A Functional Perspective
ACA News 2013 (Aug): 34–35
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.”
Neuromuscular Training for Sports Injury Prevention: A Systematic Review
Med Sci Sports Exerc. 2010 (Mar); 42 (3): 413—421
A March 2010 systematic review conducted in Germany underscores the value of neuromuscular training in preventing sports injuries. They concluded that “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.”
Recognizing the Value of Chiropractic for Chronic Pain
Dynamic Chiropractic 2008 (Sep 23); 26 (20):
The guidelines actually recommend manipulation for chronic, persistent low back or neck pain and cervicogenic headache.  This is significant because in the past, the guidelines failed to recommend manipulation, even when other treatment strategies (medication, etc.) were rated as less effective.
The Use Of Waddell Tests In Workers Compensation Claims
This article includes cross–examination questions for lawyers to challenge denial of Workers Compensation benefits following unchallenged expert testimony that a positive result on Waddell testing demonstrated "symptom magnification", "negative findings", and "exaggerating".
A Comparison of Symptomatic and Asymptomatic Office Workers Performing
Monotonous Keyboard Work – 1: Neck and Shoulder Muscle Recruitment Patterns
Manual Therapy 2005 (Nov); 10 (4): 270—280
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.
A Comparison of Symptomatic and Asymptomatic Office Workers Performing
Monotonous Keyboard Work – 2: Neck and Shoulder Kinematics
Manual Therapy 2005 (Nov); 10 (4): 270—280
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.
Exercises for Mechanical Neck Disorders
Cochrane Database Syst Rev 2005 (Jul 20); 3: CD004250
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.
Psychosocial Factors and their Role in Chronic Pain: A Brief Review
of Development and Current Status
Chiropractic & Osteopathy 2005 (Apr 27); 13 (1): 6 ~ FULL TEXT
The belief that pain is a direct result of tissue damage has dominated medical thinking since the mid 20th Century. Several schools of psychological thought proffered linear causal models to explain non-physical pain observations such as phantom limb pain and the effects of placebo interventions. Psychological research has focused on identifying those people with acute pain who are at risk of transitioning into chronic and disabling pain, in the hope of producing better outcomes.
Chiropractic Management of Intractable Chronic Whiplash Syndrome
Clinical Chiropractic 2004 (Mar): 7 (1): 16—23
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.
Upper Crossed Syndrome and Its Relationship to Cervicogenic Headache
J Manipulative Physiol Ther 2004 (Jul); 27 (6): 414—420
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.
Structural Rehabilitation of the Spine and Posture: Rationale for Treatment
Beyond the Resolution of Symptoms
J Manipulative Physiol Ther 1998 (Jan); 21 (1): 37–50
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.
Articles Supporting the Use of Proprioceptive Training
Impaired Postural Control of the Lumbar Spine is Associated with Delayed
Muscle Response Times in Patients with Chronic Idiopathic Low Back Pain
SPINE (Phila Pa 1976) 2001 (Apr 1); 26 (7): 724—730
Patients with chronic low back pain demonstrated poorer postural control of the lumbar spine and longer trunk muscle response times than healthy control volunteers.
Variations in Balance and Body Sway in Middle-aged Adults. Subjects With Healthy
Backs Compared with Subjects with Low-back Dysfunction
SPINE (Phila Pa 1976) 1991 (Mar); 16 (3): 325—330
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.
End Proprioceptive (Balance) Training
Can Doctors Delegate Care to Unlicensed Assistants?
ChiroCode Institute Newsletter 2004
Providers using CPT are instructed to pick the code that most accurately identifies the service performed. Therapeutic procedure codes 97110 – 97546 are defined in the Physical Medicine & Rehabilitation section of CPT to include: "Physician or therapist required to have direct (one-on-one) patient contact" [during the reported procedure]. Some have argued that the codes permit a doctor to bill for this code by an unlicensed therapist since CPT’s definition does not say "licensed" therapist. But that argument is found to be invalid by contacting CPT for clarification, where CPT reports that the term therapist is referring to anyone who is licensed to perform the service.
Passive Care and Active Rehabilitation in a Patient
With Failed Back Surgery Syndrome
J Manipulative Physiol Ther 1996 (Jan); 19 (1): 41–47
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.
Isolated Lumbar Strengthening in the Rehabilitation
of Chronic Low Back Pain
J Manipulative Physiol Ther 1996 (Feb); 19 (2): 124–133
The patient underwent a functional restoration program consisting of isolated lumbar extensor progressive resistance exercise (PRE) on a MedX lumbar instrument, PRE to ancillary musculature, progressive aerobic exercise, static stretching and proprioceptive exercises. She showed a 368% increase in average lumbar isometric strength, 41% increase in isolated lumbar sagittal plane range of motion and decrease in pain. The patient returned to school after 8 wk of care; at 18-month check-up, she remained asymptomatic. Functional restoration, even with uncertain diagnosis, can be effective in the resolution of chronic low back pain.
Acute Ankle Sprains: Keys to Diagnosis and Return to Play
Physician and Sportsmedicine 2002 (Dec); 30 (12) ~ FULL TEXT
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.
Rehabilitating Ankle Sprains
Physician and Sportsmedicine 2002 (Aug); 30 (8) ~ FULL TEXT
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.
When to Return to Play After an Ankle Sprain
Physician and Sportsmedicine 2002 (Dec); 30 (12) ~ FULL TEXT
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.
Shoulder Dislocation in Young Athletes
Physician and Sportsmedicine 2002 (Dec); 30 (12) ~ FULL TEXT
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.
There are other shoulder articles in our
Shoulder Girdle Page.
Osteoarthritis of the Glenohumeral Joint
Nonsurgical Treatment Options
Physician and Sportsmedicine 2002 (Apr); 30 (4) ~ FULL TEXT
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.
The Role of Nutrition in Rehabilitation and Sports Medicine: Part I
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. You will also enjoy Part II of the series.
Quantitative Functional Capacity Evaluation:
The Missing Link to Outcomes Assessment
Topics in Clinical Chiropractic 1996; 3 (1): 32–43 ~ FULL TEXT
In the quest of containing health care costs and still offering optimum care in terms of quality, the concepts of outcomes assessment of both subjective and objective varieties are discussed. Discussion of five criteria for the development of an instrument, and a discussion regarding high verses low tech functional testing, and utilization parameters with risk factors for chronicity are discussed.
Applying Outcomes Management into Clinical Practice
J. Neuromusculoskel System 1997 ( Summer); 5 (2): 1–14 ~ FULL TEXT
The paradigm shift in health care from case management to cost contained, outcomes management (OM) has vaulted the study and use of valid and reliable outcomes tools . OM, when used appropriately, can measure progress, or the lack thereof, in three critical areas which include pain management, physical capacity (impairment), and disability.
Proving the Existence of Chronic Pain
Steven G. Yeomans, D.C. ~ FULL TEXT
Pain is ultimately a subjective experience. Proving the existence of pain is therefore, not possible. In practice, when a patient reports pain, the patient is believed to have pain. Yet, not all pain is the same. There may be a variety of reasons for reporting pain to a physician---pain, drug seeking, psychological problems, litigation needs---but there is always a reason. The critical issue is how to untangle the other factors from pain, recognizing that these factors may drive pain and pain may drive these factors.
Hip Extension and Abduction Dysfunction
Donald Fedoryk, D.C., D.A.C.R.B., C.C.S.P. ~ FULL TEXT
Hip extension and abduction movements involve coordinated muscular contractions occurring in a specific sequence. When a change occurs in the sequence of muscular contractions, a new movement pattern will develop called "an altered movement pattern". Understanding muscle function during hip extension and hip abduction allows muscle imbalance and altered movement patterns to be recognized. Treatment to correct the muscular imbalance causing an altered movement pattern is the rehab treatment plan.
Scientific Support for Low–Cost Exercise Programs
Back Letter 2000; 15 (7): 73,82 ~ FULL TEXT
This one year research project reported lower costs with "active care" vs.physical therapies approaches. At the 12 month survey they reported: "All three groups maintained similar improvements in pain intensity and frequency at this juncture, but only the two group exercise programs maintained long–term gains in self–reported disability."
Award–Winning Study Finds That Current Diagnostic Techniques Cannot
Identify Pain of Discogenic Origin
Back Letter 2000; 15(6): 61,68–69 ~ FULL TEXT
The best predictor of a painful HIZ in this study was an abnormal result on
psychometric testing (tests for the presence of psychological distress). "What
we showed is that the amount of discomfort that many patients have with
discographic injection is most closely related to psychological and social
issues," said Carragee. This suggests, according to Carragee, that low back
pain may have physical, psychological, and emotional dimensions. He noted the
importance of treating the whole person with back pain, not just the anatomic
abnormalities. NOTE: You need to sign–up for a free Medscape account to access this
Immobilization or Early Mobilization After an Acute Soft–Tissue Injury?
Physician and Sportsmedicine 2000 (Mar); 28 (3) ~ FULL TEXT
Acute soft-tissue injuries such as muscle-tendon strains, ligament sprains, and ligament or tendon ruptures occur frequently in sports and exercise. Without correct diagnosis and proper treatment, they may result in long-term breaks in training and competition. Far too often, injuries become chronic and end careers of competitive athletes or force recreational athletes to abandon their favorite activity. For these reasons, an increased focus has been on finding ways to ensure optimal healing. In this regard, the question has centered on immobilization or early mobilization in treatment.
Shoulder Muscle Dysfunction and the Golf Swing:
Important Treatment and Educational Considerations
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.
Documentation of Physical Capacity:
It's Purpose in Rehabilitation
Patients need clear goals to change behavior. Workers' compensation case managers also want to see a clearly expressed goal of care. Alongside identification of activity intolerances from functional questionnaires (e.g. Oswestry), examination of physical capacity deficits provides objective, quantifiable data from which realistic end points or goals of care can be established.
Appropriate Warmup Prior to Rehab Therapy
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.
An Overview of Tonic and Phasic Muscles
The primary function of postural (or tonic) muscles is to maintain upright (trunk) posture, and that phasic muscles are responsible for rapid motions. There are other differences as well. These include the following:
Vladimir Janda Citation Collection
Shortcuts are provided to the PubMed abstracts of all the articles which are available online.
Behavioral Responses to Examination:
A Reappraisal of the Interpretation of "Nonorganic Signs"
SPINE (Phila Pa 1976) 1998: 23 (21) Nov 1; 2367–2371
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. Behavioral signs are not on their own a test of credibility or faking.
Complementary Care: When Is It Appropriate? Who Will Provide It?
Annals of Internal Medicine 1998 (Jul 1); 129: 65–66 ~ FULL TEXT
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 (1). 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 (1). 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.
Congruence between Decisions To Initiate Chiropractic Spinal Manipulation
for Low Back Pain and Appropriateness Criteria in North America
Annals of Internal Medicine 1998 (Jul 1); 129: 9–17 ~ FULL TEXT
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.
Responses to the above AIM Article from our Viewers
The Effects of Abdominal Muscle Coactivation on Lumbar Spine Stability
SPINE (Phila Pa 1976) 1998 (Jan 1); 23 (1): 86–91; discussion 91–92
The activation of human trunk muscles has been found to involve coactivation of antagonistic muscles, which has not been adequately predicted by biomechanical models. Antagonistic activation of abdominal muscles might produce flexion moments resulting from abdominal pressurization. Qualitatively, antagonistic activity also has been attributed to the need to stabilize the spine.
Guide to Assessing Psychosocial Yellow Flags in Acute Low Back Pain:
Risk Factors for Long–Term Disability and Work Loss
New Zealand Guidelines Group ~ FULL TEXT
This guide is to be used in conjunction with the
New Zealand Acute Low Back Pain Guide. It provides an overview of risk factors for long–term disability and work loss, and an outline of methods to assess these at risk. Identification should lead to appropriate early management targeted towards the prevention of chronic pain and disability.
What is the Natural History for Lower Back Pain?
We have all heard the statistics that say 83% of patients are better in 6 weeks. Is this universally advertised short term outcome true? What do we mean by better? If our goal is to improve the quality of care for back pain patients then we first need to establish benchmark outcomes of recovery. If improvement is the goal then 90% of patients are improving after only 3 weeks. But, if asymptomatic is the goal then only 46% reached this goal after 7 weeks. If not having any activity limitations due to pain is the goal, as AHCPR suggests, then only 38% have achieved this goal by 7 weeks.
Evaluation of Specific Stabilizing Exercise in the Treatment of Chronic
Low Back Pain With Radiologic Diagnosis of Spondylolysis or Spondylolisthesis
SPINE (Phila Pa 1976) 1997 (Dec 15); 22 (24): 2959–2967
A "specific exercise" treatment approach appears more effective than other commonly prescribed conservative treatment programs in patients with chronically symptomatic spondylolysis or spondylolisthesis.