebellum. movemcnt control involuntary. 26 voluntary, 26 Cervical extension. disturbed movcment pattern,. due to shortcncd upper trapezius, 135. 136 Ccrvical extensors, post isometric rel'lxatiol1, 206 Ccrvical fascia, barricr phenomenon. palpation of,202 Ccr.'iealllcxion. (Sa also Seck l1exion) disturbed movcmcnt pauerns. due to shortened sternocleidomastoid. 137. 137 Cer.·ical musclcs. (Sec alw ~eck musclcs} postisomctric rcla:.:;ation. 271-272 refcrrcd pain. 271 Cervical spine dynamic tests illustration, 238-239 1:;peS, 238-239 joints. referrcd pain. 78-79. 79-80.175.376 loading of, McKenzie approach, 237, 237-230 mobilization techniques. 2/2 position of, aftcr side bending, 217,218 postisolllctric rel'lxation. 379 rangc of motion tests, 78-79. 79-R0 cxtension, 237 flexion, 236 protrusion, 236 rctr'lction,236 static tests, types. 239 traction. 206 Ccr.·icobrachial syndrome. ctiology, 376-378 Ccrvicolhol prillcipal !!\lals. l:'i~ !JHlgr;11ll rrPlll111ioll. 159 pllrpll.'l,'. 1=',~-15·1 rcquiremcnts for. 15X-159 sat"cty llri..:nt;ltinns tll industry. 15(1 Sw..· di,h. 155 dlll\lli..· !Jilin p;lIicnls Cdll<.:;ltiolJ Ilf. ,j') motivalioll ul'. JI) trcatmcnt ;lrpro;Khcs, .j()O-...j(}1 manipulativc therapy harrier ph..:nomellol\. II)X-199 hcnclils of. 222 facct joint ~Ylldrol11c. ~6X for low h;lck p;lin. 7. 36-.~7. 1(15,359 McKenzie approach and. 225. 2:'10-251 recovery r;ltes. 166 thrust. ~13-~15. 217 oflic.: pwcti.., c,. }X4,-~H5 pain ;md dis;lhility questionnaire me. 69. 69 patient sati,Jactinn ratings, subluxation. defincd. 22 Chronic pain ;ICllte pain and. transi1ional '>lCp~. 18 ddined. ~% disability and. )1) 1-)1)2 dnlg usage and. 402 ftlnctional re'>loratioll programs. ·102-403 lifestyle changcs dllc to. 39 movelllel1! pallcrn ;lltefiltion~. 25-2<) p;ltients motivation increases. 39 rehabilitmion education. 39 psychogcnic di;lgnosis .md. 5. :195 psychological tcsts. 398-399 psychosocial faclOrs alcxithymia. 393 compensation, 392 compliance. 392 deprc.ssion. 392 gain. 393 litig..nion,392 reporting to third pari)" payor. 38 risks for developing, I (I 1 sellsory motor slilllu];llion. 321 device.s ilnd 'lids halance balls. 320 balance shocs. ~20, 321 Fillcr. 320, 321 minitr;llTJpoline. 320. 32/ rocker bo;ml. 320.320 twister. 320 wohblc board. J~O. 320 indications for, ~21. 321 mOlor leaming slages. 319-320 .~hort foot (Jc.~cription. 322 exercise program, ~22 fOntl:ltion of. 323 half step forward stance. 323 illustration, 322 passive Imxlclill~. 322 sllhst;ll1cC ahusc ;1I1d. ;'9;'i-':W() syndromes charactcristic_~. 39;; prognosis. 35. 16:'1 __________________________d. Chronic pain--{,"O/1/iJll/cd tesl hallt:ry, }99-4fX) trt:atlllel\t .ICUptllKture, 40 I behavinr;llther~\py, 40 I biofeedhack, 401-402 cognitivt: lherapy. 401 family therapy. 402 ~')~IL,. }:{. ..:no hypnosis, 401-102 pharmawtherapy. 'HJ2 rdaxatiol\ therapy. 401·...4 02 Chronicity detinet!,25 risk f;l(:tors. 34, /66 Cognitive therapy, chronic pain trt:atlllenl. 401 Compression injuries, in alhletes. }43 Concentric conlractions deli ned. 50 training spt:cificity. 51 COIll,:llrrent \·;llidity. of pain queslionnaires. 60 Conncetivc lissuc lesions of. palpalion lesting. 200. ZOO osteopathic cccentric muscle energy proccdurcs. 258 Conservative care. (St'" also Passive care) aggrcssive. 36. 165 low back pain. 6-7 nonspecific back p'lin. 360 primary gO;:JIs, 32 rehahilitation and. comparison. 3 1~32 sciatica. 5. 360 surgery and. comparison, 5 trealment methoJ.~. 6 Constitutional hypermobility, symptoms. III Construct validity. of pain questionnaires. 60 Cuntr;lcl-renex technique lower seapuhH: fhators. 28H, 29/ middle trapezius, 2SH. 290 principles. 254, 258 shoulder joint. 2H7. 288 Contract-relax antagonist contraction. 25H Convergcllce. defined. 24 CR techniquc. (S('(' Contract-relic x tcchnique) CRAe. (Set' Contr;lct-rclax antagonist COIItractioll) Crcep. ti.ssue. dellned, 16 Crilcrion v;lIidity. of pain qucstionn;lires. 60 Crossed .syndromes diS!;11.97 lower illustration. 28 posl\lral signs. 363 pelvic. 106 proximal. 97 Curvc rcversal detined. 23~ l.lbslructions to. 232 Cut;ll1eous hypocsthcsia detincd. 23 symptoms. 23 Daily acti\'ities. (Sn' Activities of daily' living) De;I(I-Bui' excrcise dc.seriplioll, JOO. 301 illustration. 347. 382 Deconditioning altered movelllent patlems..\ 1.3 J charactcristics. 13 defined. 402 joinl hyperscnsitivity. 21-22 llIuscular imbalances. ~ I. 3 J neurophysiologic clements. 17 pain relict. 167 pathophysiology. 14 Dcprcssion, chronic pain and. 392. ;'(l.:~.w5 Derangemcnt syndromc. lllcc!l;l1lic;ll :md symptomatic rcsponses, to loading. 2-1'2. 246-~50 hehavior nomenclature. 24X-249 behavior·toJlogr.lphy-dcfonllity nOI11<.'nel,,ture.249 manipulative therapy. 250-251 p;trtial pattern.s. 249 Descartcs. Rene. view.s on pain. (} Desk. proper height, 167 Diction.try of Occupation:ll Title functional c;lpacity :Ind worl\ capacity eorn::lations,93 joh listings. 93 Diga,~lricus. postisomClric relaxation. 208 Disahility pronc palient. protllc. 36 Disability questionnaires pnin measurement types. 5H reliahility, 59 types. 58 validity. 59-60 Diserimin.mt validity. respomivity. 60 Disk biochemistry. immobilization cffeet.~. /5 hernialions description, J71 ill'lstmtion. /76 low back pain and, relationship. 3 spontaneous recovery. .3 illustration. /70 intervertehral. injury mechanisms. 3·B spinal ncrve TOots and, 170 syndromes, rehahilitation management. ]69-:nO Disk eXlmsion. surgery for. 5 Distal crossed syndrome. charaelcristics, 97 Distr,lction force. joint surfacc separalion and,2/5 DistraetioflS. as abnormal illncss beha\ior sign. 73 Disturbed hody slatics descriplion. II(l, 217-21~ in muscle dysfunelion. 116 pelvic distortion, 221 Disturbed l1lovemcnt rauans asscssrnell! of normal, 117. 1/7 shortened muscles. 117-11 g weakcned muscles. 117-118 dlle to m\lscle dysfunclion biceps femoris. 122. 122 gluteus rnaximus. 120 stcrnocleidoll1as\(lid. 137. /37 Di'l.l.iness ,Iisordcrs. 3X;,-,i:-;4 Dormant lIluscle. 29(l Dorsal fascia. harrier phc11l1l1JCnon. palpation of. 201. 2a! Dorsal h,'m scn~iti/:lIi(lI1. ~~ asso..:i:~l<.'d ncural dl;lIl~"" :'.' caus,". ~3 ddin,:d.14 p;lin ;~:ld. 17 pallw:·i1ysio]ogy or. 25 DOT. IS,.,. Diction;!ry of O,,'I:l':lli(1:l:d Till<.' j l)\luhk k,: raise. f(lr p.... h'h: ,!:<.'n~\I1I'·'I. .\(J n,,\\,af:cr', hump. !7lJ [)y.Shlll'li(ln syndrome. Illc(harlIL'al ;tI1d ' : mpl(lmalic rc';:,onses. IO:lding. ]':2. 2,14-~.l(, classitkations, 24:; lI1anipulativc therapy. 250 EecclIlriL' contractions defined. 50 training specificity, 51 Education programs B:lCk school Cl!iforni::. 155 Cm;ldi;1l1 Back Educalion Units. 155 origins 154 principal goals. IS] purposc, 15,\-154 results. 154-155 Swedish. 155 history of. 154 patient. (Sa P:nient education) Elbo\\". extension tests. for hyperl1lohilil~ e\'allla~ tions. //0. III ELC. {Sa EPIC Lift CapaCity Tesll Electromyography. muscular imbalan<.'e J:lla. 26-27.27 EMG. (See Electromyography) Endurance training. effect on ml1sck. 4~--19 Engram. defined. 26 Environmenl, paticnt and. 405-406. -106 EPIC Lift Capacity Test, description. jJ<.} Erector ~pinae hypertrophy. 107. 368 inhibited. cv;l1uation of. 109 po~tisomelric rd:lxation. 268. 270. :;, :-0271.373 referreJ pain. 2(1:-; sci f-jXlstisometric rcla\~ltion. 27:;' self·metching. 270. 27/,373 shortened. tcst for. 370 thor;;cic, 206 tighmess evaluation. I(}O. 10-1 trigga poi illS. 265. 367 Ergunomics. wor\.;s\;ltion eh;;ir ~ellil\gs. 167. /79 computer, /7Y headache rdict". 375-376 ERGOS work simulator lk,uiption. l·n illu'\ration, 1.17 Exer~·i'C. actin:. j\lr low back pain. ~ Exercise hall. (Sa Gymn ,0 or. Excn::i:-e:--'nUlfillll('t! isomelric. 306. 307 SI:lhiliz.:llion, 303-3Q.1, ](N-J05 gymnastic ball. 307, .lIO-.HI chronic paill al!c\·i:l.Iion. 39 cOlllpliealing factors, 359-360 cndurance, erfect on muscle, 4S force, effecl on nHlscle, 4t\ gymnasllc h,ll1 b~I'::': ,,:oc:c!:. ~I~. 3/5. 37-1 hridgc, 307, 3M-3/O dorsal cx.lcnsion, 3 [3, 3 J.J fronl rolls. 313, 3/4 iIImar.nion. Jo.'~-3/2 lumbar clttcllsion, 31), 1/-1 scc-saw,)11.3/3 shoulder rehahililation. 381-38~ squ;l{S, 313, 3 J3-3/4. 374 "sullCrm:tn:' 309. .lIZ. 374 types. 306-.:\07, 309 imprtlpcr form hC:l:d rorw;mj posture, 187 low hack h)"pcrelttension, /85 politural faults from, .MI waisl slumping, 187 kneeling dc.~criplion. 30J or. l::'.. tn ....·F1..' ll\lll'. S~-S3 . .';.J. h'IIII,11I11':. SI..';1 hip Ikwr. SO-XI.,'\1 kllt't' 11..'\11111. S:!. 81 pdvil: 1111. Sl,: ,)y, ZI),,-}IJI. ';,';2 I\.'t·!th fClllnri ... XU-Xl. ,,1 Sl\kll~, S.'. ,<';5 pl'llll;lr. U3 pn 'pritlCept i\"C. .l2 'J ml:llurs Icst, 33-1-.1.;:' :-pill;11. .l\2 3'N-.'30 lllamlihlliar inlerft'r":Il..·l' •.H.'i musdc 1011<:, 330 orttltlplics contrihmi\1I1", Y;7 pO~lural swaying..';;0 l)u~lUr:l1 tr.linin!; pl;U(llflll..'.11\•.;j,'\ -.tahillll1\elry t.baiptioll.337 Rumberg's quotient..'\.\7. 337 ue;l11ncnl follow-up..'.'6 Fittcr d..:~crirli(Jn. 3~O . .1:26 illu~tr;l1i(\Il, 32/, 327 FOOl 27,28 tr.lining eneels. 27 r::Ili!!-uC" curve. illUSlr.ltiOIl. 17 I:CE. (St·t'.Fllflclional cap;ld:y evaluation) Fcedhaek Illcch;lnism hdlavioral syslems and :\pproach, 47 descriplion.47 llItJ\'t:Illt'1lI eorreclivc Iev::!s, 47 Flexion prolonged. crf...'C1 on lifting injury. 167 vulncr.Jh1c positions. 171 Food in lake, musclc dysfunction, /97 dorsillcxion, for hypcnnobilily c\·~llualinn~. 111.11/ proprioceptive rcccp\()r~. 3~O Foolball. lumbar spine injuries. ;;51-;;5~ Fol'\;c, dclinilion of. for tr:lining l,lad delcrminali(ln~. -Il-i Force lraining, cffecl 011 lIlu:-ck. 4S-t9 Force·angle curve fle~criDlion. 51 illu!'olration,52 Force-velocity CUf\·C de~cripli()n. 50 illllstr:l\itlll.51 impMwnce to rehabilitation. 51 1Jlccl!;lllislilS of. 50 For""ard bending. Ic~t. for hypcrlll\lhiliIY. II J, III Free lifting. cvalll;llioll of. 413 FS. (.'iff; Function;11 ~I:lhilil.;lliun) Fukuda-Untcrb!:rJ;cr Stcpping Test iIIuslrilliOll,332 pathologic asymtnl.:lry, 331 Function;tl c:lpacily cJl:tcrrtal dcrn,md and, rcl:llio1lship. IfI, /68 work capacity antI. corrclmiuns h~'I\\'ccn. 9J ----------------------- (.- lk-,ihilil~ 20+-205 face \"alidily. uf p:till qU~lionnaircs. 60 Facel joim l;yndromc dl.":!'cripliOll,366..·)67 char:lCtcristic~. , l'\l":l'llCcptivl·. J2'1 llJ,lIIiplllalillll .~.~2 '.'.'.' I"SIS. 3:\5-3;;(>. }.'5_.1.'" 1,,:uIIIIl10111r. 3J>.~".;. 333 \'i~u;ll. 1:IIIKliulI;11 \·;lr.I~·lty c\·aluathlll alll1lill; .. II~III"n ,It. 7-1-7:'i. l:ill\lj'llllll'nb "i. 1-1., lTili..·;11 f;l~'I"t, Inl". 75 liIllL·litlll;lltl"b. 77 l\lll'''·lI!(l~h,·kl.d t"L1l1,·liot\:t1 :1'1"'..,·1'. 75 'lh.k..·li\',· qll:lI1l11i:lhk 1\:sIS IIll'1Ih Fk:o:ihility dclincd. -Iii lo~ses in, low hack pain ;lIld, 15 tc,IS of ~;I~trocnell1ius.S::!-~O. )j.J hamstring. 81. ~ I hip Ilcltor. 8Q-8I,l'i1 knce. 82, tiZ qu,ldriceps, S2, 82 rcctus feJl1oris. 80-81. 81, 110 hllllt"ocl($1f:'al,3-12 Fast-twitch fibers ~ h'lal 1"I"";lillll. illll~Ir.II"'Il, ,SO Fihnlhb"l~. .'il:;lr (llflllal1\>Il, I.' Fihll!;l. 1lltlhiliZ;lIilln I,·,hlliqu,'. : /4 Fill,' 1'I)~lt1r:l1 sYStl'lll illustr'llion.303-304 locomotor system rC:l.Cti\'ation, 53 pro~ralll erc;llion, criteria. 52 role of muscular qualities in. 48 singk knee and double knee. /87 Extcnsor:> cervical. postisomctric rdalt<1tion, 200 "nee, mechanism disorders, 382-383 wrist, postisonlclric relaxation, 204 External dem:md, functiona: c:lpacity di:lgno"is. 3 palho!clgy, 345 rchahilitationlllanagclllcnt. 36l-i Iriggcr points..M7 Facct joints, oricn!:llion of. 341 Fadlit:ltcd scpncnt, defined. 22 F;ul1ily thcrapy. chronic pain IrC:ltmcm, -102 Fascia !:lan-ier phenorncpc1ll. ~Ol. ZOI Cl.":rvical. 20Z dorsa!. ~Ol. 20/ ghue;ll. ~Ol. 2()J ,• i:..:";,-,,, ..... ,IIU<.:,ii... ,,'l11. ,k..,-riptillll. ..\(I_.J' 111 lIltlllOIl (t'rvi..',,1 .. pint', iX-7$. ill_SO hip rolall{111. X~. 82¥,'.;,' lumh:lr ~plll~. 76. 77 th(\r;I~'k "pm,'. 7X. 7.'\ lrun" rut:llllHI. 7:\. 71) ptl rrost'. 7-1 qualiliahlc IC'I-. hip ;,h{\m;titlli. XX-St}, WJ hip t',\l..:n .. loll. 91. 1)2 ncd-; 11c.~i\lIl, X7. l}() Ollt' k~ "l:lIldill,~ 1..',,1, x.;,,vJ pd\"ic lilt. Xli. ,'';N 3,';1 n:Spir.llion ,"nnrt.lill:llilln. XX-S9. IJO shuuldcr ;lbtJUl:tiOll. X.'i. ,'\.'01 sqllat .\lfCn~lh, S-I-S5. 8i Sl:lntllil kn..:clicsi. X3-S-I. ,VI slenlf.x:lcidlllua'luid. S7-KX. YO tnlllk IIc.\ion, X7. WJ lrunk sid..: rai"ing slrcnglh. 'JO--9 J. 'JI rall~e W(lrk c:lp.1cil>· and. 93 FUlIl:lional ddicit," Illw h;ll:k p:lin :mt!. rcl;ltillll.. hip. IfI tIU;llItilic;l1itlll (If. fum:lilln:ll (;Ip:ll:lty C\';IIU;I· linn, n IrCalmC1lt tlf, 7~ Funeti(ln:11 pro.;:rt..... qll:lluilic:uion. -',Ii Functiollal r.mgc.l.'if'c' Tr:linillg r:logc) Functiollal rC"llJr:lIi'lll chronic pain and, -1{)~-4U~ [tlCOllllllor -,y .. lt:1Il lI1UScul,lr illlh:llanccs. ~62 p:lth(lkine,ology.3h2 pa:icnt da..,ilic;ltiull. 361 sl,in.. 1 !'o1;.Jhilily. :'I61-:HI2 lIlullitlisciplin;.Jry indlcalioll\ ..\2. J6 SChCIll;llic. Ij p:llil.'lll SCkClill)l. }.'i.'i secondary "'lll\llltlllt'fll~ 01', .'01, IS (,·;IP:~l'iIY c\'aIU:llioli. X lIlutur sy:-h~lIl rc!mhililalioll. X palient Cdut·;.lion. N p-"'ydUNl(;ial f;ll"lurs idt'ntiliGllillll. S-t) FUIl..·linll:l1 -",lahilizOllillll dilliGl1 applic;llicUl ..2t)(,_'21)7 ....\cf,·i"c chcd:li~t. J 1(1-317 cxcr'!.'ise If:llmn;!. 295 factors Ihal arkcl. ]/)(, cxercises ahdlllllinal .... .103-JU·\. 304-31J5 funcl;llu:11 .. ~ ; 423 Functi'1ll3! '!al ":.\Icll~iun, .\1 3.31': fWlIl rolb-. 313. 3/./ illll.~lr;l:i(ln. 308-3/2 lUlllh;lr .:xlcnslnll . .' 13.3/.1 ~c·saw. .lII. 313 shnulda rch;lhililalion. J8J-3~~ S4U:lls. 313. 3IJ-J /4 "sur::m1:ln:' 309. 3/2. 37-1 tYll<:S, 306-307. 309 ! ,i J I, i -~ ~ ! ~] ). ~ ~ "j 1 I •! i *~J ,I I ~ •I ~ ~ I iI i, I I Cilul<:U:- 1lI..'dilh l:Killtalll'IlI\·dull'jll\·:-. !I)(I. :!lJl Fill"'r Il~~'. J~; t'tll1<:tiOll. 102 '1;lhilil.alillll c.\..·r..·I'~·'; ..\OtJ-.'U5 . .WI ."'. (iltl1l'u.~ lIIiuilllll' flllH.:liol1. IO! rdcrrcll p;,in. 175 slahili/.;uiull c:\~·n:i .....s. JtMI-.\tl I. 301 G\.J1f, lumhar spille injuri<:s. 55.2-:\5.; 1Il1lhili/alillil I'roCl..'durc:<.. JlOSli:<.omclrie rebx- Gravity alion. pullcy.315 Gr.tvity inloler-mee. squats. 305. 306 styrofoam. 306.306-307 go,lls of. 291 principles. 293. 295 routines. 296 spinal position. 297-298 training range, 294-295 Function;I) tesling funcliom.356 lunge IC~L 296 purpose. 356 I),JX·s.297 Gain primar)". 393 secondllry. 393 ler1iary.39.l Gail evaluation of. 97 hip extension cvaIUalion!'i. 101. /05 :<.lilllCC phJ.St:. 197 swing phase. 197 Gail :1IlJ.lysis hip movcmenlS. altercd alxluClion. 363 cx-Icnsion. 363 neck flexion. 365 purpose. 30 rcspir.llion. ahcrcd. 366 seapulohumeral rhYlhm. altered. 365 1m Ilk nexion. altered, 3(..1 lrunk lowering, 366 Ghneus ma.'(imu;;; funclion:ll :l/I:11omy. lIS gcna'll Ch,Hilclcrislics, I' 8 poslisoll\ctric rcl;lx-ation, 2(1) I clTcet 011 Ir;linint: lll,al d..:lcrlllillalilll1\. J~ usc in poslisnmclri;; rdax.uillll. 20:'-21)-. 171 iIIustr.II;OIl, 176 i....;\. , .,. .=*-----:--------------------------I Il~ ~ I ~ \. \, . ~:;s Gynmastic b:tll c~cfcises bolC!.; slrclch. 313. 315. 3i.J bridge. 307. 309-JJ() dorsal cx-tension. 313. 3/./ e.>;tension.349 fronl rolls. 313. JJ.: illustration. 30.'~-JJ2 lumbar cxtensiun. 313, J 1./ pdrti;ll sit·ups. 3~Cj scc-saw. 311. 3/3 shouldcr rchabilil7(1 manip\llalivc Illl:r..lPY. 2n-~23 rchabilil:llioll Jllilnagcll1l.'lIt. ~7U-37 I. 3i)-37b types. 370 J'lcallh chills. chiropraclors ;md. rclmjoll'hlp. 360-361 Hernialiolls. disk dc.~cripli(lil. ~8-1-285. :?X6 flIl:i1iotl. r,mge (If m(llillllleSI.~. 82. 8?-s.~ }1}6 i 1 ~ Hip "bdlKlillll all.::r...d p:l1Ierns. ~63-J(w. 36-1 ("1".Irdill:llio!l I<:st, :-;9, Y! !i~l:llle ...... .c\·;llu;llitlll. 1)1). 101. /05 ;uldul'l:on. ligllll1<:s~ C\·:IIUalilln.lJlJ. 100-101 e~I\~n:-II'U. (S{'c nix" Bicep' lel1lori,1 :Ilh:rcl! p:lllems. :\(1.\ 3(j3 l'(II.'Hlin Gothic shuulder. de'crilllitlll. 109-110 lightl1cs~ c\";dU:llilln. 10./ trigg.er point!>. 2H'Glenohumcral mOl ion. :<'c:lpulohumcr:,1 rhyllHll, 3foiU Gluteal fasci;l. barrier pheuCllllenon. palp:lli(lll of. '201. 201 1 It.,," t'>;l.:k p:,in OIlld. rdalil.n.;hip. 3 sl',onl;lIll.'OIl" rCl'l\\·ay. :; kneelin};. 303. 303-304 lumbopch"ic.298-300 lunge. 305. )05 11ron.... 30i-3o:!, 302 G;l.slrocllcllliulo f1c: ~ ".'11' 'Iretdlin~. 26.". 1.6S .'l'lhili/.;l\illn c.\er~·i~cs. 3U 1_.llJ.;. 30~ _}I,.; \\'cakcncll hody ll\lllil\\' dlau~c~. I ~O. J2/J Ilisltlr11o\:d Il1OI"r pallerns. I ~H d.~turh ...·(l :-1:IIK.';. liS. J1'1 1lip n....\\Or' Ikxlhilily lcst. SO-SI. ,~I ll1(lVelllenl pallern ilnpairmcnl pinformi" shortening. /27. 128 lemm fasci;u: I"lac .o;horlcning. [24. 125 fK1Slis(llllctric r..:lax;111nn. 262. 263 .o;llllrlcned. It:sl for, 3fi9 tighlllC~\ \:\"alu;,tiot!. ~S-99. fJ9-IOO Hip internal Wl:llors. !l(lslismnclric relaxation, 267.268 Hip joill1. f'K"ll"II111Ctric rc!:lxali(lll, History. pdticllt cffect on Ireatlllt:nl plan. J~4 form~l, ,in 397-39:\ for low back pain c\·alualioll. 344. :-5i p"in drawing. W9 Hoffman rcUc:'\: :Icti\'ily, 254 Hold-relax lechnique. prindrlc~. 254_ ~5i HR lechnique, {S('c I-!oh.l·rcla.'( tcchl1iqu~l Hyperalgesia dclincd. 23 secondary, (Sa Refcrred p:lin) symplOrns. 23 Wllc.. .. skin drag di:lgn(l~i~. 198.200 Hypcrmobility :lsseS~ll1cnl of. I I I con!>titutional. III dCl'cription. III cvalwlllvc IC~IS c!buwextension. 110 fOOl dor~inc:\ion. JJ1 forward hCllding les!. III thumb hyperlell~i()lI. J10 H ypcrlonu.\. 2{W defincd. 113 vi.\u:ll impcclinll rllr. 1I(i I-Iypcnruphy. cfecl(lr spina..: muscle.. , /0-. 3(iS l-Iypllo~j:-. chronic 1};.IIl IfC;lllllcnt. 401-t(l~ Hypcr.lll;csic Hypoc~lhe\i;l. ddincd.23 symptom... CUI:JJ1C\1\IS ~:t Hy~lJ,:rc\is dclinel.1. 1(1 illustration. using slrcs!J"tr.tln CU(l'~'_ J:;lIluscle injury du<: to. 1(1 lBQ. {St"(: 1II11c."s Bch"~'i(lt QUCSliollll;lir..··' IliopsoOl\ lh:xibilily tesls, Xl .. "." I~,'<.l~ } ".", """ ]1ostisometrir rdaxatioll. "2(11-2(,3. 263,372 :r,: rderred pain. 173. IN. 261 sclf-strctching. 263, ](,3. 373 tightncss cvaluatioll. %. 9'1 trigger points, 2(,2 trunk (uri up cvaillatitills, 102. /(/5 Illness Bchavillr QUL:stilltlll;lire. ,kWI-il'tl\\I\. (,I) Illness hchavi('rs abnormal deli ned, () indications for, 6 pain and, 17 Wadddl's signs I'f, 7J normal. 18 psychosocial indi(es Back Pain Classilication Scale. (15 Illness Behavior Questiollllair"" (1<) nonorgank signs. 69 Sitkn",ss Impact Prohk, ()I) rok in patient eV'llu'llion. 57 ImmobilizatiOll biochemic,,1 changes. l.J low back p"in llaillic testing, Illlllhar 1~I,illl..'rtial. isometric ~pill"'. -11.,-114 and l'I'klnelic. n'nlp:tll· SUIl. J50 l,,'ith.'rli:ll testillg \kfllld, 145 m;l\III11ltll ;lr~'qllabk\\"I,:I\\ ;IP!'II';ldl. [.-IS h"kinc·iic· t,'"sting ,"I'lh·,'pl illln,duclil'l1. I·:" d,·tin,·d. 145 i','m,·tri,' ;lIld i~oilh.'nl;d. ,·'llllp;lri,ol1, 1511 uno lirt. 1-18 lUllIh;11" spin~', ·11 ~ r,'luhilityof. I-IS .. 112 1~1'11l,·tn..: ":('lltr;I":li(ltI~ d,'llll,',1. :'i0 tlallHllg SIl<:citicity.;=; I hom":lrI": stn.:ngthL:llillg, ill llL:ulral positioll. 346 J~\1l11,'tri~' testing (klill..:d.145 ,k,;,:,iptl(ln, 146 isokinL:lic and iSI,inl.'rlial, ..:omp;lris\lll. l,'if) rdi;thiJityof. 14(1 safct~ o!'. 146 S(lr..:nSllll t..:st, ·11·1 Ja\'din throw. lumbar spinc injuries. 3;=;2 Job di~"l1isr;ll.'tion, questi(lfln;lires, 7-1 Joh~. DOT dassiti":;ltion~. 9.' Joint mubili/,atiol1. description. 209-211 Joint receptors. stimulation of. effect on mtlsdes. 19,21 Joinb afferent excitation studies, 22 ~·eni..:;ll spine, rderreo pain. 7B-79, IY··80, /75.376 dysfunction. 2 I-22 myofasciJI trigger pIJints ;Illd, differential di, agllosis, 366 facel. 341 fixed (Je:"ioll, contrihuting factors. 23 functions, 45 imlJ1obilil.ation cllects, J5 inflammation, neuronal events, 12 lumbar spine. rden"ed pain. /75 IllU'Clcs and, functiona! illler;lctions. 30 recl..'ptors. (."'·(·i> Joinl receptors) sacroiliac ;Idjustlllents pr, dfect on rellcx r",sp(lnse~. 4 7 mohilil.ation techniques. 210 Jumps description, 323 illu>,tration.315-320 sensory motor programs. 323 Kincsiophohia.295 Kinetic chain, functional pathology, 3.W Knee extensor.s, lllcchanism disord~·rs. 3S2-}X} Knee l1c,xioll flexibility, objcctive quantiti ~clf-~ln:tdlillg, 275, "27(, tightn",.\s cvaluation, %. V8. lO8. 109 triggcr poinls, 275 LIDO lift. is,lkinClic testing, /,18 Lifestyk, p;tlicill. ljllestionnaires. 74 l.il'ting dctined, 14.1 !l;lIId PO~ili(lllil\g, 144 hl\\~·tillg ;lIld. cOlllp:lrisoll, 1,13 fr"qUL:llcy linlit;ltions. 144 "'lcGill's rules. 1(}7 1~'..:lll1i(llIeS, 16()-1(}7. 181-·-182 vcnical displae"'lIlell1. 144 Liftillg ':;lpacity factors th;lt affect, 14.'-14:'i, /-/5 sll'l.'llgth tl.'Sls. 92-93 ~'\ll1lp 150 typcs, l·~;=; WEST-EPIC test. I_P}, 1-1V II.'sting oL 143 Ligaments imnl\lhilil.atiol\ dfects, /5 stre.\slstrain curve, 10 Li~tl.'llillg, a'S component of p;ltient care, 4(l5-Hl6 Load .:ITcd on Hlllsde fatiJ;ll<.·, 1(1, 17, 19 Illlriwlltal displ,lcem~'nt, 143-144 Loading amplitude, 22:-; dynamic. 22:-; frequency,22K intensity, 228 m",chanical responses properties of. 2~0-2~3 syndromcs der:lI1gelllelll. 2-12. 246-250 dysfunction. 2-12. 244-246 po.stural, 242, 243-244 111<.l\"t.'lllelll planes. 22S-229 posture, 229 sour",,,,s. "229 spin:l!' 227 st re.~p(ll1sl.'s p;lrametcr~ or. 2.'()·"·2~J syndromcs d",rangelllenl. 2-12. 246-250 dysfunction, 2-12. 244·-24(1 postural, 2-12, 243-244 Loading strategy. COlllr(lIlent.~, 229-230 Locolliotor system, (S('(' also Molor system) chain reactions in. 359 ll)wer crossed syndrome . .'62-363, 363 uppl.'r crossed syndrome, 364-3(,(1 dysfulletioll, 196 fUIKtional restoratitll1 nlllSClilar illlbalanc~'s. 362 path()kine.~ology. .'62 patient cla_ssilic;lti,)l1, 361 ."pinal stability. .'61-362 fUll~'ti()ns of, changes in, 196 fUlll!amcnt:ll unit'S anatomic cOmpOl1<::l11s, 45 fUllctional c01l1pon~'llts, -15--4(} IlIl.'chanical cOllll',lnell\s, 45 motor control kedb;lck,47 fc'l.'df(lrwanl cOllln,l ..1(1----,17 425 ,1 J ,p,·.,tll,llllr ' ) ,Il'lll .. , • ";::,::,,,,1 Illll,,'k ...· ••1111'•• 11 ...· 1\\- ... 'lIll;'...·lh>JII~I'\>. ",. d~,flllh:ll"th. )~-~_; ..·\...· l\·i".: ;111.1 ll';tlllin:: ,'r...· '.:rll1lilllh. )~ l~ll, 1.,l, ··;lll::k ...· tH,\'. ~ 1 ··n'I".·Il~ . .·UT . . :. ~n~:'il 111,'1\11' lIlIll_ ..1'1 -5·' .;! ·';;2 1'.lllh,k H'""l"I,,~~, .:1': I'h~,"",I'l.;!I\· 1111;1111 ..., 1l1ll_(lIbl'. .IS tlf;:;lIIil', .IS ':'~"":"I :-trul·Hlr;llllalh"I\,~~. !'}- -19X 1.\111~ loop n..'lk\.-17 L'lr.lt',i,' ptlsilion. f'}t, LlIW h;I\:1( p;\in.tSt"· ,Ill.. 1.lImh:lf "pilll:J ;l(!i,,' l·:\~n:+.c h,'I1..:lll_. '\ hinp,~dlO_'lh:ial ,ll'pr, ., .. h. \j ,";tf.: '-':lllllanis..\.'-.~(,. ii," ,';1 .. ..: llI;lI\'I:':'::IIIClil pnl:;lul",,,. J·I··.16 rql d:l",ilil·;lliIlIlS. 3.~(, (O"b ;t~_~o,:iall'd wllh. ,J comp·,;u:-:llioll. Y. .: n:ducliol1:' ill. 15.1-155 di,\gno~is uf. 3:! agl··rc1;}ll'd I'Klnr...~..t~ hun..: scali. 3.11 disk hcrni:ui,lllS ;Illd. r;:J;,lillnship..' cxer,;i,;:s fnr. (Sn' E'<:rcl,csJ f:u:lorlo lhal pn:di..:t. .W(, funclional diSl1rucrs. 6. l:i high risk p;llicnls. IMI manipul:llin: Ih",r;tp~ re,uh~. 7 mi=,uiagnnsis prc\":Jknc..:. 3. -I Mruclur.11 di:I~lliNs. ]-1 symplom r":cllfr,,,ncc. 3 mislIlanagemcnt o\·crus..: Ill' surgery. =prol(lng..:d h",d r.:'1. .1-5 p"ychogcnil' ,li;ll;f1O'l" 5-6 lIlusck "lr.:nglh ;llItl. rd::tiollship. 15 nonspccilil: C,I~C rnall:tg":llIelll. 3"(1 sources of. 36 prc\"akncc (11'. 1:'3 prevcnlive 11IC:lsur..:, b:lck sch~xll. ISn' Bad.: wh('(I!) cla,\i(" j,OdY.SlliL ,\lJ:-; litll":SS cCIII..:r. ·If!X psycho..ocial pn.:dilcctmn. IJ qualilY ("an: appwac!H:' primary ctlllscr\';lli\l: c;m~. b-7 rril1l:l~' prL·v",nliun. (, SdU:lllalic. 6 second:lry fUIH-'linnal rcslllr:llillll. 7-1-: Quebec Til..k Furo.:c. 3(j1 ",ilh radicular symptoms. L'arc .,I;H)(l:mh. 3-l-35 rc:con:~'. faclOr:- lil;11 illay pn:dil·t. 3·1 recurrence risk f:u;lun. 15 rcdUl;lioll IIlctllll(b. ,lrl;ss/\lr;lin rs·l!ucliclll. 16-li ( ( \. { J ... lral,·~i,:, ..;3. ·11-1. -J /(, trunk 'lr~'n;:;h':llil1~ llnt _'('-,n l·olb,n";lliv..: l';lr,. (,-: \. 'UIKlur;,l p.llhtlllll;il..' liHdll1l;.....~-1. 13 lI<:;lhlll'nl f" .• I...• .13. ~(,_.~i ;1!;:"fllhm.35 1l;llHlll:: 'l'l·l'i1i,·Il~. l..... r,·..:pllnllll\llpl. rl'~nhllipn p..:rccnl:lgcs. 7 n:lttm II' .1'1,\c clllplllym.:nl p.:h·~nl:lgcs. 3. oJ "'1"'"1·,\'1:1":'1. '.'>C'I' I.lilllh:lr srm,:. ~IXlns ;l11d) ... t;lhilllll1~·lrl' dala. R(llllb~r{s qUlllit:IlIS. ,\.'1..;.17 106 Lumh:tr spine. (See II/SO L(lW b:Kk pain) alhlelcs and ;It;mhk conditiollin~. 348-3.19 age· related f:1Cwrs. 3:;2 b:ll:lllce reqcration. )49 !x'd rest. )-l6 common ~yndrol1lcs. 345 coordination. 349 diagllosi~. 341 injury mccho.nis1l\'" _~·C m;lOagcmcnt guidelines. 353 nonClpcrati\"c care. 3.15-346 p:ltient hi~to~·. 344 physic;]1 c.'taminalioll. J-W-3..t5 predisposing faet()~. ~.I1 rehahilitation programs, 348 hiulIll'Ch:mi.:... J4J-3-4 11isk pres'ur.:. /76. dynamic tc'l<. illustration. 2-/0 IYllCs. 2':'(1 injury mechanisms. :U.' is\lkinc1ic lcsting... I ~ joims. referred pain. 175 IH;t(lin~ or. \lcKcllzie ;Ipproach. 237. 237-2JS IIltlhilizaliclIl proCl.:duro:s poslisolTlctric rclax:lthlll. 285-286. 286 self· stretching. 2S6. 1.... 7 1H11\(11l<.:r,lli\c Ire;lltltcnl plan... 3SCJ radiugraphic imaging Il·.:hniqut:. 219 r:lI1ge of mr,IIIOJl tests. 76. 77 cxl':lhion. 137 lkxion.2)7 side-gliding Iclt 238 side·gliding ri!;hl. 238 rhythmic U(lclion pril/le. 216. 2/7 slIpim:.1I7 sp{)n~ 353 gYlIllla.. tic... 350 j:l\'dill throw. 3:'2 pole vaulling. 351 lennis.353 water sports. 351 weight lifting. 351 static lest.. illu~amtion. 2-/0-24 I types. 239 lhrust manipulatiolls. 213-215. 217 Llll1lbodorsal fascia muscle control -.237. 236-137 dyn:lmic 1ests. 237-2:W lumbar spine slucJies. 23"7. ::37-238 pallent history. 2J5-2~6 poslur;11 ;lI\:Jlysis. 2;16 II 1 ,\ \kKl'lll.it.' :ll'prl\:1..:h-nmlillunJ SI;,tic Il'St.., ~37-2.'R ,~ndf(lrnc r:tllCm." dinic:!l rca,oninl: ;lnd 11lililY. ~·ll tkrangcmClll. 2-12. ~46~2:,n dysfunclkm. 7·r:. ~.I.t-2j(> Il\l...lmal. 2.J~. 2..1:\-244 ,ul\lIliary. ~J2 P;llhtl;lIl;I!U"'~ :U1.1. 226' :1 ~"lcrinri aPJ'n'~lc·h. 22(, n:hahililalioll :lIld, 2:;1··]."2 Measurement ,\':.k,. Ill' pain hi:L"; sour........ ;q dc.;niptiull. ;'0:-type.". 5S. 58 \kch:lI1ic:llly il1l!,\:dcd cild r:lIlgc tlclllH:d. 2~2. 2.~-l Ilh,lrUCh:d. 235- rC';lrh.'IL'd.2.·.1-2.'.1 ~rccplilln. 233 1\'kchaunfcct:pwr :Jffcrcnts. pain Cfl.':tlioll, 24-25 \ktlicinc b:.tll, (St'(, Gylllll'I.'lic hall J MEl', (SC(' lvhl."ck energy proccdurcq MEr. (Sl'(' MIN:!.: Encrg.)" 'I\:chniqtlc) Mctaholk c:lpaciIY. cllcl:1 on lifting c:l.p'H:ity. I.tJ MClaC;Jrpophal:lOg<.'~1jllint. manipulali\'e (her· allY. 115 Mkr()f:lilur..:. ()\:'lJm:I1I.:C~, 15-16. 16 :"lilit'll")' PO~IUfo:. i/7 Minilrampolin..: de~riplion. J2(1. 32~ fuur point kneeling. J2N illu!'tr.uion. .121 walking on. 32i r-.'lilll1e.~ola Mullipha~ic Personality Index chronic pilin predictions. 398-399 pain dia!;r;um .:md. corrcl:nioll hctwecn. 61 !'calc.~. 399 l'\'linnesola Multiphasic Personality In\'cmury. :L" dis."Ihility pre Inde:-;; Minnesola :-'\ll\·O:llICllIll:lltCnI." .11t...r..:d l'hrmli" pain ~5-2(1 efkt.:t of chroni l' pain. 25-26 Il\u~ular imh;lbIK'e :llld, j I Ir..:allllCIIl for. :II l'nmpk:c lIS .m", di~tu'l'lcd ~·1r.:Kclll.i.: RI..'IX·'. _'~') suhjecli\"c conservative 1r'::'Illl1cnt ;md. comp'lf\!>C'tn. .ll-:l2 fU11llalll':lllah. ~55-35~ :-'hllelllclIl correclion, kvcls (If. 47 \'luhiph;l.~ic Per.~ol1.aljly II1\'cl1to1)') Mohili;r':l!ioll joinl. 209-211 cer\'ic.t!. 212 C()l1lITlamk 210-111 sacroiliac, 210-211 kyphosis, 213 ncuromuscul:ll" techniques. 210-.211 side·bending, .2 1l. 2II Modified 1l10111a~ Ie'\!. SU. 93 ~'1ood dislUrbanccs, chronic pain and. 39.J Mowr cnlllrol defined. 24 feedback mcchanism ..17 fecdforward mech:mism, ';(1----17 nCllromuscular ~truclllr.:s :md pathways. 0/6 symptoms. 24 Motor learning, concepts of, 319-320 ro.-lotnr pallcrn.~ ..(SI.'I.' MO\,":l1lcnt p:rttcrns) MOhlr syslem. <Sl'e oho Lt}ColTlOl0r sy."tel1l) cVlllponcnlS of. 25 dcclmdilioning ~ynttwlne. 13-15 rehabilitatiun aClive :10(1 passi\'e t:ar..:. 32-34 :lssCSSlllent of mJnllal. 117. 1/7 shonencd musdcs. 117-118 wcakened muscle.~, 117-1\8 due ttl l1lusde dysfunction biceps fClIIori:>.. 122. 1'22 gltllcus lIla:-;imus. 120 .~tcmockidoll1astoid. 137. 137 dieet on skills. 358-359 Movcmcnt rl:'llles. loading :md. 228-22') ~1o\'cnlents control. reeducation, ) I involulll:lry. cerebellar error conlrO!. 26 \'oluntary. cerebellar pathway.... 26. 46 :-'IP. (See Myofaseial pain) MPQ. (5('(' McGill Pain Quesliollllairc) MRT. (Sa Manual resistance techniques) ~1uhindi.lumhar. postisometrk rcla:l;mion. ~71. 1i2-273. .213 :-'lusclc. (Sa aha specific mllsclt"sJ contr.lction... accelerations in. 320 energy sources. .J9. 50 functional conditions for. 50 joint protection, 319-320 function . .:5-4(1 ease study .:mulysis. 140-141 imbal;mcc. (Set' Muscle imbalance) illllllobili7.:llion erfects. t5 inhihition. 19.21 joinls .md. functional interactions. 30 Ienglh effect on muscle ~pindle impulse fre· quency. 19 hip alxluction. altered. and. 363 hip e:-;lension. altered. :mtl. :\63 neck flexion, altered. 365 rcspir:ltion. altered. 366 scapulohulllcral rhythm. altered. 365 leSlS of. 30 trunk flexion. altered. )(,.1 low back. (Sec EreelOr spinae) motor units ddincII. 49 tYllCS :Iud characteristics. .19 pain cycle. 18-19 pha.... ic. 26 poslUrnl. 26 ~honenecl. disturbed slatics. 116. II R strength, effeCl on low back pain recurrence, 15 ~lressJstr:.lin curves. 16 tighlncss spa..~llI'lIld. differential di;l~l1usis. 97 lrealment of. 97 trigger points, 28 wasling.21 we"kne.s... anhrogcnic. ~9 \ disturl'lcd statks, 116-117 stretch. 28-29 tightness. 2R trigg..:r roint. 29 Musel..: dysfunction types. 255. 255 \'isu.lI inspecliun h:1Ck vicw. 11J-114 e;l~': study. 1.J0--141 Muscle energy procedures. 253 Muscle Energy Technique. 212 Muscle libers fast·twilch, 27 slow· twitch. 27 stiffness of. 254 Muscle iml'lalancc :Jlten:d movement patterns and. 31 analysis of. in standing position from behind of patient, 106. 108-109 from front of patient. 110-111 dinic:!! features. ~6-30. 362 compcnsalOry actions. 116 consequences of. 29 defined. 97 cx;mlplc of. 30-31 inhibiled muscles. 97 c\'alumion nl.:thods head flexion. 102. 106 hip exten!':;on, 101. W5 push up. 102. 105 shoulder abduction. 102. /07 trunk curl up. 102. 105 seientiflc evidence for. 362 tight muscles cvaluation erector spin:lc. 100. I()J g treatment fer. ~55 MuS'.:le lone organ of. 19 rol cfl\:l.:\ UIJ liftill~. 145 , I " \~; ,. ""'10, \J " ..$ 427 ''''Vt:.A ~ 111,~·uh"i.,,,·kl;d hllH:lillll-., ";luWI'II .." :lIII,llh>n I,'.b. 7·1 7~ I..l'~ .1'I'o:,:h, 75 :\l\I"III,,,\..c·kl:ll paill s~·lldr,'m~,. lllll'lllllptil':lt<:d ,,,l'lli".'ll'" ll\:IIl:lgl'lIl\:1I1 ;,:ul,ldin....... 36 :\111',"ul'h\..d.:t:,1 slrlll:llIr...... \'\k'nlal {klll:llld ;IIHI 11l1l,·II"11.l1';tp:Kily. rd:llllllbhl!,. Iii :\ 111,,11\, '1.1>:11\. PO\ti"'IlWlt'h.' r"i.: x;llion, ].oS :\l~.'l;l"r.,l p:UIl "'yndrtlllw. 1;,':,1I1II.'nl. ]9:". :;66 :\'~'\';Kll" f,'lk\ ..17 NI >1. 1.\,-," :'\,.... 1.. !>i..;,hility Illdn I N,'d. Dr",l-lIlly Illd....\ ,'r..'all<'l1 uf.lIt") d..·\"fll'Il"ll. (IS illu"lr.llnlll. tiS ;\,..'cJ.. 1l,",iOIl. (Sa olso Ccni,";d (k.\i.1I11 :lltef..'1! ,"ourdin:lli(lll. 377 :1111:1','" llI(l\"l:lIICllls, 305 .. lrt:llglhl·ll;ll~ c.'\CrL';scs. 3.'\' l..''-h. ~i. lJ(). 9:! N..:d.. lIIu_..:k:-:. (Sn'ol.WI Cl::ni"::llll1ll.~dt::-::Sl\.'r· n"..:kid'llIl;t:-:lOilil do:..:p pr\lprio.:qllnrs ill..\20 li!=hlnl::." c\"alualitlll, 9S. lJ iI ., I I ,i ,.J i t' . ::A motor. r,,;cipf()c (k'uIOll1ulor input. to fine poslUral syslem ';tw of scmicircul.H can:lls. :\:"0. 333 prism Iherapy. 332-3:n. ,U3 01:1', (Sc'/' Opcrati0l1011 Lift T;l.~k) On..: leg ."landill!= lest dcscril'ti(ln, Illuslratinl\.86 Operational Lifl Task. isoinertialll,,,ting. 141) Ordinal scale. M pain lllC;ISUTClIlellt ~kscriJllioll. $80 cxalllplc.58 Organic qllalilic~, of lot"()lllotor p.:rforl1l'lllcc. 48 Onhoplks. dfect on lillc poslur:ll SySt..:lU. 337 On!Jo."t;llic pl,)~\ure ;lsYll1mo:tries oj p:l1lwlogic, 3.11-:\32 S" phy.siolo~k. HI line poslur.ll system. 329-330 fineness of. 330 O.,t":(Jjlmhic myof'lsd.l! rdc:lsc ltlCtlllxl, 256 o.sw~stry Low Back I'ain Inc!;::x descriplion.65 ill\lSlr.tlion,66 Oulcome assessmcnt d":\'c!opment of. n f:lctors lhal 'lfrecl. 1(.1-162 functional change docuOlcntillion. 37 Ovcrhead re:lchint;. IS2. 371 Overpressure defined,228 usc in dynamic and slatic t..:sting, 239-240, 241 Overrc:lctlon. a~ ahnumlal illness bchal:ior sign. 73 1';110 acute. chronic pain and. transitional steps betwcen. IS :tvoidance n'rSU.f confrontation of. 38 tJarricr phenomenon. 199 chronic. (5('(' Chronic pilin) cortic:lli7.alion of. 25-26 Ildincd.57 c.\aggcrated perceptions of. .J8 intcnsity SC'lleS, 61. 62...(;3 l(lCallOIl of. measurcment modalilies for. 60, 6/ Inw tJ:lck. (Sr'l' Low txu:k pain) museu!:lr rcactions to, 21 rnyofasci'll. 195 psychogl::nic diagnosis :llld. 5-6 queslionnaires. (Sec Pain questionnaires) referred, (S('C Referred pain) relief posilion. 196 Slrolin and, rcJiltionship t'!Clwecn. 196 word origin. 18 P:dn behavior. assessment 100is Bur~ verb:11 rating pain scalc. 61. 63 OswcSlry Low Back Pain Index. 65. 66 Rol;md Morris Sc:.tk 65, 67 Systemic Behavioral Obscrvation. 64~65 P:lin cyclc clements in~'oJved in. 21 cXislclIccof,17-IS illuslriltion. JR. 40J P.lin di;lgram desaiption.60 illusIT:ltion, 61 outcome .\.s,scssmellt. f,O reliahilil)'.60-(11 Pain diary illustmtion.64 purpose. 63 Pain Disit!>ilit)' Index. description. 65 I':lin queslionnaires bias sources. 59 description. 5S for localizing pain. 60-(11 lllcasllrcmelll SC:lIeS. 5& for pOlill inlcnsity, 61. 62-63 for pain qualilY. 61-63 . reliability. 59 lypes.58 validit)'.59-60 Pain r<:ferr:ll, (Sel' Referred pain) P,llp,l\ion description. 198 iliustf:l\ion, 198-199 lriggcr points. 205 Pa.ssive care. (Sl!l' alJtJ Conscrv:ltivc car..:) J.clive care and, comparhon. 3S4 deconditioning syndrome and. 13 role in rehabilitation. 32-34. 33. 251 Pa.<;sive prepositioning. deflr:d. ~l)) Palhokinesiology. in kinetic chain. 358 POIlhologic asymmetry Fukudtl-Urllcrbergcr Stepping Test. 331 neck rellel( measuremenlS. 331-332 POItient chronic pain education, 39 ways 10 confront, 38-39 dis."1bilily prone, profile. 36 environment and. 405--406, 406 pain behavior asscssmcnt tools Oswcstry Low Back Pain Indc)\.. 65. 66 Pain Disability Index. 65 Rohll1d Moms Scale. 65, 67 Systcmic Beha\'iof:ll Observ:ltIOl1. 64-65 pain questionnaires bia... sources, 59 description, 58 for IOCillizing pain. 60-61 measurement St"'I!cS. 58 for pJ.in iutensit)·. 61. 62-63 for pain quality. 61-63 reliability. 59 t}'p<:s. 58 \·:llidily.59-60 Palient education (uncliOll31 r..:slorollion, 167, J5S lining tcchtliquc.~. 166-167 mOlivalion increases. 167-1(,3 rehabilitation. 165 rcinjur)' avoidance. 37 subjects for. 165 .....orkst ......... ,........ '1""\, PI)!. IS,',- !'ain Di:,,,l;Iilily Ind~..'(,) 1\'d,'r:\li" 11l0ljor 1",~ti~{lIllClric rcla:":llioll. 2i'J-2SU. :;.... 1 rl"i.:rrl.'d pain. 279 111=hIU:=S.<; evalu;l\iIIH, q:-:. IfS. 1111 I ~ ! I'C"II'r.lli" minor. p\lsli~"I11"'lri~' tc!as.;lli,'n, 2~1)·,:;;; I. 282 Pdt ;~, ":ll)\sed 'ymh.1lI1,·\. lIlIl''':!..: illlh;I!· ;1I1('~'. 1','I\'k!!!t ~IS It.·:-I Ik,,·npti(ll1. Xfl, 81) illll~lr:lti(ll1c :fJ.'';,",WI. 382 P,·lvi;,. i"lm,'lri,' 111allll:tl1r:K'lion, 2{)fJ !\'r~"'l':i\llllllltl1r qU:llilie'. (If IIX'1)1I1\I10r rl<,:rfnr· m;ll1'·~· . hip. 2S4-2S5. 286, 372 lumh;,r spine CXIl,'ll.sinn. 28.'i-2H(,. 286 rih. 2:-6-21\7, 2SS I1It1!'d..:s ;ttlduC'IIlTS. 2~9-:!61. 1M 106 rd\'k \.hliquilY i!lu'lfalion. :!lo ph~~iolo~i\." real·tim". f;lCililalilln lechnique:-. lower l\Carulac lix;lIors. 287 . US. 380 gr:wil)' and. 205-207. lOS hip illlcrnal rolalors. 267. 2ftS il\lli~;'lil\tls for. 257 j(lilll lIlohili/,;lliol1 fl~X'~'durl's tri~fL'r POiIlL\. 27 1) I ''-'I't '-'. .lX---4\) l'... rf'.rll1;lllc...·\."onlilluulIl ilhl'lr:l!ioll. 53 \\ IIldlll\" of Ilplimal a("!i\·iIY in. 52 I'cri,"h:allisslIc. h;lrrier phCIlUIllCIl(lll. p:llp;ltiun I'f. 21.11-202 !·... riph.:r:ll cOlltrllJ. (Sa Fecdh:n;k mechanism) I'cripher:tl nerve emr:l]llllen:. J-'l1 Peripheral nerve injltfY, lYpes: 342 Pcriphcrali/.ation respon;;e. 250 l'er;,cll1aliIY. ;ISre\'I~ (If. JOti PFS, '.'ire Po\lf:l\."ilitaticltl ~uelChl Ph:lftl1;ICOlhcr.tpy. dlf(,nk p:lin IrC:llmenl . .:IO::! Pha,lC l1lu,t.:k~ e,\:l1nples of. 16 lil""r type. 27 Phy,ical ac:ivily redUClion. ISc,'c' Immohilization) Phy,ical c.~all1il1alh1n ~'rih:ria filL 3·1.1 for low had pain.. 357. .197 PILE. I.)e~· I'rol=r.:ssi\·c Isoinertial Lifling E\":llualinn) Pillow. pl'lI.:CJIlelll durinr !ilccp. , .... , IlJR. {S~·t· PostisolllClric relaxationl Pirifunni.. flJllclinn;]1 an;\!\lJllY. 124 gcnt:ral cham,'lerislics, 12.:1 PI)qi\{Ullelrk rclas.alion, 208. 264-265, 265-26fJ referred p;,in. 174. 2(>4 ,horlened body cnlllilur ~h:lIlf:c!-. 125. /27 lli~IUrhc(1 hlll.1y stalics. 125. 126 dfcel on hip Ucxion mo\'cment pancrns. 127. 12:3 ligh:ness c\"alu:\linn. 100, 103 trigger rnilll~. 26:; Planl",r inpul !C.) line (1(lslllr:11 syslem. 333 11l:lllipubliull of. :05 1'i'F. lSi'(' I'f(lpril\(cpli\"c ncurOlllu,~cul:tr facil· il,llion) Pole v;mltin~. lumhar spine injuric!:. 351 P,)\ICOlllr-:lClioll inhibitioll. principles. 253 I'o\tf;lcilitati(\l\ str.:lch, 254 procedural steps. 257 f'(I~li<;ot1lelric r... I:l,'\(01lion, 201 ('crvical spille . .Ii!) eye II\Cl\'~llll.'n1S lUld. 2n4-205 ccrvh;al. 206, 271-27:! lIi,gasuic:us. 20.Ii cn:clor spinile. 268. 270. 270-271. .f73 gasIT("I(,:ncmius. 28..\, 28..1 gluteus maxirnus, 265 h;llllsiring. 258-259. 259, 373 iliI1p.was. 261-26~, 262-263. 372 infr:lspinalU$. lOS, 2.'\2. 283 Ic\"alor S4.-apulae. 2N. 275-276 !l1asticatory.207 multifidi. lumbar. 271. 272 mylohyoideus. ZOS pectoralis Illajor. :!79-2S0. 281 pectoralis minor. 280-281, 2S2 piriformis, 208. 264-265.265-266 quadr:ltu.~ IUlllhorul1l, 207, 210, 267-268. 268-269 qU:ldric~ps. 265.167 rcclu~ f~nloris, 262, 263.372 r~srirator)' synkinesis and. 205, 206 :-c.l1cncs. 207. 218-279. 179 scmispin.:llis C.:lpilUS. 272. 272 scmispinalis ccrv;cu~, left, 272. 273 solcus. 284, 286 splenius capilus, left, 272, 273 stcmoclcidolll;lstoiJ, 276-278, 277-278,378 suboccipitalis. 276-277. 379 sub~aflul3ris.2m~. 282. 283-28" supraspinalus.281-28) tensor rasciae 1.1Iac. 263-264. 16-1-265 thoracic erector ~pin3e. 2;)6 uppcrtr.tpcl,ius, lOR, 210. 273. 27:\-275 .....risl extensof":', 204 origins of. 203 procedural sleps, 257 release IIlcch:mislll. 20J lechniquc description. 2n..l l'ostisomctric traClion. cervical spinc. 206 Postur.tl :malysis hip movcments. altered abduction. 363. 363-36-1 extcnsion, 363 il1ustmlioll. 29 neck lle:doll. 365 purpose. 29 respiration. altercd. 366 st::lpulohumeral rhyUun. altered. 365 lrunk l1exion. altered. 36-1 Po.<,turnl exercises. rounded shoulder:-:. 18f) IlOS\llr.11 muscles examples of. 26 liber t)·PC. 27 lr,lining r~qllireme111s. '18 Postural syndrome. mechanical ilnd .~Ylllptnrnalic respon:'>Cs, 10 loading. 242. 243-244 Poslurnl syslcm. line. (S('(' Fine (1(lstural syslem) "1l.. ~r 11'\11:;. ,.., l""M.I·H.... 1IIIUl'lt:n;:, MJ-\I'lUJ-I.L Postural Ionic aSYnlnletry identifying. 331-332 p;l!hnlogic.331 physiologic. HI PoslUra1 trnining p!;)tfonn. for POSlUr.\1 rehahilitalinll. 33S. J.N" I \ PO~ll1r~ drivinc:.lii-I7R rurward·dr.lwll. 203. 203. 223. .MS Ih':;lJ. .lXI head rorw;Hd. 376 impropcr cxerci~c ronn .md. 361 lumhar disk prc;"sure and. 176. 176-177 lumhopclviC', 110 military correction, 177 neck,381 neck muscle activity and. 177 onhoslatie ;(synllilctric~ of. :\31-332 fine poslUral systcm. 329-:\30 fin~ncss of. :\30 roor. signs of. 177 rehabilitation postur.JI tr.lining platform. HR. 3.~8: sitting erect, 167 imJ1H1pcr. 167, 179 prolonged. low h.'lck pain and. 341 proper. 17R-179. 378 slumped. 177, 177 Posture disonkrs. psychologic aspc:ets. 33S floslurolo,gists. hisl0l)' of. 319 POSIUl"\",:!;;:;;:: basis of ccntrnl integral ion. 329-330 fine poslural system. 321) limits of. 331 Power. ddined. 48 Praycr stretch. nO or. Pr~po.~itioning active. 295 pas!\ive. 295 Pr~ssurc .,Igameter. soflli!i~llt: lendemess '1uan· lilic:ltiol1.74 Primary prevention. strall'gks, fr,lr low had pain. 6 Prism tesls. I'm oculoll\OInr I\l\l.~des. 332-.1.1.". 333. J:\5-;\36 Progressi\'e hoincnial Liflln~ Exaluali(lll Cylx:\ Uflask :md. Icial f'''lOr<; chronic p;rin alcxilhyllli'J. 393 nllllp.... lIsalion, 392 Ctlmpli:mcc. 3t)2: .... , 429 INDEX I',~..:h""\l\:ial faCltII'S-I"I1III;ml,"/} lkpr..:."sinn ..")2 ~ain. 39.' liligalillll, 392 Illllliv:ltiol\. :\I)~ r':ClIgn iii Ilil. ,N:I- :"\1)': "f tli ...;lhilily limn... Il;'licnl, 36 1l1~'lh{l\I" tl\ jlklllil'y. X-9, IS 1I\I~"<'li\llln;tin:s. iJ 1'1I11·d\'\\I~> illlpnllX'f lilflll. /WJ mcthlllis. '84 I'lhh lip. illhihih:tllllusd:, l:\';llualilll1, I'ulljn~. Ill\..:alc I 1O~. 105 Pu,hc, \ illllslrali('11.325 pmprlocc[llivc intrc:Lscs, 323 I'u\hing. uns;,fe methods, n;-/ ,i J PY~lIIJIi(ll\ cO"eel. de-fincLl. 59 QL {Sl'(' QU;ldr:lllls lumborullll ()u;ulralll., IUllllxlrulll fum:liull. Ill:! fUlKlinnal ;mal\lIllY. 128 l;.:n.:ral l;hanlch:ri.stics. 128 postisolllctric rcl:lxmioll. 207. 2/0. 267-2NI. 2Mi-16f) rdcrr.:d pain. /73.2(17 sdf,wclching. 268. 2M sh(lth:n..:d body comour ch:mg..:s, 128, 130 disturbcd body stalics, 128, 1'29 effecl OJI rmwcmcnl paHcrns hip extel\:-ioll. 12~, 130 lrunk !lcxion cXlensiun, 13L 131 ti!=II1IlCSS c\'alO:ltiull. UK), 103 trigger rx)ims. 265 Quadriceps postisornclric rcl:IX>ltion, 265, 26i sdf.stre1ching. 265. 167 .sl:lbilizalioJl exerciscs, 300-301. 301 str..:ngthening exercises. )47 QUOldrupcd tr:lck exerciscs descrip1ion. 302-303 , ) \ -1 ) jllu.~lralion. 302, ~ .. I , ), I '. i } ,) ,,): I <-)! .~:1 \.. 381 Qud)Cc Task Force pUf]lQse. -l I 5-1 16 spinal disorder classifications, 361 whiplash classilic:ttions, 361 Questitlllll R:llio ~ale, of (l<,in mC;)"t:urcmcnt desCription, 58 ex:nnplc.5B Receptive fields. referred p:lin and. 24 RI,'Ciprocal inhibition. principles. 2;i:\ Rl'condilioning ftlllctiOllal stabili7d,tion. 29:\ lrcatment stralcgies. 169 Recovery period eomplicaling (:I\;um;. 356. H()-j57 factQ~ 111>11 prcdict, 166 timdillcs for. ul1colllplic:lIcd injur· ies. 38 Rectus ahdominus gencr:ll charnclcristics. 131 wC:lkcl1cU hody contour changes. 13:\. IJJ disturbed body Slatics. 131. 1.12 dislurbed movcmcnt patterns. 133 ReclUS femoris nc.'(ihility Ics!, 80--&1. 81 POSCiSOlllCtriC rcl:lll:alion. 262. 263. 3n lightness evalualion. 98,100. 110 Red l1ags dcfined.355.393-394 diSlllrbances of mood. :\94 cxamin:ltion of mood. 394 in history. 394 p!'iycho!'iocial i~t:ucs. 394 typc.t:. .156 Reference lines. body slatic assessment b:lck view. 113-11-1. 114 fronl vicw. i i 3. i i 6 siue vicw. 114. IN. 116 vicw from abm·c. 115. 1I 6 Refcrred pain defined. 24 early discussions of. 22-23 crector spinac. 367. 36'7-368 facct syndromes. 367, )67-36.." ncuropi:lslicil)' ano. 2-1 quantific:llion of. 74 sourccs :lod.ucton;. 259 cl'rvical musclcs_ 271 cerviC:ll spine joints. /75. .lio erector spinae, 26S gastrocnemius. 284 t;luteus llliniUllls. 175 hamstring. 258 iliopsoas. 174. 261 infrccipilillis, 276 ~lJhsc:lpularis. 21\.1 ~upraspinatlls. 2S1 ICIIStlr faseine blac. 26:\ upper lrapczius. /7/. 27,1 symptoms.2 J Regional disturballccs. as ahnormal illm:ss behavior sign. 7J Rehabilitation. {St'" (d,w Atti\'e carel accelcr'\lion-dccclcration syndrome. 3'78-379 hiomechanic:tl (actors, 15-17 dcconditioning. syndromc. 13 dl'fincd.195 funt'lion:\l lesting. 355 fUllctions. ~S6 lunge teSI. 196 PllllXlSC.356 types. 297 goals 355. 358, J 1-1-.t 15 hcadache. 370-371. 3'75-':;76 imlllobili7.ation biochemical changes_ loJ musculoskelelal. eO'cels of. 14. /7 ncgativccffccts.I3-15.15 mOlor system 3ctivc and pat:sivc Can!. J·2-34. 33 ,onsc['\':lli,'c treatment and. cOlllparison. :;'1-31 fundall1cnloils, 355-358 patient selectiou. 355 primary goals. 32, 33. 39 nonspccilie back pain. 360 ou"omcs measures. attributcs of. 58 passi,'c physical thcrapy :l.nd. 3S5 patient cduc.:lIion. 165 pfll,(:ralll creation. 367 scialica. 360 Rdlatoilit:llion c)(crciscs. mu~,.'ular quality dch:rminaliQlls. -lS Rcimt>un;cmcnt, ways IQ cn~uro:::. 37-38 Reinjury. ways to avoid. _~6 Rcl:tth'c n:st. defined. 37 Rcl3.'I::uion therapy. chrl,'lni.: rain treatment, or. 401~O:! Rclia!:lility intl'r-c:<.:aOlincr.5Q paill :md disability qlll'~ti"llnaircs, 59 pain inlensity sCll1cs. t> I 1l.'i't·r~·lcsl, 59 Rcrm'toiliz:uion, Ircal1l\l'n! ~Ir:llr.:fics. 169 Rr.:p.:tition, effect on Illu:-..-k- fatigue, 16. 17 Rl'p..'litiyr,: ,qrain, dclin"d. :~ Rc~i:'lal1cr,: exercisc,", ell,'.:t ('n muscle. 49 Rcspir:llion :tlt,'ro:::d. 366, 366 h... ;H.bdlcs and. 376 lillill~ tllora)( :11. J9; R~'spir:\lion toordinali\l[) l,·~t, d,·scription. 8SS9,9(1 RL'~rira[(lry synkinesis d,·,in..-t.I.205 ll~" in pmlisomclri..- rd,l.,\,\li"'II. 206. '216 RF. ~Siti"lll R\X'k\'r ",.ard d,·:'"Tiplion.320 ill\l._lr:llio!l. 320 Rol:llIJ \lorris SC:llc, \k~~·rii'ti\'n.lt5. 6; RO\1. IS..c· R:lOge of 11I,'li,'I\' Rllll\b<.'r~·~ quotiClI1 lk·h-ripliu!l. 33CJ l\'w b:ll:"- pain i[)lPfl""~','nl" :md. :'137 . .!}i nCnl"\Oll...1 11-\1 IUN VI'" I Ht:. ~P1NE: R01:llOr cuff syndrome. (Sa Impingcmenl syndromc) ROlmors test ~rformanec of. 33<1, 33-1 purpose. 334 Running.. hnnbrlr spine injurict', 352 Sacr.ll ot.liqui(y, illustr.uioll. 220 Sacroiliac joint Syl1drolllC allered hip atxluctiol1 ;ll1d. 363 description, 366-3(,7 di;lgnosis, ) palhology, ~45 $acroili,IC joints adjustmcnll' of. effect on reflex responses, 47 mobili7"'ltion techniqucs, 210 Scalenes ' posli50lUclric relaxalion, 207. 278-279. 279 rdel'Tcd rain, 171, 278 sclf-pol'lisoltletric rdaxation. 280 sdf-slretching, 279, 280 trigg.er points, 278 Scapula conlr:.lcl-rdax techniques, 288, 291 facililation lcchniqucs, 287, 28R_289 stabilizers, stfCngthening exercise. 3S I winging of, lOti, 109 Scapulohulllcral rhythm altered de.'icription, 365 gail analysis. 365 trealmcnt npproach, 365 glenohumer.ll mOl ion, 380 impingcmcnt syndrome and, 380· Scheunnann's disease. etiology, prolonged sitting.3<11 Scialie ncrye, referred pain, 176 Sciatica case management. 3(10 enuses, 171,345 conservntivc care, 5. 360 etiology, 3 illU:'Ir:.ttion. 176 SCM. (Sec Slcmoclcidl)mn.~IOid) Scolimis, illustr:ltioll. 2]0 Sce-~,,\\' e~ercisc, 311. 313 $el.f-strclching guidelincs for. 258 joint mobilization lumbar "'pinc cxtem;ion. 286, 2Si rib. 286-287, 288 thoracic spine extension. 286. 288 muscles OldduClOrs. 261, 262 erector spinae. 270, 271. 3i3 g;\strocllelllius, 284. 285 gluteus maximus, 265. 26S h'llnstring. 259. ]fIO. 373 iliopsoas, 26~, 263, 373 levator scapulae, 275, 276 piriformis. 265, 266-267 quadr:llUS lumborum, 26&. 269 quadriceps, 265, 267 rcclUS femoris. 264 t'ealcllcs, 279, 280 soleus. 284, 2S6 lensor fasci,le latae, 264 uppcr tmpezlUS, 274,275 Semicircular can"ls, law of, description, 333, 333 Semispil\3lis capitulO, POSliSOItlClrie relaxation. 272,272 Sem;spinali!' ccr"icus, poslisolllctrie rel;l;'<.at;on. 272,273 Sen!'jti1..:l.Iion, dorsal horn associated neural cli:lIIgc!', 25 delincd.24 P:llhophpiology,25 Sensory motor slimublion device... :md :lids bal:lncc balls, 320 ~Iancc shoes. 320. 321 Fillcr, 320, 321 minitfilmpoline. 320, 321 rocker board, 320, 320 Iwister.320 \\'obble board, 320, 320 indications for. 321. J2t motor learning Slages. ~ 19-320 short fool description, 322 eltercisc: program, 322 fonnation of. 32~ half step forward stance. 323 illustration. 322 passive modeling, 322 Shcrringlon's Law of Reciproc:l1Inhibition, 26,27 Shon foot descriplion, 322 exercise program, 322 formation of, 323 h.M step forward l'tance, 323 iIlu~trntion, 322 passive modeling. 322 Short leg pelvic obliquity (ronl. 220-221 sacral obliquity frolll, 22()"221 Shortened muscles. 118 Shoulder abduclion components of. 102-103 coordination lcsl, description, 85. 88 inhibited nluscles evaluation. 102. 107 in paliellt with shortened upper uapc7.ius, 135. 135 Shoulder hl:ldc. ~tahilizalioll of. cV A PRACTITIONER'S MANUAL Skin dr'lg causes, 200 hY()I=rnlgesic zone diag.nosis, 19:-;. 200 Skcping felal posilion. ISO ideal poslure. IRO pillow pl;l\.·clllelil. 1.~1 Slouching, 240 Slow,l\\'iICh lihers. dl.lr:ll.'lerislk~, ~7,:!S Slumping, i76. In-liS SOAP notes. ddincd. :;8-1 Soft ti.~suc fmigue levels, 17 healing pha.'ic.~, 3-1 inlbmmatioll. 1:-. 37 remodeling. 14-15.38 repair, 14,37 lc~iol1.'i, p:llpation teqing' connecti\'c 'issue, 200 skill,20{) m:lIlu,,1 resislance h.'chniques. ~55-256 pain syndromes b:uncr phenomenon. 203 managelllent guiddine~:. 36 lendemess grading schefm'. iJ qunnlificntillll, iJ tension type~. 19 Soleus poslisolTlctric rclaxalion. 284. 18fi referred pain. 284 ~c1f-strclehin,g. 28..1. .; 2R6 cvnlualion. 10-1, IOi trigger points. 28-1 Somatiz:lliun defined, 391, 393 double mes.~;lges of, 395 Somali7.:nion dialhe<;i~ abandonment 396 abuse, 396 alcoholi.~m. 396 description, 393 surgical outcome. 396 Sorensollicst. for lumbar spine, 41-1. Spa:;m misdi " .-~ :7 431 Spi 11\,'--':'(1/" ;11/11,/1 pll.~tllr;)1 disorders. :n I poswral tonk ;lsyllilll"try. 331-:'U2 st:,hilit:>.361-362 ) I'l{lr.ll'i~·, (SI'e 'Jlltlr;,ck spine) Splenius ':ll,iIIlS. p!.lstisollJ"tric rcl;lltalioll. ~n.27.l SI"ll1dyloli"lhcsis dl;lr.ll'I,'ri\lics, .142 nlllllllnll sit....s fl.r. J42 htllmi,', .I·e lu\\' h;Kk p:.in tlCCUITCl":C • .3 Ire.llmenl plan. 3-'2 Splllldylulysis ch:lraCh:ristics. 3~2 CllllllllQll sites for. 341 inciucllI:c of ill gylllllasts, 3S0 ill weight lifters. 35 J Sporb. (St',' dho Athkll:s) lumhar spine injuries h311cl. 350-351 h:ls..:I:I:.II. 353 foolll;11!. 351-352 golfers. 352-353 t;.Ymnastics. 350 ja\'c1in throwers. 352 pole \".:luhing. 351 running, 352 lennis. 353 W'ller sports, 351 weight lifting. 351 Spurts medicine. 411 principles. 415 Spray and Stretch. indic:llion~ for. ::!56 Squat strength tcst. descriplion. 84-85. 87 Squats Ire:lImcn( str;Ltegics. 1r,C; Swhili7-'llioll progralll, foal,. 293-::!9-1 St:lbilornclry, line postural ~y~tCl1l Illl:a· smemcllls description. J:n Romberg's quoliclll. 33;, 337 SlilllCC phal'e. of ~ait. IIJ7 Siand to kneel tel'l descriplion. 83-S4 illustr:ltion, .% Slatic nll.'(;hanicl'. locomutor syslelll. cllmpo· nenls. 45 Stemoclcidoma...loid. {51'(' al\(} Nel:k l11u:"'l:k,) functional analOllly, 136 gener:ll charaCleristic.... 135 poslil'omelrie rda;(;Ition. 207, 2/0. "!76-278. 177-278. J7R rderro:d pain. 173. 27i. 377 shorlened body c.:on!our change'. 137,137 disturbed bod)' stali", 136. f.l6 s!renglh leSI. description, 87-88. 90 tightness C\'illuatiorl, n. YV. 110 !rigger poi nil'. 177 Slimulus·rcspon$C rd:uionship. receptor il1\'Ol\"clIlcnt in, 47 Straight leg misl: lest, 81. 8/ Simin pOlin :ind. rdOlliollship between. 1% n::pclilin: defined. 3S pOlin :lnd. 293 Slrcngth (ontilluum, as cxampk (If l1I11s(ul;lr t;~.d:!k::.·1S Sirength mea.~urclllents. nomlal funClion aud, 75 Stl\..-Ss!SIt:lil1 cur\'c dcfincd. 16 hysleresis illustr'.ltioll. /7 for ligamenls. 16 Stretching cOlll1ecli\'c lissuc...., 258 c!cctrornyographie dala or. 27 manu:11 rcsht.mee techniques and, 256 safety rulcs, 257 self. (See Self·stretching) Subacule pha...e. of injury. 34 funclionaltcsling.74 Subjecll\'e factor!', of polin, methods to me:l· sure, 74 Subluxalion. dclincd. 22 Suboccipit::llis paslisomelric relaxation. 276-277. 379 refcrred pain. 276 Iriggel' points, 276. 376 Subsc 395-396 Supcrliciallcndcmess. as abnonnal illncs!' beha\,· ior sign. n "Supcnn:m" e;(crci..c description. 311t) ill(l.~tr:ttioll. 309, 312. 374 Supmh)'llid mu~de. lightncss c\'aluatinn. 110 Supr:t'ipill:!tu, pnsli!'\\IllClric.: rclaxati(lII. 281-2SJ n:fcrrcd p.. in. 281 trigger point~. 282 Surgery n1Jlscr\,;lti\"c C:llC .md. cumparison. 5 disk cxtru_~i(ln. :' frcqucncy uf. 16t) fllr !lIW back P:lill. IWO:1'\lSC. 5 Suslaincd fX)~iti()nillg. 2:!.l:i Swing phaw. of gail. 197 S)'ltlr hcha\illral ~1.~.scSSl1\elJt, I)h~cr\'ati(m. pain h<:lla\'ior 6-1,-(») ·lennis. lumbar \pinc injurics. JSJ Tellsih: stres~()r~. 343 TCIISil>l1 111t1sdc. da\\ifit:atiull of. 255 palp~ltioll. 1~!K Tensor faSCiilC hlt~lC ftllKtiunal ~11:ltlIIl1Y. 122, 124 general ch:l(;lcteristics. 112 pusliso1l1ctric rd.u;~uiull. 2(13-26-1. 2(J-I-265 rcfcl'Tcd p-,in, 26:. sclf·strelchillg. 26..~ shoncllcd lxx.Iy conlour CIl;IO£CS, 12·:' /:!4 disturbed body statics, /13. 11..hip r.cxion mO\"ClUcnl impail111\'lu". 11-1. 1::5 ligh!ncsl' c\"llualion. 9~. 100, 110 lrigger point:-. 26·\ Tcs\·retcsi rdi;lbilily ~;:f;;;::d. 59 of McGill P,lin Quc:'liol1n~lirc. 61-6~ TR... (Sec Tcnsor fasciae I:II:1c) Thigh adductors inhibitcd, evaluation of. lOS poslisottlctric relaxalion, 259-261. Z6/ tightness cvaluation, 98-99. /00, /02 Third rally pa)'or. rcimburscmcllI from <]u:\ntification of symptomatic ,and funclional progress. 38 ways 10 ensure. 37-3S Thixolroph;c bcha::ior. 254 Thoracic crector spinac muscle. postisomctric rc· la:talion. 206 Thoroldc outlet syndromc. postural effcct.~. 376-377 Thoracic.: spine mobiliz:ltion proccdurcs poslisomctric relaxalion. ::!S6. 287 sclf·Slrctching, 286. 288 strelching exercises, 383 r.lngc of motion tests. 78. 78 Thor.\columb;n junction. forward-dr.lwn posture and. 222. 213 Throat. c\"alualion of. suprahyoid muscle tight. ness. 110 lllru~t manipulation lumbar ::pinc. 2/7 proper technique. 213-215 Thumb, hypcrcxlcn~ion \CSls. (N hypcrmobilily eV;llu:ltions. /10, II' Thumbs test dcscriplillll. 336 illuslr:ltillil. 336 Tighlnes.... muscle. ,S('(' Mu:"ck. tightnc!<-:) Tighlness \\·..· "knc..:.. defined. 9i Ti..suc illllllObiJj~.c<1. injury risks. 17 :o.of1. (Sa Suflli.. ~uc, Toc louche:.. improper tcchniquc. /S9 Tor(IUC Illl·asurcmcnt\. lumb..r :--pine. -112 Torsimla' Slfcs:-ors, ) .( 1 1'05. (St'/' Thoracic Ollliet syndrolllc) Tmcli lhrc:-hold. .::~ " Tr:lining range dl::;;lcd. 295 funclional s.t.abilizmion. 29-1-295 lumbopclvic. 298-299. 298-300 methods. 10 identify. 295 movcment sensitivities and. 29~ Training tllTc~hold. defined. 48 Tr.lpcl.iu~ lo\\'er faeilil:uion techniques. )80 hume exercises. j,li2 miLh.lk. contr;lct·rdax tcchnique. 288. 290, 290 facilitalion techniques, 288, 290, 380 home exerciscs, 382 upper referred pain. /71 tightne$$ e\'alu:nil:lI\, 98, 9.~, 109-110 Tre:ltmcllt ;lpproachcs. dtronic pain acupuncture. 401 b<::havioral thcr.lpy. 401 biofcwback, 40\ -402 cognitive {hcmpy. 401 family thempy. ~02 goals, 38. 400 hypnosis. 401-402 m:mipulmi\'c thcf:lpy. (S('(' M:mipul:'lIi\'c thef:lpy) phamI3colher::apy.402 rdaxation thc~lrY. 401-102 Triceps sur;te. tighmcss c\'aluation. lUI. /0-1 Trigger poilll~ 1()'\ facet p Icvator ~l;:'lpula..:. :!75 p..:cloralis major. 279 piriformis, 165 .... , , ........ ' .... ' , ..... , ' V U VI supraspin;ltus. 282 lensor fasciae 1;lI:.Il'. 2{H uPI'll.:r tr.tpc1.ius. 27.' lI1yofascial. joiut dysfun.:tioll :lIld.lIilTerenliJI t.liagnu.~is. 366 ned; l1c.xioll, 36.'\ flalp;ltion or. 205 rl:~rir;lli(}ll. Olilercu, .'66 sl'apulohumeral rhylhm. alt..:reJ. 3h5 s~~fl !issu~' "~"I!d~•. ~!e·.'" :!Il,~ !rullk flexion. altered. 36-1 !rullk Il1wcring frum push.up. .l6(i we;lkm:ss, ddillcd. ~9 Tri>. (5.,,· Trigger pl.\int~) Trunk body st;ltic dislllrb'\Hces. 217 dead bug exercises, 346-3~7 ..:xtensor enduranc..:, 37/ fh:~i()11 allcr..:d mO\'ClllClll. .'6-1, JfJ.J ill P;lliclll with shorlcncd qua 273-275 refcrrcd pain. /71, 273 ~clf·strclching, 27./, ::!i5 :-hortcncd body C~H\!llur chan!;c~, /J.I, 1.15 diswrbed body st;.IIic,. 133, 13.J " , ... O)r ,,~t:, ,... rnt\\..< ,;;,';,II:X,: I I I 11I"'<':111\:'" lVI~r::,n I""i""., ,::) IVlt\I'llUt\L :,~:; Iri~f..:r I'llilll'i. "273 V"lidity. u{ pain ami di:-;loility llu",tioll' naires, (1(1 VAS. (Sf'<' \'[,u:lI ;llIalo~ SC;tll') V...rhal \k,,·ripliv... sC;lk~. Bm~. p.lin illt":lI~it~ l11C,I~llr"'lll~'lIl, (.1. (,.I V":I:-idillllx·1. ;.cwbi,· hcnl'!its ..,-1') V":11\.'hrall'\,lulIlli. \S,·,· Spill") VCrlchr..1j'lilll'. /7l1 Ve:-tihular :lpp:lr;lltb. fUlleti"n..~2'1 Ve~tihul..r dl"luJas..\~3-3:\J Veslihlll:lr neuritis postural ~\\ "Weak link:' :-trenfthC'lling, 37 .''\ ) ') , \Ve"klle.~:-, lIlu~l;lc anhrogenlr.:. 29 slrC'lell, :!S-21J tighlllCS:-.28 tri~~cr point. 29 Wei£ht lifting. lumh;ar spine injuric:-. J51 WEST st;md:lrd cvahl'llioll. dc.~(:ripti\m. IJl'i-I-l'J wEST·EPIC urI Capacily Test dcscripti~ln, 149 illllstration.149 Whipl:ISh. Quebec Task Force studies. 361 Wide dynamic r:mgc lIcuruns. lleurop:.nhk pain amI. 25 Willd{lW o{ optimal ;It:li\'ily. ill pcrrorman.....: ,'t.IlItillmllll. 52. 53 Wind·lIp.256-257 Wohhle OOard. dcscriplion. nil Work eap:Icity evaluatioll fUllction:d capacity ;lIlU, cOrTl..'lalil'lIs betwc..:n. purpo:-c. is \Vmkstalinll ert:0ll(lllli{'!i dt;lir :-euing:-. 167. /79 C(llllpuicr. /if) lte:lIlachc rdil':f, :\75-:n(1 Wri.~t. C:c.ICIl'orS, postismlletric n:la.'('llioll. ::0·1 Writill,t: wcuge. 178 wSI:. (Sa WEST standanl cv,llll:ltioll) ." :i J is. ., ) ., .J .~

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