REHABILITATION THE MISUNDERSTOOD COMPONENT IN MUSCULO-SKELETAL HEALTH CARE

Transcription

1 REHABILITATION THE MISUNDERSTOOD COMPONENT IN MUSCULO-SKELETAL HEALTH CARE Burl Pettibon, D.C., FACBS, FRCCM, Phd (Hon.) Is it possible to walk through a doorway when the door is closed? That strange question is a metaphor that can be used to describe the difference in research-based rehabilitation that prepares the spine for corrective procedures that produce little to no pain versus no preparation of the spine before adjusting or worse yet: substituting strengthening exercises for rehab in an attempt to prepare the spine for correction. This article is an attempt to explain how holistic rehabilitation can open the door for effective pain free correction of spinal form and function. Gym type exercises are often called rehabilitation exercises. However, the two have little in common. Gym type exercises are isotonic that work and shorten phasic muscles thereby opposing positional changes. Phasic muscles are enervated by a1-motor fibers and are consciously controlled. When totally fatigued or injured they become flaccid and unable to maintain spinal position or changes. Postural muscles are enervated by a2- motor fibers and are controlled by the autonomic (automatic) nervous system. The strengthening of these muscles requires isometric exercises. When they are fatigued or injured they become spastic. 1 It is critical to understand that postural muscles dominate ones spinal position and function as well as posture, stance and gait. Therefore it is logical to concentrate on postural muscle rehabilitation if your goal is correction of spinal form and function. What is rehabilitation and why is it necessary for quality patient care? Dorland- s Medical Dictionary 26 th Ed. Page 1140 defines rehabilitation as; 1) The restoration of normal form and function after injury or illness. 2) The restoration of an ill or injured patient to self-sufficiency or to gainful employment at the highest attainable skill in the shortest period of time. 2 The profession of Chiropractic claims that the adjustment is for the restoration of normal form and function of the spine through correction of spinal displacement subluxations. We can agree that abnormal/subluxated spinal forms cause abnormal functions. The question is: Will a chiropractic adjustment or multiple adjustments correct spinal displacement subluxations? Answer: There is no published research that demonstrates scientifically that conventional chiropractic adjusting permanently corrects spinal displacement subluxations. However, there is published research that conventional chiropractic treatment does not correct 3, 4, 8, 9 spinal subluxations, form and function. Surveys of techniques conducted by Dynamic Chiropractic Magazine show that the clinical procedures taught in chiropractic colleges and practiced by 84% of the profession is the Gonstead technique which involves the use of a sudden applied force into the subluxated spine referred to as an adjustment or treatment. 5 What do sudden applied adjusting forces taught in college clinics and used by the majority of chiropractors, actually do? Is it possible to physically correct spinal displacement subluxations with a sudden applied

2 adjusting force without first preparing the spine to welcome the force through rehabilitation of the soft tissues that hold the static spine upright while in a normal or abnormal (subluxated) position? Answer: Guytons Physiology 5th and 6 th edition describes the functions of the dynamic stretch reflex that is caused by the adjusting/manipulation forces. This dynamic stretch reflex states that sudden applied forces that move (displaces or replaces) a body part evoke a reflex reaction that faithfully replaces body parts that are changed by the sudden applied force. 6 Obviously a vertebrae is a body part. Further these reflex actions do not take into consideration that the application of the force may have been well intended by the one that delivered the force. Research published in 1996, by JMPT, titled Lasting Changes in Passive Range of Motion after Spinal Mobilization, a Randomized, Blind Controlled Trial; tested spinal changes produced by diversified and toggle recoil adjusting. Their findings were that these adjustments caused about a 5% increase in mobility and the changes lasted for about 7 days. There was no mention of actual spinal displacement subluxation changes. 7 A more recent article, published in the Spine Journal titled The Effects of Side Posture Positioning and Spinal Adjusting on the Lumbar Z Joints, demonstrated using pre and post MRI studies that adjusting/manipulation resulted in the spine becoming measurably more displaced than before it was adjusted/manipulated. 8 Chiropractic adjusting with no mention of first performing rehabilitation to prepare the spinal soft tissues for change typically has shown little success in making gross structural spinal and postural changes. This also was tested and published in JMPT. The authors were Harrison et al in 1997, 3 and Lantz et al in In 1975, Jowett and Fidler, published research in Orthop. Clin., N. Amer., that proved the body changes phasic fibers into postural muscle fibers on the convex side of scoliosis with spinal displacement subluxations; hypo mobility and nerve root compression were also noted. Obviously the body changes muscles as needed to protect spinal position (form) and function. Rehab procedures followed by correcting of the spinal displacements that caused the convexity in the scoliosis resulted in the fibers that had been changed from phasic to postural being changed back to phasic, after the spine was corrected. 9 Neuro-muscular research has proven that the dynamic stretch reflex guards all body parts including spinal position even if it is in a subluxated position from being changed by sudden applied forces. Guyton s Physiology 5 th and 6 th Edition, explains how the dynamic stretch reflex causes muscles to replace body parts after a dynamic force has changed them. Muscles intercept sudden applied forces that are up to.3 of a second in speed. The muscles contract fast enough to counteract these sudden applied forces. This reflex protection is automatic unless the force is faster than.3 seconds. Forces faster than.3 seconds can and often do tear the muscles and then the ligaments. 6 After the muscles and ligaments responsible for normal spinal form and function are torn, then our research and the research of others finds that the spine can easily subluxate. Then correction of spinal form and function cannot be realized and maintained until after the red and white soft tissues,(muscles and ligaments) have healed and are functional. This may take up to 36 months. The protective energy of the muscles can be greatly reduced by slowly stretching the phasic and postural muscles rather than attempting to exercise them. To be effective, stretching should last at least 40 seconds and include all muscles involved. 10

3 Ligament research has proven that to instantly change a vertebrae s position the adjusting force would have to overcome 40% of the spine holding ligament s resisting force. Such high forces are impossible for a doctor to produce and could crush the vertebrae before the ligament entered the plastic range that is necessary before instant positional change of a vertebra can occur. 11 However, rehabilitation procedures that causes disks and ligaments to go through repetitive full range loading and unloading cycle s for 2 to 5 minutes produces a condition called hysteresis which gradually lowers the resistance of spinal disks and ligaments thereby making changes in spinal position possible, easy and pain free. Hysteresis can temporarily remove up to 95% of the ligament s holding energy and it lasts for approximately six minutes after loading and unloading cycles are discontinued. Within 15 to 20 minutes after loading and unloading cycles are discontinued, the ligaments regain all of their holding energy. 12 Loading and unloading cycles in the cervical spine requires slow, intermittent traction that can be produced by using our cervical traction procedures, while effective loading and unloading cycles in the lumbo-sacral spine requires full range, figure 8 cycles that are slowly applied using our therapeutic wobble chair. This action requiring 4 seconds to complete one cycle after the ligaments are completely stretched. Nordin, et al (1989) performed experiments that show the figure 8 cycles also mix and re-mix the protoglycine aggregate of the disks nucleus, necessary to mix, remix and maintenance of a perfect jell. Nordin, et al also found that like fluids, the jelled nucleus is noncompressible. When mixed and perfected daily the perfected jell equally transfers body weight from the vertebra above to the vertebra below thereby providing a foundation for maintenance of the corrected spines form and function. 13 Nordin, et al also found that loading and unloading cycles produce the following: 1) Re-hydration of the gel in the disks nucleus increases its height 2) Increases disk, ligament and tendon strength 3) Decreases potential for injury from sudden applied loads and/or cumulative traumas 4) Decreases severity of injury, should injury occur 5) Prevention of adhesions during healing of injuries and improved integrity of healed joints 6) Lubrication of spinal joints and nourishment of disks and cartilages 7) Develops the spinal core base for agility, strength and endurance training In addition they also found that the figure 8 motion pumps the cerebral-spinal fluids necessary for the metabolic interchange of glucose to feed the brain, thereby giving the patient a feeling of mental and physical well being. This is an additional benefit of our rehab procedures that is practiced in the office and at home! Home care instructions are designed to work in tandem with clinical care and will include the use of deep, diaphragmatic breathing in coordination with specific rehabilitation procedures. 14 These procedures take into account the fact that the thoracic spine is approximately 13 times less flexible than the cervical spine and approximately 3 times less flexible than the lumbar spine, therefore, thoracic loading and unloading cycles require more time and concerted rehabilitation procedures.

4 Patients are taught to prepare their spine both in the clinic before receiving care as well as at home before daily activities and before rest at night. AFTER COMPARING SCIENTIFIC INVESTIGATION TO DOGMA, A PARADIGM SHIFT IN CHIROPRACTIC EDUCATION AND CLINICAL PROCEDURES APPEARS TO BE APPEALING. THAT IS IF CHIROPRACTIC IS TO FULFILL ITS GOALS OF CORRECTION OF SPINAL FORM AND FUNCTION. Change is inevitable for the growth of any profession; without it stagnation and eventual decline is the end result. Through the use of clinical research and documentation with new and more efficient methodologies, we grow in our knowledge and our abilities. Dr. Mark Morningstar is the Director of Research for the Pettibon Biomechanics Institute, Inc., together we have published several retrospective as well as blinded studies proving through pre and post x-rays that permanent spinal corrections are possible after the spinal soft tissues have been prepared through our holistic rehabilitation 15, 16, 17, 18, 19, 20 procedures. In our next article we will discuss research that claims exercises such as walking, jogging, running, tennis and weight training pumps the fluid out of the nucleus of the lumbar disks. We will also discuss how the lost fluids can be restored when these exercise activities are followed with rehab procedures. References: 1) Divorak J, Divorak V, Manual of Medical Diagnosis 2 nd revised edition Thieme Medical Publications, Inc. Stutgart, New York Page 40 2) Dorlands Medical Dictionary 26 th Ed. Page ) Harrison DD,Jackson, BL, Troyanovich SJ, Robertson G, DeGeorge D, Baker WF: The efficacy of cervical extension-compression traction combined with diversified manipulation and drop table adjusting in the rehabilitation of cervical lordosis: a pilot study. J Manipulative Physiol Ther 17: , ) Lantz CA, Chen J: Effect of Chiropractic intervention on small scoliotic curves in younger subjects: a timeseries cohort design. J Manipulative Physiol Ther 24: , ) Dynamic Chiropractic Magazine, Survey of Technical Procedures Practiced by Chiropractors 6) Guton AC, Textbook of Medical Physiology 5 th and 6 th edition 1981 WB Saunders Company Philadelphia, Pa. 7) Nilsson N, Christensen HW, and Jartvigen J,Lasting changes in passive renge of motion after manipulation; a randomized, blinded, controlled trial. Journal of Manipulative and Physiological Therapeutics 1996; 19(3) 8) Cramer GO, Gregerson OM, et al. The Effects of Side Posture Positioning and Spinal Adjusting on the Lumbar Z Joints, Spine, 2002;27(22): ) Jowett R. Fidler M, Histochemical Changes in the Multifidus Muscle in Mechanical Derangements of the Spine. Orthop. Clin., N. Amer. 6 (1975), ) LeVeau B Biomechanics of Human Motion. Sanders Publ. Philadelphia ) Grodzinsky, Lensto,Jin, Frank:Cartilage Tissue Remodeling in Response to Mechanical Forces ) Panjabi M, White A, Clinical Biomechanics of The Spine. J. B. Lippincott, 1978 Philadelphia 13) Nordin M, Frankel V, et al, Biomechanics of the Musculoskeletal System Philadelphia, London ) Luna-Massey P, Peper E, Clinical Observations of Breathing Patterns and Pain Relief in Chronic Paon Patients. The Association of Applied Psychophysiology and Biofeedback (1985) :82-84

5 15) Morningstar MW, Strauchman MN, Weeks DA, Spinal Manipulation and Anterior Headweighting for the Correction of Forward Head Posture and Cervical Hypolordosis: A Pilot Study, Spring 2003, Number 2, Volume 2, Journal of Chiropractic Medicine 16) Horseman I, Morningstar MW, Radiographic disk height increase after a trial of multimodal spine rehabilitation and vibration traction: a retrospective case series, , , Journal of Chiropractic Medicine, ) Schwab MJ, Chiropractic management of a 47 year old firefighter with lumbar disk extrusion, 7, , Journal of Chiropractic Medicine, ) Saunders ES, Woggon D, Cohen C, Robinson DH, Improvement of Cervical Lordosis and Reduction of Forward Head Posture with Anterior Head Weighting and Proprioceptive Balancing Protocals, J. Vertebral Subluxation Res., April ) Morningstar MW, Cervical curve restoration and forward head posture reduction for the treatment of mechanical thoracic pain using the Pettibon corrective and rehabilitative procedures, Summer 2002,Number 3 Volume 1, Journal of Chiropractic Medicine 20) Morningstar MW, Cervical hyperlordosis, forward head posture, and lumbar kyphosis correction: a novel treatment for mid-thoracic pain, Spring 2003, Number 3, Volume 2, journal of Chiropractic Medicine.