The Agency for Health Care Policy and Research (AHCPR) recently made history when it concluded that spinal manipulative therapy is the most effective and cost-effective treatment for acute low back pain . The 1994 guidelines for acute low back pain developed by AHCPR concluded that spinal manipulation hastens recovery from acute low back pain and recommended that this therapy be used in combination with or as an alternative to nonsteroidial anti-inflammatory drugs . At the same time, AHCPR concluded that various traditional methods, such as bed rest, traction, and other physical and pharmaceutical therapies were less effective than spinal manipulation and cautioned against lumbar surgery except in the most severe cases. Perhaps most significantly, the guidelines state that unlike nonsurgical interventions, spinal manipulation offers both pain relief and functional improvement. One might conclude that for acute low back pain not caused by fracture, tumor, infection, or the cauda equina syndrome, spinal manipulation is the treatment of choice.
Evaluation of Specific Stabilizing Exercise in the Treatment of Chronic Low Back Pain with Radiologic Diagnosis of Spondylolysis or Spondylolisthesis
A “specific exercise” treatment approach appears more effective than other commonly prescribed conservative treatment programs in patients with chronically symptomatic spondylolysis or spondylolisthesis.
These analyses provide estimates of the effects of antagonistic abdominal muscle coactivation, indicating that its probable role is to stabilize the spine.
Congruence Between Decisions To Initiate Chiropractic Spinal Manipulation for Low Back Pain and Appropriateness Criteria in North America
The proportion of chiropractic spinal manipulation judged to be congruent with appropriateness criteria is similar to proportions previously described for medical procedures; thus, the findings provide some reassurance about the appropriate application of chiropractic care. However, more than one quarter of patients were treated for indications that were judged inappropriate. The number of inappropriate decisions to use chiropractic spinal manipulation should be decreased.
Waddell et al in 1980 developed a standardized assessment of behavioral responses to examination. The signs were associated with other clinical measures of illness behavior and distress, and are not simply a feature of medicolegal presentations. Despite clear caveats about the interpretation of the signs, they have been misinterpreted and misused both clinically and medicolegally. Behavioral responses to examination provide useful clinical information, but need to be interpreted with care and understanding.
Isolated signs should not be overinterpreted. Multiple signs suggest that the patient does not have a straightforward physical problem, but that psychological factors also need to be considered. Some patients may require both physical management of their physical pathology and more careful management of the psychosocial and behavioral aspects of their illness.
Behavioral signs should be understood as response affected by fear in the context of recovery from injury and the development of chronic incapacity. They offer only a psychological “yellow-flag” and not a complete psychological assessment. Behavioral signs are not on their own a test of credibility or faking.
It is an interesting exercise to realize, after reading and studying most of the various techniques and examination procedures, that the chiropractic profession has to offer, that there are a few that continue to stand out as new and current research is available to us. The work of Logan was clearly supported by the work of Gracovetsky, Vleeming and others; the work of Gonstead was supported by authors far to numerous to mention when it comes to the motion of the fifth lumbar vertebrae; and the original work of Illi, Gillet and Faye is now starting to show just how far lateral these men where in their thinking and methodology. It’s been my pleasure to know and work with them. From a motion palpation point of view, which changes as new research comes to us, the understanding of fascial planes, postural muscles, the tensegrity system and the various loads that result from dysfunction makes the concept of an integrated system all the easier to understand.
Warming up before exercise is a generally accepted practice. For patients involved in rehabilitative therapy — and for athletes, also — it is common to warm up before undergoing activity with the intention of improving performance and reducing the chance of injuries. 2 This is especially true if a strenuous workout is expected.
Quantitative physical capacity performance tests are ideal for establishing clear goals in cases involving chronic patients. They provide invaluable documentation of progress under care that can help motivate patients that they are on the “right track.” Patient’s who are difficult to motivate to perform exercises are ideal candidates for quantifiable functional testing. Such testing provides the clear feedback that is needed to motivate patients and facilitate better compliance or program adherence.
Workers’ compensation case managers are often reluctant to approve ongoing chiropractic care. If rehabilitation is being recommended, clear objective goals must be established to demonstrate to third-party payers the validity of the approach.
While watching the golf swing, it’s obvious that shoulder muscles are used to create a powerful swing. Not so obvious are the details of shoulder muscle activity during the swing. Fortunately, a handful of electromyographic studies have given us a better understanding of shoulder muscle function during the golf swing.3,4,5 These studies demonstrate that rotator cuff muscles (particularly the subscapularis), the latissimus dorsi and pectoralis major are highly active during the golf swing.
Hip extension and abduction muscular imbalances are fairly common problems affecting the hip, sacroiliac and lumbar spine encountered in a chiropractic practice. Understanding the actions of the muscles associated with these movements allows the practitioner to recognize any altered movement patterns, overactive antagonistic muscles, and weak inhibited agonistic muscles. Understanding that muscular changes are contributing to the patient’s symptoms, a corrective rehab program for these muscular imbalances can be prescribed. The rehabilitation protocols described for hip extension and abduction are one option available to the practitioner, in addition to manipulation to use in treating a patient with these problems.
This interview with Dr. Luke Bucci discusses the needs for protein, minerals, and vitamins in healing, as well as the superiority of glucosamine hydrochloride for joint healing.
Athletes at risk include weight lifters, baseball players, softball players, and those who play racket sports such as tennis, racquetball, and squash. Glenohumeral osteoarthritis (GHOA) seems to result from pure instability, rotator cuff arthropathy, fracture, or postsurgical trauma and predominately affects older men. GHOA generally involves the glenoid rather than the humeral side of the joint,3 which will influence rehabilitation.
A fall onto an outstretched arm or a collision on the playing field often leads to an acute anterior shoulder dislocation for high school- and college-age athletes. The diagnosis is usually made by history and physical exam. The angle of impact is an important diagnostic clue. If no neurologic contraindications or signs of acute fracture are seen, radiographs are unnecessary, and early reduction before the onset of muscle spasm is essential. Recent advances in arthroscopic techniques have dramatically reduced the high incidence of recurrent instability in young elite athletes, though nonoperative management with immobilization is still an excellent option.
An ankle sprain may not seem like a big deal, but returning to play without proper rehabilitation will increase your chances of injuring your ankle again–maybe even more seriously. Taking the time to fully recover will actually put you back in the game faster. The checklist on the other side of this page will take the guesswork out of knowing when you are ready to return to play safely.
Ankle sprains are very common, accounting for 20% to 40% of all sports-related injuries.1,2 These injuries are known to recur often and create prolonged disability.2,3 Ankle sprains are classified into grades 1, 2, 3, which generally correspond to mild, moderate, or severe. They are also classified into three anatomic types: lateral, medial, and syndesmosis. This protocol focuses on lateral sprains of all grades.
The diagnosis and treatment of acute ankle injuries present challenges to both primary care physicians and orthopedic specialists. Determining the position of the ankle when the injury occurred may help distinguish sprains from fractures so that unnecessary x-rays can be avoided. Stepwise rehabilitation restores function and diminishes the risk of reinjury. Physicians can stress functional measures of recovery to objectively assess readiness for return to play and balance the risks of incomplete rehabilitation against the desire for an early return to sports.
Functional restoration, even with uncertain diagnosis, can be effective in the resolution of chronic low back pain.
A multifactorial treatment approach using passive care plus active rehabilitative exercises can be effective in the treatment of chronic low back pain associated with failed back surgery syndrome. Chiropractors who are trained in rehabilitation techniques will be well prepared to provide comprehensive care to such patients.
Variations in Balance and Body Sway in Middle-aged Adults. Subjects With Healthy Backs Compared with Subjects with Low-back Dysfunction
Compared with Healthy Back subjects, in the most stable and then the least stable balance positions, the LBP subjects demonstrated significantly greater postural sway, kept their center of force (COF) significantly more posterior, and were significantly less likely to be able to balance on one foot with eyes closed. Based on subjective observations, the LBP subjects were more likely to fulcrum about the hip and back to maintain uprightness in challenging balance tasks compared with healthy controls who maintained their fulcrum for the COF around the ankle.
Impaired Postural Control of the Lumbar Spine is Associated with Delayed Muscle Response Times in Patients with Chronic Idiopathic Low Back Pain
Patients with chronic low back pain demonstrated poorer postural control of the lumbar spine and longer trunk muscle response times than healthy control volunteers. Correlation between these two phenomena suggests a common underlying pathology in the lumbar spine.
Structural Rehabilitation of the Spine and Posture: Rationale for Treatment Beyond the Resolution of Symptoms
Because mechanical loading of the neuromusculoskeletal tissues plays a vital role in influencing proper growth and repair, chiropractic rehabilitative care should focus on the normalization/minimization of aberrant stresses and strains acting on spinal tissues. Manipulation alone cannot restore body postures or improve an altered sagittal spinal curve. Therefore, postural chiropractic adjustments, active exercises and stretches, resting spinal blocking procedures, extension traction and ergonomic education are deemed necessary for maximal spinal rehabilitation. Chiropractic studies that demonstrate structural improvements are sorely lacking and needed. The use of passive treatment modalities as the sole means of chiropractic intervention for the management of patients suffering with neuromusculoskeletal dysfunction no longer has a place in modern chiropractic practice after the acute phase of healing has passed.
The principles of upper crossed syndrome and the use of exercise, chiropractic care, and myofascial release in the treatment of cervicogenic headache are discussed. A review of the literature indicates that analyzing muscle imbalance as well as vertebral subluxation may increase the effectiveness of chiropractic treatment for cervicogenic headache.
The management protocol in this case consisted of chiropractic spinal manipulative therapy, soft tissue work and post-isometric relaxation (PIR) techniques to address biomechanical somatic dysfunction. In addition, active rehabilitation exercises, self-stretches and proprioceptive exercises were utilised to address postural and muscle imbalance. On the seventh treatment, the patient reported no neck pain, no headaches and unrestricted cervical spine range of motion. At 4 months follow-up, the patient continued to be free of headaches and neck stiffness and reported only mild, intermittent neck pain.
Psychosocial Factors and their Role in Chronic Pain: A Brief Review of Development and Current Status
In sum, while this cognitive-behavioural model focused on fear / avoidance shows much promise; it has yet not been validated by the research to date . There are studies in progress that may further our knowledge of identifying those at risk of progressing from acute to chronic . Until the veracity of this model becomes further elucidated, depression and somatization / anxiety should be regarded as the central and dominant influencing psychological factors in the assessment for identification and intervention strategies.
The evidence summarised in this systematic review indicates that specific exercises may be effective for the treatment of acute and chronic MND, with or without headache. To be of benefit, a stretching and strengthening exercise program should concentrate on the musculature of the cervical, shoulder-thoracic area, or both. A multimodal care approach of exercise, combined with mobilisation or manipulation for subacute and chronic MND with or without headache, reduced pain, improved function, and global perceived effect in the short and long term. The relative benefit of other treatments (such as physical modalities) compared with exercise or between different exercise programs needs to be explored. The quality of future trials should improve through more effective ‘blinding’ procedures and better control of compliance and co-intervention. Phase II trials would help identify the most effective treatment characteristics and dosages.
A Comparison of Symptomatic and Asymptomatic Office Workers Performing Monotonous Keyboard Work – 2: Neck and Shoulder Kinematics
Prolonged static posture has been identified as a major risk factor for work-related neck and upper limb disorders (WRNULD) in computer users. Previous research has mainly examined working postures in healthy pain-free individuals. The present study examined whether symptomatic subjects exhibited the same kinematic patterns as asymptomatic controls during a prolonged computer task.
A comparison of symptomatic and asymptomatic office workers performing monotonous keyboard work–1: neck and shoulder muscle recruitment patterns
Results suggested that symptomatic individuals had altered muscle recruitment patterns that persisted throughout the sustained occupational task, while discomfort increased with time-at-task. These findings indicate that altered muscle recruitment patterns observed in the symptomatic subjects preceded the onset of task discomfort, and this finding may have important implications for the etiology of work-related neck and upper limb disorders.
On the basis of the results of seven high-quality studies, this review showed evidence for the effectiveness of proprioceptive/neuromuscular training in reducing the incidence of certain types of sports injuries among adolescent and young adult athletes during pivoting sports. Future research should focus on the conduct of comparative trials to identify the most appropriate and effective training components for preventing injuries in specific sports and populations.
The rotator cuff, as all doctors of chiropractic know, is actually composed of four separate muscles: the supraspinatus, the infraspinatus, the teres minor and the subscapularis. Most of the approximately 2 million people who seek care for rotator cuff injuries in the United States every year have injured the supraspinatus, but the involvement of at least one of the other muscles is more common than was previously thought, says Dale Huntington, DC, owner of the Huntington Chiropractic Clinic in Springdale, Ark. “We used to think these tears were just in the super-spinatus 90 percent of the time. Now we’re realizing that, in the converging of these tendons, the infraspinatus is often being torn as well.”