REHABILITATION

OF THE SPINE
A PRACTITIONER'S MANUAL

Editor
CRAIG L1EBENSON, DC
Los Angeles, California

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Williams & Wilkins
A WAVERLY COMPANY
I 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
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Seclioll I. Basic Principles

1. Guidelines for Cost-Effective Management of Spinal Pain . .. . . . . . . . . }
CRAIG UEBENSON
,.',
\ ..:1 .
2. Integrating Rehabilitation into Chiropractic Practice (Blending Active and
Passive Care) . . 13
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 ...................73
t CRAIG UEBENSON and JEFF OSLANCE

6: Evaluation of Muscular Imbalance 97

II () VLADIMIR JANDA

7. Diagnosis of Muscular Dysfunction by Inspection ............... .113

LUDMILA F VASILYEVAand KAREL LEWIT

,~
8. Evaluation of Lifting ................ 143

( .•
oJ}
LEONARD N. MATHESON

Sec/ion 111. Patient Education

() 9. Back School 153
PAUL D. HOOPER
()
10, Patient Education ' . . 1~

I J
CRAIG UEBENSON and JEFF OSLANCE
Appendix IO.l How to Care/or Your B(J(:k "lid Neck: A Sec/ioll Addrc.'i.\"cd J(J the
Patient __ . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . 169

\ () Section IV. Functional ReslOrarioll

I~ () ll~ Role of Manipulation in Spinal Rehabilitation

KARELLEWIT
195

)l;iii
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 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

Mobility 253
CRAIG L1EBENSON

14: Spinal Stabilization Exercise Program . . . .21.)3

JERRY HYMAN and CRAIG L1EBENSON
Appendi.\' 14.1 Ex.ercise Checklist . . ..•.....•.•......316

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 \~ Psycho.weial and Sociopolitical Aspects of Rehabifiwrioll

19. Psychosocial Factors in Chronic Pain....... ., 391
GEORGE E. BECKER

20. PatientIDoctor Interaction A05

WILLIAM H. KIRKALDY·WILLIS

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

VERT MOONEY

Index . . AI9

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BASIC PRINCIPLES

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

MISDIAGNOSIS AND MISMANAGEMENT OF Ovcrcmphasis on a Structural [)iclgnosis

THE PROBLEM
Artcr ivtixtcr and Barr's, discovery that compn::ssiol1 of a
Em'crging evidence indica(c~ the problem of low bad: nerve root by a hcrnialc<1 disk could cause sciatica. thl' medi-
pain has been mismanaged on a gr;md scale. From over- cal profession has belicved sirongly in thc pathoanatomic
prescription of bed rest to overuse of surgical interven- basis for back and leg pain.;J,::; Structur.ll cvidc;lcc of a disk
tion and advanced imaging techniques. the costs related hernia is present in Illore than 90% of palicnt~. with appro-
[0 low back pain afC unccilwincd. The U.S. govcrnmcnl re- priate symploms.:{o-~'J Unforlunalely. even whe;n using. such
ccntly issued federal guidelines on .acme low back pain .ldvanced imaging lechniques .lS mydogr<lphy CT :,canning.
aimed at promoting a quoJlit)' care modeL I RC<lssurancc. ac- or magnetic resollance.; imaging. lhe same posilin~ findings
tivity modification, manipulation. over-the-counter medica- <In.: <llso prescnt ill 28 to 50% of normal. asymplUmatic inui-
tions. and exercise were recommended as the key clements of viduals. 2h-\fI Thus. imaging tests have high s'~nsiti\'ity (few
such a model. I false negatives) hut low sped/icity (high false-positivc rate)
for identifying disk problems. Even \vhcn (he diagnosis of
disk hernia is rckvant. such pathologic change tcnds to re-
Epidemic
solve without surgical inh.:rvention. Bw;;h et ;,11. reported. "A
From 60 to 80% of the general population suffer lower back high proponion of intcrvertebral disc hcrn!atiolls haye the
pain at some time in their lives.I.I> Most of these individuals potential {() resolve spolltaneollsly. Even if patknt:, have
recover within 6 weeks, but 5 to 15% arc unresponsive to marked rcduction of straight leg raising. positive neurologic
treatment and have continued disabili ty 7-'O (Fig. 1.1). The signs, and a substantial intcrvcrtebral disc herniation (as op·
minority of patients who do not recover within 3 months ae· posed to a bulge). there is potcntial for making. a natural re-
count for up 75 to 90% of the total expenses related to this covery. not least due to resolution of the intt.vertl.."bral disc
health care problem,1l-17 which exceed $60 billion per herniation."·'1
year in the United Slates. 11 The 7.4% of patients who arc Other structural pathologic chang.es havc abo been ovcr-
out of work for 6 momhs account for 75.6% of the 101'11 rated as causes of hack pain, Linle correlation ;:xists bctween
cost lll (Fig. 1.2). The majority of these costs (60%) are attrib- r~ldioJogic signs of degeneration and clinical sympto11ls..r~-JS
utable to indemnity. with only 40% related to treatlllcm ll . 15 Nachcmson said. "Even when strict radiographic criteria arc
(Table 1.1). .ldhered 10. 'disk degeneration' is dClllonstralcd with cqu:.tl in-
Among those patients whose symptoms resolve. recur- cidence in subjects wilh or wilhout pain.".'" III a :'tlIdy of ca-
rences arc COllllllon. In some studies. recurrence rates were as daveric specimens. Vidcman c{ al. found no correlation be·
low as 22 to 36%.I'}-21 Berquist·Ullman and Larsson found {ween structural pilthologic fIndings 311U a hislOry of low back
Ihat 620/c; of patiellls with acute back pain suffered at least one pain:m Spondylolisthesis is an exception: patients with this
recurrence during I year of follow-up. 10 A long·term study re- abnormality havc an increased incidence of episodes of low
vealed that 45% of patients had at least onc significant recur- back pain.~tc Segmcntal ins(<Ibility and isolated disk resorption
rence within 4 years. 22 ;,irC other diagnoses that cannot bc validated as C.llisatiyc fae·

The incidence rate. cost of chronicity and disability, lOTS of low back pain.·'"
and high recurrence ralC add up lO a problem of epidemic An interesting silllation exists with rcspeci to two popular
proportions. In his Volvo award winning paper. \VaddclJ diagnoses-the facct and sacroiliac syndromes. Although it is
stated. "Convcmional medical treatment for low-back pain known lhat these structures arc pain sensitive. it i~ notoriously
has failed. ~md lhe role of medicine in the present epidemic difficult to conlirnl the diagnosi~ of either <..'ondition.·u ..e
musl be critic::llly eXtllnined:·~.\ The cause of this epidcmic Schw.lri,:er el .ll. used .. combinmion of scrcciling and <:onfir-
involvcs a number of f"ctors. The reasons for this fail· malory anacsthcli.... zygapophysc;ll joint blocks along with
ure or treatment .md potcntial solutions .are presenteu in typical cX~lI11in;'llioli procedures (i.e.. extension \'-'ith rotation)
Table 1.2. .lIld could not correlate injection response with any single

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 REHABILITATION OF THE SPINE: A PRACTITIONER'S MANUAL

PERCi)H cause of their symptoll\s.Jb For this re<\son, most such cases

70 ~ \
;.tre classified with the label "nonspecific back pain:'
According to Frymoyer. "Most commonly. diagnosis is

6O~
speculative and unconfirmed by objective tesling."-Il The
Quebec Ta~k force states that "before we b~coll1e I1lcsllH.:rizcd
50 ~ \
with the dcveloping diagnostk tcchnology. such lcchniques
'0 f must be adjudic~\tcd rigidly ;as to their cost/bcndil. risk/hcnc-
lit. ~md cost/cfft::cti\'t:::~~~;s r:lliOS,"11l Perhaps with diagnostiL:
30 L ,
20 lI \\ blocks paving the way. other h:ss expensive lests Illay bc
found to compare favorably to this potcntially important
"gold standard."
lOr ~
oLI -=
o 2 J 5 6 1 e 9 :0 1: 12 O\'crprescription of Bed Rest
OU~ ....TIOII OF .e.9SEIICE FRO~ WOR!': !::mnth:;)
"Because of the failure to pinpoint lhe specific pain gcncr~llors
Fig. 1.1. Likelihood of injured worker:> returning to active employ- in low back pain, bed rcst and analgesics have become the
ment as work absence increases. Quebec, 1981. (From Spitzer
typical treatment. The self-limiting course of mosl low back
WO, Le Blanc FE, Dupuis M, et al: Scientific approach to the as~
pain episodes has given justificatio!l to this pracl ice of symp-
sessment and management of aclivity-related spinal disorders: A
tomalic lrcatm';;:nl. As it turns ouL this seemingly benign pre-
monograph for clinicians. Report of the Quebec Task Force on
Spinal Disorders. Spine 12 (SuppI7):Sl. 198'/.) scription 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
PERCENi relieve pain. our whole approach 10 b'ickachc has been <as-
sociated with increasing low back dis<tbility~Despite a \vide
70 ~ mnge of trcntmclllS. or perhaps bL:C;;IU~C nonc of the them
provide a lasting cure. our whole slrategy of management
60
has been negative. bascd on rest.., We have aClUally prescribed

50 t low back disabiliIY!"~' The Qucbt:c rcpon Slated. "Bcd rest is

nor necessary for low back pain witholH signilicam radial ion.
'0 When prescribed. il should las\ no longer than 2 days,
30

20 Table 1.1. Percentage of Costs by Type of Treatment

and Compensation
10 Back Pain Costs Percent Percent

0 Medical costs 33
< I Physician's fees 11
OU;i.:.TlW OF ASSENC:: fROM \oiO~K tc.or.~f'1s1 Hospital costs 11
Diagnostic tests 4
Fig. 1.2. Compensation costs for back injury in groups wilh differ- Physical therapy 3
ent durations of absence from work. Quebec, 1981. (From Spitzer Drugs 2
WO, Le Blanc FE, Dupuis M. et al: Scientific approach to the as· Appliances 2
Oisability 67
sessment and management of activity-related spinal disorders: A Temporary 22
monograph lor clinicians. Report of the Quebec Task Force on Permanent 45
Spinal Disorders. Spine 12 (Suppl 7):51, 1987.) Tolal costs 100
Adnplcd wilh permissIon from Pope MH, Frymoyer JW. Andersson G (~cls):
Occupational low Back Pain. New YOlk, Pracgcf. 1984. p 107"
set of clinical features (history or cX~lInin:.ltioll}.'l.\ In con-
trast. a study ill\"olving chronic ncek pilin patients who had Table 1.2. The Low Back Pain Epidemic
suffercd whiplash revealed that double <lncstht:tic blocks
Thc Problem The Solulion
could identify painful joints in 40 10 68% of p:.ltiCIltS.~·1 In an~
other study in ....olving the usc of diagnmaic blocks. investiga- Overemphasis on slrucu!ral 10 deconditioning syndrome
tors reported that between 13 and 30ck of p:.llienls with diagnosis
Overprescription of bed res! Early, aggresive conservative
chronic low back pain experienced pain generah.:d from the
lherapy
sacroiliac joinLJ~ Overuse of surgery Ac!ive care lor subacute cases
Most patients witlt low back pain do not ha\"t: structural Ignoring abnormal illness Early JD of disability predictors
behavior
pathologic conditions that call be clearly determined as the

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 l,;HAt-' I t:K 1 : uU'UtLII\lt:~ FOR COST·EFFECTlVE MANAGEMENT OF SPINAL PAIN 5

Prolonged lx:d resl may be counleq)roduc(ivc."l~ Dcyo and more promptly relieved by surgery, but this has a significant
colleagues p~rformcd a controlled clinical lrial comparing morbidity and rarely mortality. Surgery is not invariably suc-
] d'lys ;.lg;lin:-:l ::! weeks or bed n.::.;(. They concluded lhal nol cessful.···11 Allen nnd \Vaddell, using the strongest possible
only was 2 days of bed fC.'a as crfc.:ctivc as 2 wc.:eks. but also Innguagc, blamc their colleagues. "The rnpid and enthusiastic
the negmivc effecls of prolonged immohilizatioll wcre also expansion of disc surgery soon exposed its limitations and
lil1litcd:~'~ failures. It was nceused of leaving morc trngic human wreck~
!
'Ige in its w'lke than any other operation in history."~5
i Frymoyer describes a particularly difficult patient group on
Overuse of Su rgcry
\ () which !O pdform surgery: "One place where treatment has an
The t)\'crus.... ()f surgery has he..... 1 perl laps tllc single lliost dam- adverse effect is surgical management of patien!s with COIll-
aging medical intervention for b'H:k pain sufferc.:rs. Bigos and pensation:'H Schneider and Kahanovitz echoed these same
Baltic said. "Surgery seems helpful for ,It most 2~~ of patients remarks. noting that even in patients who had an apparently
with back problem:;. and its inappropri:'ltc IJSC can have .1 greal successful operation for sciatica. if their problem is compens-
impact on increasing the chance of chrOllic back pain disabil- able. they are still at significant risk for recurrence and dis-
ity.··l'·ln his Volvo award rape.!'. W..lddcll said, "Such dramatic ability.52
surgical successes unfortunately only ;:\pply to approximately
l'lc of palit;llls with low back disorders. Ou.r failure involves
Overemphasis on a Psychogenic Diagnosis
the remaining 999'0 .. for wholll the problem has become
progressively worse."=' Saal and Saal supervised care for a According to Dworkin.~·\ "Pain report often occurs in the
group of patiClllS referred by neurologists for surgery. They absence of pathophysiology or any discernible peripheral
<.Htcmplcd rchabilil ..uion for these p.llients .lIld made the fol- somatic changes. This finding implies the need to reexam-
lowing obSe(valions: "Surgery should be rcser\'cd f~r tho:;e ine our limited understanding of pain. rather than leaping to
patients for whom function C,lIll\ut be s'llisfactorily improved the conclusion that such p<lins must be psychogenic."
by a physical rehabilitation progr<.tlll .. F;:tilure of passive LaRocca commented on this problem in his Presidential
nonopcrativc treatmCI1l is not suflicicnt for lhe decision to Address to. the Cervical Spine Research Society An-
opcr<lte." l" nual Meeting in Decembcr of 1991: "An assumption is
In 1970. Hakclius performed ;I study that revealed that the made that there is a pathological entity operating in the
majority of sciatica paticllls responded to consef\'ative e;:lrc.:-n spine to produce pain which, if eliminated or controlled.
In 1983, Weber reported that. cvcn in properly selected should result in pain relief in evcry instance ... The clinician,
patients, there is no diffcrc!l(c in outcome betwecn surgi- having spent his resources, is conditioned to resolvc the
cally and conservatively trcated p;.tticnts at 2 yeurs.~l Saal and m.ltter by deciding that a psychological explanation is the
Saal and their collci.lgues disco\'en.:d. ''The premise th<lt oper- only alternmive . . . The error here is the automatic leap
ative patients fare better in the lirsl year is cOlllrary to our to psychology. It assumes that all organic factors have been
rcsults:'~!j In 1992, Bush stated that, "86% of patienls with considered. when in reality the c1inician's appreciation of
clinicnl scialica <lnd r'ldiologic evidence of nerve root entrap- the complexity of such factors is often severely limited:'5~
ment were treated suc;.;essfully by <lggrcssivc conservative According to Merskey, "Slater and Glithcro~5 showed that
managcment." II 60% of patients diagnosed by distinguished neurologists
The flotion that surgery is necessary in a patient with <l as having hysteria did suffer from. or develop, rckvant
large disk extrusion is not supported in the literature. physical disease that might account for their symptoms ... "~Ii
According to Saal and Sa.li. "The presence of disk extrusion Mcrskcy goes on to conclude that most regional pain syn-
docs not adversely clTcl.:l the outcomc of nonopcrativc trcat- dromes arc not psychogenic in origin and arc oflen mislabeled
ment <lnd should not be used as ovcn....helming evidence thal as such.j'~~"
surgcry is nccessary."~') Blish ct al. found that, "Indeed, the in- This is not to say that pain behavior docs not accompany
tervertebr:J1 disc pathomorphology that might secm best pain sensation. Dworkin says. "Fin<\lIy. there is no inconsis-
suited to surgical re:;ectioll is in fact thm which shows the tency in accepting the likelihood that chronic pain patients ex-
most significant incidence of nalur...1 regression ... These n::- perience distress in the form of depression. anxiety, and mul-
suits confirm that if the pain can be controlled. nature can be tiple nonspecific physical symptoms, without having recourse
allowed to run its course Wilh the parti;:11 or complete resolu- to the diagnosis or classification of their pain condition as
tion· of the mechanic.1I ractor .... Lumbar herniated nucleus psychogenic:'H Pain behavior is common and should be rcc·
pulposus can be treated Iltln·oper.Hively with a high degree of ognizcd and addressed. Although acute pain is directly related
success.··.l l to painful stimuli. nociceplion, and tissue injury. chronic p<lin
Surgery clcarly has its place in the treatment of lumbar is attributable only in part to physical evcnls.~"}..{') Chronic ill-
spine disorders. COllscrv;'ltivc care pr'lctitioners must be able ness bch'iVior and disability arc only partially related to noci-
to select lhe paticnts who satisfy the criteria for surgical in- ceptive innuences,',I.'-"-H, Psychosocial illness behavior. in-
tcrvention. These criteriOl ;Irc morc strict than ."reviollsly be· cluding depression. inaclivity, and pain avoidance, are the
licved. Bush said, "(n :;ol11e cases, :;ymptollls may have been rule with chronic pain suffercrs.;,i-71

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 REHABILITATION OF THE SPINE: A PRACTITIONER'S MANUAL

" Because most patients do not have a diagnosable struc- on quantilicalion of fUIll..:tional delkits. cxal."i~e. education.

I
j
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tural 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-
and psychologic intCfvcntion havc proven th~ir succcss with
chronically di~3hk<1lnw-h;Kk pain sufferers or recurrelll p;tin
patients (T<lblt: \.4).

I
. sultant soft tissue irritation and pain generation. Treatments Prhm.ll')·· Prcn~ntiol1
designed for injury states or disk lesions inevitably fail. thus
Because lirst-lilll~ had, pain p;l\iell(s ;m..~ likdy to sutler re-
C·ll:-.!:ig r~p:-~(,"!0rt. desp~ir. and illness bchavior.n-JI:>
currcnces. slll,:ce~~ful primary pre"cnlion would he ut" gre;1l
a Abnonnal illness behavior was dehllct..i by PiI0wsk~.'Jl as a
.'alue ill reducing this epidemic disorder. Unfortun;l!e!y. little
! patient's inappropriate or maladaptive rcsponse to a physic<ll
I complaint (Table 1.3). This situation typically occurs when no
scientific literature <1ddresscs this topic. Those eng<l£.ed in
repetitivc liftin~ or prolonged sitting occupations may be at
i1 organic cause for a patient's back pain can be identifkd.
Descanes' view of pain as a warning signal of impending
highcr risk. but few sludics have c"alu.\tcd whether trcatmcnt
C<ln lowcr these risks. Twu of thc hcst studies performcd to
I harm has led to the advice to "let pain be your guide." which
is helpful in acute situations when nociceptive factors prc-
dalc involvc nur:-;~s nnd llurse's aidcs. 1',.sH Gundcwcll et al.
showed that ex~rciscs Colll impan a prcn:nti\"c bellclit. and
dominate. In chronic cases. howevcr, bchavior should be en-
Vide man ct a1. showed that skilliraining c:an reduce future ill-
couraged that focuses on functional reactivation and not on
jurics.7~'Jln Skill training. ergonomic: l1louilicaliol1s. and im-
pain avoidance. In fact, it is necessary for chronic pain pa-
proved Illness art: all prob;lblc ways to prevcnl lirsl-time oc-
tients to focus on. increasing their activities in spite of {hcir
currences of back pain.
pain.
Primar.y Conservative Care

~ QUALITY CARE: COST CONTAINMENT STRATEGIES

FOR MANAGING SPINAL PAIN
A pro-activc disnbility managcment program '.lggn:ssi,·dy

I Feuerstein J~ has modeled how rehabilitation deals with as-

(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 be-
I
sessment and multidisciplinary managcment of medical status
(internal, neurologic, musculoskeletal). physical capabilities fore I month and minimizing the number whose spinal disor-
(functional capacity, work capacity). work demands (biome- der keeps them idle for longer than 6 lllomhs"""1 Most Ir.ldi-
chanical. psychophysical), and psychosocial /behavioral re- tionally minded physicians arc still ignoram of the dangers of
sources (coping skills, job satisfaclion. family situation). bed rcst and immobilil.lltion. l They are too pi.lssivc in their .11'-
A quality care .approach begins with primary prevention proach to lower back p<lin. Troup said. ·'The first attack is the
and thc aggressive trcatment of any acute pain cpisodes. ideal time for active and pcrlli.lPS ;.lggressivc trc.lllllcnl. But
Manipulation is a proven cost savcr in this regard. l if it is tacilly assumed that the vast majority of patients re-
Overutilization of expensive imaging techniques to make a cover from back pain whether or not they arc treated. then the
structural diagnosis should be avoided. UM Strict crilcria for opportunity may be missed."1I1 The natural history of lower
prc..c;cribing bed rcst or surgery should be maintained. After b<lck pain is toward resolution in 80% of patients within
studying a group of patients with operable disk lesions. Blish 6 weeks. The 20% who <lrc re~istant to this generally f:lvor-
et ai. commented thut "Even if paticms have markcd reduc- able natural history. however. Iwve .1 50% ch'Ull:e of becom-
tion of straight leg raising. positive neurologic signs. and a ing pennancntly disabled if their symptoms persist for
I substantial intervertebral disc herniation (as opposed to .1
bulge).... if the pain can be controlled, nature can be allowed
6 months (Fig. 1.3).
Linton and co-workers demonstrated th.lt early aggressive
to run its course with the partial or complete resolution of the treatment (patient education. cxcrcisc instruction. physical
mechanical factor:'·'! therapy) was superior to tr<lditionaltreatment approaches (rcst
Paticnts with subacute pain should be educated about the and analgesics without physical therapy for 3 mOlllhs).
benign nature of p<lin and the dangers of dcconditioning. and "Properly administered Early Active Intervcntion may there-
be encouraged abolll the benefits and safety of becoming fore decrease sick leave and prevent chronic problems. thus
more active. Functional restor<ltion programs concentrating saving considerable rcsources. "Ie This study is particularly
powcrful in that the risk of developing chronic pain W'1S eight

Table 1.3. Abnormallllness'Sehavior

Table 1.4. Quality Care for low Back Pain
Symptom magnification syndrome
n~!~·?vo!d",O(:~ behavior Primary prevention
Psychologic distress Primary conservative care lor acute episodes
Calaslrophizing as a coping strategy Secondary functional restoration lor subacute and recurrent cases
Anxiety Tertiary multidisciplinary functional restoration for chronic. disabled
Treatment dependency patients

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 7
"',
CHAPTER 1 : GUIDELINES FOR COST·EFFECTIVE MANAGEMENT OF SPINAL PAIN

PROBABILITY OF RETURNING TO WORK ulations over a I-month period. s" Certain studies excluded
from the meta-analysis were those such as Meadc's, which
tI included other therapies. the effects of which could not

,
I
.---"
j
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
P
back paill. R5 Triano et at reported recently that in patients
, R
o
I --) ,
B with low back pain over 7 weeh, an avemge of 10.)

I,
/
•
I
l
treatments with chiropractic manipulation resulted in im-
proved function and significantly reduced pain.«l Erhard
I
T and Delitto demonstrated that patients receiving manipu-
y
lation and exercise outpcrfonned those receiving ex.ercise
alone.'u

_ _. __c ~ ~====d
o EARLY RETURN TO WORK IS A KEY
o 6 12 1B 24
TIME OuT OF WORK (MONTHS)
Aggressive care gives the best chance for early return to
Fig. 1.3. The probability of recovering from low back pain. (From work. Litigation neurosis is easy for disabled workers to ac-
Frymoyer JW: Epidemiology of spinal disorders. In Mayer TG, quire. Promoting bed rest and prolonged inactivity only in- .
Mooney V, Gatchel AJ (eds): Contemporary Conservative Care creases the likelihood of prolonged disability. Treatments that
for Painful Spinal Disorders. Philadelphia, Lea & Febiger, 1991.) mobilize the patient and auempt to return them to work
quickly are advantageous. Communication between doctor
and employer is essential because certain job modifications
times lower in the Early Active Intervention group than in the may be necessary to ensure worker safety on return to work.
traditional group. Many doctors consulting in managed care Deyo and associates said, "Our data support a recent trend to-
situations today wrongly conclude that care should be mini- ward earlier mobilintion of patients with back pain .... early
mized for back pain sufferers because most will get better re- return to work may help to prevent the emergence of chronic
gardless of carc. back pain syndro·mes, with their enormous human and mone-
tary costs."~s Cats-Baril and Frymoyer also said. "It would
seem that people who 3re able to work through the acute
MANIPULATIVE THERAPY RESULTS IN LESS DISABILITY AND
phase of a low back pain episode or those who go back to
INCREASED PATIENT SATISFACTION
work even if the pain has not disappeared after a period of rest
Manipulative therapy has clearly established its cost cfrcc~ arc unlikely (0 become disabled .... keeping people al work
tivcncss in patients with acute and subacute low back is vcry effective thcrapy."n Waddell succinctly stated that,
pain.'·~-'~"~ Jarvis and colleagues found. in comparing medi..:al "Prolonged time away from work in itself makes recovery
versus chiropractic treatment for identical diagnoses, that and return to work progressively less likcly."~J
"COSI for care \Va... significantly more for medical claims. and
compensation costs were lO~fold less for chiroprac~
Secondary Functional Restoration
tic claims."S(J Authors of a recent meta-analysis looked at
studies comparing spinal manipul<.ltion to other conser- Prolonged passive care in an attempt to ameliorate the suffer-
vative treatments for acute low back pain and found sig- ing of back pain patients can lead to patient dependency. In
nific3mly bet(er rales of recovery for those individuals the acute stages of an injury. such care is nccessary; however.
treated with maniplllation.~J In fact, they concluded that when the chemical signs of innammation arc missing. a more
manipulative therapy has demonstrated a 34% better rate active. patient participatory type of care is required. Oland
of recovery at Ihe 3~weck mark than other conservative and Tveiten said, ". . . resources from the health services
. therapies. lt) should be used in the subacute stage to enhance diagnosis,
Patient satisfaction is a critical aspect to reducing disabil- treatment, and rehabilitation and to inform the public of the
ity and treatment costs. Chiropractics (which offers over 90% benign. self-limiting course of low~back pain and the positive
of the spinal manipulatlons) has shown higher levels of pa- effect of physical training."'))
tient satisfaction than family practitioner visits for back Secondary functional restoration care that focuses on spe-
pain.S7~ti" This level of satisfaction may be auributable in parl cific functional goals and patient education should be the
to the thorough explanations that chiropractors give their pa- mode of care for subacute or recurrent pain,· paticn(s~
tients regarding the nature of their symptoms (facct. rnyofas- Comprehensive rchabilitation involves functional capacity
cial. disk. etc.}.R'1 testing. physical training. education about biomechanics and
Shckellc noted that the expert Rand panel rccommcn~ ergonomics. and identification of psychosocial predictors of
dations for spinal manipulation included about 12 manip- disability (Table 1.5).

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 REHABILITATION OF THE SPINE: A PRACTITIONER'S MANUAL

Table 1.5. Functional Restoration patients, including tho:,c for whtHl1 surgery is being consid·
cred, Again, Saal .11ld 5;l;1l said the failure of passive nonop·'
Functional capacity evaluation
Rehabilitation of the motor system erali\'c trcmmcllt i~ 1\(1t "ufticicl1t support of the decision to
Patient education opcrale.~"
Identification of psychosocial factors (disability predictors) In one: notahk stud~ l.'\lHLcrning thc tn:aUllcnt of unCOlll-
plicatcd. ,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 practi-
FUNCTIONAL CAPACITY EVALUATION tioner:" One oh\'i\\u" \.'ritiL'i~m or thi~ ~tud)' is that exer-
Functional reactivation requires .lsseSSll1cnt of the fUllctiom,1 cises were givcn l\l1 a "gcneric" basis r"ther than being
status of the patient's 010101' system, EvalmHion of pos- customized to the need" of eat.:h p<l1ient. This investigation
ture and movement or static and dynamic function is essen- call be t.:ontrastcd with l'ight other cOlltrolled studies. all or
tial and should include assessmcnl of joint mobility. mus- which show'cd suhslanti;l! bendit from exercise that lasted
cle strength. coordination. cndUl<lIlC:C. and f1cxibiiilY, for <II 1e,lst 6 l110mhs to 2 years:::.···'"1 Il-' In a well-controlled
Postural analysis and job or activity skills should also be sludy looking at cxerci...e in failed bat.:k surgery patients.
assessed: Timm found thaI "I~w·lech" cxercises (stabilization and
An objective functional capacity cv.\luation can be per- McKenzie) gave" greater bcnefit than "high-tech" exercises
fanned inexpensively and helps thc doctor understand cxactly (Cybcx),lIu
what areas need improvement. Many of the function<ll tests Moonc)' said. "Prolon~cd rest and passive physical thcr·
also provide ideal outcome asscssment measurements. which apy modalities no longer have a place in the trcatmCnl of the
provide the patient \vith visual feedback of their baseline chronic problem."'O\ According to Waddell. "The main theme
functional capacity :.lIld lets thcm see their progress ovcr time. of m•.II1agcment mU,,1 change from rest to rchabilitiltion and
It is also crucial for communication with third-party payers or restoralion or rulIl,,;{ioll.'···
for documentation in medicolegal cases, "Low-tech" tcsts
have proven reliability,9~ Such tests correlme better with dis- PATIENT EDUCATION FOR DISABILITY PREVENTION
ability than do dynametric tesls.l).'i Overuse of technically ad-
vanced tests can lead to increased expense, and therefore such P<lticnt cduc;.uiol\. L'''pc-cially rcg'lrding skill training and
methods should be lIsed only if necessary_ ergonomic~ as well at,; I;clf·carc methods. has shown pro-
mise in reducing the cn.. h associated \vith disabling lower
back pain,ll~.,.llII Berqui'I·Ullmilll and Larsson showed th<lt.
ACTIVE CARE VS. PASSIVE CARE
when compared to'1 control group, patients with acute lower
In a comparative study of pa.<;sive physical therapy versus rc· back pain who rct.:ci\·cd a 4-hour b'lck school returned to
habilitation. Mitchell and Cam1cn found. "Active exercise to work sooner <lIld had few rccurrelH.:es in the following
provide mobility. muscle strengthening. and work condition· year,H-' A recent study concluded. "Differences between back
ing has shown superior results, , , substantial savings have school participants and .1 comp<lrison gr;)up indicated sig-
been realized in the number of days absent from work and nificantly fewer injuric\ among the back school partici-
savings in the dollars expended for compensation benefits. pants in the {)-ll1onth post-intervention period,"'N Par-
There was an initial increase in health care costs resulting ticipants had one h:tIf a" many re-injuries as nonparticipants.
from the intensity of the treatment, but these costs were more They also demonstrated liignificant rcullctions in lost work
than offset by savings in wage loss C05t.'"')(' Lindstrom et al. time costs, Although thi.:"ic results un.: impressive. some
compared a group of patients treated with exercises and edu- studies havc questioned Ihe long-term results of back
cation to a control group that received more traditional trc:at- schools,III.I!.\
ment. They documented earlier return to work and decreased
re-injury in the rehabilitation group.'H
IDENTIFICATION OF PSYCHOSOCIAL FACTORS
The notion th<lt active cxercise c<ln be harmful in an indi-
{DISABILITY PREDICTORS,
vidual with back pain i~ incorrect. Guided exercise by a
properly trained rehilbilitation specialist is the optimal treat- It is the responsihility of the rehabilitation specialist (0 be on
ment program for the subacute population. A key is exercis- the lookout for carly ..igns of :.l disability prone patient.
ing to a:.pIe::.c.s.tahlli.!!£~Lquota.rather than to a pain limit.7~,n According to Frymoycr. "if a patient is identified early in the
Waddell stated. "There is no evidence lhat activit\' is harmful course of thc low hack p<lin cpisode to have a high risk for
and. contrary to Common beli'cC itdcles n(;t necc~sarily~~-~el1 disability. early, 'Iggrcssive rclmbilitativc efforts 111ay be more
aggravate the pai~_:'~~~ Saal and Saal treated a group of pa- successful ~md cost effectivc than permitting the patient to
tien(s that had back and leg pain and were referred for have a longer period of disability with its resultant economic.
surgery, They concluded, "All patients had undergone an social and medical consequences,.. ~)
aggressivc physical rehabilitation program consisting of The problcm of chronicity or "deluyed recovery" occurs
back school and stabit!7.ation exercise training, .. 92% return when disability is disproportionate to impairl11cnt.lI~ Many re-
to- work ratc."~" Active rehabilitation is csseJ\lial for all scarchers believe psychologic charm:tcristics may be more
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 CHAPTER 1 : GUIDELINES FOR COST·EFFECTIVE MANAGEMENT OF SPINAL PAIN 9

important than biomechanical ones.68--rn:·7-l1.75 Frymoyer said. CONCLUSION

'There is increasing evidence from the general field of
\Vith consensus-based guidelines emerging as the best chance
disability, and specifically low back disability, that a 'disabil-
to cut costs associated with diagnosis and treatment of low
ity prone profile' can be identified and used to predict po-
back pain. it is incumbent on us to be aware of the direction
lential disability before the condition becomes truly
in which new findings lead. Quality care will result in bcHer
chronic....., Job dissatisfaction is one of th~ only proven
patient satisfaction and reduced costs. Manipulation and ex-
predictors of disabling back pain. m According to Cats-Baril
ercise both appear to be of value if our beliefs arc based on
and Frymoycr,Il6 other predictors of low back disability in-
[he scicntitlc literature. Future studies will hopefully nush out
clude work status and job satisfaction~ injury being viewed as
which patients respond better to what type of care and what
compensable: past hospitaIi7...,tion; and the patient's educa-
arc appropriate timelines for transfening from passive to ac-
tional level.
tive care.
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 indi- Table 1.7. Multidisciplinary Functlonat Restoration
cating increased catastrophizing as a painMcoping strategy as Quantifiable, functional capacity evaluation
well as emotional distress appear to be promising discrimina- Physical reconditioning of the impaired "weak link
M

tor5.111-122 D~prcssion. anxiety. hypochondriasis, and hysteria Work hardening

Behavioral disability management
arc related to poor surgical outcomc. n .1l6 The "bio-psychoso- Ongoing outcome assessment using objective criteria
cial" model has been proposed by Waddell to address the dis-
ability problem in patie",s with low back pain"(Table 1.6).

Tertiary Multidisciplinary Functional Restoration REFERENcr~

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REHABILITATION OF THE SPINE: A PRACTITIONER'S MANUAL
!

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1995. 1973.

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75. Stcmh<lch RA. Timll1CmlanS G: Personality changes associated with 101. Mayer TG. Gatchel RI. Kishino NO. et at: Objective :lSsessment
reduction of pain. Pain 1: 117. 1975. of spine function following industrial injUl)': A prospective study
7(1. Wadddl G. Morris EW. DiPaoloa M. ct at: A concept of iIIncs.... tested with comparison group and one-ycar follow-up. Spine 10:482.
as :In improved basis for surgical decisions in low back disorders. Spine 1985.
11,712.1986. 102. Linton SJ. Dndlcy LA.Jensr.n I. el al: TIlc secondary prevention of low
77. Pilowsky I: A general c13ssilication of "bRannal illne.<;s behavior. Be J bad: p3in: A controlled study with follow-up. Pain 36: 197, 1989.
Mcd PsychoI51:131. 1979. 103. Kdlct KM. Kellett DA. Nordholm LA: Effccts of an exercise program
78. Feuerstein M: A mullidisciplinary approach to the prevention. eva)- on sick Ic<lve duc to back pain. Phys TIlcr 71:283, 1991.
uation. and managemenl of work disability. j Occur Rehab 1:11. 1991. 104. limm KE: A randomizcd-control study of acti\'e and pas.o;,ivc treatRlent!'
, 79. Gundcwcll B. Liljcqvisl M. Hansson T: Primary prevention of b;lCk fOf I.:hl'Ouic iow back pain iollowing l..:) lallllllcclOmy. J Occup .sports
\ ."1 s)'lIlptoms an-d absence from work. Spine 18:587. 1993. Phys Thcr 20:276, 1994.
SO. Vidcman T, Ranh31a H, Asp S, et al: Patient-handling skill, baek in· 105. Mooney V: Whcre is thc pain coming from'? Spine 12:754. 1987.
jurics and back p3ill. An inlcnicntion study in nursing. Spine 2:148. 106. Brown KC. Sirlc.'> AT. Hilycr JC. cl 31: Cost.. d fectivene55 of a back
1989. school intervention for municipal employees. Spine 17: 1224, 1992.
81. Troup JOG: The perception of musculoskeletal pain and incapacity 107. Moffcll JAK, Chase SM, Portek I. et al: A controlled, prospective study
for work: Prevention and early trealmenl. Physiotherapy 74:435. 1988. to evaluate tlte effectiveness of a back school in the relief of chronic
82. Linlon SJ, Hellsing AL, Andersson 0: A controlled study of the effects low back pain. Spine 11:120. 1986.
of an early intervention on acute musculoskelet:ll ~in problems. Pain 108. Versloot JM. Schilstra N, Tolen FJ. et 31: Back school in industry. A
54:353.1993. prospective longitudinal controlled study (3 YC3rs). ISSLS Meeting,
83. Shekcltc PG. Adams AH. Chassin MR. ct al: Spinal manipulation for Miami. FL, April 13-17.1988.

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,
low·back pain. Ann 100em Mcd 117:590, 1992.
&4. Shckelle PG: Spine updalC: Spinal manipulation. Spine 19:858,
199·1.
85. Meade lW. Dyer S, Brownc W. et al: Low back pain ofmcchanical ori-
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<t1 e(fc~~ of back
() gin: Randomized comparison of chiropraclic and hospital outpatienl schools in an HMO. Spine 14:8, 1989.
treatment. Br Med J 300:1431. 1990. III. L:lnkhorst GJ, van de Stadl RJ. Vogciaar TW. et :II: The eITccl of the
86. Jarvis V. Phillips RB, Morris EK: Cost per case comparison of back in· Swedish back school in chronic idiopathic low baek pain. Scand J
jury claims of chiropr<lctic versus medical management for conditions RehabiJ Med 15:141. 1983. ,

I
with identical diagnostic coocs. J Occup Mcd 33:847,1991. 112. Lindquist S. Lundberg B. Wikmark R, ct al: Infomlation and rcgimen
'>
__J
&7. Cherkin DC. MacComack FA: Palient evaluations of low back pain on low back pain. Stand J Rehabit ~·ted 16:113, 1984.
care from family physicians and chiropractors. Wcst J Med 51 :355, 113. Genaidy AM: A training programme to impro\'c hum:tn physical capa-
, 1989.
&8. Cherkin DC: Family physicians and chiropractors: What's best for thc
bility for manual h3ndlingjobs. Ergonomics 34:1. 1991-
! !·t D::r::bcry VJ, Tullis W: Delayed n.-covcl)· in the patient with :I. work
! patient? J Fam Pract 35:505. 1992. compensablc injury. J Occup Moo 25:829, 1983.
~ ('"},
"~.y
89. Curtis P. Bove G: Family physicians. chiropr.J.ctors, and back pain. J 115. Bigos SJ, Dattie MC. Spengler DM. ct al: A prospectivc study of work
! Fam Pract 35:551, 1992. perccptions and psychosocial factors affecting the report of back injul)·.

I,
C'"
U 90. Triano J. McGregor M. Hondra.'> M. ct al: ManipulOltivc therapy versus Spine 16:1, 1991.
educalioR programs in chronic low back pain. Spine 20:948. 1995. 116. C:l.ts-Baril WL, Frymoyer JW: Idcntifying paticnL'> at risk of becoming
!l 91. Erhard RE. Delino A: Relative effectiveness of an extension program disabled because of low-back pain. Spine 16:605, 1991.
and a combined program of manipulalion and nexion and extension ex- 117. Waddell G. Newton M, Henderson 1, el al: A fcar-avoidance beliefs

I -"~
.
~ 3~
ercises 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
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<ltion of low hack pain
disabled becausc of low·back pain. Spine 16:607. 1991. groups using biobchavioral \·ariables. 1 Occup Rehab 2: 19. 199:!.
93. Oland G, T\'cilen GT: t\ lri:ll of modem rehabilitation for chronic low- 119. Reesor KA, Craig KD: Medically incongruent chronic b3ck pain:
back pain and disability. Spine 16:457. 1991. Physical limitations, suffering and ineffective coping. Pain 3:!::l;l.. 1988.
94. Alaranta H, Hurri H, Hcliovaara M.el al: Non-dynaffietric trunk per· 120. Turk DC. Rudy TE: Toward an empirically derivcd taxonomy of
fonm.ncc tests: Rciiability and nonnative data. Scand J Rchab Mcd chronic back pain patients: Integrntion of psychological assessment
\ G 26:211,1994.
95. Rissanen A, Alaranta H, Sainio P, ct OIl: Isokinelic and non·dynametric
data. J Consult Clin Psychol 56:233. 1988.
121, Feuerstein M, Thebargc RW: Perceptions of disability and occup'lIional
I tests in low-back pilin patients rdated to pain and disability index.
Spine 19:1963, 1994.
stress as discriminatoni of work disability in patients with chronic pain.
J Occup Rehab 1:185, 199\,

1:
96. Mitchell RI, Camlcn GM: Results of 3 multiccnter trial using an inten- 122. WiRing FG. Klonoff H, Kokan P: Psychological. demographic and or-
sive active cxercise program for the treatment of acute soft tissue and thopaedic factors :\ssociated with prediction of outcome of spinal fll~
b.:lck injuries. Spine 15:514, 1990. sion. Clin Orthop 90: 153. 1973.
97. Lindstrom A, Ohlund C. Eel. C. ct :1.1: Activation of subaCUle low back 123. MayerTG, Gatehel RJ, Maycr H, ct OIl: A prospective two-year siudy of
paticnts. Phys Ther 4:279.1992_ functional Testor-nion in industrial low hack injury. JAMA :!SS:1763.
98. Faas A, Chavannes AW, van Eijk J Th M. et OIl: A randomi1.ed, placebo- 1987.
controlled trial of exercise thcr.lpy in patients with acute low back pain. 124. Hazard RG. Fenwick JW. Kalisch SM, et al: Functional rcstor.l.tion with

t t) Spine 18:1388, 1993.

99. Catchlove R, Cohen K: Effccts of a dircctive return to work approach
behavioral support. Spine 14:157, 1989.
125. Sachs BL, David JF. Olimpio D. el :11: Spin:!.l rehabilitation b)' work tol-
1 in the tratmcnt of workmens' compensation patients with chronic pain. erancc bascd on objectivc physic;11 ctlpacity assessment of dysfunction.

I
Pain 14:181. 1992. Spine 15:1325. 1990.
100. Fordyce WE, Brockway JA, Bergman lA. et al: Acutc baek pain: A con- 126. Alaranta H. Rytokoski U, Rissanan A. ct ,,\: Inten"i\'c physical':lOd psy-
g trol group comparison of behavioural vs. lradilionallllanagement meth· chosocial training program for patients with chronic low back pain.
ods. J Behav Med 9:127,1986. Spine 19:1339, 1994.

1:
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 Integrating Rehabilitation into Chiropractic
Practice (Blending Active and Passive Care)
CRAIG L1EBENSON

Rehabilitation and chiropractic (manual medicine) are perfect interconnections between Ihese clinical signs are shown in
partners in the delivery of high quality neuromusculoskeietal Figure 2.1.
health care. Disorders of the locomotor systc;m onen resolve The o\'eremphasis 011 trcutmellt of ('(mjeclIIrell struclIIj"al
spontaneously, but high recurrence rates dictate a more pC". pathologic change (disk. facct, etc.) has resulted in (l failure
active approach. Manipulation and exercise ·arc the two mcth~ to identify or focus on intrinsic fwu.:tit~"(ll losses. pSydlO,'W-
ods that have become the standard of care, especially in the cial factors. and extri"."ic ellvirollmelllal streuor,'i (\1'ork de·
costly aren,a involving tow back pain. New treatments must nIa"ds). This failure to recognize the limited reach of clinical
prove their value against these "gold standards. Combining:
It diagnosis has especially plagued the medical community.
passive and active care is a new art that requires certain Fun· whose overconfidence in the diagnosis of disk syndromes has
darncnlal skills. which arc outlined in this chapter. promoted an overly passive approach involving rest and

,
~
,, <J
,~ ,! FUNCTIONAL PATHOLOGY OFTHE MOTOR SYSTEM
Clinically significant structural abnonnalitics. such as disk
medication. The overcmphasis of this noomanagement phi-
losophy is typically grounded in the belief that llle natural his-
tory of most b~lck pain episodes leads to resolution.
Unfortunately. by encouraging inactivity. this approach re-
j syndromes, are present in less than 20% of patients with low
back pain. In the absence of trauma or relevant pathoanaromic
sults in immobilil.3tion of tissues and leads to deconditioning
~ of thc musculoskeletal system. Dc)'o encourages maintaining
change. the primary goals of care should be restoration of
I,1. (} function and prevention of disability, including the chief func-
function as the mainstay of treatment when a specific diagno-
sis is elusive.·
,"'-~
tions of the locomotor system; strength, endurance, flexibility.
1J coordination. and balance. Patients should be educated about
Chiropractors or myofascial specialists who concentrate
exclusively on passive intervention (i,e.. spinal adjustments.

,,t
the negative effects of immobilization and deconditioning and
~
trigger point therapy) to treat a specific pi.lin generator (joint
the safetylbenefits of early mobilization and controlled activ-
or soft tissue) arc also placing patients at risk for dccondi-
{ () ity. Rehabilitation is guided by evaluation of the functional
tioning. Unles,\" the pariefll is educated to control em'irollmen-
!
;j
capacity ano work demands of the individual. This evaluation
tal stressors and trained to recondition !ullctio1l(lj' lh:ficits.
-;j t"'s;.
i::...:.--fI'
also provides ideal outcome measures of quality care.
pai" recurrences and treatmefll dependency will be rhe !"IIle
~ rather ,II('" rile exceptio".
i Dcconditioning Syndrome
~

I,, -:,,) Rehabilitation attempts to address physical. and if necessary

psychologic. deconditioning that accompanies most persistcnt
NEGATIVE EFFECTS OF IMMOBILIZATION

~<i pain syndromes. Muscular disuse leads to weakness. inco- Prolonged immobilization results in compromise of the
~ ordination. atrophy, and loss of flexibility. Joint immobiliza- musculotendinous, ligamentous-articular. osseous. cardio-
i tion leads to bone demineralization. capsular adhesions, and vascular, and central nervous systcms2-~. (Figs. 2.2 and 2.3;
l t)
1 decreased ligamentous stress tolerance (including annular Table 2.1).
~ weakncss). Cardiovascular fitness is diminished. Decondi- 'Prolonged immobilization after an injury can lead to scar
€}
I,
:~ (~
tioning affects not only peripheral anatomic structures, but
also afferent systems, such as proprioception involvcd in bal-
tissuc foonation and lowered fatigue tolerance of injured tis-
sues, Soft tissue healing has three phases: inflammation. re·
i ance as well as ccntral neuromotor control of movemcnt and pair, and remodcling. Some form of local (issue immobiliza-
pOsture.

I
tion is usually advisable during thc inflammatory phase.
'l)
Although a specific pain generator often is diff1eult to which usually peaks around the third day after injury. Toward
j (~ pin down, the deconditioning syndrome can be identified in the end of the inflammatory phase. fibroblasts are fouild in in-
most patients with chronic or recurrent back pain by the pres· creasing numbers in the injured area. These fibroblasts con-
II g ellce of immobility, musclc weakness. and pain-avoidance be- tribute to scar formation. In a study of calf contusions in
havior. It encompasses many of the typical physical and psy· rats, Lehto and colleagues found that connective tissue scar

I ,
;
~
~ chologic signs associated with back pain patients. The various
www.bodywork.su formation will persist and become fibrotic rather than be
13

_% (3

1··- - - - - - , - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
1 ,,-~
I, \;#

~
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<$.~1
;;
 nt:.nt\OILII ...... 'VI~ ur I nCo .,r"~l:: ...... rnl-\I,., 1lllVI~cn .:::> IVIAI"-U...... L

Fig. 2.1. Pathophysiology of deconditioning recurrent pam

syndrome. (Adapted with permission from
Liebenson C: Pathogenesis 01 chronic back
I \ illness

!
pain. J Manipulative Physiol Ther 15:303. behavior
muscle pain avoidance /
1992.)
hypertonicity \ beh.,ior - - . . depression / /

,.-..~ ~ /
& disuse ~ loss of
ca:d:ovascular

joint
I \ muscle
fitness

sliffness weakness

\ ! \
incoordination atrophy

~ static & dynamic muscular performance

Enzyme defect
acquired disease
S''..nk'''90 1
Immob,I,utio"
Ad~DI~I,on
c~o~ul~r
viral infection
10 non·",><:
tinue, mental depression

/
\
Inactivity

/~
!
OCCI,rO~I'o"al
a"d g~tltl'C
helO"

Decreased
Muscle pain content of
mitochondria

Exercise
,>
intolerance
Fig. 2.2. Biochemical changes associated with reduced physi· ,
--~

cal activity. (From Troup JDG, Videman T: Inactivity and the Fig. 2.3. Effects of musculoskeletal immobllization. (From Troup
aetiopathogenesis of musculoskeletal disorders. Clio Biomech JDG, Videman T: Inactivity and the aetiopathogenesis of muscu~
4:175, 1989.) loskeletal disorders. Clin Biomech 4: 175. 1989.)

absorbed if the acute inflammatory reaction is allowed to per- live motion or continuous passive motion prevented SUl,'h ad-
sisl.~~ These authors suggest early. aggressive management of hesion forlllation.Y
injuries 10 limit enlargcment of thc injurt:d arca.~~ The remodeling phase involvcs lysis of adhesions and r~­
During the repair phase. passive and active m~tion of the orientation of coll,lgcn fibers along the lines of impos.~d
tissues positively affects the injured tissut:s. Classic work on stress. Again, prolonged immobilil.ation is. a negative fal,'(or in
knee cartilage by Salter and co-workers. showed that/after 3 proper healing. In studies of rhesus monkcys. Noyes studied
weeks of immobilization. intra-articular i.ldhesions complicate the effects of 8 weeks of immobilization on ligament stiffness
the repair phase of sofltissue hcaling.l~ Either intermittcnt ae- and failure ~~!e.;' Ligmncnt stiffness was reduced (0 69(';'".. of

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•• 0:
 '"
Table 2.1. Negative J::ffer.t~ nf Immobilization 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
Joints
Shrinks joint capsules:.) id"'lltiryin~ clioll\gic factors. Thc goal of such research is to
Increases compressive loading' idctltify what factors are causally linked to low back pain
Leads to joint contracture~·G epi:'Olks in a prcdictivl: manner. The following studies arc all
Increases synthesis rate of glycosaminoglycans"';'
Increase in periarticular librosis'o-': pnlspCl:liw,
Irreversible changes after 8 weeks immobilization')" i\<l<tny (csc;lrdlcrs have found that muscle strength is
Ligament prospectively correlated with future incidences of disabling
Lowers failure or yield poinF·H> '5-"
Decreased thickness of collagen libers 'l'I_~ ha... k pain. Chaninlir~a dcmonstratcd in 1973 a correlation be-
Disk biochemistry twccn der..:rcased 111llSCuiar strcngth and increased incidcnce of
Decreases oxygen~' lo\v bar..:k pain::" Cady ct a1. found decreascd isomctric lift-
Decreases glucose~l
Decreases sullate 2 ' ing strength and endurance in firemen who later developed
Increases lactate concentralion~.l' lirst time episodes or low back pain,SoI Rowe found decreased
Decreases proleoglycan cooteot n abdominal muscle strcngth in 50y.~ of those who later devel-
Bone
Decreases bone density:n-3' oped symptoms. ~~
Eburnation" Losses in muscle strength have also been found to corre·
Muscle late with the increased likelihood of recurrences in an indi-
Decreased thickening of collagen fibers 18 .3.l'
Decreased oxidative polential1.... 3~ vidual once they have suffered a disabling back injury.
Decreased muscle mass::'2.3C>-3? Biering-Sorenson found that individuals with lhe greatcst
Decreased Sarcomeres'o number of recurrcnces of lower back pain had decreased iso-
Decreased cross-sectional area t l -4)
Decreased mitochondrial contenr" metric trunk muscle strength in flexion and extension,}6Troup
Increased connective tissue librosis"~ et a1. reponed that dccreased dynamic trunk nexion strength
Type 1 muscle alroph~2.,o."T is a good predictor of recurrences or persistence of lower
Type 2 muscle atroph~e.• ~
20% loss of muscle strength per weekUl back pain. ~7
Cardiopulmonary In olle study, physically fit nursc's aides had shorter re-
Increased maximal heart rate~' coveTj' periods after injury than those who were less fit.~8
Decreased va: max,"l
Decreased plasma volume'"' Gundewall c( al. demonstrated that nurscs and nurse's aides
who spellt 20 minutes per day for 13 months exercising their
(From liebensoo C: Pathogenesis of chronic back pain. J Manipulative
Physiol Ther 15:303, 1992,)
backs had fewer injuries than those who did not exercisc,~;J
These (wo groups were divided randomly and the exercises
included trunk extension strcngth and endurance as well as
nonnal after 8 weeks. After 5 months of reconditioning. stiff- pushing and pulling, Vide man ct at round that back injuries
ness was reduced to only 7% of nonnal levels.} Five months could be reduced by increasing the patient handling skill of
of reconditioning improved the tissue failure rate to 80% of nurses,toO
normal. and after 12 months of reconditioning, the ratc was The correlation between losses in normal flexibility and
completely nonnal.} the likelihood of developing a disabling episode of back pain
is not as clear,',) although decreases in normal flexibility do
relate to a higher thall normal rate of rccurrcncc.~7,61 Troup
FUNCTIONAL DEFICITS ARE PROSPECTIVELY CORRELATED
and co-workers found a decreasc in saginal nc~ibility, espe-
WITH LOW BACK PAIN
cially in extcnsion. in those persons who later developed
Patients typically become inactive when they cxperience symptoms,:;7
pain, and this inactivity promotes dcconditioning. \Vith de- Deyo and Bass reported that decrc~sed physicnl activity.
conditioning comes greater susceptibility to typical postural along with smoking and weight factors. were predictive of fu-
or occupational repetitive strains. A chronic cycle of recurring ture episodes of lower back pain,62 The American Academy of
pain is easily established unless function is restorcd./lf pain Orthopedic Surgeons stated that "functional deficits become
relief is the only goal of treatment. and functional restora- the dominzlIll physical impairment associ~ted with disability
tion is ignored, painful recurrences arc more likely". Spons in the patient wilh chronic back problems,"63 Table 2.2 sum-
medicine specialist Stanley Herring says, "signs and symp- marizes the functional losses prospectively correlated with
toms of injury abate. but these functional deficits persist. ' . , episodes of back pain,
adaptive patterns develop secondary to the remaining
functional dcficits,"~ Focusing on function helps patients
Biomcchanical Fclclors
to develop control over their symptoms and to prevent
recurrences. Musculoskeletal structures (ligaments, joints, disks. muscles.
In many retrospective studies, investigators have docu- etc,) are constantly subjected to biomechanical forces such as
mented that various functional changes in musculoskeletal tension, torsion, compression. or shear. When functional
performance arc associated with episodes of bnck pain. al- capacity is less than work or activity demands. microfailure
www.bodywork.su
 · .. _._ , 'III.:: VI""U'IIC:. J-\ r'HAl,; IITtONER'S MANUAL

Table 2.2. Intrinsic Functional Losses Correlated High

Prospectively with Back Pain Episodes

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~
Injury /
(fatigue) and eventunl injury arc the result (Fig. 2.4). The
stress! strain curve explains the mech:Jnics of the relationship
Non-injury
between extemalload (~aress) and lissue deformation (strain).
The applied or elongming force is termed slress. The amount Low ""- _
or percent of elongation is the strain. Stress is measured in Deconditioned Highly
newtons and strain in percent (%) elongation. trained
Loadittg of biologic tissues produces a characteristic Functional capacity
stress/slrain curve demonstrming the amount of stress (load~ Fig. 2.4. Relationship between exte.rnal demand and functional
iog) required to produce a set amount of strain (percent cion· capacity.
gation or deformation)I"- (Fig. 2.5). Thc initial concave por-
tion of thc curvc is lhe "toc" region, which corresponds [0 the STRESS
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<ttion occurs with ac(:vlIlpi.t·
MacrO- failure
nying microfailurc. Only 4% deformation is necessary to
cause microfailurc. M
After prolonged or repeated loading-sometimes. just 15
minutes-tissue (:reef) will occur, resulting from thc "gradual Micro·lailure
rearrangement of collagen fibers. proteoglyc~ms and water in
the ligaments or capsule being slressed:'j.i Once a tissue is
. Slack' and
stressed. ir tends to havc difficulty returning (0 its initial
crimp
length. The encrgy lost aftcr prolonged or repetitive loading is removed O,,'?-
callc~ ilysleresi!i. and is represented by the differcnce between \1>(' I
CliniC a \ I
lhe new and old stress/strain curves (Fig. 2.6). Hysterisis only ,
occurs when loading exceeds the point at which ~11I crimp is
removed from the tissues (4% elongation). According to
2 3 4 5 6 7 ,
)
STRAIN ('X. Elongation)
Bogduk and Twomey. "the further ..I structure is stressed be- ,
yond its toe phase, tlte more bonds arc broken and the grc.Hcr Fig. 2.5. Stress-strain curve lor a ligament. (From Bogduk N,
the hysteresis and sct:·(..1 Twomey LT: Clinical Anatomy of the Lumbar Spine. 2nd Ed.
'Mild strains can causc microdmnagc. <1nd if repe~lted. they Melbourne. Churchill Livingstone. 1991.)
frequently result in tissue deformation.:; According to
Bogduk and Twomey. "what proportion of collagen fibers
need to fail before mucroscopic failurc of a ligamclll or c<.tp- pectcdl)' applied oul'ing their vulncrable. recovcry pk,~~."M
sule is not known ... "(..I At a certain point 'Ifta loading has According to Andcrsson ... It is generally believed thai r~pe!i­
led to tissue fatigue and microinjury. tissucs begin to fail and tive loading causes failure becausc of faligue of the various
frank rupture of structural clements occurs. Under conditions tissues:· I •.\ Brinckmann and Pope condudc under repet-
of cxpos~re to prolonged cycles of repctitive stress, less cx- itivc loading. the yield strc~s of thesc l1lillcriilb .tIld the
ternal 1000Id is required to cause tissue failure. Bogduk .1Od strength of struclllres buill from these matcrials i:-: n:duccd
Twomey conclude that hystcresis makes fatigued tis;ucs more with respect to the stress or strength obscrved under a single .,
vulnerable to injury. "after prolonged !'train, ligaments. cap- load cyclc..f .... (Fig. 2.7). l?educillg ('xjJo.mre 10 high /t.\.e/.\" of ;;
sules and intervertebral dises of the lumbar spinc muy creep. load-sllch as trunk flexioll wilh eilher CO/1//u·(!.uiofl or rota-
und they may be liable to injury if ~i.;dden forces arc UIlCX- tion-is Ol/e! of 1he 1110.\·1 i/1/{Jorlwll le/1('I.\" (~r pre vclIIioll oj 1011'

www.bodywork.su .~
 11

STRESS 250

200 -19\ --------

LOAO 150 CONTROL

INI 100

50

oO~-:-l--:2--'30'--'-4--:;;--'6:-'
OEFORMATION (mm)
Fig. 2.8. The strength of rested tissue deteriorates dramatically
Initial length compared 10 normal tissue. In this medial collateral ligament of a
rabbit knee thai rested for 9 weeks, two thirds of the strength has

I Set
STRAIN
been lost. (From Mooney V: The subacute patient: To operate or
not to operate. In Mayer TG, Mooney V, Gatchel RJ (eds):
Contemporary Conservative Care for Painful Spinal Disorders.
Baltimore. Williams & Wilkins. 1991.)

Final length
Neuroph)'siologic Factors
Fig. 2.6. Stress-strain curve illustrating hysteresis. When un-
loaded. a structure regains shape at a rate different to thai at As tbc activc component of our locomotor system. muscles
which it deformed. Any dillerence between the initial and final arc often called on consciously or by reflex to protect othcr
shape is the ~set." (From Bogduk N. Twomey LT: Clinical Anatomy tissues' under stress. Compcns3lOry adaptations (facilitative
of the Lumbar Spine. 2nd Ed. Melbourne, Churchill Livingstone. ;llld inhibitory) typically follow any strain, whether or not it is
1991.) painful. \Vhat may begin as a segmcntal, reflex muscular
'Idaptalion to pain may become "programmed" in the form of
<l new movement pauem stored in the central nervous system.
Injury. inflammation. joint nociceptive activity, sensitization
of dorsal horn neuroncs. or pain perception can all trigger
muscular reactions. These adaptations arc an essential part of
Injury the deconditioning syndrome.

tS THERE A PAtN CYCLE?

Th~ existence of a pain-spasm·pain cycle has been a \vell-

Repetition acccpted concept of physical therapy and chiropractics. As a
Fig. 2.7. A fatigue curve illustrates the importance of repetition criteria for therapeutic decision making. it is one of the most
and load to fatigue failure. (From Andersson GBJ: Occupational il\lluel\tial "" priori" assumptions of many practitioners. espc·
biomechanics. In Weinstein IN. Wiesel SW (eds): The Lumbar dally aillong those who lise extensive passiv~ techniques
Spine. Philadelphia, we Saunders. 1990.) and/or soft tissue manipulation. Its validity is unproven. how-
cver. and currently. it is often ignored. The litemture docs
show thm prolonged or intense pain can lead to both psycho-
back pain. Similarly. frequent microbrcaks. t~lkel1 as often logic (abnormal illncss behavior) and neurologic (dorsal
as every 20 minutes. C'ln help reducc thc chance of injury horn sensitization) consequences. Either or both of these
.Iner exposure to repetitive overloading. Frequent micro- behavioral and physiologic dysfunctions arc at the heart of the
breaks can prcvclll the instability that arises after tissue transition frolll :.111 .\cutc to a chronic pain syndrome.
creep has occurred. Such breaks can prevent repetitive strain Significant external loading that exceeds intrinsic functional
injuries noted after prolonged stalic loading such as from capacity leads to tissue fatigue and altered biomechanics. To
sitting or repetitive overuse from sports or occupational maintain spinal stability following biomechanical changes,.
activities. such as can occur after creep and hysteresis, type I and type
The more impaired lhe sort tissllt:. the less stress required II affcrcllls arc stimulated to maintain accurate proprioception
to reach the soft tissue fatigue or f:.lilure p~int. Im/1/obilized Crable 2.3). The initial firing from the joint mcchanorecep-
fisslle.f; are more I'IIlllcrable t"OI/ I/orll/al (issues to similar tors, muscle spindle affcrents. ilnd Goigi tendon organ affer-
WJl01U1ts oj/1/cc!ul1lical stress (Fi,t:. 2.8).' Pre\'elllin,~ the neg- Cllts allows ad'lptation to occur so the fatiguing tissues can
ative effects oj ilJl11lobilizmioll is O1W of the primary goals of avoid failure. Because these receptors arc adaptive. they do
relwbilil£llirm for 11I11scuioskeleUlI complaints. not continue to discharge if the biol1lechanical changes :lr~
www.bodywork.su
Table 2.3 Nerve Types and Functions and limit external SOlfl"ces of [);o/lll'chan;nt! ovcrlo(ld; (2)
early idelllificatioTl of psychosocial j{zctors (~r abnormal iff·
FAST SLOW
MYELINATED UNMYELINATED Iless behavior; and (3) idellfijicatio/l and rehabilitatioll (~ftlu'
LARGE SMALL functional pathology of the motor system (i.e., dl'COlldit;ollill~
High Thresholdl .~~vlldro/llc). This third aspect involves looking for specific
Low Threshold/Adaptive Nonadapting joint and muscle dysfunctions so that patient reactivation can
II III IV be promoted and deconditioning prevented. Figure 2.9 shows
how chronic pain can arise from dccol1ditioning syndrome.
A alpha A beta and g~mma Adelia C
, Pain is dcrived from the Latin term "poena" mcaning
Golgi tendon, Secondary muscle Acute Chronic pain, penalty or punishment... Unfortunately, pain docs not always
primary spindle, gamma pain postganglionic serve as a good early-warning system, but/oftell arises only
muscle efferent to intra- autonomic,
spindle, al· fusal muscle dorsal root af- after damage is done,. Pain alone is just a symplOm-the COIl-
lerenls to spindle ferents scious perception of nociceptive aClivity. If [Jain relilf is the
skeletal 01l/Y goal of care, thell decollditiolling afld variollsfulIctiOfwl
muscle
pathologies will remain as precursors to future bio/llccJ/(mi-
cal failures. Functio/lal re:"'toratio/l ill additio" to paill reliel
are appropriate goals because prevellfion of recurrent or
present for a long period of time. As a result, repetitive strains chronic pain is the ultimate goal of a cost cOlllainmellt-
eventually exhaust the adaptive capacity of the body's dc v
oriellled approach. In as much as we can identify specific
fenses and lead to painful injury. functional pathologies that are causally linked-trigger points
Once tissue failure occurs, inflammation, mediated by or overactive muscles, weak muscles or abl1of!lIal movement
bradykinin. substance P, and prostaglandin E2, lead to stimu- patterns, and joint dysfunction-we can then not only provide
lation of nonadaptive, types III and IV nociceptive affcrcnts. symptomatic (pain) relief, but also restore function. Evcn in
Various changes in the muscular system occur automatically the absence of uncovering a clear chain of functional patllo-
when injury occurs. For instance, muscle inhibition follows logic changes. identifying deficits in functional capacity can
acute low back pain or knee injury/inflammation. 67.(,~ drive the reactivation of the patient by rcrnediating pain
Additionally, increased neuromuscular tone also results from avoidance behavior.
strong nocic.:.ip;iVt .Hiiiiulation,!,9-71 Protective mechanisms-
nonnal illness behavior-to immobilize an injured area are
MUSCULAR PAIN, TENSION, AND INHIBITION
usually appropriate in the acute stage. If they become memo·
rized as a "pain-motor program," however, they can lead to a Muscles are often ignored while joints or disks receive the
chronic state. Abnormal illness behavior, such as excl!ssive or majority of recognition as potential pain generators. For
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
THE PAIN CYCLE:
chronic pain.
INJURY REPETITIVE STRAIN
Testing with evoked potentials of patients with chronic
back pain revealed lower pain thresholds and higher than nor-
mal evoked responses at thresholds than are noted in normal ~ Swelling &
subjects. 72 Magnetocnccphalographic study with sub, supra,
Inflammation
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 re- ~ Soft Tissue
sponse was attributable to central nervous system hyperre-
sponsiveness in the primary somatosensory cortex.
Acute pain involves biomcchanical insult (i.e., injury,
~~('oPain ~
repetitive strain), biochemical mediation (inflammation), fa-
cilitation of algesic pathways, and finally neuromuscular Gradual 'VO/ Muscular
adaptation. If repetitive biomechanical insult is not avoided;
abnormal illness behavior is present; or deconditi~ning oc-
curs, resulting in inadequate neuromuscular adaptation, then
M~ru,,,~ ~09'""'~:
chronic pain with central nervous system involvement (corti-
calization) can be expected.
To prevent the transition from acute to chronic pain, three
things should ocq~r once the initial acute, inflammatory Joint Stiffness
phase has passed: ( 1) patietll educaricm about how to idenllfy Fig. 2.9. The pain cycle.
www.bodywork.su
 \,.,on""r I t:.M .:: . In 1 cur·"'", I 11\l1I Ht::HAtjllllAllUN INTO CHIROPRACTIC PRACTICE 19

years. skCplics have enjoyed pointing out thc unproven nature

I
of such clinically popular concepts as myofascial trigger High gamma
points. RC\'it:wing the lilc:ratllrc on muscle p~lin. however. rc-
veals the error or this omission.
Traumatic injuries overload the structural components of
muscles and lead In frank lissue dis£uplion and failure. Under
Afferent
impulse
frequency
/ !/LOW
___ } gamma
lhese circum~tances. incre'lscd muscle pain is predominal1lly
a result ()f neurochemical events. "Tr~lumatized muscles rc-
~---"'t. Ieasc various chcmi(,;;'lls capable of aCliv;'lting no..:iceptl\'e
, ~'

pain gcncr;nors.;J These chemicals can also activate noci-

ceptive pathways via (HHaSsiulll. br;.ldykinin. or histamine Muscle length
extravasation.
Increased mll~c1c (one or "spasm" has been widely used Fig. 2.10. Inlluenee of muscle length on spindle impulse fre-
Quency al two different levels of gamma motoneuron activity.
as a descriptor for palients with p;'llpable stiffness in their soft
(From Korr 1M: Proprioceplors and somatic dysfunction. J Am
tissues. Unfortunately. viscoelastic connective tissue and neu-
Osteopath Assoc 74:638, 1975.)
romuscular factors arc rarely differentiated. Additionally,
terms such as increased muscle tone. muscle tension. tight-
ness. stiffllc~s. shortening. hypertonicily. spasm. fibrosis. and patients with low back disability.'" In addition. sustained
others arc llsed loosely and without ~dcquate definition. EMG activity has been found in the nidus of trigger points.'9
Scicntific work in this field has been l~cking. but researchers It has also been noted that when pressure is applied to an ac-
arc beginning to redress Ihis situation.74.7~ live trigger point. EMG activity increases in musclcs in thc re-
Although it is admiuedly unproven. muscle tension is ferred pain zone.l;O
widely believed 10 go hand in 'hand with p~in. Muscles as the Static overstrain. such as from prolongcd sitting or slump-
active components of the locomotor system are responsible ing, has often been suggested as a high risk activity for indi-
for both reflex and centnllly mediated adaptations to repcli- viduals with a back problem. Sustained contractions of only
tive strain. injury. or pain. 4% of thc maximum voluntary contraction possible have been
The significance and \'alidity of p~lIpable increases of soft shown to lead to negative cffccts.(,·~·111 Metabolites are pro-
tissue tension or stiffness have been called into question by. duced that stimulate groups 1II and IV aUerents and increase
among other things. the poor reproducibility of electromyog- gamma motor neuron activity. It has also been shown that in-
raphy (EMGI and lhe poor reliability of palpation. Nonethe- creased interstitial potassium concentrations sensitize the
less. as Paillard expl'lins. muscle tone is a key aspect of mOlar groups III and IV muscle afferents. ,n resulting in an increase
control: "Muscle tone. once widely used as a basic semiolog- in the sensitivity to stretch of muscles with convergent affer-
ical dimension of clinical neurology. is now almost totally ent inpu(Sj (Figs. 2.11 and 2.12).
ignored by neurophy:-:iology. It (;'crtainly de:-:efvcs new COI1- Study of muscle fibers has shown that conditions of con-
sider;,uions as a potent contextual dimension of motor pcr- stant 10,1'1 affect the ability of a ltlusde to achieve efficient rc-
form;mce. "7f, laxation.'4 As a result. tension and pressure build up in the
The organ of muscle lOne is thought to be the muscle spin- muscle.'J The more the muscle contracts. the greater the en-
dle. which sels the sensitivity of the muscle to streIch. Boyd ergy expenditure. Local ischemia is another key factor in-
refers to the muscle spindle <.\s " ...•1 marvel of control engi· volved in increased muscle tone. Under conditions of is-
ncering. incorporating many of the features of an engineering chemia. groups III and IV muscle affcrents become more
'servo-control' systcm."n In theory. muscle tone is greatly in- sensitive to strelchX-l (Fig. 2.13).
fluenced by the amount of gamm<.l activit>, present: the greater Ischemia itself is not painful; however. if II muscle
thc background gamma activity. the larger the intrafusalspin- contracts under ischemic conditions. pain develops wilhin
die response to any given change in muscle length (Fig. 2.10). I minute.lI~ Br~ldykinin is released during ischemia and is
The gamma syslcm is under the coolrol of descending im- therefore thought to be associated wilh ischemia-produced
pulses from the cX.Ir'lpyramidal motor pathways. These higher pain."lJ Under eccentric muscular conditions. mild over-
cortical centers (i.e.. the limbic lobe) arc more active under load may swell muscle fibers without inflammation.!((;
conditions of emotional stress. Heavy eccentric exercise leads to swelling and necrotic in-
Many examples of increased soft tissue tension arc un- flammation. 1I7
equivocal. such as cases of acute lumbar strain. tonicollis, Joint receptors. if stimulated. cause both facilitation and
acute appendicitis. peritonitis. and whiplash. To What, degree inhibition of muscles. Low intensity stimulation of joint af-
st!ch ncuromuscular changes "lrc attributable 10 rencx, central, ferents in the knee have been shown to influence the sensitiv-
or other mechanisms is unclear. It is also unproven to what ity to stretch of Illuscles around Ihe kncc.w.llt-91J Also. rellcx in-
extent the muscle spindle or gamma system participlltes. hibition of muscles has been noted when joints and ligaments
Increased EMG <Iclivity in muscles has been shown, as in the ;,ue <Irthritic or swollen;r,7.'ll,·J~ vasilis mcdialis inhibition is the
case of the loss of the lumbar "ex ion relaxalion www.bodywork.su
rcsponse. in mOSl famous eX<Jlllplcyl Muscle fatigability resulting from in-

......-_._-_... _----_.
 • ._." ~ vr- Inc: .:)rll\lC: "'" t'HAl.; 1IIIONER'S MANUAL

/'\J$Ck' reccplOfS
(stmAi: metabolilt's
l.'le<:lrolyles J
1lI,IV

H!
I
F'R'H!JlY "-'SUE

tVsch? spindlr

~t;t~';;:;;'Mt'\
,
i
(}yn.:mc W'Sit';ty\

SECCNJARY "-ISQE
Fig. 2.11. Pathophysiologic model for mechanisms possibly in-
volved in the genesis and spread of muscular tension in occupa-
tional muscle pain and chronic musculoskeletal pain syndromes.
(From Johansson H, Sokja P: Pathophysiological mechanisms in-
volved 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 irrita-

tion of the small nociceptor afferents from skeletal
muscles. (From Dvorak J: Neurological and bio-
mechanical aspects of back pain. In Buerger AA,
Greenman PE (eds): Empirical Approaches to the
Validation of Spinal Manipulation. Springfield,
Charles C Thomas. 1985.)

alpha·Molor
III.IV A.lI::on "
AH.r.nts j

,.'

www.bodywork.su
 CHAPTER 2 : INTEGRATING REHABILITATION INTO CHIROPRACTIC PRACTICE 21

Leclon Fig. 2.13. local vicious cycles in damaged muscle

as a possible peripheral mechanism for chronic mus-
i. . -->-. cle pain. The right-hand cycle is assumed to be
~

IA started by a tissue lesion that releases vasoneuroac-

live substances (path A). The centrallactor of the cy-
Rc le4se o[ cles is ischemia, which can be produced by venous
v4soneuTo~ctive congestion, local contracture. and tonic activation of
substances muscles by descending motor pathways (path 8).
(From Mense S: Nociception from skeletal muscle in
relation to clinical muscle pain. Pain 54:241.1993.)

; Fa Hure o[ LOCo'll

I Col++ pu:~p ischo'lemia

OedemA

I \ Jt'
I Contracture I
Venous
conqcstion

I I
18
1~ I
I
Increase in
1
,
muscle tonc
via descendinq
pathways

i
) hibition of certain muscles required for a task is a likely con- TIIP ;/lirhtl muscular reactioll to pain alld injury has tra-
I C)
~
tributor to overload injury or pain.9.,.I1~
Hides et al. documented/unilateral wasting of the multi-
t/itional/y been as.mlllct/to be im:reased tell-fie", ami slijJ"ess.
Data ill Ihe lilerlllure indicate ilihibiliull is at least as signifi-
1 ~

fidus muscle in patients with acute low back pain/"~ With real- callt. Tissue immobilization occurs secondarily. which leads

I {.
<"1:\
\y time sonography. they measured cross-sectional area (CSA) to joint stiffness and disuse muscle atrophy. Such changes be-
of the muscle and determined that the wasting was isolated to come a habit. mediated by central motor regulatory pathways

I
ii
'..y one vertebral segment. The wasting occurred rapidly in a 10'
calized area and was thus not considered to be the result of
as a new "pain-motor program" forms.
The combination of trigger points. muscle inhibition, and
()
i~ disuse atrophy. The authors were abk to correlate the area of
wasting with a dysfunctional segment identified on clinical
joint dysfunction arc kcy peripheral components of the func-
tional pathology of the motor system. If sustained over a pe-
~
~ -"-.Ji manual examination (i.e.. motion palpation)....ln patients with riod of time. these components 1ll.1Y outlive the elimination of
~
chronic back pain. CT scanning demonstrated generalized at- what caused them in the first place. This f<lct is of concern in
\ C~ rophy but a relative increase in the CSA on the symptomatic
side~~ Such a relative increase in the CSA could be explained
cases of cumulative trauma (rcpctilive strain) disorders and
prevention of recurrences after acute injury.

II ~
;;

.~'~
'-..>;.JI
by Ihe findings of increased paraspinal muscle activity% and
hi..ologic evidence of type I fiber hypcl1rophy on the symp-
tomatic side and type II fiber atrophy bilaterally in persons
with chronic back pain.!H
Bullock·Saxton et al. described gluteus maximus and
JOINT DYSFUNCTION AND PAIN

According to Schaiblc and Grubb. "The major sensation th'..lt

is ascribed to the joint is pain:" l ,(] The joint is involved in

I (,)
medius inhibition during gait. and their subsequent facilila-
tion after a brief course of propriosensory retraining."ll Janda
also reported r~ciprocal inhibition of the abdominal mus-
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

I
~;--""

-J.;.J}
cles as a result of stiff. overnctivc erector spinae musclcs.r~) and position sense, proprioceplion is primarily a muscle
He showed that the abdominals became spontaneously sense.IOlJ.11J1
!-~ (} stronger following inhibition and stretching of the erector /fyperstmsitjvit)' (increased or abnormal paill respo/1se)

! f} spinae. Headley successfully demonstrated inhibition of the

100ver trapezius muscle during shoulder Oexion or abduc-
ofjoints to movemellf is a key factor ill the developmellf ofthe
dec:omlitioning symlrome. Groups III and IV afferCnlS can de-
i tion when active trigger points in the upper trapezius are pres- velop "long-lasting 'sensitization' to mcchanical stimuli after

I
cnt.lI~ Simons also reported inhibition of the deltoid muscle the onsct of joint inflammation.... many of them have been
during shoulder flexion when infraspinatus trigger www.bodywork.su
poilHs arc fOllnd to exhibit ongoing uisclwrgcs whcn the joint is kcpt in
prescnt.!!!) its resting position."II~' Mcch.mo-inscnsitivc affercO!s arc also
I
!
 ••• _ ....... ' •• , ............ ,,<;;. M. r'"t'1,",,1.,..11 t IUNt:.H·::; MANUAL

Enhancement olthe Increase 01

ellecliveness 01 descending
inhibilory inHuences nculopeplide ..-'"
PrcduCliOn\)
Increased a!1Clcnl ,nllow
I (group II. Ill. IV sensory MIleS)
_ ,~r- l_.__

Release 01
transmitters and
modulators
Release 01
neuropcplldes
from allelcO( ................
Increased synthesis
of neuropeplidcs fibres

Gene expression
Hypercrcilability
01 spinal neurons
wilh articular input

Ascending fibres
\ \
Synthesis 2M
e.g. spinothalamic tracl release 01
inll<1mmar:;rj
medialc:!.

Fig. 2.14. Overview of neuronal events in the course 01 an inllammation in the joint. (From Schaible HG. Grubb SO: Afferent and spinal
mechanisms of joint pain. Pain 55:5, 1993.)
;

prCl\ellt. These "silent nociccptors" also can become pain in these sllldic~. hut spinal joim dysrullI,;tion has hecn com:>
prodlicers when sensitized by inflammation. II.) latcd with mll\dc \vasting in paticlIis \\ illt aL'utc low h'lck
Joints as a source of pain are ,111 too frequcntly ignored. In p;lin ;IS wei I.""
J
,
a study of318 consecutive patients with intractable ncck pain.
examined by provocation diskography and/or zygapophyseal
SUBLUXATION. REFERRED PAIN. AND NEUROPATHIC PAIN
joint blocks. 26% of the patients had symptoms aSl\ociatcd
with a joint. whereas 53<;(: had symptoms related 10 a disk.lU~ lllc chiropractic ··suhluxation·· involves biOl1lcdlal1ical alter-
In a similar study. 56 patients with neck pain a"od no l\igns of ;'Itions such <I" viscoelastic "tillness in addilion 10 neufuphys-
nerve root involvement of at !C;'lst 6 months dural ion were ex· iologic,i1ly mcdi'ltcd dorsal horn scnsitiz'ltion. Such sensitiza-
amined. The results shO\vcd 23% had a symptomatic joint. tion has .1 nCl!foanatorni<.: basis in primary 'llfercnts and
20% had a symptomatic disk. and 41 % had symptoms rel;'ltcd secondary dors.t1 llllrn neurons. ikcausc of ncuroplasticity. a
10 bOlh a disk and a facet joint. lU.\ rcduced pain threshold fmll1 primary affcrellls coupled with .,,
Referred pain is often ascribed to nerve root irritation. bUl an exaggerated p;tin rc~ponsc 1c;tds 10 hyper;llgesi,1 and re-
joints arc also a likely source. Activated joint affcrcnts arc C<l- ferred pain. Tod;ly'S pain \cicl1tists call thi" sensation "neuro-
p<lble of giving rise to referred pain. Cat spill<ll cord neurons lXlthic pain:' Previous rC'Icard\ W.IS led hy ostl'opalhs who
with knee input had clHl\"t~rgent input from muscles in the termed this neurolllcchanical phcnomcn;t thc "facilitated seg-
thigh and lower leg and the skin. )(J.I Cutaneous reccptive fields ment." Pmtcrson says of Ihe facilitated segment thm " ... be·
were found as distant as in the foot. C;IUSC of ;;Ibnonnal affcrem or crferellt sensory inputs to a par·
Johansson et a1. reviewed the motor rcnex effects of joint ticul<lr area of the ~pinal cord. that area is kcpt ill ;1 state of
afferent excitation.(~} Under non-noxious stimuli. joint affer- constallt increased excitation. This l"'lcilitation allows nor· ,
ellis excile significanl amounts of reflex galllll1<.\ motoncuron mall)' inefl"cctual or sublimirml slimuli to becomc dfc<':livc in }'

activity,6Q which probably <Issists tnthe regulation of stiffness. producing cfferclH output from the bcilitatcd scgmcllt .. _.. It~1
Long·lasting noxiolls stimulation results in activation of thc (Fig. 2.16)
nexioo reflex (Fig. 2.15).loints me also supplied with effer- As long ago ;IS 1883. Stlll"gc suggested th"\1 an injury
ent sympathetic nerve fibers. which .arc cap;'lblc of consistent could trigger a dwngc in the ccntr;:11 nervous system such
rencx discharges. wo , that lIormal inputs would evoke ~1Il ex•.lggcrated rcsponse. HI~
As mentioned prcviowdy, joint inflammation call give risc [n 1893. ;vbcKcllzic proposed that referred p'lin ..:ould fC·
to fcnex inhibilion of lllusc!CS.{·7.'.11.'}2 The knce was the modcl suIt after sensor)' impulse" from injured tissue IW\"l~ created
, www.bodywork.su
 vNr\1"' I tH ;.: : ; IN I tUHAIINl,;i REHABILITATION INTO CHIROPRACTIC PRACTICE 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.)

IMMOBILIZATION . . . . - -

,I
J <--~

!,
<~
\)

I ()
~ FlJxI:::/
I
!
<)
--w? CONTRACTURE

!J

I
an "irritable focus" in specific spinal cord segments, II", Perl most exciting is lhallhcy Me attacking the notion {hat pain 1';1-
cl al. lOi and Kcnshalo and co_workcrs lt1lt made the initial tienls with few objective signs have psychog.enic pain.
() experiments that showed that noxious sensory :-;tlmuli pro· Ncuropathic pain is considered cOlllmon in causalgia.
duccd heightened sensItivity 01 dorsal horn neurons to future rcOex sympathctic dystrophy. posl-herpelic ncuralgia.
I stimuli. stroke. syrillgolll)'cli~l. syringobulbia. multiple sclerosis. and
A new concept called "ncu1"Opmhic pain" iJ being pitt for. spinal cord injury. Ncurop:.lthic pain C;1l1 also result from

I
ward to explain the common clinical prescuwlioll of persis· a rcpclilive strain initiating strong affcrclll nociceplivc
[e/lf pain. hY{Jer.w!ll.'iitil'jry, alld poor motor cOlltrol ill the ab- b<lITagc to dorsal horn ncurons. eventually leading to sen·
,,} ::('II('e of a pallia-til/atomic or Ileurologic expJlIIull;01l. sitization of those neurons bec.lUse of central nervous sys-
Bcc<lusc of the poor correlation between presenting symp· tem plaslicity. As (f re.vu!t (~r sensitizatio/1 (~{ secondary
~ toms and objectivc physical signs, the pain experienced by donal hom l1eurons or II dt'crellsed thr(!s!lo/d for prinulI:r
I .c':~
\J
these patients is commonly misl~lbelcd psychogenic. Ac·
cording to MCP.'kcy. "There is increasing cvidence lhal signs
peripht'ral (~{/('re1l1s-illdlldillg I/ormally [Jai,,- i"sellsith'e
groups I and f( ({{erelll.'i. i1lput/rom I/ormal m('chwlOreCt!fHor
and symptoms tlwt were wkcn to be proof of hystcria-or ufferelll!i {'(III be interpreted as lIoc;;ceprive. 11.\ Sensi[iwtion rc·

1,)
~
of behavioral disorder-such as a failure of complaints to
observe anatomical boundaries. may have ;:; physical
suits in allodynia. deep hyperalgesia. poor motor l..'ontrol. and
an cxpansion of the receptor field.
b;:ISis."I(~I.11O ·@.cgional pain syndromes and regional loss of Neuropathic pain is relnted 10:
I {')
sensitivity can have a. pathophysio¥logicalorigin-·r:C"Gt·cdto
Allodynia-Lowering of pain thrc"ihold (c:",:n [() 110n-
-;-J
expansion' 6r-rcceptm- fi-eld~ th'ro~ugh the responses lo pe- no~iolls stimuli) and pail'!... thai ;:Irises front activali.illL

t0
B
ripheral injury of spinal cord ncurons." l lJ'J.llli According 10
Nachemson. "various pool501' ncrve cells in the dorsal
_~of$cnj,:.orv channels l~l;lrULw~)f\:cd~\Tn<e.g.. low
Ihrcsllold l1lcchanOrcccplors ILTMj,.
columns can be hypersensitized and thus c;:ln sigrml.a pai~ful Tnt: Scnsitivity to non-lluxious stimuli ;IS in light p,t1patiotl or

I
condition oven though there is-vcry lillie-peripheral inpl}l."'lll percussioll of noninjurcd lissues and pain wilh physiologic
The implications of Ihis research in v;:llidmi'ng the com· joint 11l00'cmcnL
()
plaints of millions of pain sufferers is remarkable. The sub· Hypcnllgcsiu-lncrcOlse ill rcspollse to ~upr;llhreshold (i.c.. IlOX·
luxation hYl'othe.\·ix backed stead/waf), by rhe c:hiropractic ious) stinlllii. fI,<techanic;ll hypcralgcsi<l is pain during movc-
ments in lhe working range or pain Oil g('lIll(' pressurc.
l'/'(~fcssion appears to be Oil rite \,(!(t:e of scielltific valida-
i, (} tiOf/-if/ a modljied form-by (1/1 independellt group of neuro-
Closely n:[alcd 10 persistent pain.
Test: Posilivc jump sign (p;lli('lI( wilhdra\\'~ll) with son liS$UC'

I
plrysiologists .\·wdyillg poi" fl/ec!wninlls ami behavior. That
palp,lIiun or Iloninjurcd rissllc. Withdrawal with passive m'cr-
() this group of scientists 1ll.lke no mention of chiroprJctic nnd pressur~ at lhe end or Ihe physiologic r;:mge (l( joint move-
ollly occasionally refer to the physical medicine theories of ment.
~ rnyof<.lscial pain by Travel! and Rinzlcr and of zygapophyscal
~ CutallCHlls H~'(lnc<;thcsi:l-[)ecn:::lscd sensalion ()[" :,cllsitivity.
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pain by Bogduk .Illd Twomey is intrigllillg.'~·Il~)·"~ What is Tnl: DecrcOl:'cd ~cn~atioll III pin prick.

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 REHABILITATION OF THE SPINE: A PRACTITIONER'S MANUAL

De'!.cend,nQ lUres. Stimulation of viscera docs not .tlways produce

sysl~ms
pain. btU \'isccral aftcn::nts projecting into the dorsal horn
I do lypic<lliy converge Wilh skin <lnd/or deep somatic
:->lructures. I ).I.117
- Small d'OmeTer ,npvl COl\\'crgcm::e and (elllral neural plasticity provide the
ncuroanatomic basis for pain rdefr<ll. It hus been reported thut
lll;lIlY :.lllercnt units. whcn noxiously stimulated. elicit pain in
two distinct rcceptin:: fields (RF).Ill'1 Branching of the "ffcrent
fiber 1ll:'1r its termination point is thL: likely anatomic ex pia nil-
o To osccnd,nQ
syslem!> lioll. According to MCllse. this convergence would. "reduce
the spatial resolution of the nociceptive system ilntI thus could
contribute to the diffuse nature of deep pain."n It has been
~:.llown that dorsal hom neurons are able to change the size.
·J\ulllbcr. and sensitivity of their RF under thc innuence of
noxious slimuli.lI<,l·'~1l
When noxious stimuli arc applied experimentally. re-
(ommon pool or ferred pain into new RF typic'llly takes a few minutes to
COnnC(lor neurons OCCUr.1~ Ncuroplaslicity seems to be QI?£filting as ncw central
With thruhold K
ncrvous connections are formcd after peripheral injury. It hilS
j been shown lh~llvi~~ceral pain, such as from a coronary .in-
. farct, can be referrcdJ9. ;U.n.Ys..-cJi::.J.!ku~~...1!£c'oralis!!!'.lj9r.ll~
The muscula.r l<lrget for rcferred pain may also show signs of
Ilype-r.algesTa~m--
- The·pr~ncc of nondcrmatomal referred pain and hyper-
algesia implies thnt ccntrill changes independent of conver-
gence 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 re-
ferrcd pain to the treated tceth. ,~~ Distant referral of pain to a ,
nondermmomal arca can also occur. such as in cardiac pain j
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)'
Fig. 2,16. Physiologic mechanism 01 the ~irritable focus in the
H
respond to mech;:moreccptivc ilfferents as if they were noci-
grey maHer of the spinal cord. (From Grieve GP; Simulated vis- certors, 12f,.I~~ \Villis explains that a nociceptive barrage leads
ceral disease. In Grieve GP (ed): Modern Manual Therapy of the to central sensitization of dorsal horn neurons:I~(J "If these
Verteberal Column. Edinburgh, Churchill Livingstone, Edinburgh, lH>ciceptivc neurons have convergent input from mcchanorc·
1986.) ccptors. their responses to both innocuous and noxious me-
chanical stimuli will then be increased.... Sensitization then
causes formerly subthreshold responses to rench threshold
Poor 1'..lotor Contro'-lncoordin~lIi{ll1()r POD( balance. and trigger disehargcs."'u, According to Mayer and col-
Test: Incoordinatcd !novcmClH pallcrns or gait; ro~ilj\,c leagues. "Overwhelming evidence suppons the conclusion
Rhombcrg or Hamanl tcst that a change in the central processing of input from low-
Referred Pain or Sccondur)" H),JlCnllgcsia-Sprc:ld of p<lin or threshold mcchanorcccptors is responsible for secondary hy-
hyperalgesia 10 uninjured or normailisslic in ,I dcnnatom.Ll or peralgesia to light touCh."I~lI Silent nociceptors that arc
nondemm(omal distribution.
mechano-insensitivc also can become mechanoscnsitive once
Test: Trigger point cvalu<ttiol1, pain I1mppillg.
sensitized. 1flo Table 2.4 lists the neural changes associated
Sympathetic Symptoms-Vasomotor effect".
'1esl: Moisture. thermal ch.mgcs in tissues.
with sensitization and Figure 2.17 depicts the p::Hhophysiol-
ogy of sensitiz'ltion.
Neuropathic symptoms have been shown to be rel,lted How Do Mechalloreceptor A[[ereflts Cause Pain? The
in part to convergent input in the dorsal horn from skin Neurochemistry of Neuropathic Paill. The p:'lthophysiology
and/or deep somatic (visceral and nonvisccral) struc;. of neuropathic pain involves peripheral ilnd central neural
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 CHAt-' I cH Z : 11'1 I I::UNAllNli Ht:HAI:ULlIAIIUN INTO CHIROPRACTIC PRACTICE 25
) I
I ·tc
Repetitive strain

(") 1
() , 1 Hysteresis and deformation

I -
~~-)
t T
Decreased tissue fatigue/failure point

1
Sustained aHerent barrage in types III and IV
()
Mechanoreceptorslnociceptors
o ~
Sensitization of dorsal horn neurons

1°
r,
j
()
I
Neufopathic pain
Fig. 2.17. The pathophysiology
of sensitization.

10
10
0 c\'~nts. Sustained activity in types III and IV (small diameter) rounding inhibition.I''' Increased c.xcilability Icads to ex·
1
! ~.)
primary affcrcnts leads to a rclcflse of excitatory amino acids
(gl~t<lD]_aJc) ,and _neV~...P.£21iQe.s, ,(sllbs,t,al1:~~~Pt:i.I.l~·~lre··dorsal
CilOlOxicity_I~!I.I.\I.1I:
The most sensitive neurons ilrc small
local circuit inhibitory neurons. 1.'1' ~vlorphol()gic changes have

10 I -.
h.orn. Increased concentration of these neurochemical media
tors lowers the firing threshold for primary sensory affcr-
en Is. 116.127 In the presence of certain neurotransmitters, sec-
w
been demonstrated in thc r..1t dorsal horn after p;lnial nerve
injury.I.'o.l.I.I

I () ondary dorsal horn neurons may become hyper-responsive

I~
CORTICALIZATION OF PAIN ANO CENTRAL MOTOR
because of cxcitatory amino acids acting at N-methyI4o-as-
REGULATION
partate (NMDA) receptor sites and activating dorsal hom no-
I ciceptive neurons::t>·,;!.7 Secondary neuron hyper-responsive- The locomotor system has peripheral (sensory and motor) and
10
,~
ness after repeated stimulation is called "wind-up" and is central (programming) components. The peripheral compo-
nents (somatosensory. vestibular. visual) pro\'ide input and
often short term. Inhibitory amino acids such as GAB A arc
i• ;)
, 't,

()
present to dampen this exaggerated response. but. over time.
segmental inhibition is deactivated by the flood of cxciuttory
<Imino acidsy'I.I.'O Long-lasting changes appear to be the re-
feedback (afferent) as \\'ell as carry out the instructions (ef-
ferent) of [hc central motor regulatory centers (cortex, cen:-
bellum. basal ganglia. etc.) (Figs. 2.18 and 2.! 9). Prolonged

,, l'
.(~
\,j)

-,J
sult of oncogene activation by strong nociceptive input. 11f'
Oncogenes such as c-fos enter the nucleus of the neuron and
regulate lHher gene activity. According to \Villis. "The impli-
cations of this chain of events arc still unclear. but a potential
or intense noxiolls. sensory stimulation call !e;IO lo dorsal
horn sensilization. reorganization of somatotopic maps. lim-
bic dysfunction. and ··reprogr'.lI11ming" of movcmelll patterns.
Abnormal illness behavior in response to subacute pain
~ result could be long-term changes in the responsiveness of encour<1ges ehronicilY. Poor slecp habits. high Icvels of emo-
I () nociceptive ncurons.··I~r; lional stress, and excessive fear or anxicty Illay stern from a
l Pathoanatomic Changes in Neuropathic Pain. Periph- limbic dysfunction. This condition negatively affects the mu:o;-
I ()
'~ eral nerves can sprout after peripheral nerve injury so that low culoskclctal system by promoting physical and psychologk
i

I () threshold I11cchanoreceptors C..1Il extend to tcrminate within dcconditioning. Magnetocnccplwlographic and evoked poten-
! the superlici"ll dorsal horn and make direct connection with tial studies in patients with chronic low back pain ha\'~
1~ 0 nocicepwrs.I.'l.I.Dl According to Dubner. peripheral nervc dam-
agc Icads to an expansion of the low lhreshold portion of wide
dcmonslralcd ccntral nervous systcm hyper-responsiveness in
the primary somatosensory cortcX. n :i .1 M"lgnetoencephalog-
,j {# dynamic range (WDR) neurons bcciluse of a loss of sur- mphy has revealed a somatotopic cortic,ll nl<lp reorganization
in patients who um.lcrwent reconstruclive surgery.l.\.l TheH the
i J.)
Table 2.4. Results of Sensitization ll2 central nervous system is involved in painfulml1sculoskclcwl
! Increased spontaneous activity of types III and IV primary afferents disorders is no longer a question.
Prolonged after discharges of afferents to repeated stimulation In response to chronic pain. ncw movement patterns arc
,i () Decreased threshold to afferent input
Expanded receptive fields of dorsal horn neurons
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adopted that aHcmpt to reduce noxious stimuli: these arc often
~ tcmleo "pain-motor progr<lllls:' Movement patterns repeated
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 nc.nMOIL.llf\IIUN OF THE SPINE: A PRACTITIONER'S MANUAL

MOTOR
CORTEX

RED NUCLEUS \
r.:::J..+-r

MESENCEPHALON,
~-~--11 PONS, oml
MEDULLA
\ SUBSTANTIA
NIGRA ---
Corticospinal
Irocl
Reliculospinol
Spinoc.etcb~Uol • - and Rublospinol
hoC I • IIoels

Fig. 2.18. Pathways lor cerebellar control 01 volunlary move-

ments. (From Guyton AC: Basic Neuroscience. Philadelphia. we
RETICULAR
Saunders. 1987.)
fORMATION

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 Fig- 2.19. Pathways for cerebellar "error'" control of involuntary
movements. (From Guyton A: Basic Neuroscience. Philadelphia,
consolidated rcperloirc of motor capacities. either inherited or
secondarily acquired. is now all incomrovcrlible fact of con-
we Saunders. 1987.)

tempof<lry ncurophysiology.";(' Treatment of chronic condi-

tions will likely fail if only peripheral targcts (i.e., muscles.
joints. etc.) ure ~t<.ldressed. Successful care for If/{' chronic "a-Sherringtol1'S Law of Rcciproc~1I Inhibition (Fig. 2,20). Thus,
tiem will likely im'o{l'i' treatmellts aimed at the peripheral if Cl TU/'ilum{ mllscle SllC" as the iliop.WlJ.\' become.\· .'ihortem·d
pain generaror.>;. central motor regularion. lind psyr;/lOsocial frorfloverusc. flot olily will it lJu!(:lumically {imit Ihe rang('
facto,.s. \/tlf
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· ,,
Clinical Features tion of biomcchanical and neurophysiologic influences is a
strong stimulus to the creation and maintenance of muscular
MUSCULAR IMBALANCE
imbalances.
\Vhen muscles reacl lo protect the body from harm or lo re- Electro'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 ago-
lIluscie fatigue results. For such prolective reactions, [he pos-
lural or anligravity muscles arc activated most easily,
Conversely. muscles wilh a primarily dynamic or phasic func- Table 2.5. Postural and Phasic Muscles 13S )
tion 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
Janda l11ul co/{eaglles (.'x"llIined that the basis for most Reclus femoris Rectus abdominus
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, Ereclor spinae Delloids
reperiiive tasks, gravity stre,'iS, inactivity). They identified Quadratus lumborum (QL) Digaslrics
PeCloralis
that the pO!'itural muscles tend toward overuse and eventual Upper trapezius
shortening, whereas the ph'1Sic muscles tend toward disuse Sternocleidomastoid (SCM)
and weaknessl~-l~l (;rable 2.5). These muscles arc oftcll Suboccipital
Masticalories
grouped as paired antagonists and appear to be affected by

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 CHAPTEH 2 : IN' ~l:iHAl ING REHABILITATION INTO CHIROPRACTIC PRACTICE 27

Sensoly ncu:uOl 1, ...,10 Fig. 2.20. Reciprocal inhibition 01 motor neu-

flelCOf muscle! spindle
rons to the opposing muscle. Impulses lrom
\ ttle contracted muscle .e.xcite motor .unit:!,(
Inhibitory
Intclnouron the same muscle (faclhtory synaptic)nllu-
ence designated with a plus sign) and inhibit.
E.. lcnsor through an interneuron. motor units in the
nlusdc
ttdeeps) opposing muscle (inhibitory synaptic influ-
ence 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

First Recordino Second Record ing Fig. 2.21. Electromyographic

activity before and alter stretch-
J\)' N "'_,-- ~....: _!> ing light muscles. (From Janda

... ...... -.
"" JV '....- V: Muscles. central nervous
1 :l , 41 S 6
-. I '.1. r--r::x::;rj ", • motor regulation and back prob-
recto abd. lems. In Korr 1M (ed): Neu-
~
...
upper left robiologic Mechanisms in Ma-
nipulative Therapy. New York.
Plenum. 1978.)
rect.obd.
lower left ~

~.
I ". ~ f
er. sp.left
~,~
_:~~....L
loop,vL
ISEC.

nist. the abdominals. Alkr the crector spin'Jc muscle has been An intermediale muscle type is FR::::':J~I~!_~~y.itch fatigue
strelched. not only docs it relax during trunk llexion. but ulso ~sistant:' This typt: resists fatigue but illS0 has f,lst COlli rac-
:'1 significant. spontaneous facilitation effect is seen in the an· tion nnd relaxation speeds. The FR type has both aerobic and
dorninallllllscics. Figure 2.22 shows the typic<lllowcr crossed t1naerobic metabolic e<lpacilY. Like type I unilS al rest. a high
syndrome. which rrcquclHly develops as a result or llluscular met,QJ:tolic price is paid for Illaint:.lining this fiber type.
imQ.al:.Ulcc in the Iumbopelvic region. ,'- L'v1uscle types COtll he convertcd with trail1i~.lli.L1" With
'The lJO...wrai or lUlligra\'ily muscles mUitUllin ereCl SIlt/fli- ./ regular electrjc~ll stilllulatiol~ muscle hbe~:s' c:.1Il begin
illg ill gaif. The majority ofllormal gait is -'"lJell! on olle Ie}.:: ! to have altered contractile char<lClcristics within 2 weeks.!.l'l
,here/ore. special l'lI/pllll.,·i", ix placed 0" the mlt.w:lex lIl\'olved }I By 6 weeks of training. histochemical ;lppeOlrance is altered.
ill olle leg ",'allC/illg. Sedentary life in modem society resulls I and within 5 months. lhe muscle behaves cntirely like a pos-
in Overuse of postural Illuscles. thus encouraging lightness to Ltural muscle. Keeping rats under hypergravity can turn fast-
develop. Simultaneously. the ph:'ISic or dynamic muscles tend twitch into slow-twitch libcrs.""Endurancc training CJon also
10 become weak from disllse. Postural and phasic muscles arc alter rnt!scl.~~harilctedstics. When stimulation or lrain-
yp
lll~c up of miXCirfi6Cri cs; however. "slow-twitch" fibers irll! is withdr:'l\vn. however. the Illuscle gradually rc!!ains ilS
ro;mer prop..crties./~-- __ ·_n - -' .. ..-
(type I) .Irc predominant .in_ postural llluscles antI "fi.IS(-
twitch" (type II) fibers arc pr~d(;;;;i~~~~t' in -phasic muscles" A-gro\ving body or evidence shows that Illusele im-
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Table 2.6 dcsl:r{bcs the chilr;lc-icristlc:<>-or[rlcsE-dlff:C~~~-ttYi)esl b;l1anccs (Illusde atrophy and hypertrophy) are prescnt in
 REHABILITATION OF THE SPINE: A PRACTITIONER'S MANUAL

Muscle imbalances alter the performance of related move-

ments. Repeated performance of abnormal movements leads
1 incvitably to further strain, which can perpetuate muscular
Erector Spinae I

,,,
Abdomlnals imbalances andjoim dysfunction. In the work place, the com-
I bination 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
I 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
Glu1eus Msxlmu$ Iliopsoas as being related to either viscoelastic, cOllnccth'e tissue.
llnd/or lIeuromuscular facrors. Trigger points. acute torticol-
lis, appendicitis, lumbar strain with anlalgic posture. and loss
of the flexion-relaxation response in disabling lumbar pain
syndromes arc examples of incrc<'1sed neuromuscular tcn-
Tight Weak Of Inhibited sion. 76•77 Elevated EMG activity typically is present in such
situations. C.Q.nnectivc tissue changes in a muscle or its fascia.

X
such as adhesion or scar foonation, usuallx arise gradually
after trauma whcn the acute, inflammatol)' phase is pro-
longcd:'5 Improper healing allows fibroblast proliferation and
eventual scar fonnation. 45 Viscoelastic changes without in-
creased neuromuscular tension also occur in the gradual mus-
Weak or Inhibited Tight
cle 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 con-
dition is thought to be related to abnormal illness behavior-
slecp disorder, depression, anxiety. fear-and is <lccomp:micd
by generaliz.ed soft tissue tenderness. Sarno used the descrip-
tive tern1 "lension myositis:' whereas others commonly refer
to this neuromuscular tension as fibromyalgia. 141 Fibro-
Fig. 2.22. The lower crossed syndrome. (From Jull G. Janda V: myalgia patients tested with laser evoked potentials have been
Muscles and Motor Control in Low Back Pain. In Twomey LT.
documented to have hyperalgesia. 142
Taylor JR (eds): Physical Therapy for the Low Back. Clinics in .~
According to Janda, the most typical types of functional ,
Physical Therapy, New York, Churchill livingstone. 1987.)
muscle weakness arc as follows. Tightness u·(·akw:s.'O devel-

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
--- -
ops when a muscle is chronically shortened and eventually
loses strength (i.e., IJSO<lS).I.I,1 Stretch weaklless occurs if a
-----
Table 2.6. Characteristics of Muscle Types"'il·l20
,"
generalize,! atrophy in paticlIIs with dmmic back pain. but (l
rd(ltive increase ill the CSA was noted 011 the symplOmafic Type FF -Fast-Twitch ,,
-",yide. 9J Type I Jiber hypertrophy on the symptomlJlic side and Characteristics Type S "Slow-Twitch" Fatigable"
........... tYl!!. II fiber atrophy bilarerallv have been documented in Type I Type II
c~roTllc back pai" patients.,}7 Fatigability Resistant Easy
Muscles housing trigger points have been shown to have Metabolism ""Oxidative Anaerobic
Energy MitochondriaJATP Glycogen
dramatically different levels of EMG activity within the same Capillary Extensive Minimal
functional muscle unit. Hubbard and Berkoff showed EMG network
hyperexcitability in the nidus of the trigger point in a taut Metabolic Constant muscle (MUSCle shorteningJ
preference length
band that had a characteristic pattern of reproducible referred Speed 01 can· Slow Fast
pain. 79 Case studies. havc also revealcd that trigger points in traction,
one muscle are related to inhibition of another functionally rc- relaxation
and force
Imed muscle. 7l1•9 !i In particular. Simons showed thalthe deltoid generation
muscle.can bc..inbibl~d _~Y!lc~1JlLcre· arc infr~~p)'na1Us trigger Metabolism al Low
points.ll(t HC~ldley has .ghown that lower trapezius inhibitio~ is rest
Function Posture "antigravity" Phasic "fight or m9ht~
related to trigger points in the upper trapezius:;: -. -".'.
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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=- ~29

muscle IS p~lp.:tually plOlced in ;1 lengthened po:'\i(ion so that Table 2.7. Consequences of Muscular Imbalance
rhe l1lusclc...:<;pindks become dl'SCI1",itizct! 10 strctd, ~i.c .. glu-
Allercd joint mechanicsJuneven distribution of pressure
(eus l1laXilllusl.I~' .:f.;,hrogt·";c W('lIkIlCS... occurs when noci- Limited range of molion and compensatol)' hypermobility
ceptive affcrciH barrage from a j()im or ligamcllI causes a re- Change in proprioceptive input
ne" inhibilion.I~.1 Examples arc the V<lslu'" medialis "ftcr Impaired reciprocal inhibition
"" Alle,ed programming of movemenl patterns
injury of the alltcrior cruci;llc li~t or Ilh~~S or gluteus
IUAxin~~wcak~~~_~__whcn ;1 sal.:roiliac dysfulll'tioll js prc- (From Janda V: Lecturc. Los Angeles College of Chiroprnclic. Rehabilitation
Ccr1lhcahon COUISC. 1993.)
WL l-'J. Fin;'llIy. ,,.igga ,milll \I"("okm'.'i.\" occurs whell a muscle

!") C3nnot fully .1(ti\";ilC all its conlr,Klik libers hel'allse or the
presence or
a trigger POil1LI~\ The gcneral crfects or llluscular imbalance ..Irc listed in
I"'"/ Common types of ItmSCUI;\f dysfunction. like tri~c.cr Tahle 2.7. Muscular imbalance is lypic<llly iJcmilicd by pos-
points, arc bc:o;t understood in till' context of IlHISl'ubr imb:d- turnl analysis (two ;lIlt! one leg st;I11CC). gait analysis. muscle
ancc. A short. tiglll po:O;\lIral !l\u:o;ck lllil)' house trigger points Icllg,th te~;\s. and evaluation of key movement patterns.
because or its incrcn,Scd Ilh.:t;lbolic dcm'lI1ds and lcnsion. l'o:Hllral lIl/lIlysis (Fig. 2.23) seeks to identify structural
1 :"~ which call produce ischelllii\ and irritilting metabolites. Also. asymmetries (i.e.. oblique pelvis. winged sc"lpula). pelvic po-
1· J
an inhibited phasic muscle l1lay form trigger points as a restlll silion (i.t.': .. anterior pelvic tilt. rotated pelvis), hypcrtrophit::d
I""' of its greater than normal f,ltig;tbility and thus susceptibility muscles (i.c.. thoracolumbar erector spinae. upper trapezius),
'.J
j (0 overload and mC<.:hani<:al f:lilurt:. . and atrophied muscles (i.e., gluteus IH<.lximus, lumbosacral·
i€ ('-""
~~jJ

~ ~- ...
§ '"
~~.... ~3'
Muscle Hypotrophy Muscle Hypertrophy Fig. 2.23. Depiction of the layer syn-
drome. (From Jul1 G, Janda V: Muscles
and Motor Control in Low Back Pain. In
,
i'i Twomey LT. Taylor JR (eds): Physical
% 0' J Therapy for the Low Back, Clinics in
1
Physical Therapy. New York, Churchill
Cervical E'ector So"'.,
liVingstone. 1987.)
Upoer Trt'lpe,iu'
levator Scapul. .

Lower Stabiliters
01 the Scapula

Thofaco1urnblll
Elector Splnu

Lumbosacral
Erector Spinae

Gluteus Maximus

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 •• '-.,,......... , ... , ''"''1 tUN UI- rHE SPINE: A PRACTITIONER'S MANUAL

erector spinae). Postural analysis in onc leg standing observes Table 2.8. Muscle and Joint Functional Chains'''~

presence of glu'teus medius weakncss, pelvic obliquity, and Joint Muscle

other muscular compensations. Gait Clnalysis mostly ad-
dresses hip mobility (decreased hip hyperextension). in- CO/1 Suboccipitals, SCM.· upper Irapezius. (masticatories.
submandibular)
creased pelvic side shift (weakness of glUlcus medius). Cll2 SCM. levator scapulae, upper trapezius
compensalory hyperlordosis, and lack of pelvic motion at- cm SCM, levator scapUlae. upper trapezius
tributable to a sacroiliac lesion. Muscle leugt" tests arc spe- C3I6 Upper trapezius, cervical erector spinae, ([email protected]
exJ=r~l-
cific tests to identify the amount of muscle shortening prcscili. C5.'T3 _). SCM. upper or middle trapezius. sc::aleni (subscapularis)
Six basic. stercotypic 1I1O\'('l1Iem [umems arc tesled to cvall1~ T3fT10 Pectoralis, thoracic erector spinae, sena-iiJsanlerior
ate the muscle activation sequence or coordination during. (SUbscapularis)
.1.19AL._-,<~~~~!.qtus.lum.b:o.rJ.lm. psoas. abdominals. thoracolumbar
performance of key hip, trunk. scapulothoracic. scapulo- erector spinae
humeral. and cervical movements. L2IL3 Gluteus medius
L3IL4 Rectus femoris, lumbar erector spinae, adductors
L4/L5 Piriformis. hamstrings. lumbar erector spinae, adductors
CORRELATING MUSCULAR AND JOINT DYSFUNCTION
L5/S1 Iliacus, hamstrings. lumbar erector spinae. adductors
The most common pain generators arc likely to be those SI Gluteus maximus. piriformis, .iliacus, hamstrings, adduc-
ductors. contralateral gluteus medius
structures housing the most nociceptors (articular surfaces, Coccyx Levator ani, gluteus maximus. piriformis (iliacus)
joint capsules. ligaments). Regardless of whm is the eXilct Hip Adductors
. pain gencrator. the entire motor system will rcact and com- ·SCM. sternocleidomastoid.
pensate. Long after strained soft tissues havc becn injurcd.
adaptive patterns will p~rsist.
Muscles arc the medium through which ccntral motor
certain. stcrcotypit: 1ll0vem~lH patterns. The Ilcgatin: rela-
commands or renex spinal activity compenS31e for any dis~
tionship bctwct=n various individual functional p~uhologic
lurbance. Certain muscles typically rcact when specific joints
changes and the abnormal pcrfonllanct:: of basic m(l\·t::mcllt
arc injurcd or are dysfunctional. This relationship can work in
patterns is self-perpetuating. Ahcred or f;'llIlty movemcnt pat-
either direction in that impairment in a muscle or joint will
terns thcmsch'cs place new slrains 011 the locomotor systelll
eventually lead to some compensatory change in its func·
and lead to the spread or a local problcm beyond a single
tional partner. Clcarly. if a Illuscle is shoncned llr ovcr~lctive.
rcgion.
increased pressure and strain develop in the joint capsule and
Slid, mm'emellt paltcms ira£, ji,.st n:co}.tlli;('d clinically
tcndopcriosteal junction, Also. a muscle that is inhibited .md
by Jonda. who noticed tlla! til(' do......i<: 11111.0;<:/(' testing (~r
weak is associated with poorer stability for the relatcd joints,
Kendall allli Kendal{ did flO' differel11iat£, !JctU'('CII normal rt!-
with compensatory fhations or even hypermobility resulting.
cruitmew of re!med musch,.\" and ",rick" puucms of.';IIh...ti",-
As described previously. Johansson ct al. correlated non-
tirm durillK a spedjic (lc/ion. So·callcd "trick" movt::IllJ.:l1ts arc
noxious joint afferent activity with inc~ased rerlex gamma
unecollomical and place unusual strJin on the joints. The)' in-
motoneuron activity.(,',I They hypothesized that long-lasting
volvc muscles in incfficient or incoordinmcd ways_ which
noxious stimulation may activate the flexion \vithdrawal rt::-
thus are prone to fatigue. On thc c1~issic tcst for prone hip CX~
flex.6'l Similar reflex dischargcs from the joints mediated by
tension_ it is difficult to identify ovcractivity of the lumhar
effcrt::nt sympathetic fibers wcrc described by Schaible and
erector spinae or hamstrings as substitutc!' for '1I1 inhibited
Grubb. lm Joint innammalion in the knee c.m lead (() reflcx
gluteus maximus. All llwt is notcd is the ovcmll slrength or
muscle inhibitioI1.t.1,.".,,~ Hides et ai. correlated segmclliai. re-
quantity of OUlput. nol how it is accomplished-its qfwli!.\:
flcx muscle atrophy in the low back with acute low back p;.lin
Janda's tcsts arc far more sensitivc .md allow the clinician to
in patients in whom specific lumbar joint dysfunction was
identify these clinically pertinent musclc imbahllK·cs and
manually diagnosed.('~ Bullock-Saxton et ill. showed a corre~
faulty movement patterns by seeing "bnormul substinltion
lation between poor ankle joint stability and inhibition of the
during muscle testing protocols.
gluteus maximus and medius during walkillg.';~
By wufersl(",dill~ the relationship between specific l/llIS-
Whcn a movellH::nt pattern is altered. the .tcti\·~llil)ll se-
)'
,
qucnce or firing ordcr of different muscles involved ill a spe-
des and joints, therapcllti<: shortcuts elllJ (~rf(m he f/llcO\·crt:ll.
cific movement is disturbed. The prime lllover lTlay be ShlW to
Finding a dUli!l reaction bellrcen IIruscrdar i1ll!JaI01l("(', WI al-
activate while ~yncrgists or stabilii'.t::rs subslitute .\I\d bJ.:(OI1lC
lered flfOl'cment pattern, and specijic joint dysfunctions en-
ovcraclivc. New joint stresses will then be encolllliered.
ables thl' clinician to find the k.ey factors in tile developfllf.~111
of functional pathology, and t"W, c{lfaly::.es the therapeutic
Sometimes, thc timing sequcnce is normal but the o\'e1';.1I1
range Illay be limited bccau!'c of joint sliffness or ant<lgonist
program. Lewit identified spccific joint dysfunctions that arc
linkcd to individual dysfunctional lllusCles (Tablc 2,8).lH,I~~ muscle shoncning.
A classic example of muscular ill1balanc.:e c.\Using an im-
ALTERED MOVEMENT PATIERNS
paired movement paHern is when tight hip flexors arc L-Olll-
billed with wc.tkncss in the gluteus m;\ximus. causing ;.tn in-
The ,ifcscnce of pain, muscular imbahmcc, trigger points. or cflicient or incoordinatcu hip cxtension movement pattern.
joint dysfunction alters lhe :.Jbility of thL' p'lticHt to perform The gluteus maxilllus lllay be inhihited and activatL' poorly \

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 \,,;n/"\I'" I en G . ,,~ ..... vn/"\. II"\): H.t:Hf't:SlLlIJ\IIVN INIU <;HIHOPRACTIC PRACTICE 31

Table 2.9. Muscular Imbalance and Altered Movement Patterns

Weak A£;onis: Overactive Antagonist Overactive Synergist Movement Panero

Gluteus maxim uS Psoas, rectus femoris Erector spinae. hamstrings Hip extension
Gluleus medius Adductors QL. TFL. piriformis· Hip abduction
',. Abdominals Erector spinae
Pecloralis major/minor
Psoas
Upper trapezius. levalor scapulae. rhomboids
Trunk flexion
Serratus anlerior Trunk lowering from a push-up (scaptltar
fixation)
Deep neck llexors Suboccipilals SCM' Neck flexion
Lower and middle Upper trapezius. levator scapulae, rhomboids Shoulder abduction or lIcxion (SC.J.;::";!':::'
, Irapezius fixation)
.j Diaphragm Scalenes. pecloralis major Respiration
·OL, quadraluS lumborurn; TFL. lellsor l<lscia latac; SCM. stCfOoclcidomasloid.

during thl: 1l10\~ell\C;IH. leading to ovcrm:tivity of the st<lbiliz~ lified and the individual is not rc-educmcd. This ne-ed to re-
ers ill the lumhar spine. the erector spinae muscles. Although learn is an important reason wilY p'-lin often outlasts lhe elim-
such an ;I!tcred p;:l1tcrn nwy havc formed as a result of hip ination of its cause.
flexor cOlllpen.\atioll to a lo\\' back :-:tr.lin. hypcrpromllion Janda advanced the concept that the control of mo\'ement
prohlcm. kg kll~th inequ;dity, cll.: .. it cvcnlUally perpetuates by the cenlral nervous system can be re·educatcd, Thi$. thcory
instahility h:- on.:r.slrcs:,;ing tile IIlInbOl1' joilHs on its own_ In wns tested in a study in which propriosensory stimulation ex~
this C.ISC. the follO\ving functional p<lthologic ;:tbnormalitics crcises were given to individuals in an llltel1lpl to improve the
will he intt.:rl"lHlnCelcd: shortening of Ihe PSO;:lS. inhibitionl speed of recruitment of the gluteus maximus and gluteus
weakncss/trigger points of the glutcus m<lxirnus. ovcractiv- medius muscles during gait.')!; Individuals performed balance
jty/trigger points of the lumbar erector spinae. lumbar spinc excrcises for 15 minutes per day for 1 week. These exercises
joint dysflJllClion, :lnd ;:lltcrcd conrdination/endurancc of hip led to significant increases in the speed of HCli\'ation of the
extensioll. particularly.' during gait, gait muscles. Such propriosensory retraining improved
Testing individu;:11 muscles for strength wilhout concern gluteal ;:lctivity "automatically and subconsciously. and nOI as
for the speed of ;:lctivation or rebxation or the ;:lctivation se- a voluntary muscle contmction."'ls
quence of agonist. syncrgists. and stabilizers is an elTor.
According 10 Korr. 'The tmlin thinks in tcrms of \I,:hoh:: mo- REHABILITATION OF THE MOTOR SYSTEM
tions. not individuallllllscles."IJf. Musclcs may h<lve anatomic
Rehabililation includes functional capacity cvaluatil..... n. reha·
individuality. hut they function interdependently. to create
bilitativc carc, patient education. and psychosoci~l! fJ.:tors, It
SIllOOlh. wcll-on:hcslr;:ltcd movements.
is ideally suited for managcd care pr<lcticcs bC(.:;Ju"e it in-
Exa1llplc~ of lypical p,tirs of overaclive and weak muscles
\'olvcs qU<llllificatioll of function;:)1 progress of (he patient.
and the related altcred movement !)aHCrnS arc listed in T'lblc
outcomcs <lSSeSsmell(, provcn cost-containment Illethl...ds. and
2.9. Thc~c paucrns me used as a scrccning evaluation to cor~
sdf-c;:lrc,
I'd ate joint o\·crS{rcss. lrigger poims. tight muscles. and in-
hibited or weak IlIllscies. Olher kcy functional dcmands such
Hchal)ilitation ,,"s. Consl:r\'ativc Tn.·atmcnt
;.IS squatting, lunging. rC<lching. <.:1<':, C;:lll also be assessed for
muscle imbalances. incoordination. and olhcr dysfunctions. Rchabilitation is different from Heutc. conscrv;.uj,,(' carc.
711l' plfl"lmse (~f idt,lItifyiJJg aju'r<'d IIlfwemelH !J"w:ms (11/(/ Conservativc cme is ideal for acutc disorders. h l",uses on
1/11.l2.c:le imbalances is to dis(:m'('/' WhOl to stretch. strem{thell, stabilization of the injured part. pain control. and pr('lllotion
alld adjl/st ill pati('~jl~t" di}.<;'QHl/i'iQJ.l{/.l!L~IlIdml!.t.SrlJi.'i ;11- of soft tissue healing. Rehabilitation is concerned with restor-
]lJl'lIlClfioll {/!l()\l'S IfS to scorch Jor /Iu: c1illical shortcut,\' aJ- ing Illusculoskeletal function in p<Jlicnts with "ubi.lcutc.
fordf.'d f,y If/ldt~,.st{///(Ii//X the (:of/flec/ioll be/H'cell altal'll bio- chronic. and recurrent conditions, Rchabiliwtion ~m('mpts to
/I/cc!/(/Jlin (/1/(/ neurophysiology of potients with p(/{llOlogic prevcnt or manage dis'lbilily through function<ll re"tOratioll.
Jilllc/iotl (~r the malo" systelll. work hanJcning. and psychosocial ill1avcntion.
Trcatment of altcrcd lIlovcment patterns is described in In the first issue of the Journal or
Ol:cUpatiollal Rl.'habili-
Table ",I (I. talion. Feuerstein described thc changing. p:'lr<1digrn I..""lt muscu-
Pain motor programs. poor poslUral habils. or altered loskeletal care: "Activc rehabilitation efforts usin~ J sports
movement paHcrns arc mcmorized jusl as is normal g;'lil. ski-
ing. or ViflUOSO lllusici'lIlship. Inefficient or uncconomical
movemcnt p<ltlcms. once learncd. will perpetuatc the muscu- Table 2.10. Trealment for Altered Movement Patterns
lar imbalmu.:c and joinl dysfunclion that 111<.1)' have caused Relax/stretch overactiveftight muscles
lhem, TreatnH.:nt aimed OIL peripheral funclional p;:lthologie al- Mobilize/adjust still joints
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ICf;ltions. such as tight l11uscles. trigger points. or joint dys- FacililaleJstrenglher: we"k ;7;:..;::;cles
Rc·educate movement pallerns on reflex, subcortical basis
fUlll"tioll. often fails ifaltered movemcnt p;tlterns are not idcl1-
 32 nL..",....... '~,· •• • ...... " ... , .,. __ .

medicine model directed at rapid safe return tu work l:oupkJ i.vlii>:li il,,,::)· ii..::.;d ;" ~'..: propaly traincd. It is csscllli;t1 10 ;H.I. ,
with ergonomic intervention h<lve replaced much of the tradi- dress deconditioning ;\1lJ leach .. worker 11m\' 10 reduce Ill!.>
i tional passive. i.e., modality-driven. approaches to rchabilita- chunk,1i strcss while :-;.illllllt:lllL:Ollsly training them Hl illlpnm,..•
~ tion of musculoskeletal injuries."IH their functional stalU:,>.

I The key difference between rehabilitation and tradilional

conservative care is the primury cmphasis on function rathcr
Individuals wilh "hnnrm,,1 illncss bclwvior arc lIlore
likely to becomc dis;lbkd tIl' \0 th:vclop chronic p,lin syn-

I than pain relief. P.. ticnts ',ire cduc~llcd thai pain perception
will decrease as physical functioning improVt;s. This focus
dromes. Quick shiftin;; from p:lssivc (nlllscrv;uin:l h) ;lI.:live
(rehabilitative) care ,,:an prevent llllH.:l1 disability. Rd~lTal flll"
,
......

I
1
transforms the patient from a pa'isivc. dependent recipient of
care to an active p.u1icipant engaged in the process of rcha-
nlllhidisciplin;I1"]' fUlll.·li'lllal n~Sl\lralioll. involving psyclh1-
logic support and hh)bt'h~l\-ioral rt.'-;.:dueation lllay also he in-
,
i bilitation (Table 2.11 l, and the doctor's role becomes that of dicated.
helper rather than healer. Although treatlllent dccisions an.: oflcn llIade on the h;'lsis
~ Rehabilitation involves lifestyle changes and behavioral of a di'lgnosis. palicl1\s with spinal pain n:sist ;ILTUf;lle labcl-
re-education (functional restoration). and thus is part of a ing. Painful spimll syndroml:s arc considen:d mcchanical dis-

I
biopsychosocial approach. The palient's suffering and iHn~ss orders mosl of the lime. bUI many ex pens vicw the psycho-
arc morc important than a specific disease process. logic or social factors to bc prcdominant Polin-sensitivc
Historically. this approach was appropriate for physically ex- slructures abound in th~ spinal region. :lnd pcrhaps hecausc of
ceptiollal (athletes) ami physically impaired (lulIIdicappt:d) the ovcrlap between ~itcs or
rcferred pain from lllust:les.
individuals. To(/a...,., it is ~lCces.\'llryfo"l1lost pai" parients. The joints. ligaments. fasl·i;l. nerves. CIt.:.. a diagnosis orten is
i"dicmious for rehabilitation indude the subacute Slage oj ill- given on (he basis of lhe physician's pathoph)'siolo~icphilos-
jU0~ chronic pain, disability, or reCllrreHT pain. Tile purpo.H: ophy rather than on any provable hYPOlhcsis (i.c.. dcgcncr<l-
of rehabilitation i.\· to trcat or prc\'ellt deconclitiolling syn- tive disk. sacroiliac or myofascial syndromes). Unfortunately.
drome (llld abnormal illness belUll'i01: .J cel1ain patho;umtomic di;'lgnosis C'1Il only he det .... rmillcd ap-
proximately 20% of the til1le.111.1·1·'.1~ll including I.:onditiolls
ranging from disk syndromcs and S\l;nosis 10 thc much rarer
Blending Active and Passive Care in Practice
spinallr3uma, rhcumalologic dison.krs.•lIId infcclil1us or neo-
To be a rehabilitation specialise a health care provider must plastic discases of the spine.
identify" red /Iags. .. shift from passive to ucth'e care. lIlIder- The obvious limitation of thc Quebec Ti.lsk ForL'c dassili-
stmul the emerging guidelines for care. peryorm outcomes as- cation is that it suggc~ls Ihat 80% of <.III back p<.lin cascs re- )
sessment and functional testing. and identify psychosocial quire no individualization of carc. Attempts to subcl;lssify the
factors re!llling to abuon/wl illness belull'inr. It i:; impol1ant nonspecific pain group arc under way. and progress has been )
to rulc out morphology, infcction, carcinoma. and Visceral,
metabolic. rhcumalOlogic. or neurologic discases (red nags)
reported by Delino C( :II. l~l Thesc uuthors have shown pre-
5criptive validity for an approach thal identifies cxl.... nsiol1 and
,
.1
before attcmpting rehabilitation.I-lS Such patients should be sacroiliac mobilization subclassilic.uions.I.\I Di3gnostic anes-
referred to the appropriatc specialists. Acute disk problcl1l~ thctic block tests h~I\'e also been used to identify s<lcroiliac

I
and traumatic injuries require fonowing specialized conserv- joint pathology as an etiologic f<lctor in 10 lo 30C;,c or chronic
..tive care protocols. bUl these p.uients eventually will become low back pain paticnts. t~: Similar methods have dt.'lHlmstriltcu )
candidates for rehabilitation. that greater than 50Ci, of chronic neck pain aftcr whiplash in·
Current guidelines dictate Ih.u exercise .md .. ctivc care arc jury involves the cervical zygapophysc<ll joints. I~I Un- )

I crucial to the management of subacute. recurrent. and chronic

condilions. Bed res!, medication. passive methods, injections,
fortunately. no physical cxaminalion tests corrclat~ with the
diagnostic block tcchniques.
,.'
I
surgery. and manipulation all have their proper place in trcat- Passivc and activc carc arc both impol1,lI1t in casc man-
ment planning. Being able to define (Ill apprupriate re!woili* iJgemenl. passivc care being more impol1anl initially ;,tnd ac-
tafion goal depends 011 knowing !low To judge fimcfiOlllll j"!a- tive care later on. Table 2.12 describes the stages or
trealmcnt
(lfS and work. dem(/luls. If ;Ill individuat has a high \vork and their goals. anu ~OlllC specific interventions uming thcsc
,I demand. grcatcr functional status will nced to be achieved. sHlgcs are outlined in Table 2.13. We must mcnlion. howevcr.
Injured workers should be vic\\'cd as "occupalional athletcs" somc important exceptions. For inswllcc. McKenzie methods
racing high levels of stress/strain in their work placc for may be used. even in acute cuscs. Whcn these methods arc

)
Table 2.11. Primary Goals of Rehabilitation and Conservative Care

Pain Reliel Promote Tissue Healing Functional Restoration Passive Patient Active Patient

Rehabilitation + +
Conservalive care + + I

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

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----- -11'
 CHAPTER 2 : IN I "GRATING REHABILITATION INTO CHIROPRACTIC PRACTICE 33

Table 2.12. Goals of Treatment

Acute Intervention Remobilization Rehabilitation and Reconditioning Lifestyle Adaptations

Reduce inflammalion Increase pain·free mobility Increase muscle strength/endurance Improve ergonomic factors
No pain at rest Minimize Clecondllioning Improve coordination Education about biomechanics
Minimal pain with unstressed Promote tissue repair/regeneration Increase flexibility' Address psychosocial lactors
daily activities InCrease aerobic capacity
Decrease muscle ~spasm~ Promote tissue remodeling

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 ~"J

Table 2.13. Treatment Strategies

I "(...,~
\3
Acute Intervention

AesVice I
Remobilization

Chiropractic adjustments
Rehabilitation and Reconditioning

Functional strengthening
Prevention and Lifestyle Factors

Stress management

I ,
~-
~
...~
§
"SupponsJbraces
,'Gentle stretching
, Physical therapy
: Anti·inflammatories
':"Solt tissue maniputation
~ Physical therapy .....
.4Postural correction ...
5 Functional exercise ......
Slretching
(Cardiovascular fitness ' \
'. Balance and coordinati~9-'
Ergonomics "work station-
Biomechanics ~liltingJbending­
OieVnutrilion

()
y
-I AcnvE CARE
l .'-~

i i3
,~ C'
, ~
"j PASSIVE CARE

I ~
% r'~

I %2 successful. thc)' arc able 10 impart cnoml0US (~)st savings. positive impact on improving functional integrity, RcslOring
~ Similarly. a trial of manipulative therapy for a chronic suf~ function by rc\'crsing thc dcconditioning syndrome is Ihe prj·
,j
11 [~
'i..# rerer who has not previously had such carc is also indicalcd. mary goal. as opposed to mercly treating symptoms, Highly
Rehabilitation of lhc motor system involves restoring nor- lcchniculmuscle function testing and training apparalll:'t's arc
l lllal joint mobility: inhibiting ovewctivc musculature (includ- not nccessary to achieve this cnd, Proctit;oners ill s11/al/, pri~
ing trigger points): improving muscular flexibility. coordina- l'me practice.\· who (/.\".'iCSS a1l(/ frettf .!ffflcfiollal /)((t"ologic
tioll. strength. and endurance: stretching retracted soft tissues: problems while tmini"g alld educ(I{ing ,"e p(l{iellf ill hou' fo
propriosensory re-education; cardiovascular training; and
poslUral rc-education, Passive and active care are both re-
quired to achieve these goals Crable 2,14), Physical training
alone would fail to address specific joint dysfunctions or
ll10vcment incoordination. Chiropractic adjuSlJllcnts alone Table 2.14. Integrating Passive and Active Care
in Rehabilitation
would fail to address muscle imbal;.mces or faulty movemcnt
patterns. A.uC"\",'iflleflf slum'd idcllfijV fIle various links ifl fIle Goal: Improved posture and motor control on a reflex, semiautomatic
elwin tl./imcriollal pafllOlogic processes. Often the prob- basis
Increase mobilitylllcxibility
lem is in the patient's posture or work activities, Rcgard- Joint mobilization/adjustment
less of what other influences exist, rehabilitating the motor Muscle relaxation/streIch
system requircs that we scc the interrelationship betwcen Improve coordination, strength. endurance
Muscle lacilitation
the functional pans and between thc patient and his or her ·Spinal stabjfization~ or lunclional exercise training
environmcnt, Propriosensory retraining
This approach is cmpiric in that one identifies functional Cardiovascular training
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deficits and seeks those interventions that can have the most
Posturat re-education
 Hl:::HAtlILI j A IIUI'l VI- I Ht: <::>1"""11'01:.: A I""" HAl,... 1lllVI'Icn 0 IVI .... I'IU .... L

Table 2.15. Factors that May Predict a Longer Recovery Patil.'lHS ha\"l.' traditionally been categorized as having
(from the Mercy Guideline) anHe. subacute. dtn\llic. or recurrent disease. depending on

History of more than 4 episodes - ~ -

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
Longer than 1 week of symptoms before seeing a doctor
Severe pain 1;1~1> het\~.~11 2-l __~!llLZLh()lIr~ The subacutc phase. in which
Pre-existing structural pathology or skeletal anomaly (i.e .. spondy-
rl'l~ai"r and regeller;lllnil occur, !:lst.. . from 24 hours to 6.wecks.
lolisthesis) directly related to new injury or condition
Till' linal phasl' in\\ll\"~ . . relllodc\ing. which pro(~eds from
(From Haldem.:.n S, Ch<\pman·Smith 0, Petersen OM: Frequency and dura;
lion of care. In Guidelines for Chiropractic Quality Assurance and Practice
the third week !\l 12 l1lonths after injury. These phases or soft
Parameters. Gaithersburg, Aspen, 1993, pp. 115-130.) ti . . slt~--llc~\iTi\g--ill:"II~~~il."e for 1~~lli~I-1IS sulTering traumatic in-
juries. hut for illlli\"iduab expl'rietH:lng. pain syndromes re-
lated to cumulati\'e l1liewtrallllla. such a framcwork is not ap-
preve1lt reoccurrenccs rC'present the ('osH:ll<'uin' FOllt /ille propriate. Ikca/fsc of rht' pl"csC/lce of a!JJ/ormal illncss
against roda.v:\· soaring costs for caring ./f)r illdividuals with hdw\'io/, dis/ll"Ollol'ti(lJlatl' to illlpail"lllel1~ or strtlctura! parI/()-
low back pain. 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

Case Management and Standards of Care chr()nic.!~S
PROGNOSIS
The individual suffering an episode or pain an~r injury or
The natural history of uncomplicated spinal disorders is to- trauma should be better in 7 to I() WCCks.'~·J The <lCllt~ phase
ward resolution within 6 weeks,I.JS.I<U More timc may be nec- ma\" last I week (J~llltil the patient has no pain at rest and he
cssary for modcrate [() severe traumatic injuries. prolapsed or she. can perlorm , unstressetI (,II ,.. I~')AU
I " Y acl1vttles. ' \..:: P to.3 to 7
disks with nerve compression. or if certain complicating fac- da\"s of "relative rest'· and illllllohilization mav be neceSSar\0
. - -.~-
tors arc prescnt (Tables 2.15 and 2.16). Intervention for un- Prolonged imlllobili/.atlon lllust be -a\"oided, however, be-
complicated cases is considered successful if the patient is calise or its deleterious crrects (sec "Negative E~rfects or
asymptomatic within 6 weeks. Traumatic injuries may require Immobilization"). The subacute phase should -.t,tst ,6"J0_J)
more time. depending on the severity of the injury. Disk prob- weeks if it is iI minor to moderate injury,'<" This phase may
lems may also require more time bccause of the poor healing last H-'It) f6-wceks if the injury is moderate to severe.I~" For
potential of the avascular annulus fibrosis (particularly in soft tissue injuries. any patient still experiencing symptoms at
smokers). The goal of modern care of tile spine is to minimizc the 16-wcck mark should be cOllSidered in the chronic
the incidence of chronic pain and disability by focusing on phase.l(~) Soft tissuc healing is completc at this point. except
restoralion of function as soon as possible. Nordin comments. for the most sevcre injuries.
" ... there is a very small window of time in low back pain The popular mcdical practice of assigning the label "nOI1-
care; we must act quickly within 4-6 weeks to bring patients sped tic or idiopathic back pain" is likely to lead to decreased
into an activc reconditioning program if we expect to return patient satisfaction. II.! Some pf<lctical patient l~lassincatiolls
them to productive lives and prevent recurrence."1~4 should be sought that can be used to direct thc choice or ther-
apeutic intervcntion,l.<l f\llost patients have a gradual or non-
traumatic onsct with nonradlcular symptoms. Repetitive
Table 2.16. Risk Factors for Chronicity strain is the most likely etiology for the first time or recurrent
History/Consultation symptoms. If there is no nerve root involvement. such pain
Previous history of low back pain episodes should be expected to resolve within the same time
T9.tal work loss in past 12 months
v+i"e-avysmoKffig' frame as allowed for mild to moderate injuries (6 to 8
Personal problems-afCohol, marital, financial weeks).I.lIu~u The prescnce of complicating factors as listed in
Adversaria! medicolegalprOblems Table 2.15 may legitimize additional care. JI/.\·t~I.'·illg (l lOll}.:!'/"
Low education attainment·
Heavy physical occupation'
recovery time because ortlze S((Iges (~r\'(~fi lis,\'lu' healing is WI
Questionnaires/Pain Drawings or Scales in{{ppropriate application (~r{{l1 ae/lll! injury model to patie/lts
Radiating leg pain--":· suJ)£'rill}.: from clI/Ilularil'l! (/"(//111/(/ or. n'[J(,tith'e straill. 1~II,1.~')
Low job satisfaction -~
Psychologic distress and depressive symptoms-BMG
The patient with radicular symptoms (symptoms distal to
Examination the knec or elbO\v) and cvidence of nerve root compression
Reduced straight leg raising (i.e.. nerve tension signs) is a specific example or a compli-
Signs of nerve root involvement
Reduced trunk strength and endurance (dynametric,
cated case. the natural history of which involves greater than
nondynametric) 6 \I,.'ceks before resolution can be expected. This prognosis is
Poor physical fitness (aerobic capacity) due to a strong correlittion between clinical symptoms and
Disproportionate illness behavior (Waddell's signs)
structural pathologic lindings. Nonctheless. even patients
'Only slightly incre<lses the risk of Chronicity, bul signilicantly increases Uw with large disk prolapses can he expected to recover without
dillicuHy of rehabilitation.
surgery.III.I.IU~lI,!/,~,lt,\ Treatment in such cases might follow
(Adapted from CSAG Clinical Standards Advisory Group Report on Back
Pain. London, HMSO, 1994: 1-89.) a similar time frame as for moderate to scvere injuries.
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- - - - - - - - ~- -_.,-
 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:
Yes - - - + - Goal -to facilitate active rehabilitation
• Adjust analgesics
• Manipulation (avoid if severe or progressive neurological deficit)"
No - Active exercise, "hurt does not equal harm" (gradually increasing)
t • Physical agents (gradually decreasing)
. - Increase activity
"Red Flags" (See Table 18.1)
~ Non-mechanical pain (constant, - Early 10 o! distress or depression
progressive, no relief wiJh ...
bed.r~
- PH: carcinoma. steroids,
HIV. drug abuse
• Weighlloss i ' V yes...... Return to Normal Activity
• Malaise"":""\.oo-'
- Unremitting flexion restriction
• Fever _.
• Violent trauma No
• Widespread neurology
+
Timeline: 6 weeks
No Reassessment:

~
• Review diagnostic triage
- Consider imaging & lab work
• Leg pain> back pai - Psychosocial & vocational assessment (see table 18.4)
- 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)
No - 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 .
• Low back. buttocks. Ihigh
antidepressant, injections. supports)
pain
• ·Mechanicar pain (varies with Yes-+-I Simple Backache f-- - Objective outcomes utilized·'
posture & movement)

PH • past medical history

Is function improving within
12 weeks. even if still
with some pain?
Yes +-I Return to Normal Activity

SLR • straighlleg raise tesl

Lap· low back pain
A Continued next column. No

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
Fig. 2.24. (A) Diagnostic triage algorithm. (8) Treatment guide- - Behavioral medicine principles with functional objectives
• Close liaison with the work place
lines algorithm.
• Type of manipulation should change if no progress after 2 weeks (t84).

•• Treatment beyond 6 weeks must be tracked by acceptable, outcome assessment

measurements. Failure to show significant progress by the 8th week of an uncomplicated
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B 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,; IIIIUNI::H'S MANUAL

Table 2.J7 ~ulnmarizcs the pnlglHl~i~ for tll~ \'ari(lll~ g~n~ral Table 2,19. Guidelines for Management of Uncomplicated
Soft Tissue Musculoskeletal Pain Syndromes
typ~s of cases, Th~ algorithm in Fi.surc 2.24 is llsd'ul for UIl-
dcrst;:lIldin!.! the indicati()n~ for bed rest, m<lnipu!;lIion, ill;livc \. Bed rest should nOI exceed 2 days and passive methods 6 to 8
care. <lnd ';'llitidisciplinary fUIKtiollal restoration, weeks.
2. Treatment frequency IS. 210 5XJweek for the first 2 weeks (pas·
Certain patients can be idclIIilkd e;lrI)' as being "di~ahil­
sive care with manlpulalive therapy appropriate).
it)' prone,"!f,.l A certain profile of the chronic pain or disabil- 3 From week 3 to weeks 6 to 8, treatment frequency should be
ity-prone patient has emerged that can be lIsed 10 pn.:di<.:( .:1 decreasing,
poor respOllsc to <.:al"l.::,,·I.IM ('J'ahle ~,J:-\). These raLIUl'S arc nol 4. Functional capacIty evaluation is recommended when patient is
subacute (week 2 10 4) and mandatory.'3t 6 to 8 weeks.
Slnlctural or function;1I (organic). hut om: psychnsoci;1I 5. Progressive exerCIse prescription and sell-care advice recom·
(nonorganic).I.~-:.II.• Such psychologic fat·tors as poor pain cop- 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
ing stratcgies. cXl;{~ssive anxiety. depressioll. and ~ymptolll
.--. 8 weeks,
m;onific:'17ion arc si!.!nilicant.'l~. 1M Soci;11 or economic f"l;tors ( i· Advancgq ima9!,:l.9.~r,tqu_~§_2rc appropriate only when n~ur_o­
lik;job dissatisfaction. pcnding litigation, low income level. V .{og;c.function is deteriora1ing or progressive exerCise therapy has
and low educ;ltion levcl ;Ire 'llso ill\portant.If..t.lh.~.I'''' \Vaddell r:"- failed.
',8. Evaluation by a palo behavioral specialist may be appropriate at 6
and colleagues studied the relationship between pain, impair- months.
ment. and ~disability in patients with inappropri3h~ signs or
symptoms of illness behavior. nil An individual who is ullwill- r~dllcing futur~ recurrcnces and prcVl'nting the emcrgence of
ing (0 move from being a pain avoider to becoming a pain duonic pain SYOl.lrolll~S,~'I.r,(un.r:.' Bush showed that <lggre:--
m;n.llgcr is such a patienl. Exccssi\"l";: dependenc)' on medk:l- sivc conscf\'ativc care is highly successful for the managt:'-
tion or passive forms or thempy. along with an unwillingness ment of severe di:-k protrusions with nerve rool compr~s.­
to develop internal control ovcr symptoms hy Ic'lming ~clf­ SiOll,l"1 Muhidi:-.dplinary. function;,.l restoration programs.
treatment skills. ;lrc clear signs of a potcmial chronic pain ha\"e rCpc~ltetl:y demonstrated their success in returning (he
patient. chronically disabled back pain sufferer to work,lf-oll,174-111, Otha
The treatment plan for spinal disorders focuses on aggres- studics havc shown that failurc of passive therapy ap-
sive. conservative care for promotion of soft tissue hcaling proaches docs not imply tll,:lt active rehabilitation efforts will
after an injury, When p.llin is a result of a repetitive strain. fail. m.17!I
conservative care may be approprialc for p:lin relief. but treat- Pain relid anti prc\"clllion of recurrenccs ;:m:: thc primary
ment goals must quickly change to rehabilit:Jlion or rcstor;,,· aims or C<lrc. Restoring function is the means by which thc:;.('
tion of function. Intervention involving manipulative therapy ends are <.lchievcd. III 11I0.\·t u/lC:omplicated cases illVoll'illg
has demonstrated a clear advantage over other methods (re- SlI/mcll1e or rt'('//rretlt pail/, treatmellt aime(/ at pain relic/wuJ
duced disability) in the initial care of the patients with pain. 17J Jill/eriol/al restoratiol/ takes betH'cel/ 2 a"d 6 weeks, Illirial
Early. active intervention: preventative education: and reha- In.'alll/cJl! /requency 'thrce tillle.\·J!!r week f(Jr 2 weeks) is )
bilitation approaches have all shown their positive imp'lct on
often .mfJiciCl/t to idelltif.), !!!l!. keY/I,mc.r.~'.!.!!~lJp.~~t!I(!{~!£~~ prob-
lef,-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'-
Table 2,17. prog~o(Musculoskeletal Pain qllency for approximately another 4 Il'eeh is I;sually llppn l -
Syndromes'5!J '/
!,riate. Additional care is often required in ca~cs or Jnodcrm('
Syndromes to .,,>c"cre trauma, di'do-; prolapse with nerve root compression.
or chronic pain, or when significant complic.iting factors or
Acute Subacute Chronic
abnormal illness behavior arc present. The disability-prone
Mild-moderate 2-3 days 6-8 weeks patient often requires intcrdisciplinJry rcferr"l. Table 2.19
injury
Moderate, provides an ovcr\"iew of these guidelines. which arc also dis-
<1 week 8-16 weeks 4-12 months
severe injury cussed in Chapter 21,
Repetitive 2-3 days 6-8 weeks
strain
Nerve root REPORT OF FINDINGS
<1 week 8-16 weeks 4-12 months
compression
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
Table 2.16. Profile of the Disability Prone Patient back pain,lf.1 Kirkaldy-Willis discussed the cardinal signs of
Symplom magnification difrerent sources of nonspecilic pain. such as facct. sacroiliaL~.
Pain avoidance behavior and myori.lsciul.l!'~ Cherkin and MacCornack noted that of-
Psychologic distress fering <In explanation to patients and clearly outlining goal:,
Job dissatisfaction
Anxiety for care leads to 2featcr patient satisfaction. I -N ,lIm Bogduk
Treatment dependenc'r and Simons summ·arized the kcy clemcnts for di'lgnosing
Catastrophizing as a coping strategy myofascial sources of pain from articular sources (sec Ch.,p-
Pending liligation
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ter 18),'~'

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

After the patient has been given the working diagnosis. ii fUllctiuilai restoration .......ays to rl.:ducc eXIHlsure to h;:lfmful
37

I is important to explain that although most {Xoplc gel bcltcr

within 6 weeks. recurrences nrc the rule rather than the cx-
ceptionY' For this reason, it is prud.:nl to spend some time
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

i 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
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
well as biomcchunical issues will need to be <Iddrcs~cd. lheir symptomalic arcas. They may feel ;\ "hum" in thl.: lllLlS-
Referral LO a psychologist SPCchllizing in biobchavioral cdu· cle being trained. bLH thcy should not cxpaicnce pain ill tlh:ir
calion may be necessary. symptomatic area.
Simple chans can be used (refer to Fig. :!.4) to educal!.: the Manipulatioll alld OIher thcrapie,\· may be used to acldrcss
patient about the importance of reducing external demand key trig.~cr poillts or)oillr dyJjillictiolls \\'itll the' goal (~frl'iax­
and/or increasing functional capacity to prcvent re-injury. The ing and IIwIJili;:';lrg t(-'lI.'it· or sriff tis,\"fIc'\" (.H't! Chal'tt'l' II'.
more external stress, the greater (he chance of injury. Such ex- Then. IUlJiems Icum abOlll strellgt!tL'lling and sIahlli:i".!: III('
trinsic sources could include prolonged sitting. improper lift- "wea~ link" b)' training Ihe "l1ig:'.,l,IJUsr!t..'s (,!I/adri~·{'l"'i.
ing technique. or repetitive manual handling activities. The gluteal. (lb~~.~) to do 1~IOSl oj the \\"ork and to m'uid
simplest way to avoid fwure problems is to reduce the exter- o~·!!I~!8..Jhe "s/1~~ll1e!~·__ p.!!.:g!~rt.tI II1IlJdl'S alld clapa
nal stress. III as Ilmdr as this change is IIot a!l\fllYs possible, ,~P..!.I!!!UJrJ((t!tres.This training may lead to sOllle postexercise
intrinsic fiU/ctiol/al capacity call be iI/creased. Various intrin- soreness, but this discomfor:L~hQ~].I~UrlY,o(yc_a[ea.'i_quiil:dis-
sic factors such as muscular imbalances of strength or f1e~d­ tinf.!Jrom their primary area of complaint (sec Chapter 14).
bility. postural faults (i.e.. slumpcd posture). structural asym- \Vhile training these "big". muscles. the patient is taug.ht to
mctry (i.e.. shon leg). impaired coordination or balance. or pers...~~~.-!.~~~af~~~~~T.p~~_~~lrc.With repetition. lhey
poor cardiovascular fitncss also predisposc to recurrent pain ICi.lrn to cOlllral their posture bClIer. by dcvcloping improved
episodes. TIle dangers of even low level repetitive strains kine~_tic.l\..~a~~ness.and to lise the "big"' muscles to pCI'·
J_:,·.
1~ ,'~ should be made clear (refer to Fig. 2.7). InstnIction should formJJ1Q.S!9f.the work, \~:.~ic.~Jakcs strain off all the structur~s
".J
stress taking frcquent "microbrcaks" from either prolonged oLl.hc_l)p.inc.._W.isk~..ligaIJ1ent,j oint. etc.). Uhil11alcly. their im-
slatic loading (i.e.. desk \\"ork) or repctitl\'c activities (i.e.. proved motOr conlrol should become automatic, r~qlliring no
1Il<1IIW,!i m;,ucri;,li handling). conscious effort.
Whalcver the pain complainl, proper managcmelH hinges (S() long ns the patient's case is uncomplicated. recovery
on reducing strain so .IS to promote healing and to prevent re- c:.H~e expected within 6 wcc0 If r~lclors are pre:.;cnt that
currences. In the acule stage, especially with disk syndromes complicate the cast.:. these should be explained to lhe pmient.
or trauma, reducing load on the injured structures is called Such a paticnr should be apprised of lheir poorer prognosis. It
"relative rcst:' This measure, along with chiropractic, physi- call bc mentioned lhat approximmely 15Cj( of p~Hielll!' with
c.11 therapy. and exercise. may be used to reduce tissue low back pain develop chronic pain syndromes. and at least
swelling or irritability and to prOlllote a good environment for 33% of illl paliellls suffer recurrence5 at :,;ollle time.
healing of soft lissue injuries. Complicated cases require pro-active management to dCftlsc
PatielHs C;1n be cdUC;'ltcd about the dangers of recurrences tllese "ticking time bombs." It is bCHcr (0 inform such p.ltients
as pain subsides and [he need to increase intrinsic back fItncss of their risk for chronicity lhan ((l allow them to build up
and decrease exposurc to harmfUl. extrinsic sources of back anger and rcsentment when they arc fnJstratcd by lheir unsut-
struin. Comparing the patient's treatment w that of an alhlete isf'lctory progress. A brief course of manipulati\·e therapy,
will help to motivate Ihe patient tow;.1rd seeking m,ore than rollowcd by aggressive rehabilitation efforts with an active
just symptom<ltic rdief. Tables 2.12 and 1.13, along with care focus, arc cssential for thcse patients. If thi~ :.;cqucncc is
Figure 2.9. can be used to show the palient how the spons unsuccessful. a biobehavioml approach incorporating multi-
medicine paradigm of rchabilitation is the best method for disciplinary SUppOrl is necessary.
achieving optimal results. For example. an injured p'!liellt
learns that he'lling starts with innummation. The goal of treat·
REPORT TO THIRD PARTY PAYOR
ment is lO decrease swelling and p;:lin. The stratcgies used in-
clude rest. icc. SUppOl1S, t;lc. A pOitient with subacute injury It is imponanr to be able to communicate lhc rationale for re-
learns thal their tissue:; arc going through repair .lIld various habilitation to the group responsible for financial reimburse-
passive methods along with exercise arc necessary (0 relax ment. With musculoskeletal injury or pain. changes will occur
and mobiliz.e lheir healing tissucs und simultaneously prevent in_.t1!c ;,trcas of strength, mobility/Ilexibility. balance. coordi-
scar tissue <'lIld dcconditioning. Next. this patient learns lhal nation. and c;.Ifdiovascular litncss.~" These functional losses
they must strell.luh('JI lind stabilize their "weak link" or in- arc a result o(immobilil.ation <Ind'·adaptation and arc termed
jured tissues to pre\'ellt recurrenccs. "deconditionj!lg."I.~s To prowct YO/lr riMht to reimbursemellt
A p;:lliClll wlto suffers pain withoultrauma IC,lrns thal oncc for ,\'er\'ice.~ I'l'I"I('l"{'d IIwt ad"en' to stwuJards of Ctll"(-'. follow
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serious medical causes <:Ire ruled out. trcatment will focus on t!lese .'iteps: (f) Documellt tIll' pr('.H'lICe of OilY complicating

I 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 out- trauma" from prolonged overuse and/or constrained postures
cOllies a......cJslJleJl( /(wlx /0 doC/mlc'lIl (Illy fimcliOlwl changes I~ads '0 gradual dcconditioning o( the strained soft tissues.
Of subjeclive illlpml'(.'l1wllf: (3) IJUr"1'(Jllfi(lf(' ch'od.\' betwl'eJl This deconditioning weakens the various musculoskelct3.1
passin: a/ld aClin! can: tre(ll/lll'1/T lIPIJI'oac!/{'.\': lind (4) Quote stnJcturc..~ to the extent that painful injury can result without
I-J/lblislted gtfidclil/cJ (Quebec. Mclt·y. AHCI'U and CSAG) /0 any trauma. Such pain ean occur without the innaml1l<ltion or
(/('IJ/OIlJlrare the op/,mpriate!lCJS (/1/(1 pIcK{' of llulIlipu/mioll sw~lling :lssociatcd with <In acule injury. The treitUnent is sim-
alld eXl'rc:ise (oClil:l' ('til'£'). US.l'1.11.l~: ilar 10 that for mild to moderate acute injuries.
It might he hdpflll lO explain the phases of care <lnd ap~ Another type of case is that involving the putiefl! I\';rh
propdate trC<ltmctll ~dct.:tilln for each phase. After a ",;id ttl dmmic pain. This patient Ims completed all soft lissue heal~
1II0c/C'f(llt.' iujury. lhe ~o;lls or iniliallrcalillelll arc to reduce in- ing. and often has abnormal illne~;s bchavior disproportionate
nnmmation/swdling. cOlllrol rain. anti resl lhe injured soft 10 impairmenl or p;,nhologic evidence. The goal of treatment
tissues. This acult.; :'\!agc of l;i.Irc lypkally ILists only 2 10 3 i~ rehabilitalion with an emphasis on functional restoration
days. Trc;ltmcnt is indusi':C of resllice. supportslbraces. gen~ rather than on pain relief alone. Psychologic intervention to
tic stretching. physical Iherapy technillues. chiropractic joinl incre<lse coping skills and to reduce fe'lf is neccss.uy in com-
manipulation. illHJ nutriti<.Hlal supplemellts. Progress is mea- bination with a physical rCHctivation program.
sured by using spccilic. quantilii.lblc olltcomes assessment Patients with uncomplicated cases and not suffering unsta-
lools. OUlcomcs assessed include mobility and pain intensity b~~J!1juries or chroE2£~!)l syndromes should be fully rehabil-
(Visunl Analog S<:'lle). itated wlthm 6 to 8 weeks. A severe whiplash. grade; II or III
Once inlli.lIl1111;'lIion has subsided. the paticnt cnters the rc~ knee ligmncnt injury. or disk herniation with ri:ldiculitis me ex-
pair or regeneration phase of soft [issue healing. This phase amples of unstable conditions that usually require lreatment
usually lasls from 72 hours to 6 weeks. In this subacute stage, well beyond 6 to 8 weeks. Complicated cases may require
the goal of treatment is 10 promote ~he repair/regcneration more (reatment limc because of the presencc of chronic pain
proccss and remobilize the patient. This goal is accomplished with its associmed physical and psychologic deconditioning.
by mobilizing the soft tissues. Treatmclll is inclusive of chi~ By demonstrating to the third party payor what type of P;,l-
ropractic joinl manipulation. soft tissue manipulation. physi- lient is being lreated: the standard of care of treatment for that
cal therapy techniques poslllral exercises. and individualizcd patient typc~ and progress being achieved through objccti\·c.
exercises for muscular imbal.mccs. Progress is measured by quantifiable outcome measures. the c1inici;m should be able [Q
improvcd mobility. dccreased pain. ;lnd increased ability to justify reasonable ex lens ions of care for a complicated ca~c
perform normal activities of daily living (Le.. Oswcstry (fable 2.20). When functional outcomes do not improve with
Survey). care. then continued care is not justil1ed and referral becomc~
In C;'lses iJl\'olt'ill.~ moderme 10 Jc\'er(' i"jury. Ihe acute appropriate.
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 INCREASING PATiENT ADHERENCE, COMPLIANCE.
is to promote reillodeling of the s·;)n tissues and rehabilitate AND MOTIVATION
any lostl11usculoskclctal function. Rel110deling after a moder-
ate to severe injury can 1:.1St up to 12 months. Treatment is in- Converting a pain patient from f.l passive recipient of c;,m: to ".'
clusive of muscle siretching. strengthening. cardiovascular an active panner in their own rehabilit::llioll involves beha\'-
filness, coordination exercises. and decreasing applicmion of ioral psychology::'(l,lll.l specifically. making. the shift fwm
physical ther;'lp), techniques and chiropraclic joint manipula- being a pain avoider to a pain manager (Fig. 2.25). A key 10
tion. The goal is rehabilitation of the patient to their preinjury Ihis process is convincing lhe patient that their pain is not a
level of functioning. Measuremcnt of specific outcomes be- stop light warning them away from all activily. Reassuring an
individual that we do not advocate a no pain - no gain ap- ,
")
comes essenlial to prevent patients from developing chronic
pain syndromes. Outcomes evaluotcd include mobility. activ- proach, and instead teaching them how to differcnti,\tc !:'I,,>
ities of daily living. and muscle strcngth. tween hurt and harm. helps Ihem become re;,\ctiv<.lled. Chronil·
For patients who suffer pain without any acute trauma. a 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-
repetiti\'e stra;n is the likely cxphmalion. Repelitive "l1\icro~

Trunk Flexion and

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

219/94 30 85 20/60 and 5125 78

2/16/94 60 50 40/60 and 15/25 54
3/1194 75 26 50/60 and 20125 30
3/16/94 85 1.3 60/60 and 22/25 04
'SLR, str;lighllcg r;lise; VAS, visual analog scale; ROM, rango 01 motion,

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,
,
i
 l'HAI-' I t:H ~ : IN I t:t:iHAIING REHABILITATION INTO CHIROPRACTIC PRACTICE 39

) Injury plained that this tightness or weakness is what leads to irrilU-

tion and pain with activity. They must learn that rchabilitation
+
Nociceptor activity Of restor,ilion of function will prevent pain from arising in the
first place. and although such rehabilitation Illay be more
+
Acute pain Fear of pain painful in the shon term, improving function is the key to
long-tenn pain relief. Always seeking tcmpormy pain relief

~ Psycho3ocial
/ will do nothing to prevent the problem from sHIrting again.
\Patients can be re<lssured tlmt most of their exerciscs \\'ill
be relaljycly pain frce. Everything that can be done to rc-
context: lax and-mobi1f:t.e-thcir-tiss..ue~ill.De done before attclllpt-
Stresslullife-events i'!£-JQ...~n.gthcn--lhCJll)The ultin~~te·--g~~il is increased
Personality kinesthetic awareness and improvcd stability. Exercise will
Familial influence focus oo.strengthening the "big muse 's" that arc neighbors to
Medical influence tlH~.p'ain.~L~p'~~~~.~"p.~~~.~cas. he D~;ri~~Fl_:~?'_gain- phl- ">
Personal pain history .!2~jJ.hY. __<JQ~s. _nm~W_t..9-c.h~on i~ . .~j!L.~~.h!l~.i.!.Hat i(l~l})
Pain-coping strategies 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 symp-
tom.alic area (spinal muscles) is activated during the exercise_
the movement is stopped. When we can achicve an illlcnsity
I of training that leads to postexercise soreness in dccondi-
Pain-confrontalion Pain-avoidance tioned tissues without exacerbating the original symptoms.
Motivation Fear of pain we arc well on our way to a successful outcome.
Calibration of increased Objectification of function is a key tool in mOli\'ating
pain-stimulus with Exaggerated patients. Helping patients focus on function rather th,m on
pain experienced pain·perceptic pain is an important first step. Then. baseline levels of func-
Rehabilitalion Secondary gain tional impairment. pain distribution and intensity. and levcl
Full recovery Chronic 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 objec-
perception. (From JOG Troup: The perception of musculoskeletal tive. functional capacity cvalu;nion. Progress can be moni-
pain 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
ness :.md wcakness will othcrw'ise dcvelop. which will only as in the number of trunk curls serves as positive reinforce-
complete a vicious cycle causing more pain. not less. Once <I ment. Pre- and posHre<ltment checks of painful mancu\'t:r:, or
pain <1voidcr is identified. additional timc spent with patient mcasumblc functional deficits (i.e.. strength. llcxibility) is an
cducation is csscntial. excellent way to motiv<lte patients.
The prinwry goal of patient carc is to rcduce ;IllY disabil- Rchabilitiltion seeks to reduce function:'11 impairmcnl. It
ity. Often. patients havc sacrificed different features of thcir docs not focus on the symptoms. Quamilic:.ltion of fUIl<:ti(lllal
lifeslylc as a result of pain. An Oswe5ry survt:y can quantify capacity and paticm education nbout well behaviors are the
thi!' level of adjustlllent. Such things ;IS decreased siuing tol· keys. ManipUlation to restore function to key muscles ;mel
cnmcc can be identified in the history. The paticnt may say_ "I joints is cssentiallo initiate patient reactivation. Fin..lly. phys·
can'l go to the movies anymorc:' Indi\'iduals m:'IY have givcn ical tr<lining that focuscs on stabilizing the lurnbopclvic re-
up or compromised certain activities such as tennis or golf. If gion and trunk is the !inal step in rchabilitation of the mowr
a patit:1l1 says they alw:'lys feel pain after 9 holes of golf. :'1 system.
goal may be to be nble to playa full round. Sexual ,Ictivity
may also be a problem. Whatc\'cr lifestyle changes they h:.wc I(EFERENCES
made as a result of their pain should be uncovered in the his· I. D~Y\l RA: MeastJrill); fum:liullOlI (}WCUI1\~'S ill Ih~r;lpcul1l: lri:ll~ t"\lr
tory, Then. the festoration of these activities becomes:'1 mutll· chnllli' disC;L'ie. C(ll\lwlled elin Trials S:::!D. 19R-l.
ally agreeable goal of rchabilitalioll. Establishing functional 2. Binkley J. Peal M: "h~ effect nf inllllobili1.:ltion Oil the ullr.l~tnt..·tur~
restoration as a goal. along with pain relief. is csscnti<:ll to and m~ch:lllical prOI'ICrtics (If the fitt mcdi:-ll ,u!lalcr.ll Iig:llll~lll. elin
Onhnp 203:30 I. 1%6.
achieving a positive outcomc.
3. Noy~.~ F: Funclional pror~nie" of knc~ ligalllclll:O :1Ilt! :111~ralilll1~ ill_
To achicve lasting pain relief. the patient is educated d\l(~'d hy illllll(}hili/:llinn. Clill On!l(1!' 1::!.l::! 10. 1977.
tholt their musculoskelewl function c:.1ll and should be illl· -1. Vi~klll;lll T: Ellpcrinl"'nt;11 lllutlcl" HI' lI~lcllarthrilis: 'Ille mk ~If i1HlIlt 1-
www.bodywork.su
proved. if their muscles arc too tight or weak. then it is ex· bili,a!iull. eli" lli,lnh'dl 2:22:\. II)H7.
4U REHAtilLllAllUN UI"" I HI:: :::it"INt:: A I""tiAl;IIIIUNl::H-:::; MANUAL

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! .)
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I0
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~
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-~
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~ '" Blackwell S..:ienlific Puhli":;\lillll Ltd. 1992. Ther.,py. New )',,1(,:. PlenulII. 1978.

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 ....nMr-' I t t i ~ Ii'll t\,jHAIING REHABILITATION INTO CHIROPRACTIC PRACTICE 43

153. B:lmslc)' L. Lord SM, Wallis 61, et al: The prevalence of chronic cer· 170. W:uJddl G, Bin:her }'1. FilllaY~llll 1>• .:1 :11: SYIlI(lhllIlS :.lIld si~m::
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,,
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perccptions and ~ychosocial factors :lffecting the report of b:u;k injury.
Spine 16:161. 1991.

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3 Training and Exercises Science
JEAN P. BOUCHER

Human behaviors ;Ire dictated by many laws. constr.lims, and including the feet. legs: and thighs. l Any measurable discrcp-
dcgrees of freedom. In other words, (hI: human s)'stcm has ;lucie,., in the measuremcnt.s from olle side to the other ~,re
·limilalions. Many IimjtJlions in rcgartllo mOlar bcha\·iors. or wken ~,~ an asymmetry. Tr'lditionally. an<llomi'c asytlll11ctric$
movcments. are wcll dOCUl11cnL~d in the field of excrcise sci- 'Ire derived from differences in lhe It:ngths of the bones de-
ence or kinesiology. defined as the science of movement in bi- tcmlined radiogr<lphically or on the basis of external tapc'
ologic syslcms. Such limilations liS the muscle dynamics lind measurements. The latter technique presents. however. seri-
the fundamental facLors of performance arc discusscd in this ous limitations.
elI,j!)(cr.
MECHANICAL (STATIC COMPONENT OF POSTURE)
THE LOCOMOTOR SYSTEM COMPONENTS
The locomotor system. which is responsible for all motor be- The mech'lllkal factor represcllls the static mechanics Of po-
haviors involved in locomotion. is composed of fundamcntal sitioning or the joints. The mechanical components arc de-
\lnits that must be controlled to achieve complex movcments. scribed as the st~ltic postural units of the system. lllcse units.
such as walking or runni~g. Understanding the locomotor the joilll~ and soft tissue holding lhe bones together. dictate
systcm rcquires then a knowledge of the fundamcntal units thc passi\'c mcchanical alignJ1ll:nt of the l11ultiscgl11clllal
composing il (e.g.. boncs. joints. and musc.:les); of the quali- links. such as thc 10\\'l:f limbs. the trunk, and the upper limbs.
ties characterizing these units: and of the operations im'olving These unit~ ~lrc then responsible for the passive basclinc me-
them. Concentr<lting on function. these fund<lment:ll units can eh'lIlies that thc system must t.lke ..s a starting point when ex-
be labeled as anatomic. mechanical. and functional. It is im- ecuting and cOlltrolling 1ll0\'cmCllts.
portant initi:llly to consider these units <lnd their molar control The mechanical factor is measurcd through thc honc-bone
that underlies smooth execution of movcments before dis- rel:ltionship. or joint ~mglcs. A lllcchanic<J1 asymmetry can
cussing training and exercise topics. then be operationally defined as a difference from one side to
the other in the lower limb joint ilngles, or as <111 above-nor~
Fundamental Units mal amplitude in a specific joint ;:lIlgle. It is important to rnC:lw
\Vork by Desmarais ;]nd Boucher l and Boucher and Hodgdon~ sure lhe<;_~ ;:ll1glcs in a normal wcight-bearing situation to ap-
focuses on the need for systematic invcstig<ltion of the funda- prcciaLc fully the implications of the mechallic~11 factor. With
menial units activated during any movement. Funclionally. this in mind, the lower limb lengths ilnd pelvic till mcasured
these units have bt.:en defined in three scts: the anawrnic. me- in a weight-bcaring position art:: ;lIso considered mechanical
chanicaL and funelional componenls. Thc subsequent defini- variables.
tion ~lIld description of thesc components of lhe locomotor
systcm reflect that Illost of the work concentrating on the fun- FUNCTIONAL COMPONENTS
damental units has centered on the lower limbs and their
The fUl1Clional components, llluscleS and motor units. are rc~
aSYIl\111ctries.
spol1siblc for moving the bones around the joints. In other
words. lhe functional units make it possible fOf movement of
ANATOMIC (STRUCTURAL) COMPONENTS
the structural units to occur. st'1l1ing from the posture dictated
The "n.Homic components represent lhe Slnlctufal units of the by the mechanical or posturalullits.
system. They dictale the status of lhe internal environment The functional f<lctor characterizes the execution of any
that must be controlled. These units, the bOlles or rigid seg- functiori. This factOf is by far the more complex to assess. The
ments, represent thc baseline informalion requircd by the con- asymmetries in functional patterns ean be brought to light
trol system to producc fluid. well-coordinated movements, only through kinenmtic," kinetic.~··l or clectrophysiologic'~.I'
FOf the lower limb asymmetry model. the ~matomic factor analyses conduclcd during ,I given normalized function.
is defined by the lengths of the scgmenls in the lower limbs. Hence, functional <lsymmetries can be operationally defined
www.bodywork.su
45

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 MCMI-\OILIIf\1 tUIIi ur I Ml: -=:.t'll'H:: 1-\ t"HAL; 1llIUNI:H ~ f\.iANUAL

I
,
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
..: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
Ihe different I1ll'l'hanis1H:", hm abu how Ihe:-=c l11edl;ll1i:"I1IS

I the difference between the pilucrns. or by establishing sidc-[{)- interact 10 ;Khicn: hKOIlHlli\\n or any oth..,!" i.:oordillal~d
side ratios on specific discrete variablc~. movemenlS.
According to these definitions. all three f;Jctors penain
to mutually exclusive sets of struct\m::s. Anatomic factor!" CENTRAL CONTROL IFEEDFORI'IARD)
reveal the staWS of the hones. the mechanical factors
The fccdforwarJ conlrol ml"l'h:llli'Ill, also n:fCITl'd ((1 ;1-. Cl'll-

I
reveal the status of the Iig.aments hulding the bones to-
tral or supras~gmenlal control. i... d~:"nihcd ,I:" Ihe dir~l'l L'()ll-
gether, and the functioll<.ll factors revcal lhe status of the
trol {)f effector" by the cel\tral na\'Olls sy:"h:m withOlIl ill{cr-
muscles producing Ihe funclion or .mo\'cmcm of the bones

I
J1
and joints. Using this three-component approach. Desmarais
and Boucher~ and Zarow ct all> demonstrated that functional
aClion with thl.': information fwm Ihe I..':llvironlHclH. i.~ .. Ihl..':
moving limb or segmel\t. UnJ~r this type of control. move-
mel1ls arc carried oul by the excnl\ion of 11lotor COmll1alKls or
::i components and not anatomic or mechanical components
~ arc the major contributor to sacroiliuc joint dysfunction
programs whik the :-;ystem is nol concerned by the feed hack
I and chronic low back pain. Systematic evaluation of the
coming from the afferencc:-; ;lCli";'llcd during the mOWIHCtlb.

I human system according to its fundamental components

The motor commands arc sent d\)WJ1 dilTerell! ~lru(llIr~" ;md
through pathways or tracls rl."prescl1lcd :"Chclll;lticall~ in

I
will allow a better undcr!'i1anding of specific factors under-
Figure 3.1. Such a I11cdwnislll j, useful for underslanding Ih~
lying any dysfunctions. and a wcater chance of efficient
execution and control of fasl. hallistic movements that arl' :"0
treatment,
rapid thaI fcedbck contraction, cannot modify the llHl\'C~
'11 ment. Learning or modification or (hi:" type of 1Il0VCllh:1H {':Hl
Ii Motor Control
occur only by modifying the motor commallds after thl" fact.

j Following the siudy of the units composing the human sys-

tem, a greater challenge is to understand how this system can
by using the knowlcdge of response inform;,nion. InfoflU:llion
about the error committed can be incorpor~ted through ~Xle­

I
produce and comrol voluntal')' movements, In general. move- roceptors or proprioceptors and the ccntral (ol1l1nand elll be
ment comrol C;;1Il be divided into two mechanisms: (I) fecd- modified as to reduce lhe alTIOUIl1 of error detccted. Thi:-; lype
forward conlrvl and (2) feedback control. These modes of of learning or plasticity is then (arricd out in ;,ttl 01Jt:n loop

TRACTS

I
STRUCTURES Fig. 3.1. Neuromuscular slruc-
tures and pathways or tracts im-
plicated in motor control. J
- - - - Cerebral Cortex

i
l Conicospinal-------'.\
'f:
:~ 1------ Thalamus
f
Cerebellum ;
;

II RubrospiJlal-------~==='1Ioi

Reticulospinal-------_.I'
Vestiblllospinal--------Itt-
'-----,'---- Red Nucleus

-+----- Reticular Fonllation

01

lI
.f4------ Spinal Cord

Muscle Fibers
Ii'S
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~
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1, - - -_ _-,-
,l<j
;i ..... .'
IIIi'1lmi.lIi~·
.-
r
l
~
f1

~
 ..... NAt" I t:.H ;j : I HAININlj AND EXERCISES SCIENCE 47

system in anti knowk't!gl' of response ;11'("

\\'hidl ;llllkip:llillll n.::huivc positions. etc. R~ceptors play an important role in the
llCClkd \I) modify fnlUrt' 1ll00'L'llll'nIS. The cxc.:c.:t1litlll-l!c!l.'C· COIuwlof movement ;,IS well as in lhe learning ~r modification
lioll-inILgr;lt;on-n.'('\l'l.'l!lillll loop is S:I;(\ ttl hL' Ilpl.'ll hl't'au:>:!.' of motor behavior. The status of the locomotor system, and of
the <.it.'tC(titlll anti intcgration arc lUll I'l.::lii/cd IHl·line whill: the IllllSdcs. al any given time is influcnced greatly by the dis-
the Illovement is \)Ilgoing. hut rather :1t'1I.:!" thl' I\hl\'L'llh,'nl is t.:hargL· of reL:eptors. Their role must then be well understood.
Icrmi n:ltctl. especially for functional rclmbilitmion. which is often based
FUl1hcrl11orc. it j, illlll\ll"t,IlH to 1l01l' that the motor (""Ill- 011 heha\ ioml approaches.
l1I:lIld rl"ponsihk rill' I Itt' cxcnJlion {If :1 1Il0\"l,'mCllI under Relwrioral Systems and lipproaeh. Ajoinl adjustment or
I'ccdltl\\;lrd COlllnll i, rc"pol\sihk IhH (lilly for the ,lew;!1 lIlllhilizalions basica;iy it funclional stimulus applied to the
1ll0\TIllClit. but :t1su for the pllslllr:1I :IJjusllllCllts needed to bouy. Th~ body. in lurn. can be seen as ;,1 behavioral system
maintain Ihe equilihrium. H~l1t.:L·. Ihe pO~lural ;ldjustlllellt j~ in lhat it hehavcs ill a stimulus-response mode. In other
not only a rdlcx fl'aClion to ,I pCl1urh~lIiol1 c;luscd hy thl.' won.b. all heh:lviors of lhe human system are Ihe result of
,, () lllO\Tllll.'llt: it is pn1l!r'111111l1.;d within the movClll~'llt C0111- a stimulus that is perceivcd ..md integrated. and then a re-
i manus .md pre<.:cdc~ the aeW,,1 1ll00·cm~nt. Pr;,\ctIGilly. this sponse i~ org;'lnized ;'lnd carried out through lhe effeclors (e.g.•
...
I _

;<.3
,~

fact is imp0l1<tnt hceau"c postural mllscles. often invoh'cd in

dysfunctions. arc highly intlucnced by tl;c execution of 1ll0VC-
musclesi. Therefore. for a practitioner to be successful. he or
she must understand well the stimulus-response relationship
I lllciHs under volulltarv control. Undcrswnding the underlvin!!. associated with any given functional or behaviorallcchniquc.
I f) causes of;l dysl;ullt.:ti<f)lj involving p()s1lJralm~lsdes must ihe~ A successful practitioner will be able to prescrihe and admin-

I include thc evaluation of 1ll0\'CI11CI1IS involving l\\(lrC than the

control of postun:.
ister the proper treatment because he or she is able to predict.
with acceptable accuracy. the outcome of the treatment in the

I,
. ("lo,..
}; Fin;llIy. C\'CII thnll~h U~dllito cxplain some level of con- specillc case. Naturally. lhe receptors represent lhe first line of
11'01. man)' tnovelllcnh ;Ift; l"crlainly l"olllrolled and learned COIll:tct between the environment and Ihe human system. In
.1
differently: i.e.. sl(1\\...: r mon;lllcllts ,m; correctcd as they arc fact. a qimulus-responsc reaction will be obtained only if the
1~ pcrformcd. Thc next "l.'clioll is ..I disclission of the fecdb~lt.:k rce(;ptor~ mc simulated and'l response is triggered. Therefore.
I Illec.:hanisms involvcd in this other lype of (·ontrol. the efficiency of any behavioral approach depends immensely

I
on the ability of slimulating specific receptors. The mecha-
() nism triggered th~lt will ultimately produce the desired re~
PERIPHERAL CONTROL (FEEDBACK)
sponsc is no longer under the control of the slimulus. il is oc~
i i\'1an)' movemcnts :lJ\: corrcl:led as tht::y arc produ('cd. If lhe curring Iwwrally. This explains why several researchers are

I
object wc arc picking up i~ displaced immediately before wc now intcreSlcd in the role of different receptors in (he rnodu·
\\,;,lIlt to grab it. mo;;t of the timc we will be able 10 change the I~llion of neuromuscular information.
trajectory or (lur hand in order to m<ltch the new position of From our study of joint receptors especially. some data
(} the object and thCll pid it up. The efficient corrcction of on- stlgge~t IhiJt sacroiliac joint adjustments and direct sacroiliuc
going movcments is lll;Jde l)()ssihlc lhrough feedhack control. pressure arc responsible for a significant modulation of reOex
II The inronn<ltion from the cxternal and internal environments
is const;,mtly monitorcd and compared with the internal goal
respon"c ... ::"~ Such results conflnned that sr:inal infonnation or
commands call be modulated as a result of a joint :ldjustmcl1t.

II
(e.g.. picking lip the objccl) in ~uch ..I \\'ay that the illlcndcd ami th;'lt the pressure component especially could be the trig-
.'~-~
movement is executed. The execution-dctcction.integr'llion· gering mechanism. Such a reaclion could be medialed
~~-
rccxeculion (or -correction) loop is then closed. The sy:w::m is through joint receptors. Further. joillt receptors. more so than
;,ble 10 keep track of th~ Oow of inform;'ltion and nuid move- muscle or tendon receptors. are interesting becausc some me
lllCllls arc organii'.cd. i..'.xccutcd. and corrected if ncceS~:lry. slowly adaptive and nonad<tptive receptors. Thus. Iheir effects
The sensory information needed for this control is transmitted ;'Irt.: longl<tsting and can thcn be rcsponsible for long-term dys-

i through sensory p:uhw<lys and sent toward the different struc-

tures shown in Figure 3.1. Three levels of correction arc rec-
flillCliolls or treatmcfll effects.

I
ognized. First. tht.: short loop or myolactic rdlex O<:Cllrs
TRAI:"I:"G OR EXERCISE SCIENCE
within thc lirst 25 milliset.:onds (mscc) and .is mediated
1)
~;
through the spinal cord. Sc<.:ond. the long loop reflex. which T() undcr\l;:md lhe behaviors ;and modific~lIioll in lhose behav-
occurs in 85 to 12) mscc. is cOlltrolled by subt.:onical stnJc· iors of the locomotor system. one musl study not only the fUll-
:.g
lures such as the ct.:rcbcl Illlll. Third. when the relkx contrac· d:unental units. but also the operations of the system and the

I
,f;' tlOIlS tin: not sunk-ient 10 correct the movcment. tlit.: voluntary lJualities of these operations and unils.
~~q

cOl11l11and must be triggered from cortical Slructures.

g The role of n::<.:cptors is fUlH.lal1lcl11al lO (his type of con-
Fundamental Physiologic Qualities of Pcrrornwncc
trol. For cx;,ullplcs. the eyes provide information on the accu-

1 racy. while proprioccptors {c.g.. muscle spindles. joilH recep·

tl)l'S. etc.) prr)vidc information relative to the status of {he
The physiologic qualities of the human or locomotor system
arc divided into thret.: categories: organic. muscular. and per-
I iIHcrnal cllviml1lllent: joint position, speed of displacemcnt.
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ceptivomotor.

I~ .~"'"
'<;;~

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 H~HA~llIIAlION OF THE SPINE: A PRACTITIONER'S MANUAL

I
; ORGANIC QUALITIES v()llIm~). Thercr\lr~. w!ll'n p:"escrihillg rc!wbilil,ltion excr~

i The organic qualities can be presented on a cUlHinuulll based

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
I
---~

on the type of metabolic processes underlying lhe production

spct.:ilic nature 01" ll111SI,:k training. The prescript1tlll of exer-
of energy needed. These qualities ;Irc: C/UlltrtlIlCC, rcsiSf(l/lcc.
Q

and POWCI: The aerobic processes. underlying the cnduf,ancc

,I
l';:-;e is disl"lISSed rurth~r in sllb."~qlll·nl se('liol1.
Trainiu/.: COl/sid{'rtlt;tH/s. Til...· !HO\( important cOllsidera-
quality, are those realized in the presence of (l,Xygl:ll. On till.:
tion for the prcscriplillll of Ir:lillill~ cx......ciscs ;tntl pmgr:uns is
otlter hand, resistance and power arc based on the (///(/('fof,ic
the: Iraining InaiJ Ill' O\"l'r!O<ld, Till' load is dC\I:rlllined with 1"1.:-
processes available when the oxygen is not presenl.
speet to the quality 10 train ami the "pt.:cilk dfccl desired.
Endurant.:e training. for C.x.lI11Pll'. requircs a low 10:11..1 (e.g.. 50
MUSCULAR QUALITIES
to 60("1(- of Ihe maximum force). At thc other end of the COI\-
TIle muscular qualities of force. <.'Iu/ural/Ce, resi.'lUlJlcc. and tinuum. j"orl.:e tr,tining requires loads neighboring. IOOr;{ or

I fJowerarc best understood using the concept of the strength con-

tinuum. This continuum ranks the strength production capabili-
ties from the production of a movement requiring vel)' little
maximum force output.
When considering the. eoillrol of the training loau. it is '1lI-
tomalic and simple to think abollt illcrcasing or JC(Teasing the
"j

Ii force (e.g., moving a limb without an cxtCnl31 loading). to the

production of tile maximal force output. On <l relative scale. this
continuum ranges from a contraction demanding almost 0% of
the maximal force output [Q a contr..lction producing I(XlCk of
that possible output. A contmction requiring pure force is one
that demands 100% of the maximal force output. At the othcr
:unounl of weight lIsed as a Iraining stimulus. as just pre-
sented. Two CQlH':CptS IllUSt be atldrcssed, htm·\?\'er: (1) lhe
lraining threshold. and (2) the ddinitiol1 of fOfCe: (i.e.. F =
m x a). The concept of training threshold is r('\<.lti\"t.:Iy simple.
The trilining. stimulus. i.e.. the load. 11l1l"t reach it ....atain value
relative to the subject"s Glp<lcily in ortl('r 10 ha\"c a training. ef-
, f
""

•I end of the continuum. contractions dcm'll1ding below 50% of

the maximum can be sustained almost indefinitely and arc siJid
feel. The magnitude of this threshold Illust l·onsidcr two "key
pm..lInetcrs: iHll'lIsity (i.e .. lhc 10'lJ expressed ;IS a percelll of
to require endurance. Ifa contraction reaches a level between 70 maximum force outpUlJ and \"(J!W/1(-' (i,c.. the Illllllbr.:r of series )
and 90% of maximum, the blood flow to the muscle will be al- and repetitions). The specific training stimuli ho.\\"e been de-
tered and the amount of oxygen available to fuel the contraction scribed. The second concept conccrning Ihe ddinition oj"
will be drastically reduced or Slopped. These conditions repre- force is imponant for controlling the tr'lining. ('omJitions and
sent the resistance quality under which contractions can be respecting the tr:lining "pccilicity rcquircmcIHs. i\10n.:: specif- )
maintained for a limited amount of time. Power is a combinmion ically. the t1clinition of F = III X ..I makes liS r('ali/e th;'lt the
of force and speed, A powerful contraction is one thm is iJS load (i.e.• F fm force) can be l1l<lnipulated by ...· hanging lhc )
strong and as fast ali possible. Finally.flexibility is <.11so consid- miJSS (i.e.. Ill) and/or by manipulating the aCl·l'!cratioll (i,e..•1).
ered a muscular quality. his in fact a quality that is dictated by The mass e<1Il be modified in thc usual fashioll. by increasing
the ability of the muscle to relax and let itself stretch passively or decre<lsing the amount of weights" Most peoplc, however.
and by the elasticity of Ihe soft tissue surrounding the joint. Ac- forgclthat the effective training load can a1:-;\l he manipulated
cordingly, flexibility is more accurately called articu/omu.H:u/ar by changing the lever ann used for lifting th(' IllaJ. PI;.Icing
amplitude. because it is a function of articular <IS well ns musclI- the 10o.ld closer or fanhcr :.J\\-<l)' from the joint will decrease or )
lar structures. incre<Jsc the tr.lining !Himulus, rc~pccti\!dy. Till' te:dmique C.1l1
TIle qualities arc import.lI1( to consider for exercise Of be useful when prescribing rehahilitation cXI..·rl·i:,e:s with sur-
training prescription. In fact. training is highly qualily spe- gical tubing or Thcr;:lbands (Hygcnic Corporation. Akron,
cific. Force training produces a stronger muscle without im- OH). The last way to control the training load is to manipu-
proving the endurance. i.e.. Ihe ability to produce a lillie con- latc lhe gravily. which is (he aceeler.llion applie:<..I on the mass"
tri:lction for a long time. The reverse is also true. Endurance Bec<Juse gravity is a vector alw:.lYs oriented in {hc S'lme di-
training increases the efficiency of the muscle tlt producing rection (i.e., pointing!O the ct;:nter of the earth\. Illl)difying the
small cOlHractions for a long period of time but will not in- position of the body makes gr'lvity a<.:( lll(lrl..· or less on the
crc<.1SC p,ure force. Therefore. knowing that different muscle mass. modifying the effectivc training slil1lulll~. Trunk nex-
groups arc used differently. one should then rCi1lizc that they ions. or sitllpS. me morc demanding when pcrrl1rm~d on an in-
should be trained differently, clined surface because raising the pelvis relative: to the hcad
For example, postunll nmscles (e.g.. abdominal and dor- allows gravity to .Iet more cfticicnlly ;.lgain~t th..:- trunk along
sal muscles) arc used for long periods of time at a low level " greater range of movement. thus producing" more impur-
of force (50% and below). Accordingly, exercise aimed at de~ tant training slimulus,
vel oping those muscles should involve endurance training
(Le.. low intcnsily and high volume). On the other hand, for
PERCEPTUAL OR PERCEPTIVOMOTOR QUALITIES
muscle groups involved in high intensity contractions (e.g..
typically upper and lower limb muscles). or occupations rc- As the name suggests. the pl:rccptivomotor qualitit:s represcllt
quiring high force Ic\'els, exercises should target the forcc. re- the interaction between perception skills ;lI1U l1lotor output. .,
www.bodywork.su
sistance. andlor power qualities (i.c.. high inlellsily and IO\\-· qualities specific 10 the ncurollluscul.lr SystClll. The differellt
 CHAPTER 3 : TRAINING AND EXERCISES SCIENCE 49

pcr.;:cptjQ 1t11l1!Of qll<lli(i~s ar~ reclClim/ rilll£'. SP('('(/ of /11O\'C- muscle is the immediate source stored in the muscle <lt the
11/('111. /1/(1(01" (1('j'lInIey. ;lIlU hody ill/{/,t!,('. \Vhilc Ilwintaining contraction site. Thi~ source of energy is short lived and is
-,i amJ fO(lI:-in~ 011 the phy~iology of motor hehavior. it is as im- <lvailable for only a few seconds (30 seconds maximum). The
porlilill to be PI\,:oCl.:upicu by the diffcn.:nt way~ in which the oxidat;\'(' metabolism is the result of rC<lctions taking place in
fundamcntal unil:-: can be activated and controlled. The pcr~ the presence of oxygen. This energy production system is re-
ccptivlllllotor qualities address hmv the motor actions afC CO~ sponsible for cndurance excrcises during which smaller con-
unJinah::u ;lI1d how perception is imponanl in the control .1Ild tractions arc produced. Stronger contmctions obstruct the
I.:Xl.:l'Ulillll of any 1110101' (ask. blood now to the muscle. thus Slopping the flow of oxygen
.) and preventing the oxidative processes. Endurance contrac-
Musdc Dynmnics tions in which blood fiow is not obstructed C.1O be carried out
almosl indefinitcly. Finally. the lwlloxit!ative metabolism un-
Muscle dynamics focus on the mechanisms underlying mus-
dcrlies forceful and powerful contractions. During this type of
cle fU1Iction. First. the smalkst functional unit of the neuro-
contraction. blood vessels in the muscles arc crushed and
llluscular sY;";'Clll lllust be addressed: the motor unit. Then. the
blood flow is stopped for the duration of the contraction. The
basic mechanisms arc di~l:u.sscd in light of the strength con-
I
j (,-"::;
'U tinuum. which facilit:IICS the prescnt;,uion of lhe contraction
oxygen is no longer available and the reactions that can occur
to produce energy use glycogen for fuel. These reactions pro-
i o typc~.
duce byproducts. such as lactic acid. however. that reduce the

I
I
,~
o 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 IllU5-
contractile possibilities of the muscle. especially when they
accumulate. Therefore. this type of energy source is available
for a few minutcs only.
The objectivc of training is then specific to the type of
1 ck libt:r types call be catcgorized in lllany different ways. The exercises executed. Endurance exercises increase the effi-
! Illost objcl:livc ways arc',IC(;ording to electrophysiology. fa- ciency of the muscle in using the oxidative processes. On the
I
j tiguc resistance. ~izc. and histologic classifications. In all of other hand. resistance training forces the muscle to work
i thesc quantitativc motor unit classifications are three types of without oxygen <lnd it must increase its capacity to contract

I
units: [<.1st fatigable. f<.lst fatigue resistant (imemlediate motor with a greater oxygen deficit. Finally. force training is al-
") unit). and slow motor units. Edington and Edgerton ll prc- most independent of the metabolic processes because pure
sented one of the 1110re comprehensive descriptions of the mo- force and power w,c immediUlc encrgy sources almost exclu-
101' unit types (Fig. 3.1). sively. It should then be obvious that parameters such as
:0
To fully apprcdalc thc mcchanisms underlying the muscle speed of movement, resistance to movement. and duration

I dynamics. the cnc;rgy sources that fuclthe contraction must be

discussed (Fig. 3.3). The first source of energy available to the
influence greatly the depiction of the energy sources nnd

I FF Fig. 3.2. Summary of the

motor unit types and char~
acterlstics. (From Ed~
~i ington OW, Edger-
Motoneuron
Ion VR: The Biology of
Physical Activity. Boston.

t ·'0
la EPSP
Houghlon·Mifflin. 1976.)

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Fig. 3.3. Energy sources

available for muscle con- Oxidati ve i\l eta boliSIll \ ..
tractions.

Nonoxidativc Contraction
Glycogen - - . I 1---.1 ATP ADP + Pi + Heat
Metabolism

---',
, 1
AT? Stores
AD? +- Creatine Phosphate
ADP+ ATP

FORCE-VELOCITY RELATIONSHIP
"
,
should be considen:J can::flllly when cXl:n:iscs or training :Irc
prescribed. A schematic representation of a typical force· ...elocity curvc is
Finally, <IllY discussion of the motor units ;'ll1d their COI1- shown in figure 3A. This curve shows clearly that the grt:at-
lrol would nOI be complete without a prcscntmion of the cst amount of force is produced in the eccentric condition. )
concepts of series clastic and of reflex or spillal control. Thb faCl could he explained by t\\to distim.:t mechanisms ac-
Sludied together. these concepls rcveal that the muscle C;'1ll tivc simultancou .. ly during muscle lcngthening ecccntric con-
be perceivcd as an intelligent clastic lh;'lt is <luachcd 10 ;1 tractions. One mechanism is lht: \tretching of the clastic COI11-
simple level. This simple but imponall( definition helps 10 poncl\ls in the muscle. In fact. the muscle acts panly OIS an
appreciate the impommcc of the contraction types ,lIld their clastic: it is able to si(lre energy while being stretched. This
control. storage of energy automaticillly increases the force output
monitored. The \ccono mcclw.ni\1l1 is based 011 the ncuromlls-
cul;'lr control jJvail~lblc to Ihe muscle, Receptors. the muscle
CONTRACTION TYPES
spindle specilically. arc sensitivc to stretch. When the mu:.dc
Simply stated, muscle contractions C<1I1 occur under only is being stretched. the spindle is excited. the Ia afferent libel'S )
three functional conditions: (I) the external force (F) is thai connect directly on lhe alpha motoneuron respollsiblt.: for
equal to the contraction or muscular forcc (F,) or F,. = F",: the ongoing contraction ,Ife soliciled. and thc nerve output to
(2) the external force is smaller lhan the muscular force or the muscle is increased. producing gre;'ltcr force. These (wo
F.: < F",: and 0) the external force is greater than the mechanisms arc speed dependent. Accordingly. the forcc-
muscular force or F > F . The lirst condition. vielding velocily curve Ic\·cb off at greater levels of negative velocity.
contractions while no "rnov;;ncnt occurs. produces i,~olllelri;' As soon as movement starts in the desircd direction (Le.. ---!
contractions. The second condition. usu;,tlly the desired ('on· concentric contraction). the capacily of the muscle to produce
dition. makes it possible for the expected movement to force is drastic<.llly reduced. At greal speeds. force production
occur because of shortening of the lIlusck producing a dis- goes down to 30 to 40% of the isometric force levcl. This rt:-
placement in the expected direction .It a given ~pccd. This '1liwtioll is disconcerting. because usually the object of mus-
type is known as cOllcell/ric contraction. The third condi- cle contraction is to produce a given 1ll00'Cl11cnt and in that
tion is the exact opposite of the second. Eccentric: con· vcry condition the muscle is less efliciem
tractions afe produced while the muscle is aClUaliy being Onc can ask: so what? Wlwi is the relevance of the forc~­
stretched and movement is going in Ihe dircclion opposite velocity curve? Outside of acknowledging our limitations in
to the one the muscle would normally produce. For that rea- producing force during voluntary movements. it is impor-
son. cccentric contraclions <lrc oftcn said 10 be involved in tant to consider the force-velocity curve for two rc'lson:'.:
so-callcd "neg<ltivc work." These definitions <Irc <It the core (I) training spccificity and (2) recognizing naturally occur-
of the understanding of muscle dyn.unics. They arc funda- ring eccentric contr<u;tiolls <.Juring which the risk of injury
mcmal to an important aspcci of musck contraction known is greater. These aspects of Illuscle dyn'\Inics arc discussed
as the!orce-\'(:!ocil): relationship or curvc. subsequently.
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 vHAt" I t:H ;j: I HAININ\j ANU EXERCI::iES SCIENCE 51
, ~";
Torque (Nm) Fig. 3.4. The force-veiocify
relationship.

100% (nux L'iOI1H.1riC)

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FORCE·ANGLE RELATIONSHIP
cilk painfrce <1I1glc to achieve a functional treatment effect
Figure 3.5 presents an idcaliz.ed force-angle curve. The im- within the painful or dysfunctional r<lnge of movement.
:......,~

I
-::. 3 portance of this relationship is the dcmonstration that .1I1Y Further. it has been recognized th.1t the risk of injury as-
muscle. or muscle <'IffillP and jQint system hilS an~()ptjlllai :-.ocialcd with eccentric or negative \\!ork is greater because of
\".q!ki_~£..p..Qs.it.ion. Joint position or angle, related to the Icngth the higher levels of force output achieved in this condition.
"
of the n~1s._~nfluenc~~Jh<:...f9J:ce p~oduc~i.9~ E.~P~~.!.!J' of the Do we produce eccentric conmlctions in rcal-Iite situations'!
m~le.~ the knee extensor muscle group. for example. the in fact. any contruction needed 10 decelerate ::l movement reM
maximum forcc output is measured at between 80 and 90° of quires cccclllric work. and lhe muscle accumul.ltes energy
f\\

I
'-\/ Jn~c flexion, Again. this relationship is important to consider while it is Mretchcd. Thc bcst example of that situation is in
because of its implication in training effects specificity. locomotion. w.llkillg or nllluing. when eccentric contr.lctiol1s
<Ire executcd many times c\'cry day. Two muscles especially.
lhe tibialis anterior controlling the fore foot contact during:

I
TRAINING SPECIFICITY
gait, and the hamstrings decclerating knee extension .1lso dur-
As suggested previously. training effects are known to be ve· ing gait.•Irc constantly used eccentrically. Afrcr an injury or
[) locitt~·'·l and position (i.e., joint angle) spccilk.I~.I~ Training immobilization. those muscles should be remlincd using ec-

I with neg.llive work. for example. increases force output of ec-

centric contractions without affecting. thc muscle capacit)'
during concentric contractions. !':urther, training at a specific
centric exercises to ensure that they regain the necded level of
strength for their specific diJily activity.
Some muscles arc used eccenlrically because of their bi-

I
joint angle (full joint flexion. for example) will not or may not articular nature. The gastrocncmius .mel hamstrings arc good
influence the force omput of the muscle group when the joint examples. Such muscles often arc stretched at one joint while
{/J is nenr full extension. This fact suggests {hat a rehabilitation lhey arc required to contract to move the other jqint. When
program ~hould be specifically adapted to the muscle. the lifting a Imld. for instancc. the hamstrings arc required to ex-
tffi joint. and the task t<.Irgclcd. Accordingly, a person expected to tend the hip (shortening contr.1ction) while the knec is being
iM
do static work requiring isometric comractions in a specilic
joint angle should not be traincd or rehabilitated in the san~c
extended (hamstrings being str~tched). On th~ one hand. this
synchrony is lIseful because the energy can be transfcrr~d

i way as <l pcrson working in a dynamic situation.

A training ovcrnow, or :m-called window of nonspeci-
from Ihc knee 10 the hip by only keeping the hamstrings.tt Ihe
same length. When the knee extends. the hamstrings i.1uto-

I, .. ~:"""
-tJi licity associatcd wilh isomctric cxercise~. was mcasurcd. I(' Wc
demonstrntcd th.1t training the knee isometrically at 90Q innu-
matically pull on lhe ischial tuberosity to produce hip exten-
sion if they <irc able to keep the same length. Bj·articular mus-

I cnced significantly the concentric and eccentric forcc over a

r<.lIlgc of up to 46(' (i.e.. from 54 to I O()~) of knee flexion). Su'.::h
cles arc indeed good for transferring energy from OIlC joint to
lhe other. On the other hand. this type of sustained and re-
i findings suggcst that a joint can be If<lincd st;,ltically at a spc-
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peatcd activity Gill explain why these lllllsclc:- arc often tight

I, (-.$ mrary I.P.H.

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Torque Fig. 3.5. The force·angle relationship. I

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and prone.: ttl l:onlraCllIr..:. Hem:..::. hi ...Ulil·ular lllllscks. such as popul;lIion segment to which the concerned individu<ll he..
the hamstrings and Glif mu~des. should be trained (0 pronl(lle longs (c.g.. age. sex); and (4) the targeted quality (i.c.. where
elaslicity. through cIH.lur.lIlCe and stretching exercises. and not 011 the continuum will the persOIl exercise in function of the
force only. specific lask to be executed?).
finally. the neural <ld<:lJHation underlying exercise or train ..
ing cffects is oflen taken lightly. In raet. l-trcnglh increase can
USE. OVERUSE. MISUSE. AND IMMOBILIZATION
be obtained through modifications at the neural level alone. n
\Vhcn morphologic changes do occur. they comc into play af- Dysfunctions are often associated with usc. overuse. misus('.
5: ter the neurophysiologic modificmionsl~,I'J Illeasured. for ex- or immobilization. It appears that too much or too little move..

I
ample. through motor unit recruitment frequency or synchro.. ment brings aboul a functional problem.
nization of molor units. Funhcr. the highcst Icvel of twining Movement in men and women is neither accidental nor in.. -,
J
specificity may be in the neural adapt'llion underlying the mo- cidental. Movement is cenainly csselltialto heahhy life. if not
tor programming or Icarning associillCd \vith exercise. The its essence. Realizing that both use and immobilization. two
motor comral levels achieved with a specific exercisc can bc opposites. can or will cause functional problems leading to
J totally inappropriate for il given functional task. even if the discomfon. dysfunction. or dys..e'lse. highlights the need to
!~ same muscle groups arc used. A slrong recommendation is to define what can be called a u'ilU/ou' of ol'lima/ a<"li1'il.\: On .1
selecl training or rehabilitation exercises according to specifIC !1(.',!ormlllKe COIII;IIuum (Fig. 3.6). this window should bt:'
~
I motor tasks taken from the patient's daily activities. placed in a functional zone between rcactivation and activa ..
.~ tion. This concept of performance continuum. including tilt:'
;j levels of intervention (i.e.. rehabilitation. reactiv:.Hion. and ac..
I, EXERCISE AND/OR TRAINING PRESCRIPTION

Professionab dealing to ~ grc:1l extent with functional prob-

tivation). the types of intervention increasing performance.
and the eve illS leading to decreasing perfornlance (see Fig.
~
• lems (e.g.. pathologic or traumatic) or dysfunctions are often 3.6). should help to organize the research needed to under·

i•
)
calkd on to evaluate. treat. and rehabilitate Illuscular func-
tions. 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 ..
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. .;
~ ative (0 the force-velocity and force-angle relationships and Such a conceptual framework is the bal·;js for the re ..
training specificity arc fundalllcntal to the practice of exercise search. in chiropractic, kinesiology. and SpOrts medicine.
1»
:]
prescriplion.
More specifically., when confronted with exercise or train ..
produced in our laboralory. Our focus is on imbalances.
knee dysfunctions, ,lOd lhe relationship existing between
$I
t ing prcscription. I always consider lhe following: (I) the ob- the mechanical and neuromuscular cOl1lponellls of function.
~
jectives or goals pursued by the exercise program and the This research program should help 10 understand this win ..
i~ concerned individual (c.g.. rehabililation, well-being. compe..
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tition); (2) lraining specificity (e.g.. velocity and position): (3)
dow of optimnl activity and the consequences of being oul ..
side of it.

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 CHAPTER 3 : TRAINING AND EXERCISES SCIENCE 53

LEVELS of
REUADIUTATION REACTIVATiON ACfIVATION
h'lTERVENTION

TYPES of II\TERVENTION

Incrensing Pcrformun(:c

..
DECREASED "NORMAL" INCREASED LEVELS of
Pcrfornlance Performanu
PERFORMANCE

EVENTS LEADL'~G to ..
PlIlhology
., Ule

TnlUnlll ImmoblllLatloD

Decreasing Performance . ..
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
disciplin<try approach to enlist .lIld bencfit from the assistance
All exercise science appro;'lch outlined in this chapter should of an exercise sciemist or kincsiologisl.
be useful in guiding functional cvalu<Jtions. All three funda-
mental components of !he systclTl-anawmic. mechanical.
<Inu function..l1-should be investigated systclll<lticaJly to dc~ REFERENCES
•", (~ termine objectively the course of events after the evaluation. I. OcSI1l,lr:tis F, Boucher lP: t\ Illwer limh a'YlIlIll..:lry modd: /\nal<llllil:al,
i This course of eVCnls, 1c'.Iding to the rcstoralion of the dy:--
mceh:lIlil·al. and functillll;d faelnr,. In Pmc..:..:~ling' (If Ih..: 1991
! ,J function, most probably includes reactivation and aClivation
tntcmation:11 Cnllf..:r..:n..:..: (Ill Spinal \l:mipul:uitlll. FeER, r\rling.t<1l1.
~ VA. 1991. pp 129-133.
¥ of the functional units. The cxercises or techniqucs lIsed to 2. Bouch..:r JI', Hodgdon JA: AnalOllIk:ll. m..:chanil'al. :llld l"1I11cli(IIWI l":IC-

I 0
,
:'Ichieve the rC<lctivation goals should be guided by: tors in l':lIdlo-fclllor...1 p:till sytldrome;,. Chiwpract Srorls M..:d 7: I.
199::!.
;;) The type of muscle involved {Le., firer type (.-()lnpositionl 3. DCSI\l:U'alS F. Boucher JI': . \l1;l{(lmk':11. mech;lIIic;,1 ;mtl f!llIctioll;\1 dt:lr-
~ The type of delll'Hld or work normally imposed (111 the muscle (Le .. ;IClcri/.:llioll of ~:tcroili:1l" .i~linl lixali'Hl. In Prol'ccdings of lhc 199.\
<i concentric, i~llrnctrjc, or eccentric conlractions for p()~tllr,,1 or \"0- hlletllaliol1:tl Confercncc Ill} Spinal ~talliplIl:lti(lll. FeEH. Arlin~l(lll.
i () litional work) VA. It}tn. I'l' 52-53.
i,• 'J The normal work r;lllge of motiull (i.e., angle specificity) ..1. Hcrwg. W, NiJJg OM. Read JL: Quallljl"~'illt,: 111..: df..:t:b of ~pill:11 Illa-

f,
~i
" The luad required for the specific development targeted (i.e.. Spt>
ci(ic muscular qLl,ilit}', endurance. rcsist:lllce, force, power, or ar-
nipll!:tt;olls (Ill JJ:lil, llsil1g p;It;cnb with low h;lCk pain. J ~hniJ1l1"'li\'·e
PhpiolThcl' 11:151. Ins.
-; t)
":,:
ticu!ol1lUscular <Ullplitudc)
5. Roy SH. Dc Luc;1 CJ, C'Isa\,:llll DA: Ltllll!>;lf mu!>dc f:lIiguc :lml
i• l~
chronic lC'w b<lek p<lin. Spine 14:992. l<J~9.
brow FM, Boucher JP, Hsieh J: Anatomical. mech:lIIical :lIIl1 (unc-
Only when all these "spects arc considered carefully <m~ (I.

I 'd
t' the reactivation and activation goals reached systematically.
lional cha;';IclCrizalit)ll or dlronil.: low b:Jl.:J.; pain. In Procecdings of lhc
1993 l111crl1;llion;L1 COI1t'crClJl.:C Oil Spin:l! i'bnipul:llion. FeER.
;;
•,"~ 0
Therapists lacking background in the exercise scicnces which Arlin~ltll1. VA, 1993, flP 5"'-55.
is needed to appreciate aHlhe important details underlying the 7. Ch,Hh(lnn{':1U M. Boucher JP: Scgrncnl<.J1 nw<!u!:lti(11I Ill' T <lnd H rc-

'8
~ J reactivation and activation techniques, should seck a lIluhi-
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llcxcs and ,....1 \'I:I\'C lollnwill,!C ;1 chiropr;lcllc :ldjuslIllCIlI: A pilot sllldy.

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1: :~
 b4 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· 14. Bcnder JA. K:lplan HM: 111e llluhipic anglc test ill£. rnelhod for
Ilipublioll. FeER. Arlingl<lll. VA. 1990. pp .19.1-:198. lhe evalualion of muscle stren~th. J Bone Joint Surf: lAm) 45,\: I 35.
S Ldchwc S, Ch:lrlwnlll:all M. Ihllldlcr JP: :...1odllbtioll of scgmcllIal 1963.
~pin:ll c ....cilahilily hy mC'l.:hanicll :-Ifl'"'' l'l)tl11 Ihe s;\cf(l-ili;tc joint: I~. ~k)'C;rs C: Effects of 2 isometric roulincs on sln=nglh. size and endur-
Prdimin;ll)' rcpt'rI. In l'rt>l'ccdill~S IIC tll..- 191).1 llllcm:llional Confer- :llIce uf excr~'i~ed :md lion-exercised anns. Res Q JSA30. 1967.
c:nc..: on Spin;\l l\1;1I1iplll;tliulI. feEK :\r1in~lOn. VA. 1993. pp %-57. 16. Boucher JI'. Cyr A. King MA. el "I. )ltOUlClnc t(:linin/; ll\"er!ltlw: Dc·
9. ..\slr'lIld PO. Rodah! K: Texthook (I( \\'prk Physiology. New York. lerlllin;l\ioll of :1 ll(lIl':"I~ciliciIY winuow. ML:d Sci SPllriS EXL:n.:. 2:':
!'-IcGraw HilL 197i, SD4.19<)J.
~
! 10. Ba:'lI1ajbn JV. n.,.. I..U~·.1 CJ: ~l11"l;k Ali, ..... 5lh co. Baltimore. WilIi:nns 17. EllOk:t R~'1: ;-':curumech:lIlic;11 Ibsis til' Kiuc..il,lugy. Ch;ullllaij!ll. 1L.
I & Wi\kills. IlJS:\. Human Killclin BI1lOlks. 1985.

i! 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
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. implica-

I 50:1693. \970.
13. C:liz...o VJ. I'erille. JJ. Edgerlt1u VR: Tr;tinin~·induccdalteralions of Ihe
tions for injury rehabilitation. Spuns Med 5:196. )9SS.

~ in "jvo fllrce-vcllx-:ilY rdalinnship of human muscle. J Aprl Physiul

I, 51:75n.1981.

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4 Pain and Disability Questionnaires in
:1,
Chiropractic Rehabilitation
HOWARD VERNON

"An old joke: \Vhich is better to have. a watch that's dcfinitions ,Ife helpful. a com:eptual model .Iids greatly in
slOpped. or a watch that's always five minutes fast? Answer: clarifying the c.:omplcxities in\'olved. Locser's modd depicts
T.!!c wmch that's slOpped-because m Icast it's dght twice a pain as a multidimensional hicrarc.:hy. hc~inl1illg ill its lowest -
day!" level with nocic.:eption. which leads to p.lin. which h,.'ads to
[[valuation is the cornerstone of clinical mcdicin,flNo di- pain beha\'ior and ultimately to suffering,I,I'Each of thcst.: di-
agnosis can be reached and no effective treatment can be ren- mensions lends itsclf to particular kinds of ;lsseSSlllcnts. On
dered without conducting a clinical evaluation. which allows the other hane!. the further \.... c asccnd in the multidimcnsional
for the identification. of salient signs and symptoms 9f lhe pre- hiermchy. the more it is that uny p:.lrticular phcnomcnon is a
senting disorder. This fOfm of clinical assessment is con- product of e~cll of thc dimensions subscrving it. For examplc.
ducled by using a time-honored system comprising a patient tcndcrnes!' levels measured in the somatic tissucs may reveal
intervic\\' or history. obscrv~Hion. and clinical examination something abollt nociceptive activity and its interprctation <IS
procedures. These procedures often include established and pain. espcci~lIy in tcrms of the threshold to perception by the
traditional "tests" 10. for eX<lmplc. provoke p::tin. feci for tis- patient. This particul'lr measuremcnt. howevcr. ma:' have lit-
sue changes. visualize the struclUrcs.•lOd otherwise diagnose tle to do with other pain outcomcs, such ~IS retunt to work.
the condilion. In the biomedical disease model. I some physi- Return to work is a function of the social dimcnsion or pain
cal disorder must account for the disease. and the process of and is thcrefore inlluenccd by a host of factors beyond that or
clinical evaluation permits the most precise nnd trustworthy the current quanlum or nociccplion experience by thc paticnl.
d~tcrmillation of the nature and underly::lg cause of the dis- Also warranting considering is the currently ,ll'L'Cpted
order. model of p<lrallcl and interactivc proccssing of scnsory as
New clinical models challenge the limits of the tradition•• 1 compared to affcctivc l1lotiv.ltional dimensions of pain. l~ It is
··disease model"·:·.1 and of its classical fonus of clinical c\'alu- generally accepted that tests and measures that cvalualc olle
atien. One important new way of viewing disorders of health of these crucial dimcnsions may nOl be applicolble to the other.
is GlUed the "functional modcl.··.,\-s In this model. it is recog- Whcn considering p:.lin •.Illd loss of function. especi<.llly ill
nized lhm .llthouglt'two patients may havc.J!!£ same diag- regard to low back pain. a cfucial distinction musl be orawn
~~~cd_condition. each may have diffcrc:~t_a!.t~!.:l.~~~~.~~~unc­ betwecn disease and illncs'\. \.11 The illness beha\'ior 1110dcl
11011. CSPCC1<ll1y In rclev<lnt areas ofl1JTiy--hVlng-antl wmk y provides it framc\vork within \l,Ihich the subjct:tivc expericnce
"~,e altcr~ltions arci)'pic<llly dCfl11C'd as lc\;cls of disability. of discase becomcs legitimizcd conccplually as illncss. which
.tnd they arc not always fully measured in the classical clini- is then viewed operationally as disability./the physical corn-
cal evaluation. poncnts of diseasc .rcqu.irc treatment. whcrc;;'ilic illness COrtl M

Also of imponance is the "illness behavior modcl.'·'Lll in ponent of disability requires care.,Trcatmcllt and earc become
\vhich the distinction is made between "disease:' defined in a two distinct opcr<1lional domains with differclH objectives.
mechanistic sense as disordered physiology, .md '·illness.·· de- different measurcments of assessmcnt and diagnosis. dilTcrent
lined as the manner in which thc 'person with the disordered strategics of managemcnt and. most important for this discus·
physiology adapts to his or her own cnvironment These two sion. different outcomcs. Gaining separatc but ilHcgr.ncd per-
1110dels arc p.mkularly appropriate when applied (0 rehabili- spectivcs on thc outcomes of treatment as opposcd to thusc of
talion of p.linful disorders of the musculoskeletal system. c.lre will substantially improvc the delivery of rdlabilitation
services.
CONCEI'TUAL BACKGROUND

It is useful for this discussion to st.lrl with a definition of pain.

Properties or Measurements
as originally ..dopted by the International Association for the As a preface to a discussion of lests for pain and dis'lbiiily. the
SWdy of Pain: ':,Pain is Ih.'1l associ<t(ion of stimuli with re- HAlder should .'pprcciate ~cvcral axes alUund which tests such
sponses whic!l.ffiSll.1tl~anunplca.~am cx~rience which hurts
www.bodywork.su as these arc configured (subjectivc \'s. objeclive. qualil;.ltivc
a I~ and from which they \\':!~tto-tx;·-rrcc·d:·li·.A:fihou-gh vs. quantitativc). l..,lcasurcments arc idcally designed to mini·
~~-' .~.-_._- - ',"-' ....
.~-------_ _~

57

,,,

t,
!
('it
v

!u
 H~HA~ILIIAIION OF THE SPINE: A PRACTITIONER'S MANUAL

Table 4.1. Attributes of Tests in Clinical Rehabilitation 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
• Reliability • Specilicity
• Responsivity
really represents 25% of the tOlal value is. at best. uncertain.
• Validity j
• Sensilivily Nonetheless, this relationship of ::In ordinal scale to the value '-.
measured is often assumed by users, prompting some inap-
propriate conciusions.
mize error and 10 reduce variability. In the clinical selling. In the ;ll1en'al scllic. numbers do not merely n:prcsellt
the involvemcnl of the patient in the process of measuremcnt units of value. they constitute the units of \'aIUl~, Thi.;. ,;,c;lk j..;
of pain creates a great dC<l1 more variability than O1:lny scien- synonymous with a type of data known as "continuous daw.··
tists arc willing to toler<ltc.1.~-17 Nonetheless. hy its vcry defl- On the interval scale. data points arc true numeric rcprcsenla~ }
nitton as an experience and not ,10 objeclitlable state, pain tions of the value of tht.: parameter in questiollUI,ese data
eludes such rigorous O1l1alysis. Often. the best we can do is to (X?i nts c::ar~..~~~~l~~~51.{~t J<:.<}~t ~1).t?~!e~i~al!y.l1IJ1Qinfinitely
n)anagc systematically thc high degree of variability in pa- smaller uni~s. each of which would still repreSCIlL3 true unit
Hem groups. Whcn discussing the issue of outcomes measures .of~ea-~u!~·!l,lc-l1tof~h~,p'.ax~_mS:,~r.'Forcxamp-I~.·tempcratureis
in chiropractic rehabilitation. numerous attributes of such measured on a continuous scale, whereby a measurement of
measures must be undcrslOod.lI'u" Table 4.1 lists some of 10Q is hotter than 9::1. and colder (han 11 0 , and the diffcr~nc~
these attributes, 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 ..
i"leasurcment Scales
at least on the Fahrenheit and Celsius scales. there may not ~
All instrulllents usc a scak to measure a specific para mc- ..In absolute representation of the measured vnluc by the scale.
ter.!(I,:1 Typically. the scale is only representative of the phe- in thm 20° may not be twice as hot as 10°.
nomenon itsdr. For example. the increase of temperature is The laner aspect is the feature of scales known as ra-
really measured in lineaf)lnits of increase in a column of mer- lio scales. When measuring the angle of the straight \('g )
cury-a thermometcr,@milarly. the visual analog scale raising test, the angular scale from 0° to (typically) 90 to I (Xl~
(VAS) uses a 100-mm line [0 represent pain intensit . In this is used. Data are continuous. and ratios can be formed such
ins-iilllcC:-the anchors or ell poll1ts of the scale arc both ab- that 20° of angle is. indeed. twice as I~,uch as 100. This
solute and arbilrary. They are absolute because they are in- scale allows the observer to make true comparisons l:le-
tended to measure the phenomenon from its lowest to its tween measured results of a test under a variety of con-
highest level. On the other hand, they are arbitrary because ditions.
the numbers assigned to these and any intennediate states arc As an example of appropriately ratio scale comparisons.
purely a miHter of the choice of the designer of the scale. In consider a patient with low b~ck pain who scores 30 oul of 50
fact. many pain sC<llcs usc the numbers 0-5. 0-10. or even on an ordinally scaled disability questionnaire...Hld whosc
0.:101. wl.lcn. all thc while. there is no more p<lin with one straight leg raising signs. bilatenilly. arc limited to 45<:. If.
scale than with the nex.t! after a course of treatment and rehabilitation. the dis<lbiliry
The manner in which numbers or units are used in a scalc score drops to 15 Oul of 50 and the straight kg raising signs
is organized according to the degree to which the scale :lctu- increase to 90°, it is reasonable to say that an increase of
ally represents the quality or quantity being me~lsured. The 100% h.<ls occurred. Because the disability scale uses ordinal
lirst scale uses a numeric code to represent the response data. however. we are advised to conclude that a subst'lIltial
category. If only two answers-yes or no-arc possible on decrease in score has occurred. but not Olle that really rcprc-
a cenain scale. and numbers such as_lor 2 are assigned to SCnlS 50% less disability.
rcprc.sent these answers. then these data are said to bc
"omit/al (lata. In this respect. the numbers actually represent
- a code for other data. Nominal data :lre said to' be the low- Table 4.2. Scaling in Pain and Disability
est order of data in !hat liule of the actual parameter mea- Questionnaires
surcd is revealed by the dat~1. All the qualities of the P~l­ Nominal Scale:
~Do you have painT Yes/No
ramcter thm are measurable are reduced to one of two
1 2
statcs-presen[ or absellt. yes or no. male or female, etc. As Ordinal Scale:
such. this type of data is also referred to as "dichotomous wHow severe is your painT
dala" (Table 4,2). o2 4 6 8 10
none awful
On the onlinal scale. numbers arc still used as codes for Testing
other characteristics. but the numbers arc used to rank the Interval Scale:
level of llle characteristic and. therefore. bear some (if only Determine Ihe thermal pain threshold in a pain patient (Range:
40 to 55°)
indirect) relationship to the measured value. On an ordinal Ratio Scale:
scale, the number 2 represents a greater value than I; how- Determine the pressure pain threshold in a pain patient
ever. the true intervals of such a scale arc really unknown. In (Range: 0 to 10 kg,'cm l )

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 CHAPTER 4 : PAIN AND DISABILITY QUESTIONNAIRES IN CHIROPRACTIC REHABILITATION 59

Sources of Bias
SP~llbl' expectation that the patient merely fulhlls. The de-
One funuallleiHal premise tllltkrlying dinil.::d lllC;lSllrl.'l11t.:nl is llh::.IIHll· of lhe examiner and the cucs and instructions they
Ihe notion Ihall'lTOr and bias Ill.,)' l..'.\i,q at :lll len::ls and from gi,·l' af(' all iIl\POI1~1I\t in minimizing lhis sort of error.
.111 sources throughoUl Ihe measun::mcnt pnH;ess.: I :: Thcsc
sources include lhe subject. the instrullh.'IIt. ;Iud till..' l..'.\alllincr. Rdiahilily

Rdi"hilily m.ty he ddlned most technically as the degree to

THE SUBJECT which random I..'rmr in a tc~t is reduced. More colloquially, re~
Emotional. f'."ycIJ%gic. ami pl'rsollalily jt'C!o"x illl..',·ilahly liability is charaClaii'.ed by the degree of l:onsistcl~cy in the
pl;t)' a p;U1 in lhl' :-uhjel:I's n,:spOllSl' hI lllcaSlirCIllCIll.:; bc it rl..'sulb oht;lined wilh repeated lesting. The d'lI01 obtained rron~
sclf-r.tting qucslionnaires or physi":<.ll paforlll.ult.:e lcsls. Such only nne 'Ipplicalion of a lest can reOcct results from any~
fal.:lors as p'lin IOkram::c, sdf-image. beliefs ;ll1d ;l\titudes wht::r(' ill the typical range of the tt::st. With repeated 'Ipplica-
:"\ tion~ of the test. the.: results tend to Ilarrow ill their variation.
•.
_-~ <loom health and health practitioners. mood. and underlying
Illotiv.ltion Ill.ty .tll innuencc Ihe participation uf'lI1 individual In fact. in c1assiL:-mcasliremcllltheory. the reliability of a sta-
in functional measurement. tistic increases ill proportion to the squ.tre root of the number
Physiu(o!-:ic factors certainly pia)' a rule in physical per- of additional data (or test applit.:atiol1s). The mean of 16 data
fonnill1t.:e testing. For example. fatigue. nellrulogk sti.ltll:>, and points is four times morc rcliable lhan that of a single data
pain Ie\'c!s may all influence testing. patll!.
Cogllitil'cj(ICIOf!i playa crucial role. especially in the .lrea In rcgard to pain and disability questionnaires, the mos(
of instructions for test activities. Language and cullural and important fonn of reliability is test-retest reliabilit)~ which
cdUl.:.uional lal:turs all impact the subject's comprehcnsion of mcasurcs stability ovcr time in repeated applications of th~
the ovcmll purpose of .IIlY tesl. as ,\:ell as the manner in whit.:h Icst. Some assumptions must be made when considering lhis
it is to be conducted. form of reliability. In delCfmining if thc tcst itself is i.1 source
Fin.lily, In.tditioll:.ll sources of IH.n.:/wl/Il!lric bias oist.:! of error, all other factors th:lt c:.tIl contribute to variability in
such as in the tendency of subjects to choose responses in the the I('st result must remain constant. In c1inic.ll settings, the
mid-range or at the extremes of a scale; the crfccls of the natur;.1! histQry of the condition under invcMigation is .1 vari-
order of different responses, itcllls. and, indeed. of different able. Changes in the course of the condition will n.llurally in-
tests when using a battery of tests: and Ihe tendency of sub- troduce variability \\lith repcated applications of the test. mak-
jects to ovcr- or underestimate depending 011 their pcn:cp- ing it dinicuit to determine the reliability of the test itself.
lion of the responses expected in the lest. Typit.:ally, two applicmions of the test are made in an in-
ten·al of time that is suitable for the n.ltllral history of the con-
dition itself (typit.:ally within hours to I or 2 days). The results
THE INSTRUMENT
01" these tests arc t.:ompareu using some form of reliability
The coll1elll domaill of sclf-reponing instrul11ents Jll~IY be in- statistic, such as Pearson's R or the Intraclass Coeffi-
surllcicllt to capture all necessary chLlrac((;rislit.:s of the para- cient. Acceptable levels of n::liability range from 0.70 to 0.90
meter to be mC.lsurcd. The [On/1ll1 of qllc.'ifiOIlS eilll ilHroduce and up.
errors or response bi.L<.;cs. by providing too Illuch or tOo little Olher mcalls of determining lhe reliability of question-
prompting information. If <Iucstiolls arc alw.lys rilll"ed in :1 naires for pain and disability include the "split-half' method.
similar order, thell order bias may creep inw a p.tticnt's re· in which the responses of one h.t1f of the test ar(' comp<trcd to
sponses. Finally, the ill.Hruc:ticms, either on the form or by the thosc of the other half. and other tests for wh~ll is known :I:'
ex.uniner. m.1Y be insufficicnt. misleading. or poorly under~ "jOlcrnal consistency:' or the degree to which ~lIlS\""ers to in-
sLood by thc patienl. dividual items rcncct the towl score of the questionnaire. :(,
Another important lypl:: of reliabilily is the.: consistency of
THE EXAMINER findings between dirferellt raters (inter-examiner rclinbility)
or in mcasurements made by the same rater (iIHri.I-cbservcr re-
The cmlf£'.W (lthe cli"ical .'lellillg is an important aspect of the
liabilily). Depending on the type of data lIsed in the instru-
mcasurcment. Questionnaires may be filled Ollt differently be-
ment, reliability stiltistics. such as Pearson's R. ll1tracli.\~s
fore relative to after seeing a health practitioncr. The quality
Coefficienl, or the Kappa Com.:ordant.:e slatistic, can bt:
of the ovcrall health care experience of Ihe patient may influ-
used.: 7
encc their responses.
The IJI"('scm:e or ab.\"(!/l(:e ofall examiner while the piiticl1t
Validity
is completing various lests may influence their responses.
Response expectations 1ll.IY be operative. such as the The concept of validity pertains to the accuracy of any test. or
Hawthorne ctTect,:1.2S in which the patient's responses may be Ihe degree to which it truly measures the attribute under in-
inl1ucnccd by the knowledge that the)' arc being tested, or the vestigation. McDowell and Newell proposc a somewhat
Pygmalion crfect.: 1.2S in which thc patient Ill:"y erroneously broader definition of validity (() include the (,.'ontext in which
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assume th.u the practitioner or examiner has .1 ccrtnin rc- the lllC.lsurCl11cnl occurs, "(he r..mge of inlerpretations Ihat

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

may be placed upon the test; what do the results mean !"21 This opposite. wherein test r:cgativc:~ C\.ji.i'HC :lig:,l::; .,';;::; :ruc
definition also L<ts the advantage of connecting results (data) negatives (with low false positives).
of the tcst to the theoretic constructs underlying the use of thc Respolls;l';ty. One form of discriminant validity involves
test. In this way, data plus mcaning becomes something use~ the perfonnance of a test ovcr time. It is reasonable to de-
ful; i.e., information. terminc if the test accurately measures the amount of change
in a condition or attributc when such change truly occurs.
FACE VALIDITY In the development or the Neck Disability Index (NDI)..'s
we studied 10 subjects with neck pain who had under-
Face validity, or content validity. refers to the dcgrcc to \vhich gone chiropractic treatment for 3 to 4 \vceks. All 10 indi-
the questions or procedures incorporated within a tcst make viduals reported improvement. They were asked to complete
scnse to its users. Typically, a group of experts is asked to re- two instruments-the NOI and a visual analog pain scale
view a test and come to a consensus on the overall sensibility (VAS)-at the beginning of treatment and again at the cnd
of its components. of the treatment period. We correlated the change in VAS
scores (as a percentage) with the change in the NDI scores.
CONSTRUCT VALIDITY The average change in VAS scores was approximately 757c,
This term refers to the degree to which a test and its result whereas the change in NOI scores avcraged only ,\bOUl
fit with accepted theory. As an cxample, lift strength test- 50%. These data correlated at 0.62, which is a relativcly
ing has a high degree of construct validity when used in good level of correlation. \Vhich test result reflectcd the true
assessing an injured worker with low back pain whose job level of impro\'ement'? \Vhieh was the more responsive? Only
involves significant manual handling and carrying. Assess- fUl:ther research using statistical techniqucs dcsigned specifi-
ing small differences in the length of the legs in such a worker cally to study responsivity~(J-:lI will provide answers to these
has poor construct validity given that no evidence sug- questions.
gests that a small leg length difference equates with work
impairment. MEASUREMENTS FOR PAIN AND DISABILITY
Each instrument discussed subsequently is representative of a
CONCURRENT VALIDITY greater number in each category. This section provides a SUlll-
mary of the content and description of each instrument and
One way of determinir..; th;.::: ·.. ~lidity of one test is to correlate
then a discussion of its reliability and validity.
it with another test done at the same time. In some cases. dif~
ferent tests have been designed to measure similar attributes.
Location
For example, a VAS for pain intensity can be validated by
comparison to a verbal rating scale for pain severity. In this Pain may be localized by using the pain diagram.1>·t 7 (Fig.
context, relatively higher correlations are expected between 4.1). a standardized self-report measurement of the location.
tests of similar attributes. On the other hand, a test of one at- extent, and, to some degree, the quality of pain. As well as
tribute can be correlated with tests of another attribute that is these descriptive features, the manner in which a patient de~
related. at least theoretically if not empirically; for example. piets his or her pain has been shown to reveal a grei.1t deal
reduction in levels of activities of daily living with levels of about interpretations of the pain experience, mood, and psy-
pain severity. In such a circumstance. the levels of expected chologic state and behavior while in pain. In this respect. till-
correlation are usually lower. ing out the pain diagram becomes a pain behavior, and it can
demonstrate an appropriate as opposed to an inappropriate
CRITERION VALIDITY manner on the pan of the patient..1~
Outcomes are derived from the pain diagram in a number
One form of concurrent validity that is particularly robust is
of ways. First. subjective ratings by trained observers Gill be
to compare the results of one test with the best test available
made from the appearance of the diagrams. These ratings. in
at the time-known as the gold standard. If the new tcst per-
facL can be system~tized, using rankings from more 01'-
forms in a relatively similar fashion. then it can be said to
g:'ll1ic/more realistic to less organiclless realistic and, perhaps.
have good criterion validity.
psychogenic or inorganic."'" Second, scores from a checklist
DISCRIMINANT VALlDtTY
of penalty points, which rate the anatomic fidelity, the pres-
cncc of cxtraneous markings within and outside the body. etc.,
This attribute of a tcst refers to its ability to discriminate arc compiled. The higher the score, the more likely it is to re-
between major categories of test findings, often referring flect inappropriate pain behavior:''<'··l(, Third. body area charts
to categories such as "normal or abnormal," positive or neg~ can be used to quantify the size of the painful area so a single
ative, symptomatic or asymptomatic. S'ellsirivilY is the at~ mcasure can be derived from the pain diagram:l1
tribute of a test whereby a positive test result is highly corre- High reliability of the pain diagram has been reported.
lated with the true diseased or abnormal state; i.e .. high Murgolis et aI" reported test/retest correlations for body area
true-f.'(\~!tive rmellow false-negative rate. S[Jecijicily is the to range between 0.83 and 0.93; for pain locatio:•. they found
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,
 V.,.... ,.. I r:n .. : r-'f\Il'l AI\lU UI::>At::HLlTY QUESTIONNAIRES IN CHIROPRACTIC REHABILITATION 61

PAIN DIAGRAM PAIN DIAGRAM

INSTRUCTIONS INSTRUCTIONS

On the following diagrams. indicates all areas of : On the following diagrams. indicates all areas of :
)
pain -xxxx pain -xxxx
stiffness
numbness
other
- /I /I
-0000 ,., I
.":"',"
'-,

. !
stiffness
numbness
other
- /I /I
-0000

(specify) (specify)

.: i
l:ll: ,.\.
t;
.. ,
,

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

lest/retest .lgreeJ11elll to be 7(IVr. These authors rCluno no .lge Concurrent validity among these scales and with mher
or gender differences in the degree of reliability. measures of p.tin ;md loss of function is reponedly high. SCOlt
With regard to validity, high pain orawing scores h;'lve and Huskisson~7 reponed comparisons of the VAS and the
been correlated Wilh elevated hysleria .lno hypochnndri;'lsis VDS-t)'pl' sc.alcs that correlated at 0.75, where:'ls a coefficient
scores 011 the l\;1inncsota l\·1ultiph;'lsic Personality Index or 0.63 was reponed betwecn the VAS scores and MPQ
(MMPI): greater chronit:ilY of low back pain iJnd higher 110s- scores.~7 The VAS tli.lS been shown time and again to be sen·
piWliz<ltion rates: and high McGill P;'lin Qul'stionnaire (!V1PQ) sitivl' 10 treatment cffccts.~s although Scott ;,md Huskisson
scores. l < t::.Iutioned that providing lhe original scorc or using a VAS for
finally. with reg;'lrd to its usefulness. the strengths of the relief or improvement may be more appropriate.~oj Other au-
pain diagram are case of administration. relative ~a:-c of in- thors disagree with this stf<llcgy. however. and n:quirc ;,111 ab-
terpretation. and implicit facc validily as a tool with "'hich pOI· solute mcasuremcnt. ~rl.~1
lients can effectively COmltltlllicatc their compbilH [0 health The scales just described arc casy to administer and to
care pr<lctitioners. SCNe. although the ordinal scales of the VDS-typc scales
should be uppro;'lched with caution. especially in regard to in-
Intensity tergroup comparisons. There is a high degree of sensitivity to
change, especially on the linear st:ales.
Several simple ~calcs e'xist that arc designed for lhe sell'-
rating of pain intt.:nsity. The visual <lnalog scale (VAS), dc-
Quality
vised by Huskisson in 1974:'1'\ (Fig. 4.2). is illlumerically con-
tinuous scale th;,1t requires that pain level be identified by In 1975. Melzack introduced the McGill Pain Questionnaire
Ill~king a nwrk on a IOO-mlll line. The uniformity and density (MPQ).~1 "lIId it has since been llsed in numerous studies or
of this type of pain scale creates a high level of sensitivity to musculoskeletal and other pain syndromes. It has undergone
Vmii.Hions in pain ratings. a great de;'ll of rcplicmion ,,1I1d is acknowledged :ls onl' of the
Verbal descriptive scales (VDS) also cxist·N ....;.: IFig. 4.3); gold standards in the field of pain assessment. Tht: MPQ con-
some are ordinally scaled. like the Present Pain Index of the sists of 20 category scales of vcrbal descriptors of pain.,'I.l5~
MPQ.'-l and others arc r,nio scaled. like the Borg pain scale:": ranked in order of severity and clustered into four ~ubscales:
The numeric rating scale ;'lIld the Borg pain scale arc IO-poim st::nsory. affective. evaluative. and misccllaneol1:-i scales. us
scales. In lhe newer Numerical Rating Scale (t\RS) 101. well as a five-poinl "present p;'Iin rating index." Scores can be
which is a version of the VAS. u patient chooses a number be- obtained on the rank scores added for the total instrument or
tween I and 100 to rate lhe severity of their pain.-l·· for each of the subscales. or grealest inlerest to researchers
\Vith regard (() reliability. these pain sc::lcs arc lhe main- has been the ability to distinguish the scn~ory and the affec-
stay of most pain studies <lnd clinical tri;,i1s. The original n.:- live domains of the pain experience.
ports of reliability included correlations betwcen the vertical Test/retest reliability had been confirmed as high from the
.Illd the horizontal forms of the VAS. which arc reported .IS outset. with Melzack's lirst report indicating .1 70% consis-
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high as 0.99. with simil;'lrly high test/retest reliability, 'li.-l~--l" tency of responses of three trials over a 3-day period.~1 Aikll

'0
;;;
(',~
 Ht:.NAt'ILIIAIIUN UI" IHt:. ~I""INt:.: A PRACTITIONER'S MANUAL

Fig. 4.2. Visual analog Make a mark (I) along the line which you think rGprese;,~:; y~.;; CUi;en~ :l;:ve; vi IJdill in youl
scales for rating pain (A) and major area of injury, somewhere between ~No Pain At AII~ and ~Pain As Bad As It Could Be",
:1 visual analog scale for rating
improvement (B).
No Pain Pain As Bad

I
1t
,
A AtAIi

ABF YOU RETTER SI~CE YOUR EIRST

IREATMENIl
As It Could Be

I
1
Nam~

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.
Date

i
I 1. P~IN RELIEF.
..',>
I j

I No relief of
pain since ~
o
Complete relief
- of pain since

I treatments
began
1 2 3 4 5 6 7 8 9 10 treatments
began

I
slight moderate lots of .
WORSE
relief relief relief
DOESN'T APPLY
TO ME

I
2. ACTIVITY INCREASE (walking, standing, working, exercising, etc)

No increase Complete
in activity recovery of
since - - all activity
treatments 0 1 2 3 4 5 6 7 8 9 10 since )

I
began treatments
began
slight moderate lots of
increase. increase increase. WORSE

I
.. ~

DOESN'T APPLY ..J

B TO ME
)
I
,~,

and Weinmann~·~ reportcd similar results over four tri.tls torial structure, especially of the sensory and the affective

I
within I week. Phillips and HUlllcr~(o studied tcst/retest rcli'l- scales.:>1'{,(J The concurrent validity has been confirmed be-
bilily of the MPQ in patients with headache and reponed cor- (ween the MPQ and the MMPI and many other instrumcnts .J
relation coefficicilts as follows: for the Presclll Pain Index. that measure pain intensity. mood state in pain. and psy-
which is the total scorc. an R of 0,94; for tbe sensory scale. chosocial disturbance. Phillips and Hunter reported an inter-
~ 0.83; and for the affective scale, 0.95. These findings indicate esting and significant correlation between MPQ scores and
i thut people can, wilhin a rel.ltively short period of timc. re- the pain diary in headache subjects.~ ..J

I member their pain state from one measuremcnt intcrval to With regard to discriminant validity. Dubuisson and ,
I anothcr. Melzack!>-l found that 77% of 95 pain p;.nients could be cor- .J

i Thc greatest imcrest with the MPQ has bcen in the area of
validity, Numerous factorial analysc~ have confirmed the fac~
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rectly classil1cd into diagnostic groups on Ihe basis of their
MPQ score alone. Reading~7 studied patients with acute ilild ,
,
; ..
 'vM/"\t"j t:H 4 : t"AIN ANU UI~At:HLlI'Y UW:.::> IIUNNAIRES IN l,;HIHUI-'HAL; IlL; Ht:.HABILlTATIQN 63

() Fig. 4.3. Borg verbal rating pain scale (A) and ver-
bal pain rating scale (6) (from the Roland-Morris
Patient Directions: scale).
On 8 scale of 1 • 10 place 8Jl X In your current pain level

NORMAL LOW PAIN MODERATE PAIN INTENSE PAIN EMERGENCY

( )0 ( )1 ( )4 ( )7 ( ) 10

( )2 ()S ( )8

( )3 ( )6 ( )9

t:
3
!! t)
;.,: The pain is almost unbearable
,
I () Very bad pain
1
j
1 ,)
I {) Quite bad pain

I,
I
')
'.-

")
"<,
Moderate pain

Uttle pain
~~
? No pain at all
i;
"2
~
I,. 0
I 0
B

I• :..) chronic disorders and found that the fomler 'used morc sen- vals; the sevcrity and actual dUr<ltion of these episodes: med-

IJ sory words whereas the laner. as predicted by the theory. used

more affe<.:tive and c"i.llu;nivc words.
ication usage: and effect on activitit:s of daily living. All of
these parmnctcrs can be combincd into;1 compact instrumcnt.
I, \)
~
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
Thesc various c"llcgorics me typically l:ombined into ordinal
or continuous scales with frequency COllnLs and cominuous

I
~
>:)
usefulness lies ill its relative case of administration. Also, it
is casy to score and rich in data, particularly with regard to
dma on the time. course. and duration.
Bl<mchurd reviewed the stabilily of pain diary data. espe-
"li
ii the sllbsc;llcs and how their scores may apply to the thc- cially for headache (an episodic complaint). and determined
#;
(Hetie <.:Ollcerns mentioned previously. Because of its that an avcruge of 2 weeks is sufficient to obtain stable
strengths. it has taken on the status of a gold standard in pain baseline values from the diary.('~ For COllst<!nt pain syndromes.
3 aSSCSSlllCllt. such .as those involving the low bi.lck or neck. stable val-
"
i ()
,{i
ues ought to be obtained within days of i.ldministr.atiml. The.
drawbacks of the pain diary arc the bi;'ls and Hawlhorne
Course
~ effects that arc likely to creep into the data recording pro-
•
,~
~
t)
<X.,.

The course of the complaint can be monitored by using the cess. as well as th~ rarc instance of <:omplctcly rabe and
p;'lin diary (Fig. 4.4). The diary is im often-used tool ror on- misleading recordings. which arc more likely from a com-
i \J going. patient sclf-rcpol1. It <lllows for continuous recording of plete malingerer. As slich. pain diary dal<! should. if at ..iii pos-
i () a wide nlllgc of pain-rcl;,ncd outcomes, such as the frequency sible, be cross-chccked with somt.: comparabk obscrver-
I~
of painful episodes: the time course of constant pain com-
www.bodywork.su based datil ;'IS to the pain behavior Of clinical sWtllS of the

j ()
plOlints. which can be recorded o\'er daily and hourly intcr 4
patient.

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

PAIN DIARY PAIN MAP

Day 1
Day 2
Day 3
Htl:::l+t-:::::: - i,; :
I
,
'-'- -'- -!-'<
l

[~F::: --
_L
,

;
,'
"H-!-;,;"
"
_.I..! , ' . Day 17
I ! i
Day 16

,Day 18 - - - - - - - -
_

Day 4 "" -;- -- -- --.- . Day 19 - - - - - - - '--',

Day 5
",
" ' k . . -'
''l;,,,{
,+.
__L.

-:
Day 20 -
Day 21
_

Day 6 , ?;i

Day 7 ,," L
H+t-+'T-,, Day 22 - - - - - - -
Day 8 H+l-+-f-fLif Day 23

Day 9 :::..il Day 24 - - - - - - - .-~'\

!
. , Day 25 _
Day 10 i-+::::I-H'-H1' ,
+-Ht+-H-+-: .~: Day 26 - - - - - - - -
Day 11 1-·L , Da 27
._L. y -------
Day 12 I I ,
r-r-i Day 28 _
Day 13
;j--!-+-+-+,r-=-8 I
Day 29
---------
Day 14 ;-i'~ Day 30 _
Day 15 Day 31
Fig. 4.4. Pain diary.

PAIN BEHAVIOR
firmed the high dcgn:e of reliability of th(; prolOeo!. They re-
This section addresses five instruments. the purposes of ported inter-rater agreement Kappa c(xflicicl1ts betwecn O.SO
which .Ire less to describe the p'lin complaint itself than to as-
sess the behavior of the individual in pain <lnd come 10 an un-
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
,,
derstanding of the motivational components Oflha! pain state. treatment changes <is wdl as high cOITc!miolls with pain in-
Le.. to assess the illness/disability component of the disorder. tensity ratings. physical findings. and functional disability
The foclis of this discussion is on systematic behavioral ob- scores. They also demonstrated high correlation bClwc(;n
servation. and then four scales that m~asurc activities of daily scores of tr'lined versus naive observers. Sf) these pain behav~
living: Oswcstry.;'-' Roland-ivlorris. fol Neck Disabilily.:Ji and iors arc consislent aems:, ev.dualOrs.
I, Pain Disability.('S The pain behavior :,cores discriminate betwecn pain pa·
tients and control subjects. Author:, (,f a recent sHidy found

I S)'slcmic Behavioral Obscn·alion

that the obsen'alional melhod can i.lCtlIally discrilllin~\tc !"(lUr
subgroups of back pain with different pal1cms of pain behav-
I
~
Keefe ct all,(· devised a method of observing a patient's pain
behavior in order to provide qUilnlifi~lble data regarding lhe
ior: in other words. people who 11<I\·c a hOl11ogelle(lu:-: pl\1h-
lem. like back pain. appear to behavc differently. and. in r"ct.
patient's dis~lbility that would be directly relcvant to func-
I
,~ tioning. Thcy identified a group of overt behaviors thut ap-
consistently in those differences. In this study. guarding and
rubbing were lhe behaviors ohserved mo:-t often.!'?

I
~
peared to be unique for the pain cxperience: grimacing. brac-
ing. guarded movcments, rubbing.•md sighing.
In n report by Jensen el .11.',7 the tolal pain behavior SL'(,rt.:s
correlated significantly with the VAS ~lnd the Bor~ pain
~ Thc protocol of Keefe et al consists of a IO·minutc video scales. as well as with measures of reduccd spinal mohility
i of the patient undergoing a standardized series of movements. (i.e., where flexion and extension w~r(" reduced) and in-

i They walk. sit. recline. and stand lip :.tgain, and lhe frequency
of various pain behaviors is recorded by trained obscrvers.
creased medication usage. In tllei! sHldy. correlation with
depression '!nd two sC~lles of thc Sickness Impact Profile
I With regard 10 reliability, Keefe ct al reported interexamincr (SIP) were also investigated. The only pain hdlavior III l"lm·c- J
I agreement levels as high ~lS 88%.(,(> Findings from a study of (<ltc consistently with these psychosocial pan11l1ctcrs was
i patients with chlonic low back pain by Jensen el al1>7 COtl- "sighing:' which was actually the (c~lSI observed o('havior.
.~ www.bodywork.su
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J,----..,.----------------------------- .J
i$ •.•.. ---_._.~---._--

'.. ~
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I
 ,~n '1' • rM."" M.liV UI;::.1\t:SILII Y UUESTfONNAIRES IN CHIROPRACTIC REHABILITATION 65
Neck Disability Index (NOI)'" (Fig. 4.7)
Nonctheless. lhe link between pain behaviors and pain sevcr-
ily i~ not lirlllly estahlished. evcn at the thcorctil:al levcl. This index. a re\'ision of the Oswestry Index. W.1S developed
Observers haw noted a grcal dcal of pain behavior in (he ab- at thc Canadian Memorial Chiropractic College by Vernon
sence of high lc\'cl~ of pain severity ilsclf. ns well as dimin- and Mior to address the nced for an instrument specific'llly
ished pOlin beh~l\'i()r <lnd even recovery of relatively normal designed to measure reduced activities of daily-..Jiving in
function in the presence of severe pain. So. theoretically and l?~lents \rilh....n~1in.Q.·he lcst/retest reliability was found.
empirically. beh~l\'ior and scvcrity may not be absolutely in a suitable sample of subjccts. to be 0.89. The total Crol1~
linked. b:1Ch's alpha. which is :.\ measure o~lal reproducibil-
ilY. was 0.80. and all of lhe itcms acilic\'cd aip1la·lc-\~els
Oswcstry Low B<lck Pain Index (Fig. 4.5) above 0.75.
Regarding lhe construct validity. scores were nonnally
Thi~ index W:IS reported by Fairbank ct ill in :980.t..' It is a
distributed and clustered al the moderate severity level. which
IO-i\cl1l scale in which each item has six ranked detractors,
was approprialc for an ambulatory clinical population. \Vith
scored from 0 to 5, so a total score of 50 can be compiled. The
regard to concurrent validity. wc compared NOI to MPQ
lirst section is a pain-rating s~ale. Thc other sections deal with
scores at an R value of 0.73. and sensitivity to change was
various daily activities deemed relevant to low back disabil-
measured by comparing changcs on the NOI to visual analog
ity by the consensus tcam,
scale rating changes. This correlation wns 0.60.
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 Pain Disabilit~· Index (POI)
only th,lt O~wcstry scores lowered after ~l 3-wcek rest pcriod.
The PDI was first reponed by Pollard in 1984. 65 It is a ~cven­
which is presumed to indicatc sensitivity to trcalment effcels.
item scale using VAS to rate illlensity of disturbances to a va-
Triano ct al f " provided a much necded study of concurrent
riety of psychosocial variables and activities of daily life. Tait
validity. They compared Oswestry scorcs to measures of mus~
Cl apo reported a Cronbach's alpha value of 0.87. As for \'a-
cle dysfunction and reponed a good correlation between
lidity. POI scores for inpatient groups were higher lh,lIt those
higher O~\\vcstry scores and the prcsence of signs of abnormal
for outp.ltient groups. and more recently. Tait et ai' I found tllat
muscle function. with the conversc correlation existing as
high PDI scores correlated well with higher psychologic dis-
well. This finding speaks, if only implicitly. to the sensilivity
tress Slates. higher dis:.lbilil)' 1C\·cls. high pain dcscriplion
and specilicily of this instrument
scorcs (from the MPQ). <Jlld higher pain behavior scores frum
the protocol of Kcefe and colleagucs.f~' The adv'Ultage of the
Roland Morris Scale" (Fig. 4.6)
PDI as opposed to the other indices is tll.1t it is nOl specific for
This scale consists of a sct of 24 questions pert<lining to work. one type of pain and Ihe seven categories can be applied 10
lime at home, \v.llking, personal care, sitting, etc.-a widc virtll<llly .Iny pain syndromc.
range of activities rclevunt to patients with low back pain. The
tcstJrctc~t coefficient (half·day interval) was origin:.ll1y n,::. ILLNESS IIEH.-\VIOR
ported as 0.91. The internal consistency of the itcms. Il\ca~
The psychosocial indices of illness behavior warrant dis-
smed using an "agreement percent cocflicienl," was ca1cu-
cllssion.
I'lted as 0.83.
To Icst the validity of the inslrumCI1l. the original authors
B:.\ck P:'lin Classificalio(l Scollc
compared test resuhs to a verbal pain raling instrument and
reponed lhese to be in "good ngreement." Some test questions Leavitt and Garron !ina published this scale in 1979.': It is a
were compared to doctors' physical findings. with generally subscalc of a larger check list of symptoms .Ipplicablc 10 back
gooo·to·cquivocal agreement. Scores \\!erc not related to age. pain. Of the 1,Irge list. 13 words werc found to discrimin<ltc
gender, or social class. indicolting th<lt wide lise in gencml pain of organic origin reli:lbly .md accurately. These words in-
practice was probably well supportcd. cludc the negatively scored items: nagging, dull, throbbing.
One criticism of this instrument is that it uses the nominOlI inlcrmiuent. shooling. and punishing. These lerms as a group
scale. and therefore may miss important inform<ltion about pose some interesting par'ldoxcs. COllvcrsely, the words
clinical SlaWs. Patients arc forced to agree or disagree com- squeczing. exhausting. si<:kening, troublesomc, tendcr. numb.
pletely wilh each of the tcst items. when, in fact. the stutus of .lI1d tiring indicate a high likelihood of ~I psychogenic origin
most patients is usu<llly a maHer of degree of some limitation. for the pain complaints.
not whelher it .is present or absent. Nonetheless, this attribute Tcstlretcst reli~lbi1ity after I day achieved a corrclalion co·
of the instrument may lend itself to an improved level of re- efficient of 0.86, where'ls the split-half rcli;lbility score wa...
sponsivity. Hsieh et OIl found the Roland-Morris scalc superior reported at 0.89. Cross-validation with the MMPI sl'a1cs is
in its rcsponsivity cOl11pnred to Ihe Oswestry Index (which high. Improvement ratings correlate highly with the Back
uses an ordinal scalc) in dClcnnining levels of improvement Pain Classification Scale: that is, "organics" respond better
in patients wilh low back pain."1 www.bodywork.su th~11l "psychogenics.'·1:.7'
 uu HtHAt::lILIIA1IUN Of THE ~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

Name Date _ _-"-_ _1-_ _ ' File #

lnstruclions: Please mark lho ONE BOX in each section which most closely describes your problem.
Section 1 • Pain Intensity $eclion 6· Standing
0 1. Tho pain comos and g005 and is vory mild. o 1. I can stand ~ long as I want without pain.

0 2. Th p",in is mild and doos not vary much. o 2. I h;)vo somo pain on Sl.1.nding bUI It doos nol incroa!iC with timo.

0 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.

0 '. The pain is moder<lt6 <Inc! doos not v;uy much. o 4. I cannol stand tOf longor than 112 hour without incro<lsing pain.

0 S. The p.,in comes and goos and is SOVetG. o 5. I cannot stand lor longer than 10 minutos wilhout inaoasing pain.

0 , Tha pain is sovors and doos not vary mIlCh. o 6. I avoid SI<1ndlng boc,luse 1\ lI'IOO<lSOS lho pain immediately.
Section 2 - Personal Care (Washing, Dressing, etc.) Section 7 • Sleeping

o I would not havo to chango my way of washing or dressing o 1 I got no pain in bed

I
in ardor to avoid polin.
D 2 I got patn in bod but it does not prevenl me Irom sleeping well.
o 2. I do not normally dlntlgo my way of washing or dressing (lvon
though it causes some pain. o 3. Becauso 01 pain my normnl nights stoep is reduced by less than 114

o 3. Washing and dressing increase the pain but I manage not to

change my way 01 doing il.
o 4. Becnvso oJ pain my normOll nighlS skwp is reduced by leSs than tft

£:] S. Bocavso of pain my oarmi1l nlghLS stoep IS reduced by less than 3/4
o Washing and dressing increase the pain and llind it nacossOiry

1
4
to ch<lnge my way of doing it. o G. P.:r.in prevonts me from slooping :1t all.

o "':>1

I~
S Because of tho pain I am unable 10 do some washing and drossing Section 8 - Social Life ):
without help.
01 My soaal hie IS normal ;lnd gives me no pain.
o 6. ~cause 01 tho POlin I am unable to do any washing or dressing
Without help. 02. My soci<'lllife is norm<ll bU\lncreasos tho dog roo of pain.
~, Section 3 - Lifting 03. Pain has no signiflcanl effoct on my social lifo opart Irom
"
.~

o I can lilt hoavy weights without extra pain.

limiting my morQ energelic inlerosts. e,g.. cklncing. olc

I 02 I can lif! heavy weighls but it givos ex'lra pain.

0,.
05.
Pain has rC5lricled my social hie .ilnd I do nolgo out very olten.
)
j 03. Pain prevents me biting heavy weights off the lloor.
06.
PaIn has toslllcted my SOCI.il1 hie 10 my homo.

I have hard1-, any socinillfe because of the polin.

o

I
4, Pain provents me filling heavy weights otllhe Roor, but t Cin
manage if they are conveniently positioned. o.g .• on a table. Section 9 - Traveling

£:] S. Pilin prevents me from ~Iting hoavy weights but I can manage 01. I get no p.ilin when 1r::Jvehn\J
lighl to modium weights ;t thoy are conveniently positioned.
02. gel SO'TlC pnin when It;lvehng bUI none at my usuallorms
~
o 6 I can only lift very lights wflights at the most.
I
of travel m.,kc II any worse
~ Section 4 • Walking D 3_ I gCl cl(tra pain while lr.ilvcl<ng but it (foes not compel me to
I
I o 1. I havo no pain on walking.
04
sook nlternativo forms 01 travel

.~ IgOI Olllra pain while travu!lng which compels me 10 seek

;j £:] 2 I hi1VO some pain on w<llking but it docs not increaso with d'is\.1nco altern;)tive forms aflrnvol

~ o 3. I CMnot walk more than ono milo without incr<l<lsing pain. 0 5 . Pain tCSfticlS
30 minutes
mq 10 shorl flUCP.ssary journeys under
o
II
4, I C<lnnOI walk more than tJ2 mile with increasing ptlin.
06. P.ilin ICSttictS alllollTls 01 It.ilvel
o 5. I cannol walk mote than "4 milo without inC/easing pain.
01.
o 6 I cannot walk al all without increasing pain.
Pain prevent!;. all fOlms of lr,wel ~I(Cepllh.il1 dono lying down

Section 10· Changing Degree of Pnin

Seclion 5· Sitting
o t. Myp;un is rapIdly 901l<n9 bettet
I 0 1. I can sit in any chair as long ilS llike.
02. My pnin fluclualos bUl overall is definitely gening hetter.
)

1~ 0
0
2 1 c.Jn ~il only in my fOlVorl!O chair as long as I like

3. Pain prevonts me sitting.mom than 1 hour.

o 2 My p,lin SCorllS 10 be gell<ng "',ner but improvement is slow

,fi 0 P"in prevents me lrom sil!lng mora than 1/2 hour.

o 3 My rmin is nr:ilhN gr:llin!) h(!ll<:!f nor worse

~ 0·1 My pilln I;' gr;ldually 'watsonlng

0 5 P.1in pmvents mo Irom ::oitting lor moro than 10 minutes
~ 0 6 I avoid silting because it incr03ses pain immodlately.
o 5_ My pain is rapidly Vlorsemng

I Fig. 4.5. Oswestry Low Back Pain Scale.

I< www.bodywork.su
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11
i-f;
,!_----~----------------------------------­
N -
 ... _._ . . . ........ ,u~ ..... n~.;:J 11" ..,. "nurn/'\"" I I"" t1t:.NAI:HLlTATION 67

o 1. I stlly home most of the time because of my back.

o 2. I change position frequently to try and get my back comfortable.
o 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 usu-
ally do around the house.
() o 5. Because of my back, I use a handrail to get upstairs.
o 6. Because of my back, I lie down to rest more.
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 9. I get dressed more slowly because of my back.
o 10. I only stand up for short periods of time because of my back.
o 11. Because of my back, I try not to bend or kneel.
o 12. I find it difficult to get out of a chair because of my back.
o 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 15. My appetite is not very good because of my back.
o 16. I have trouble putting on my socks {stockings} 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.
Fig. 4.6. Roland·Morris Back Pain Scale.

www.bodywork.su
 . . . • . _ •• ~ ••• ' ~ " , I , " ' .. ' vr .

NECK DISABILITY INDEX

, ,

Section 1 - Pain Intensity Section 6· Conccntr3Lion

[=::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.
=
=
I can concentrate fully when J want to with no
difficulty.
I can concentrate fully when I want to with slight
c::J The pain is fairly $CVere at the moment. difliculty.
,
[=::J The pain is very severe at the moment.
= I Mve a fair dcgroc of difficult,y in concentrating
when I want to.
c:::::J The pain is the .....orst imaginable at the moment.
=
0

J have a lot of difficulty in concentrating when 1

S«tion 2 - Personal Care (W.ashing.. DK'5SinS dc.) W,1ntto. -
(=:J I can look after myscl£ nonnally without causing
~ra pain.
= I have a great dC3.l of dimculty in concentrating
when I w;mt to.

= I can look after myself normally but it caUSl'S

= 1cannot concentratc at all.

= extra pain.
It is painful to look after myself and I am slow
and careful.
Section 1 • Work
c::::J I can do as much work as I want to.
=
= J need some help but manage most of my personal care C=:J I can only do my wual work,. but no mot"C..

= 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,
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 3 - Lifting
(=:J 1can lift hC:lVy weights without extra pain. Section 8 - Driving
c=:J I can lUt heavy wcighls but it gives extra pain. c::J I can drive my car without any neck pain.
c:::J pajn prevents me from lifting heavy weights off the c:::J I can drive my car as long as I want with slight
pain in my neck.

=
floor, but I can manage if they a.rc conveniently posi
tioned, forcxample on a table..
= I can drive my car as long as I want with moderate
pain in my neck.
Pain prevents me from lifting heavy weights,but I can
manage light to medium weights if they arc convcn
= I can't drive my car as tong as I -want because of
moderate pain in my nock.

=
=
icntly positioned.
( can lift very light weights.
= I can hardly drive at all bcc:auscaf severe pain in
my neck.
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
= J can't drive my car at aU.

neck. S«tion 9 • Siuping )

= I am read as much as I ""'ant to with slight pain in my
ncd<.
c::J I have no troublesJccping.
c::::J My sleep is slightlydisturbOO (less than 1 hr. sleepless).

= r can read as much as I want with moderate pain

in my neck.
c::J My Sleep is mildly disturbed (\-2 hrs. sl~less).
= My sleep is mooCr.ttcly disturbed (2-3 hI'S. slc:cplcss).
)

= 1can't read as much as 1want lxxausc of moderate

pain in my neck.
c:::::l My sleep is greatly disturbed (3-5 hrs. sleepless),
c::J My sleep is completely disturbed (5-7 hrs. sleepless).

I = ( can hardly read at aU because of severe pain in

myncck.

I = I cannot read at all.

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.

I
S«1ion 5 - Headach~s
~ I have no hC<1dachc:s at all. = J am able to engage in all my I"CO'C.1tion ;]ctivitic:s, ....; lh -J
some pain in my f\CCk..

II
[=: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.
= I am able to engage in most, but not all of my usual
recreation activities bocausc of pain in my neck.
[=:J I have $Cvere headaches which come frequently.
~ r have headaches <llmost aU the time.
= I am able to engage in a few of my usual recreation
activities because of pain in my neck.
}I
1\ = I ca.n hardly do any recreation activities because
of pain in l-:ly neck.
11

I• = I can'l do any rccreJtion activities <It .111.

~ Fig. 4,7. Neck Disability Index.

I
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 <;HAPTER 4 : PAIN AND DISABILITY QUESTIONNAIRES IN CHIROPRACTIC REHABILITATION 69
ILLNESS UEHAVIOR QUESTIO,,"-:AIRE (IBQI LSES OF PAIN AND IJISAIIII.ITY
QlESTIONNAIRES IN C\SE
First reported by Pilow~ky ilnd SPCl1(~ ill 1<J76.;~'-· the IBQ
YL\\A(;E\IENT ITahl,' ~..\l
\Va!\. dcsignctllO aSSlOSS fundamclu;11 altitudes (Owanl "i...· kncss.
the role of doctors. ~lIld a VariL:ly of ~Hha psychnst\\..'ial v<tri· Timin~
abies considered imponal1\ in explaining abnormal illlll;SS
/;0.\,'1"11", TtH:d s\..·ores I'm each lest help to darify and quall-
bchJ.\'ior. It consists of 62 items ;\n:'i\\'crcd in ;\ yc"/no 1';\"
\ ., .
" shion and comprises sevell factor seaks. The no'liability of
tif~ Ih\..' \..'\Ielll of
p;lill :l1ld disability. Tlll~sc scores l:all be eOIll-
parl'd lt1l'XPCl:tcd \';lIuc... in thl..' literature or within Illle·s uwn
J
thc:-.c scales 011 test/retest correlations has been hel\\ l"L"n 0.(17

I ;\"") dillll"al p\lplIl;uit\ll.

ano (1.~7.
Indi\'idu;lI ilellh I..·:in [ll"\lyide IllL':1I1ingful inrtlrlll:lli\lli (,n
The following !"oK!S h;\\,c hccn rcpl~rlcd ;lhllUI the IBQ. II
\\t)r'I-~':h~' i~~lle~. rtlr cxalllpk. Illl thc Chwestry llr NDI
) has good correlation belween patient .IItU spulIs,,1 ~\'aIUaliuns.
~c;lk,. any itl..'lll sl"orillg -l or :' rcprcscllts a key issue in
so it seems to be consistent. Factor ;'\Ilalyses have L'01111nnc<.l
Illl.' paticnt"s lire. Id\..'llIifying tllal ilCIll (i.e., driving or lift-
the seven scuk structure and. in fact. other scales ha\'c been
ing. ctl.',) as imponant and 11101'\..' highly i1\lj'h.lircd allows
found by Main and W"lddell. 1h Compar;.ltivc and L'olltrol stlld~
for indiddualizcd ~oal sClting ill Ihl' l'l'hahilit;lliOIl pl;lll of
ics demonstrated dirfcr~lIces bc(wCCIl symplOIHatiL' and
managcmcnt.
control subjects, be(wc~n various clinical groups, and be·
o twecn responders and nonrcspondcrs. Concurrcnt v.llidity has
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)
heen established bctwcen the IBQ and the ZUllg depression
() scalc;7 as well as other IllCi.lsurcs of anxiety. Waddell.
allo\\"~ for ongoing evaluation or progress. Puwiding feed-
hack to the patient C<l1l be an imponalll source of I\lotiv<ltioll
Pilowsky, and BOlld;~ correlated the IBQ to previollsly deter·
10 "ustaill their compliance with the program requirelllc1lts.
mined <'lbnorll1i.l1 illncss behavior. which incluth:d thc non·
tl A./rer m:(l//I1('lItldischargc. The hnal CV<ilLwtion Gill be
organic signs of WaddcIL 1 ') One of the strongest findings in
I
I tlwt study is the impon<1llcc of the disease conviction scale of
compared to b<lseline levels for a dctennin;llioll of towl in-·
progrill1l bcnclit.
the IBQ in distinguishing p.uienls with low buck pain who

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demonstrate abnormal illncss behavior. In other words. they
Mode of Applic'Jtioll
belicvc strongly that Ihey havc il serious problem. even
though they may not. 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".
I
~ Sickness Imp"cl Profile (SIP) is suiwble Ii-x l'ohort rcsl'..m.:h. ill which some level of palicill
1 blinding is useful to reduce bias ill sclf-n:p~,rling.
The SIP~o",~~ consists of 136 statements clustered into 12 catc·
DoC/or plus PllI;CI/{ .I(>clllwd.:. Ongoing n.:suhs_ especially
gorics thm involve issues ranging from those from the simpler
~"'!-t in the form of simple !\crial C()lllP~ll"isons (i.e .. "Your pain
ADL scales as \\.'cll as Ihose from the abnormal illness be·
'1
I,)
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level is 50% reduce,!"·'. arc provided 10 the patil'llt for,llloti-
havior rc.lIm. To address the n:liubility of the SIP. Pollilrd
vation <Ind c:ncou.r.;lgcl1lc}1t;'ll1d as I?a~ or _the learning process
cl <.II'" rcp0l1cd (estlretest coefficients between 0.88 and
th<.lt underlies the 'lpplic.ttion of;l rch"bilitati(,m program (i.c~.
0.92. with an intcrvicwcr·~ldministcrcd <Ipproach achieving
learning 1(\ cmiii,'ly-wilh iilstrllc!;(JliClC~irrl"ing tile mcaning of
a higher reliability than the self-"ldministcrcd approach.
various disahility issues relevant to their own condition), This
,£ The shorter version of the SIP has bCi..:11 rcportc.;d as equally
dis ..·u ... "iofl is especially mcrul for the h:y itcms identified al
I rcliilblc.~·l
ba... c1inl.: (i.c" '" sec your kvc1 of comfort while dri\'ing is in·
i ".--~ crc"... ing. That's good:".
Nonorganic Signs

I:
{)(J('(rJr ,,111,\· patiell( pIli.\" .\"((~a: In programm;Hic care. all
The 1l00IfJI".!.lllllic siglls of Waddell and colle"lgllcsl'J arc lISC- Ien:l ... of the clinical rehabilitation te<ll11 share in the scri'll
ful in dislill~lIishing those Ixuicll1s who manifest abnorm'll data (."ollcction Clnd feedback process_ This approach maxi-
dines" bdl<l\'ioL These signs arc the palient responses to mize (lpportunitics for positive reinforcement fnr identifying.
sevell di(ferellt tests performcd by the practitioner and in· area of poorer response, ..llld for risk-nlUnaging "redllag··
1 elude (I) tenderness thtlt is superficial or llonanatornic in areas. Pl'ogr;,un staff should usc the ongoing. data for modify-

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locillion; (2) pain with axi;i1 loading or (3) full trunk rot,,·
tion in the :'I;mding position: (4) lack of p;'lin on sit-
'--
li.Q!! straight kg raising (when supinc. lest W·'S POSItIVC):
ing the plan of llli.lnagclllcl1t as necess<lry and for kt:'cping the
program on targct for the p;.uicnt's individualized goals.

~ (5) uncxplaill~d weakncs~ and/or (6) sensory dislUrbancc: Table 4.3, Uses of Pain and Disability Questionnaires in

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and finally. (7) a pilllcrn of exaggeration 10 all pnwoc<ltive
testing.
The highc.:r thc number or positive signs. the higher thc
likelihood of l'~sponse bias to the pnill phenomenon and .111
Patient Care

Timing
• MeasufCs of post-treatment
outcome
Application
• Doctor-only
• Doctor plus patient feedback
~ • Measures 01 ongoing
cxaggcnllcd response representing critical f~IC((lrS in the p'l-
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improvement
• Doctor plus palienl plus staff

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ticlH's conditil)IL

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 I ' , ...... ~- 1I'lIt::. M rNA"" 1IIIUNt:H'::; MANUAL

CONCLUSION 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.
As r~habilitalion pro~rams develop and expand within chiro- 29. Guyal! G. Walt..:r S, Nunllan G: Mca...uring changc ovcr lim..:: Ass:.=.ssing
jlmctk. a corresponding need ~lriscs 10 document both the u.~dulne ...s of cV:llu'llion inslrul1lCnl.". J Chronic Di$ .JO: 171. 19X7.

progress of the pmit.:JH and the outcome of the care pro- 30. Bombardier C, Tugwell P: McdlOdologica! considerations in fum:lion:ll
assessment. J Rhcumatol 14(Suppl 15):(1. 1981.
\'idcd,t'~·S6
regardless of its spccilic components. The instru-
31. Kirsdmer H, Guy:m G: A IlIclhndologic:lI fralllcwnrk fm ils~cssing
ments discussed in this c1mptcr will hdp lhe modem chiro- hcalth indices. J Olronic Dis 38:27. 1985.
praclor meet the chalk'ngcs of outcome ;lSSCSSl11cnt. .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;,
REFEHEi'I'CE.."i drawing. inslfUlllcnt. Pain n:49, 19Htt
I. Valli.~ "DiC I\kHugh s: Jllrl~'''''s hehavior: C'h:dkllgin,!; Ihl.: lIlcdiC;lllllOOCI. :,\-I. Marg.olis Ril. Tail RC. Krause SJ: R'l1ing !'ysh~m for usc with p:ttielll
HUlllan.: ~·h:d . \::~. !Y:\'7 p:lin drawings. Pain 2·+:57, 1%6.
2. En~d GL: The need f(l(;l new medic;,1 nltl(kl: r\ Ch;lllclll;C for biomedi- ;\5. Tail RC. Chibn'lll n. Margolis RB: P'lin C:(lcnt: RelaliOlll' Wilh psycho·
cine. Sdcllcl' 196:1~'J. !y77. It1gic:!1 stme. polin sc\'crity, pain histnry anu uisability. Pain 41 :295. 1990.
3. Wadddl G: A neW dini\:JI llltldd for the tr,;-;lIl1lcn\ of low hack p;lin. 36. R:lIl.~fmd BV, Caims D. Mooney V: 'n,C pain umwing :1S .m aid 10 PS)··
Spine 12:632. 19X7. dlUlugical c\'aluation of paliellts with low hack pain. Spine I: 127, ItJ76.
4. Frc)' WD: FUnCli(ln;l! :t~"'e~~l1lenl in lhc 'SOs: A conccplU:l1 cnigm'l, 01 ;\7. Uden A. Hstrom M. Bcrgcnudd H: P.lin dr:!wings in chronie hack pain.
technic:11 chalkll!;c. In lhlflCm liS, Fuhrer ~'1J (cd!'): FUI1I:tion:t1 As· Spinc 13:389, 1988.
SC~SmC111 in Rl'h:ltJililalit'll. lbhimorc. !';lUl Brooks, 1984. J8. I-luskisson cC: r-,·1t.'asurelllClll "fpain. LUlcc, 2:127, 197..1.
.'i. Forer SK: Flln~li{lnal :t~~C"'Sl1lCIll inslnullclII" in nH:dical rch<Jhilil<Jlioll. 39. RC:lding Ac: CompOlrison (If pain ralill~ scales. J Psychosolll Re... 2J: 1/9.
J Or~ani1.Olti()Il:l1 Rchahil [vOlluOltOrs 2:29, 1982. 1980.
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~
(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.
.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·
-iJ 7. Gallin RS. GiwlI C\\': The COllCo:jll :lIld dassilicatiOIl of disability in loguc scale. I);lin 1:379. 1975.

~
hC'lllh inlcrvJcw sun'cy", Inquiry D:J95, 1976.
S. Harfl\:r A<;. H;u1lCr [),\. L:1l11l1cn U. ct al: Symptolllsof illlpainllcm. dis·
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
,,
I ability and llilndic:lp in low h:Jck p;lin: A taxonomy. Pain 50:189.1992. cxperimental pain. Pain 37:295. 191'19.
~~
9. r..1 cchanic D. Volkhan EH: Illness behavior and medic:!1 di:lgllO.~i~. J 42. Jensen MP. Kamly p. Bravcr S: 11,c meOlsurC1\lcnl (If "lini":11 pain inlen·
i~
Health HUlll Beh:!\' 1:86. 1960.
10. Pilowsky I: Anllorma! iIlne,." bchavior. Br J ~lcd PsychoI42:3J7. 1969.
~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;;
,~ 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
scales. Ann Rheum Dis ~1::n8. 197X.
44 Huskisson EC: Mea....urement Ilf pOlin. J Rhcum:11(I1 9:7(lloi. 19X2.

I, !
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
.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·
)
)
ChiroTt.'<"h 2:1~1. 1990. logue »Calc. Alln Rheullll)i.~ .JfI:R7. 19HI.
i~ I .1. Loeser J(): COIKCptS of pOlin. In Stanton HM. Bo.. . !' RA (cds): Chronic 47. Scott J. Huskisson EC: Verticalm 1I\)ri7.(1I1I;11 \'i~ual ;mall1gue scales. Ann
Low (hick POlin. New York. Raven Press, 198~. Rheum Dis J8:560. 1979.

I 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
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. )
I J Meil 293:(,.;2. 1975.
16. Waddell G. ~hin CJ. Morris E.w, ct al: Nonnality and rcliabilil)' in clin-
49. Seem J. Huski!'s(lll EC: Accur<Lcy of ";lIhjccli~'c 1lH,.'Ol,.;urell1ents Ill:ale willi
or withoul pn:\'iQUS S(.·ore~: An il1lptlrtam MlUfCt= of crror in serial mea·

I ical 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
surcment of suhjccti\'c stalcs. Aun Rheum Di~ 3X:5~S. 1979.
50. Cheng RSS, P()tnemnz B: Electrotherapy of chmnit' llltisculo,.;keklal

I
clinical finuinp ill low back pain. Spine 4:(J7. 1971). polin: Compari!'ull of electroacUplilicturc :Uld ;11.:t1puncturc·like tr.lI\~{·ula·
IS. H.lIlsol1 DT. Ayres JR: Chiropr.lclit· t1utcomc mea.~ures. J Chiro Tech neou' eleetricOllner...c ~tillltJI"tit)ll. ('lin J P'lin 2:I·n. 19:-:7.
3:53, 1991. 51. M:lrchin D. Lewil11 (iT, \\'yIStJll S: I'ain lIle:lSllfelllenl ill ram]olllizl'd
J 9. [kyo RA: i\k:lsuring l!le funCli(lnal stalu~ of p:llieuts with low back dinic'll trials: A cOlllparis{lu of 1\\'11 pain SC.I!c.... Clill J Pain 4: Ill!. 198$.

iI 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.
.'i2. ~-IcIZ.lCk R: 'lllC fo.-lcGill P;lill Que,"l;lllln;lirt.,: :-"l:~\lr pr\llx'nies ;lIJd !'l·or·
illg melhexh. t)ain 1:277. 1975.
53. Metl.ad R. TmgcN)l\ \\/5: 011 thl' l;llI;;U;I,gC or pain. Anaesthcsitllngy
;\4:50. 1971.
5..1. Duhui....~on D. Md7.a1.:k R: Cla"silh:"ati(lll (If clinical pain dl's<:riplillrl~ h~
~2. Bennell AE. Rilchie K: Qucslionll;lin,:.~ in i\lcdkillC: A Guidc 10 Their nlulliple gwup discrilllin:l111 analysis. Exp Neurol 51 :..1::'0. l fJ76.
Dcsign .lIld Usc. London. Oxford Univcrsit)' Press. 1975. 5:'1. Allcn RA. Wc;nm,lIIl1 RL 11le MPQ in Ihc Ili;lgllHsis uf headadl l'.

I,
2.1. Fordycc WE: Beha\'ioral ~lclhods in Chronic Pain and Illness. 51. Louis, Hcadache 22:20, 19K2.
CV Mosby. 1976. 56. Phillip, I-IC, Hunter MS: P'lin b..;havior in hC;ld:l1.:he pali~'llls. Beha\' All:!I
24. Bradhurn NM. Sudman S. Blair E. Cl .11: Que~li(lll lhrt=at and rt=sp<m"c Mod 19:251. 19SI. ,
hias. Public Opiniun Q .J2:221. 1978. 57, Reading AE: 11n: inh:rn'll "tmclun: nf the. McGilll':Iin Quc!'liunnain: in ,;
25. Philips RB: 111e challenge of proving lhe cfficacy of chiropraclie: dy."mellOrrhoca patiCnls. Pain 7:.153. 197 1).
Plat:coo. Hawlhorlle and Pygmalioll effccts in rcscarch. ACA J Chiro 5X. Pricto EJ. Gcisinger KF: Factur-;lIlalytic studies l,r Ihc McGill P,tin
20:30, 19S~. Que"lionn:lirc. III Mclz:u.:k R (cd): i':lin l\-!c'l'un':lII\,nt alit! ASS6SIllCJ\1.
26. Cronbaeh U: E!iOSCllli'lls of Ps)'cho!Ufic,11 ·lCsling. 3rd Ed, New Yt)rk. New York, ROlven I'n: ..... 19RJ. pp (1,\-70.
Harper, 1970. .'\9. Byrne M, Troy A. Bradlcy I~t\. \'1 al: Crll~~·\"'lliil;lti<lll "I' lhl.' f'lctnf stftH:-
27. Keating J. Ikrg:llI:lIln T. Jacoh.~ G: Inlcr-~xailliner rdiabilily of cighl lurc f)f the MP(). !'ain Lt 193. J fJS::!.
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cvaluati\'c dimensions (If lumbar scgmcntal :lbnormality. J M:tnipubti,·c
Ph)'.~iol Th~r 1.1:-163. 19~)(J.
(-(t. I't=:lrce J. Murley S: I\n C1\perilllClltat ill\'e~tig,;Jlioll llt' Ihe Cllllstnscl va·
lidity flf the McGill I';lin C}llC_"lilllll1;lirc. I'ain ."\9:11:', IllS\).

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 CHAPTER 4 PAIN AND DISABILITY QUESTIDNNAIRES IN CHIROPRACTIC REHABILITATION 71

J 61. llurkh;lrt.1t ('$: Tho: usc ui the t\ktllii 1';1111 Vl....:-lh'llll.":.: III a,~",'..,in;: :-.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.
! )
anhritis P:lill. I):lin 19;305. 19SJ.
6~. Alldr:lssik F. Bbnchard EB. 1\llk:- T.":I al: Ass...ssin;: Ih~' rc·.h.:ti,·c·;I' WC'1l
.
-::.. l'illl'\.~"~ I. Sl'l·n..:.... Nt>: ,\I:lIllltd f"1 lh' Illtt~'" l\,,:h:I\·ltlr Q\lco~ti(1l1n;\irc
j :IS lho.: s...nSUf)· comjlnno.:nl of hcad;l.:h~· pain. 1k;lIl:ldl': : I'~ IS. IIJS I.
63. Fairh;l1lk JCT. Couper J. Davio.:s JB. <:1 al: 111.... OS\W~lI~ I.,\W Had, 1';lil1
OBC)). :ull Ell. Addaitk. AIISlra!l;I: L·nn .... r:-ll}· uf :\ddaitk. 19S.~.
it,. :"bill CJ. W.,.I,ldl G: A t.:1l111l'ari~(ln ,'Il")~l\ili\'c lll~':hllrcs ill Inw 1':I..:k
I (--
, .I ludcx. I'hysiotho.:r:apy 66:271. 1%0. p:lin: SI:IIl~II~·.11 ,trtKlllrC ;tnt! dinicli \:=Iidil\' ;11 initial ;1':-CSSlllCIll. I'':lin
1 (~. Ruland t-.'" Morris R: A study of th..: nJllIr.11 hiSl<If)' tlilcm 1-o;l("k pain. }';I(I .1(,:~:n. !,JIlI
"
J 1. De"elopment (If a reliable and ~':lhili"o.: 1110..':1:-111'...' l't" ,h •.lhility in hll\ i7 l'ilo\\":-k~ I. Ch:q'l1l;1ll CR. lh'lli c';1 JJ !':Iill. do.:Pl\·~~itl!l :lI\d illl\\.'~'; b..:·
had.: pain. Spin.: S: 141. 198.3. 11;\l"i"r ill ;I P:\l1l dini.: p'lplllatillil. I',llll -l: I:-\:;-. l'n7.
!l." Polb~;l CA: I'rdilllin:lry valid it) ~llIdy of Ih... I':lin ()I •• lhility Im!.::--, 'So W;lddcll (i.I'lllll\,ky I. BlInd t'.... IR: CI:lli,·:tl a~"~',~~I1\':111 :Illd illl ...ql1.:t:llillll
Pcrco.:pt Mot Skill~ :'19:974. 19S·l. or abnpl'l1l:11 illll"" h.:ha\'illr in 101, 1'.,.. " paill. 1':lill ,,1):-11, IIlX'J.
j 66. Kccofc FJ, Wilkins RH. Cook WA: I)irn·ltlhso.:r\,alit>n Ill' r;l1n h.... ha\'il)r in il). W;ultkll G. \J..:Cull~lCh J:\. KUtIlm.-l E. ~'I al: N'lnnr~:mil· phy... il·al .. i~ns
(")
I ' / low b:u.:k p:lin palicol\ls durin~ phy:-kal cX:lIuinatiun. 1';1111 ~n:~'it). It)X4.
(17. JcIl~CIlIU. llr:.Jdk)· LA. Linton 5J: \'alidatioll (If:1II \lh:-.:n;ltiuII m,,:thtld
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..:
II iJ
XO.
of pain a:"s.....~slIlcnl in non·chrunil' h:ld: pain. Pain .31J::to'!. 19S1). \'alill:uillll ,,1';( he:lhh sial us 1ll :I~lIr..: \1.:11 Clr.... 1J::'I7. 197(1.
, £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.
S 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
()

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1987.
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.
X~.
~1altlS tlll~·'II\llln;li,~·. lin J I kalth Sa, h:}I)Y. I InCl.

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.
~ 71. Tail RC, Chibnall JT. Kr:1USC s: 'nK' P':lin Di.~:lhi1iIY Illd~": P~ych(llll~'lrk R-l, D"'yl\ J{,\: C(ll1lp:lI':lti\"~' \":Ilidity 1'1' th.: Sidll~'SS llllp;ltt Prolik :\I1d
t)
I >'. properties. Pain 40:171. 1990. shmlcor ~c:lk, fur fllll...·li,lll:11 a...:-...·."m.::1l in It.\\, "a~·k pain. Spin..: II :'J." 1.
I 72, Lcavin F. Garron DC: Validil)" (If:l Bal'k P;lin C1a~...iliC.lIl(ln St.:;lk ;UlIilll¥ 19X6.
)
J p<lliclllS with low back pain nul a"o,:iated wilh d~'m(\n~lraMc organic
dise"sc. J Psychosolll Rc.~ 2.3:301. 1979.
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.

1! q, ,.)
13, Lca"in r-. G,lrron DC. V;llidity of a R~d Pain C1assilic':Hion Seak for do.:·
lccling psychological di~lUrhancc :1-.. me:lsllft:d h)' lh~' \1\1P1. J Clin
Psyclml 36: 186. 198C}.
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.

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

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Determining. th~ most cosl-clTcCliw IrC.llmclll {kp~nds on ap-
propriate lllcasur~-!.!l~L~).r tr.catlll~lli resulls. Sut.'h measurc-
ment is called ouTcomes lIS.H'SSllll'lIf. The dcvc!()pnlcni·o-r out-
COIllC "ssessmcnt tools for -objccti vc measurement of a
sirive IOw'\I'(.1 objeclive quallliliC<ltion .md measurement. we
s!lollidnollimit ourselves 10 quantification alone.
Objective Ollu.:ome mcasurcments :'Ire incrc:'lsingly rc·
quircd to ensure reimbursemclI( for care prO\·idcd. They help
(<, p<ltient's response to C.lre Iws becomc a major research en- 10 document Ihc pillient's status in terms of Iheir subjeclivc

1 " deavor. for musculoskeletal problems. it is essential to assess

ohjeclivcly deficits ill hiomcchanical function. including
complaint. functional loss. changes in acti\·itics of daily Ii\,·
ing, psychosocial problcms, and timc off work. They also pro·

I --~-'~

\.J'
r.mge of motion. muscle strcnglh/cndur:'ll1cc.•1l1d (;IH.liO\,;IS-
cular fitness. Questionnaires. algometry. ;Il\U other loob .lIso
vide objective baselines thai C~lIl be used to show the palient
their progress oycr time. This feedback is a motivational aid

I make il possiblc 10 qUiHlIiry disahili\)' and Ihc suhjeclivc cx~

pcricnce of pain. Using functional outcome assessment tools
to evaluate the progrcss of an injurcd worker or p:nicn! allow!'
Ihe provider C.lll usc 10 encourage the patient.

MEASUREMENT OF PAIN, DISABILITY, AND

I a shift in emphasis away from subjective f.lctors of pain 10- PSYCHOSOCIAL STATUS
;)
ward more realistic funclional mC'ISllrcs. Rchabiliti.llion begins with a Ihorough history from the p;;J-
In lhe majority of soft tissue injuries. functional changes liclll. The history should identify various features about thc
")
-, ,

!, arc the only objective findings on which to base treatment and pain. occupation. lifestyle, and psychosocial status or Ihe in~
,,) to judge progress. Unfortull'llcl.y_.lUOSLOrlhapcdic exmnil1a- divid\lal. Cerlain objeclive lools that complemcnt the tradi-
'" -
lions rei\' on te~as that search for structural lesions (i.e., nave
.
root compression or tension). Although structural lesions arc
tional history.taking process arc shown in Table 5.1.
\Vaddclrs signs of abnormal illness bcha\'ior arc impor-
0 present in only abou.l.f9.?t oX cascs. ovcruse of expensive di· tant in paticnt evaluation. The presence of three of five of
agnostic tcsts (i.e" magnetic rcson::tnce imaging) is typic.1I in Ihese signs is signifk:antly correlated with dis~lbility.l~
Ihc search to diagnose such struclUral pathology. I The r~­
Supcrlicial or l1ollal1atomic tenderness: WiJL':;pr~;\d sensitivity to
~~) rnaining 80% of p.atients havc no idcntifiahlc.structural patho.
iI ligll1 low.:h in Ih~ lumb"r region and pain rckm:d 10 olher ~rcas.
~/./logic-a6oormati"[Y-andrequire treatment based on the evalua·
"ud~l..Qr..x. ~;U;fllnl. or pclvi~.
I -liqn of functional deficits. Outcomes assessment that includes Silllllilltior;: ;\.xial ](~jing (ligi"lt prc.\surc 10 tilL' ::kull) ~h(lllld lHH
4 objective functional testing gives third P;\flY payers. the pa- ~i~lljtic;llllly incrca~c low h;lI.:k paill~ Passive Hlt:l1i~)l) of lhe shou!·

I•, ()() tient. and the doctor a way 10 measure progress over time and
thus adjudic:'llC the prescribed treatment 'Ipproach.
Treatment of functional deficits is addressed W~h.J~llIlC.­
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
~ lieun' D"lcliv·Jtjon/rcsloratiun.programs. SlUdics havc demon· straight leg raising Icst~.
! () s(rated Ihal more than 809r of chronically disabled individu- ncgional dislurlmnct.'s: SCll~ory or m(llm t1i:'lurhancc ("giving
I~ al~ can rcturn to work if n.:habiliti.llion based on objectivt.: way") th'll is not ncurologically correlated.
Ovcrrc~lc.lion: 11l~lprropri~llt: ovcrrcaelion. such a:, ~uartji!lg. limp-
0 quantification of function is used as the standard of Glre.>:
t, Although quantification of functional deficits is the goal. this
attempt is only in its infancy. Many physiologic paramctcrs or
ing. rubbing the affcclcd .In;a. bradng (lllc~c1f. !=ril\l:\cing. or sigh.
ing. arc all sigll~ of illncs:-; hehavior.
.~
thc musculoskeletal system C~lJlnol be realislically measured Wernecke el al found thallhesc bchavioml signs could be il11·
i <)
~: quantifi'lbly. Intersegmental <lcccssory motion between artic- proved in individuals in a phy:-ic:.i1 retwbilitation progr:,ull.1.l
Ig ulations is palpated regularly. but interexamincr reliabililY is
poor and no quantification is possiblc. Palpation of areas of
Measuring pain intensity and flll1ctionalloss as a result of
pain <Il 2- or 4~weck intervals helps to dOCUlll!.::nta patient's
il tenderness by :.Ill algomcter docs nOt resemble mallual p'llpa- progress ull(Jcr'c;lrc~'Thc Visual Analog SCOlk (VAS) c:~n e·~cl1
i f.) lion, although it is quantifiable. Visual inspection of th~ pos- be ~;Scd -\vlih each visit along with a pain drawing (sec also
~
tl ture. g<lit. ilnd movement skills of'l patient is pan of a qllali- Chapter 4). The VAS c:m be liSCO to assess characteristic pain
1y {,) tiHivc eX;llnin~ltion Ihal is clinically invaluable. While we
www.bodywork.su
intensity "right now," ";l\!er~~;d.~ain:' and ··\\'(~.t pain"'::--~i
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 HCNAOlLIIAI1UN ut- IHt: ~PINt::.: A PRACTITIONER'S MANUAL

I Table 5.1. Objectification of Subjective Factors

Pain
Visual Analog Scale (jnlensily)~'
ferred pain). Finally. it helps to identify signs of neuropathic
pail1 (hyperalgesia 10 non-noxious.stimuli).

Pain drawing (localion)(,'

1I McGill (qualilyy
Psychosocial
Beck.~·
FUNCTIONAL CAPACITY EVALUATION

A key to successful rehabilitation of the musculoskeletal sys-

I1 Zung 7 ' O tcm is funclional assessment. In contrast to the clinical exam- I
Back Pain Classificatlon Scale"
j SCL·90·R"
ination. this cvaluation is not important until thc patient is I
I
"out" of thc acute episodc. As soon ;IS a paticnt cmcrges from
I FA80'J
Waddelrs behavioral signs ,-,- lhe :Jcute st<1ges of an injury. objective mcasurement of func-
I
I .,,

I LifestylclOisability
Osweslry\~'
Neck Disability Index'(.·
tional Olj{comes is nccessarj. 111is infonnation gives the dac-
lor. patient. and third pany payor means by which to commu-
"I
! "")
I MiVion"
Vermonl'~
Roland·Morris'~·
nicatc the status of the patient and to identify the goals of
c'lrc. ;
I Dallas Pain OueSlionnaire:;>Q'
Sickness Impact Prolile~' n
The chief purpose of the functional capacity evaluation
(FeE) is 10 demonstrate objectively an individual's level of ')
i!
Pain Disability Index;~
impairment as it relates (0 both pain and disability.)'·.l~ This
Job Dissatistaclion
Apgar~~ cViJluation gives objective infonnation to the health care .,
provider who can then rationally prescribe treatment aild then
'Especially simple and practical 1001 lor oHice usc.
monitor its results. In addition. it provides (he patient with oh- ")
,

I
jectivc feedback on how their injury and/or pain aff~cts their
Average and wo~st puin should refer to the previous 6 months ability to perform normal activities. as well a.c; an objectivc ,
"

in the case or a chronic patient. If mcasuremcnts arc made at way to see their progress. Finally. the FeE provides the third
intervals during the provision of cme. it should refer to the pe~ party payor with objective. quantifiable evidence of imp<lir- .~,

,~~
riod since the I<I:-;t asscssment. lllent from injury or subjective complaint.
! ,
1 The mean of the threc pain intcnsity mcasurements should According to Mooney. an FeE is recommended 2 weeks ;
be multiplied by 10 10 yield a 0 to 100 scorc. Characteristic after injury to identify the "weak functi0nal link" (sec
pain intensity less than 50 is cl;]ssified as low intensity; any- Chapter 21). Trian"o suggests 4 weeks as an appropriate time )

II
thing above 50 is classified as high intcnsity.17 to begin testing (personal communicntion. 1(94). Harr.
Questiollnaires such as the Oswestry or Neck Disability Iscrnhagen. and Matheson wrote thilt the indications for func-
Index, pain dhlgr•.lIns. and the VAS should be used Crom the (ional testing include plateau of treatmcnt progress. discrcp-
outset of care. A good rule of thumb is to obtain baselines at .mcy between subjective and objective findings. difficulty re- ,)
the patient's initial office visit .md repeat thc outcome mca·
surements a~ weeks 2. 4. and 6. After 6 weeks. most patients
turning to gainful employment. and voc.llioTlal planning or
medicolegal case scttlement. H FUIlCliofla{ (esting ill the sub-
, /!
are well. Whcn treating a complicated patient (one prone t.) acute .wage can prm'ide ideal Olltcomes Wi lI'ell (IS help lu

I
chronicity), however. it is rc,lsonable to continue tr..lcking idell/lf)' key fimctiolloJ pU1Jwlogies Ihal !iIIOIlIcJ b<' m/(/resJ('t! )
their OlUCOlllCS cvcry 4 wccks. These measurements c<ln help u:itlllll(lllipularioll, addce. (lIf(J exerci.w?
immeasurably with stubborn insur.mce adjusters or utiliz<ltion The FeE allows objective confirnwtion ()f patient staWs to
reviewers becausc they docul1lelH the patient's progress under complement the patient's Stlbjcctivc sclf~repol1 of their symp-
~1 your <:arc. toms. It also documents patient progress ovcr time, which
I Quantiflcatioll of soft tissue tendcrness is also possible helps to motivate the patient to pursue re<lcti\,.ltion after in· ,/-
I with a pressure ~llgotlleter.~~ This device measures soft tissue
compliance. Prc- and post-treatment chccks of tenderness can
jury. Prolonged passi\'c care (e.g.. hm packs. massage. ultra~
sound) directed at providing symptomatic rclid may only
[.

I thus be quantified. Qualifiable ~lsscssmcnt of son tissue ten- achievc short-tcrm resuhs,·\.l·-'~ \Vhcn symptom:ni(', not func- )
dcrnes.. . is also possible~'J··"J by applying 4 kg of digital pres- tional, outcomcs arc the patient's only goal. incomplete hcal-
sure (cnough pressure to blanch the tip of the thumbnail when ing. chroni<.: pain. and ovcrtrC.lllllCllt oftell n:slllt.,I.I.\~ This

I
pressing the palmar surface of the thumb against a rigid sur-
face). The grading schcme shown in Table 5.2 is adaptcd Crom
\Volfe ct aF'} ;lnd Hubbard et ~11.·lU Table.~ Tissue Tenderness Grading Scheme~.>o· .J
h i.. . also of value to notc the presence or absence of rc· Grade o-no tenderness
ferred pain (expanded receptor field) 'lssociated with soft tis· Grade I-tenderness with no physical response
.~ Grade It-tenderness with grimace and/or flinch
sue palpation of an ilfca of tenderncss. Documcnting areas of
I soft tissue tenderness. along with their potential patterns of re-
ferred pain. serves a number of purposes. Firsl. it helps to es-
Grade
Grade
III-tenderness with withdrawal (+Jump sign)
IV-wilhdrawallo non-noxious stimuli (i.e.. super1icial palpa-
tion. pin prick. gentle percussion)'

I
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tablish a baseline level of soft tissue tenderness or sensitivity.
'Adapted from Wolfe cl OIl...• and Hubbard el at:>'>
www.bodywork.su
Second. it helps identify trigger points (+ Jump sign and rc· lin noninjurod lissue, a sign of neuropathic pain.

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 .... n1-\r-1 t.H :J : UU I COMES ASSESSMENT IN THE SMALL PRIVATE PRACTICE 75

(.:011111\1 111 _,illJ:llillll i" lilt' ;llb.Hross til' ":l1lploycrs ,lIld insur;uKe Table 5.4. Key Aspects of Musculoskeletal Function
((lmpallil..'s ;llikl:.
Static (Maintenance 01 Posture)
The "~pons medicinc" appro;lt..-h. which l1lcaSUfe~ fulH.:- Posture
tion;1! impairmcll\ and lI:'\CS active cx..:rdsc to rdl:lbilit:lte in· Balance
Dynamic (Production and Control of Movement)
jured ti'slIcs. is rCl,"ognizcd as the "sl:llldanJ of c;lrc" for :'\ofl Mobility.1lexibilily
tisslIl' injuries.:· t:.;,. This ,Klive approach is bel1er suit..:d 10 ;ll~ Strength
Ic\'i;ltill~ p:lill, (ulllpkiing sofl tissll~ he:lling. and pn:\"l:llIing Coordination
Endurance
I
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1\.'(ll,"l..·urrI..'IKCS.

Thc FeE shoultl be m.lI1datory for any patient slill ..:xpe-

Cardiovascul~r lilness

riclI(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 normal fum:tion,"" Using elcctromyogmphic (EMG) evalua-
fUlIctional tests mcasure nexibility. strcngth .. ·.mortlinmioll. cn- tion during isometric trunk extension, they demonstrated dc-
tlm'lll(c. ;'lcrobic capacity, posture, and balance. coupling or asymmelric lumbar paraspinaf muscular activity
The FeE idclHifies intrinsic jmpairmenls in the individ- in pmients with low back pain who were considered nonnal
ual. Oflell. the extrinsic dClTl.and~ of the work environillent arc on dynamomelric tcsts. This dccoupling was also useful in
thl: o\'l:r\oadin.g or injurious f..tctor. A work capacity e\'alua~ differentiating pain and noupain subjects.
lioll (WeE) or job i.lllulysis Illay be required to identify such The study by Grabiner and colleagues points out th"11 mus-
potl:llli,11 sources of repclitive overload or injury. The combi- culoskeletal function involves coordination as wcll as
nation of an F"CE, a job "lll,i1ysis. and a WCE will help to idcl1~ strength during performance of a specific task. Simply be-
lify rctunHo-work outcomes and spccilic crgollomic and ex- cause u patient passes a battcry of technologically advanced
cn.'ise instructions for safe sining. lifting. or other repetitive tests docs not necessarily mcan their spinal funclion is nor-
tasks in lhe workpl<lcc.'-·1., mal. The EMG tcst not only points out the limitations of high-
The focus of the FeE should bc on rdeY,lnl functions that technology dynamomctric testing of muscle strength and
C;1ll be safely and reliably measured. Normative d:lta bases. endurance. but suggests that overl}' harsh criticism
wllerc they cxist, arc most helpful. \Vhcnevcr possible. quan· of 100.,.'er technology evaluations of coordination may be
lilicalion is ideal. The IllOSt valid teslS arc those Ihal most unjustified.
closely resemble: the ;letual \v;'IY lhe body is used. As Lcwit puts it ..... in many fields of medicine the im-
Unfortunatcly, validity is often ignored as evaluators become portance of changes in function is now well recognized.
infmualcd with highly technical tests possessing high repro· whereas in (he motor system.. where function is paramount.
ducibilily .md rc:liability. Matheson says. 'The intcrprctation this fundamental aspect is rarely considered. However, the
uf the test searc should bc able to predict or reflect the c\'al- functioning of the locomotor system is extremely com-
lIec's perfonmlllcc in a larget task."·1') If'lll effort factor can be plex, ... and diagnosis of disturbed function is a highly so-
mcasured, this information will help to unlllask .1 m<l.lingerer. phisticated proceeding carried out. ns it wcre. in a clinical no
lvla,hesoll indicntcs that the best tcst is onc that is valid. rcli- mall's I:.lnd..... l
'11.11e, and safe..\'1 Tables 5.3 and 5.4 pro\'ide thc imponarn :lS- In the Presidential Address to (he Cervical Spine Research
peets of functionaltcsls and the kcy functions of thc IllUSCU- Society Annu.i1 Meeting in Decembcr of 1991. LaRocca crit-
loskeletal system lhal are necessary to c\·alu<ltc. icized his colleagues for jumping to a psychologic dingnosis
An FCE docs \lot requirc great cxpense of time or money when they cannot Hod a structUl:.11 C<\llse for a patient's per-
in Ihat it can be. accomplished with low technology instru· sistent pain: ..... The error here is the autornmic leap to psy-
J. mcnls such as a lapc measure or inclinometcr, A "low-tech" chology. It assumes that all organic factors have been consid-
I approach CiHl be accomplished in nbout 20 minutcs of ofl1ce credo when in reality the clinician's npprcciation or the
( complexity of such factors in often severely limited.'·~~
tittlC. Highly technologic dyni.lmetric assessment of low back
gi
I
function has becomc the gold standard of lumbar spine func-
tional USSCsslllcnl. Because:: il is reliable and reproducible. it
Newton and \Vaddell said, "There is no convincing evidence
Ih;,1t isokinetic or any other iso-measure has greate::r clinicnl

01 servcs ..IS an cxcellclil outcome assessment tool. The validity

of it number of technologicillly advanced tests, howcvcr. is
utility in the paticnt with low back pain than either clinical
evnluation of physical imp<iirmclH, isometric strength, simple
questionable. Grabiner el al demonstratcd that norillal isoinertial lifting or psychophysical testing...~:t
strength Ille.lsurcmcills ;,lIone do not necessarily correlate with At prescnt. the quality of high technology rests is nol
I
01 demonstraled sufficiently to lead to the abandonment of lower
i technology tests of spinal function. Many low technology
W:'lyS to identify functional pathology arc reliable (sec
Table 5.3. Critical Factors for Functional Tests
Chapter 8).~11 Often. if the musculoskeletal function of a pa-
Valid/relevant Normative database tient cannot be quantified, qualifiable tests may be performed
Reliable/reproducible Cost! practicality that give insight illlO valid muscle imba1::lOccs. joint stiffness.
Safe
postural dysfunctions, .1I1d movement incoordination.
www.bodywork.su
76=- -:R.::E::H.::A.::B::I.::L-:1T~A~T:.:IO:.:.N:..O.:::..F.:.T~H::E:.:.S::P~I:.:N.::E:.::
A-:..:..P:.:R:.:A.:::C~T:.:1T~IO::::.:N:::E:.:R:.:'S:.:.M=A:.:N:.:U~A:.:L

In 1987. the NIOSH Low Back Alias idclltilicd 19 tests

with signilic<llH reliability <.7-l Cohcn'~ Kappa and >.79 co-
cflicicnts 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
!lether had a sCllsilivilV of :'\7~;,--;:llId it sp~'.itkil\:~oL9J.s:~/rhc
;nost i1l1!1ort<lnl 1l-1c·~i·;:~H:c~i~~·~!s \\,('rt.'
or SYlllll1~.try, sll:cnglh.
passive mobility, <Ind dYllalllil.: mobility. Rissancn and co-
\vorkcrs found thaI lH)lluyn<ll11ol1lctric lests ClllTC1<ucd h~'ttcr
with pain and disability than did isokinctiL' tcsts."s Thcy COll-

Fig. 5.2. Dorsolumbar extension.

eluded. "The non-(I\"namomctric tests arestillJJsel"td ineJini-

cal practice in ~Jih~~i~·;~h;I;·I~~~;·of aecur;!tc ll~~';~­ more
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 pa-
tient..; with chronic pain,li! Alaranla and co-workl..'r.; ~hnwed
t"eli;lbilily and cswhli;-;hcd a normtltin.; databaSL' fllt" h\\\ lcch-
110h'S)" les!'> on more than 500 indiYiduals,7!
Fig. 5.1 Dorso·lumQar flexion. "Inclinometer used is the Duater ."\"sessing impairmcnt i.., crucial to rating t11'..' k\ ~'1 \.'r per-
from JTectl (324 West 1120, North American Fork, UT 84003). \.'1..'111 Ill" illlp;!innclIl ~\ patient !J,IS surfered. II is al.;,' lill: ollly
www.bodywork.su

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<.;HAP'':'R 5 : OUTCOMES ASSESSMENT IN THE SMALL PRIVATE PRACTICE 77

\)hjc,.:II\ ..· way 10 ~Il()w pro~r~ss and 10 dOl'lIlllCnl the Ilt.:'cd for • Sensors arc 7.crocd and paticlH is requested to ncx max-
(unhl'r <rl';l\lllL'tI!. It i~:lbsolulcly l'ssl.'lltial ill cases il\\'oh"ing imally. the new angle is recorded
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
C· ..::. 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 •
_
J
till 1111l\;':[";;l1 OUICOlllL'S ;lssCssmcnl tools. ;1IIt! l)uamiliahk
tl!L';\,.U: ..'UlC:llt is ;lh... "ht!l.'IJ' key to this proCC%. ErrCII.'i;rl/l (Fig. 5,:!)

Starting position is the Silme as for tlexioll

FUIH:tioll:l1 Tt'sls
P.uicJ11 is requested to extcnd maxim'llly. and the angle
Durin.:: fUIll:tion:d (~~til\g.
thc clTcl:(s of movcmcnt and posi- is rCL'ordt.:d
litlllllll lh~ ht.:h;lVi~lr of pain. thc painful or painfrce range. and
thl" I.,'fl;.'..:ts or rcpc~ltt.:d tcsting should be determined. Lateral flexio/l (Fig. 5.3)
Sl."IlSilrl. ily hI various movcmcnts ,llld positions. along \vith
Starting position is lhe Same ;,IS for flexion
any \\l,'i:;ht-hcaring illlolcr<lncc. should ilIso be dctermined.
Palienl is requested to side bend maximally to the
This inl(lrmillioll helps to cSI,tblish the functional or training
right/left
r.LlIgt: !lIthe p:llicnt (sec Ch.lpter 14). Evaluotion of posturc.
To minimize rotation. patient is inslructed to slide fin-
g<lil. ilnd muscle length arc not discussed in this chapler. but
gers along the side of their'leg
this a,,;.'o;Sl11CI1( is L'ollsidered important clinically (sec
Angle is recorded
Cl1apll'r~ 6 ;Illd IX).

QI/lIllt ificat iOIl

Ohjf.'l:ti\l·. Quantifiable Tests '
Final angles arc recorded
STAND,nG
Normal vaILlcs~·1
Lumbar Spine Ral/ge oj ~/otiol/ Trunk nexion, 60° v'"
I-'I('X;(lI; / erector .,,/lil/etc jh'xihi!ity) (Fig. 5. I) Trunk extension. 25°""---
Trunk lateral flexion. 25" v
P~lticlltst:lnds with knccs straight ,lIld feet slightly apan
S;.'n~ors arc pl~lL'cd on thc sacral apex and TI 2 spinous
PIIl/)OSe
proct:ss (lise skin marking pencil) --
Screening tests for erector spin.ac (ncxiotl) or quadratus
':\ \ hk,,:.. ~·: ~,]{I ul',I.,I...,I"'\:""lrl,llillrl r,.rll" un lit... hmcliunal C:lpKily C\':.h/:lliun h~' S.
lumborum (Iateml flexion) tightness
,"''''llI,:n. ~:-: ,,'o>ll:Ihk fr'"11 xon""'}.'-72fi.'>. Screcning tcst for lumbar joint stiffness

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Fig. 5.3. Dorsolumbar lateral flexion.
 Ht:HAtjILIIAIIUN Ur I HI:. ~~INl:.: A PRACTITIONER'S MANUAL

TllOradc Spine Range of J\1otioll (Flcx;Ol1IExtcllsitm) QuwHijinlli(In

(Fig. 5.4) .......
The 1\\'0 ;lngh::s im: l'lllllbinl'd for t\lI;t1 lllC;lSlln":1l1l'lll
• Patient swnds with knees straight and li..'t:l slightly apan Norll1;l1 ,";l!ue. (l!J"~:
.:...-Scnsors <Ire placed 011 II and 1'12 spinous processes ,,.
(usc skin marking pencil)
l Sensors .m.: zeroed and p:ltiClll is n.::qucslcd Iu lkx
if1lally. the new an~k is n:cordcd
111;\:\-

i
1
SCIl:,orS an.:: zeroed :!gain after patient r::lt1rns to upri~h:
poswrc <lnd p:lIicnt is asked to extend maxim.lIly and SEATED
final angle is recorded
Trunk Rotatioll Rauge oj IHotitm (Fig. 5.5)
1 Patit.'01 is sCOIh::d slfOlddling the tahle
I Paticnt \Urns shoulders and torso as far as possihle while
avoiding trunk lkxioll or cXlCnsion (l11ay lise Slid.; 11('~
j

I Note
hind back 10 hdp \'isllali~c asymmetry)

1 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' "

J
To itlcntify if ,Isylmnctrk tfUllk rot:Ltioll lllol1ilily is
presellt. indicating probable thontcolumbar joint dys~
function
I een-leal Spine Rauge of /\!o!iou ~V,!.f,.\

I
F!ex;oIlIExJ('II.\ir", (Fig. 5.6)

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

Il recorded
Patient is requested to extend neck m,lximally and angle
is recorded

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

1 and right: angles arc recorded

I Rotatioll (Fig. 5.R)

0'"fn A.M.A. tests. paticnLis_-supilll;;
i~~15!-=.d~
g~'!Vily_ indin~lIllL'h:r

1t,
Fig. 5.4. Thoracic lIexionfextension. • P..l1iCIll TOWles hl.:'ad flllly and angle is rccordl.:'d

'd
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,~i

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 ""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.

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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
(If d>t.d l.·lId Il( II,,: fl'lIll1l'
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, r':·'.t'l'o int:lilltlllll..'I,·r till

Ihi::h ,\!ld IlIl'1\ h'l'tlll! klll'l' "ll~k h~ pl:Kill~ .. ,·Ihtll' 1111
di ... t.d ,'lid or libi:t

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,\"! ,"
IJ

A firm table is r~qtlircd for accurate 11l~<lSUrCJllClll

P~ltic01 sils at edge of tahle ~lIld brings knee 10 che ... ,
linnl)' to natl~11 low back
DOL:lor helps p;UiCllt ilS'-llllH..' supine position
Allow tcst~d kg. to cxtcnu orf table Fig. 5,6, Cervical rotalion,

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 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 pSO;I'- ... horlcnillg
Identify rlTIU, fcmori~ shnrlL'lling {lltlrln:d i:- till kill'\.'
lkxinnl
,, If hip llcxcs without klll'L' extensioll 1.11" lhi~h ahdlll.:lipll

i 0 (psoas)
! If hip Hexes wilh kllL"c cXh:nsiull (reCIll-> femoris)
!: 0 Ir hip flext . . with thigh ahthlt:lioll (TFL I

I," () No(('
!
I, n 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'x-
I, 0 lending 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'.
i~ Straiglrt l.eg Rai.'(;' (flam.\"i,-iIlJ,: Flexibility J 'Fe..:t
! iJ (Fig. 5,11 )JJ.J~.~I.~J.;<II.t.1I.M.r.r,

Iq Fig. 5.9. Hip extension and psoas. Patient lies supine on a linn tahle: Sl.'ll:'>llr is pl<lccd mid
tibia ,lIld zeroed (or strapPl'd to lower h:~ with Veknll
I Ci
;~
'<""';>'
Patient's calf is placed ill (rook of doctllr'~ elbow
Doctor holds inclinol'llL'ICr in placl.' \\'illl one hand
while opposite hand st;,hilizcs oppl':,iIC pelvis IiI'
Jhol1la~: lest is p~siti\'L'. pla~p'il1o~·_t~~_~~ OPPOSilC
knccl
P,lticllt's leg is flexed \\'ithout flermitlinf any knee flex-
ion (0 occur
Angle is recorded whl..'l1 pelvic 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 Hip ;Illgk is recorded <lflcr passive overpressure into hip

I {)
]1
':'".'
i
extension
Knee angle is recorded with addition of p<lssi\'c over-
pressure into knee flexion
1;-
(~ ,, Add hip i.mglc to knl:l' angle 10 obl'lin rectus fClllori~
i Illcasun;lllcn{ Fig. 5.11. Straight leg raise and hamstring.
i 'J"
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:"
 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 ~() abduL'liull
and tested leg at ry' abduction
Doctor firmly stabilizes pelvis
Patient's knee is placed in 90';> flexion so that sok faces
the ceiling
Sensor is placed midtibia (laterally for measuring exter-
nal 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

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 es-
timate 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
Fig. 5.12. Quadriceps. sok (11" !"pol

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 VI IM"- I en :J : UU II...oUMt:." A::i::it:.::;::;Mt:.N I IN THE SMALL PRIVATE PRACTICE 83

Foot is maximally dorsincxcJ. 11~;lking. :~i.lfC ~;,~ Pl::~ ~:::

hcel fully (knl'l' is kcpt in eXlension)
~'lay a!:-ill hl' ll' .. h.:tl Wiih patll'IH "l;llldill~ (\1' pmllc
Angle i~ Illea:-illfetl
Soleus Flexibility "['cst H.J~ (Fig. 3.1 (1)
Palil..'nl is prone wilh kilt;\,: ht.'1ll hl 90"
, Qfu,t/riJkClt;t",
Sellsor is I.el'nl'u to horizontal pblll.: alld tlll'lI pl:ll"l'd
!,
Oil

Angle of dorsilkxion is recorded sule of ('oot

~ ~orl1lal is IOlt\ 15° .• 1 FooL is lllaxil\l;dly dmsilkxL'd. Ill<l"il1~ ~1I1\: III pull 011

,I
IlI.:d rully (klll'l' is kepi at l)()( )
Angle is IllL'a:-.urcd
l • QUi.lnliry gaslrncl1cmius flexibility
QfltlUfijinl1 it"l

I!
'I
Angle or dorsilkxiOIl is n.x:onkd
Normal is 25 to 30"
~
II

I
I '"'~'"
<....J
Purpo,\'t.'
• Quantify soleus nexibilily
I,
I i~"
Notc
May also bc lcs[cd with paliclH 'tanding
I
-~.J

!I Qualifiablc Functional Tcsts

STANDING

I D
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-
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 po-
sition
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.

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__..~ , :-':.:'-,,'_.'_"_.-_'-_.'_'_'_"_'-=~:-":,,:~_.'.::.:'_.' :.:'":..: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
Pass/fail straight to about 90"' of knee llcxion
Positive tcst if patient flexes trunk while performing tcst
QWl!lrijica tlon 71
Also note:
Balance of forward fOOl Record number of repetitions patient can fX.'rform
Strength of quadriceps Alaranta ct al has published normative dm,llxlsc for dif-
Mobility of hip joint and flexibility of hip flexor" of ferent ages and genders. ~ I
back leg

Purpose
Quolijicwioll
Pass/fail I
• Qualifiable tcst for balance, coordinmion. hip extension Positive test if patient flexed their trunk or ..:annot reach I
mobility, and quadriceps strength 90'''> knee flexion

I
Squat Strength/Coordination Test Mt •71 (Fig. 5.19)
Patient stands with fcel about shoulder width apan and No!e
is instructed to perform a squat If heels raise off floor (sokus tightness)

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 !'lIr.!'! ":'

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

'Irl·I\~lh. :'(Ik'Il'" IkxihililY

SEATED
l'a"/bil
S !loll!dcr .'\ htlll('riIJII Coordiuotio/l "/('Sl ~ I.'," \ Fi g. :'. ~111 1\I,ili\\' 11."1 if 'clpubr \.'k\;liil>1l or ftilalilill 11;lll'r:lllyt
.~
.J Palil.,.'lll i, "l';l\...-d willi I..-'Ibm\ lh"l'd 1090 11' 1111lil llll- 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 <lllriblll-

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

Fig. 5.16. Soleus.

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 •••• "., ....... 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
1
Purpose

! Evnlu..ltc lumbopt.'hic coordill~ltion and control

Lower abdomin<tl strength test
i

I
f;

I
I
$
I
II
I~
I ~ --f~--~~!~~~~ -~~~ -.~~~
II 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 pa-
) tit.:nt to lirst arch. then llallen low back without r;lising
bUllocks off the lable (A)
.i• Doc~or l1l:.ty cue movement ur offer counter resistancc
~
to facilitatc coordination

I P.llicnt then asked 10 hold had l1:.lt (posterior pelvic tilt)

while sliding legs to c:Hcnt!cd position (8)·\7

i·v
Pa\ielll then asked to mise bUlh legs while holding hack
1l;1l <kgs s!l(ii.lld he hl'lcl for 2 to 3 st:collds) (C) Fig. ~,.18. Lunge lest.
,
~
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 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 gen-
ders and most age groups," Test is performed holding
duwn both feet _md recording llumber of repctilions
ulIlil f:lilurc.

QU(1I (tina ;(111

~
Pass/f;\il
J F;.til if unable [0 perform 10 repetitions without h~~b or

I ~)

0
)umh;\r spine rising off t'lble

I;
Pilr/u}se

f) • QU;'lI1tify rcctus 'lbdominus slrength/cndurancc and co-

ordination
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 Back of head should be only I to 2 em off of table

i 1) Overpressure may be added at end point

I ()

<)
Note·
If chin juts forward during movement

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

II ()

~')

0
Fig. 5.19. Squat test.
off the table and maintaining constant force of the h~ad
into a pressure eufrll

Q lUll ijj("(ll io"

Pass/fail
i () Trunk Flexiun Coordinlltio/l (II/(/ Strength JI,f,ll.(,!(,I"',lI Fail if chin juts forw;.srd during mo\'cmcnt
I (Fig, 5,23) Fail if cannot hold head just I to :2 elll ofT of tai,"lk but
I P;.lticnt is supine with knees bent. arms forward, across wiscs up further
.~
chest or behind neck (without pulling)
~
0
~~: ','
DoclOr may cont_l<:1 palicrIl's hcels or pl<Il·C hand under Purpose
,
II
the palicm·s lumbar spine
Paticl\l is instructed 10 perform posterior pdvic tilt and To identify if nel:k nc,'(or weakness or incoordin:llil..'l1 i~
'" to raise trunk. up until scapulae ;.Jre off table and thCll present
() hold for 2 seconcJs In particular. to identify if deep neck flexors art' weak
Paticlll shoulcJ hold pelvic lilt while lo\\:cring back lO ;'lIld sternocleidomastoid (SCM) muscle is overa('lj"c
"j (<tble Ste,.,wcleidomastoid Strength Test (Fig. 5.25)
Patient is asked to pcrform 10 repctitions Patient is supine and is asked to wHite head to one side
i fJ Then to raise head lip while mainwining rotatif1n and
.~
Last repetition is held for 30 seconds
hold for 2 to 3 seconds
.~ 0 Note
~ (J If hecls rise orf tablc (posilive test)
NON!

II 0 If Cimnnt maintain pelvic tilt (positive ICSt)

If excessivc shaking m:curs
If IK';1l1 i~ fonvaHlllt' trunk www.bodywork.su
If can reach full rotation
If cannot maiI1lain rotation \vhih: lifting head
if t.:;lOnot lift Ih.';I{!
i 0
"'t
~
~i'i
';j
0 L
k
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~
~
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 ' n... ' , ....... , .. , ' ..... , 'V'''( VI"" I Me ~t"INt:: A PRACTITIONER'S MANUAL

A
'")
B
.,,
-,.'

Fig. 5.20. Shoulder abduction test. Correct

c (A and S, and incorrect (C).

Qualltijintfioll

• None • To idcntify wcakn.:-ss of SCt\'1 Illtlscks

Respiration Coordination Test ~l (Fig. 5.26)
QlUlJjJicmion Supine patient is asked to take in a deep brc~lth
Pass/fail )
Fail if cannot lift head or rnaiIHain head rotation Note
Grading Doctor ob"ervcs for excessive chcSI breathing
I-Normal Also n(Jh~') hHeral chest excursion
I1~Hcad i.. lifted. but without full rotation or il canl10t Note jf ~c:alel1c muscles arc visibly ~\l,:tivc durillf rt'spi·
be mainwincd for 3 seconds r;ltion
III~Hcad cannol be lifted J

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 . . . . "1\,.... I tH ~ : UU Il,;UMES ASSESSMENT IN THE SMALL PRIVATE PRACTICE 89

Gmcemric Tc.'i(
• NOlll' Upper leg is raised into abduction and held for
2 seconds
(jlluIUi('(u;()/l Note
• If patient can raise leg
Pa~~/f;lil
:.. Shaking or twisting
Fail irdl~~t r;li . . c~ more [h;lll abdomen
.~·......A~lX hin..flcxion or hip external rotation
• Excessivc hip hiking
1'111"/10.\'1'
• Posterior rotation of upper ilium
'I'll idcntify prc~t:ncc of paradoxic breathing (chest Quantification
bn:;tthing predomillatc~ (I\'cr diaphragm) • Only with dynamic electromyography
Qualification
SIDE LYING Posslfoil
Fail if cannot abduct leg without hip flexion. if foot
Hip t1bduc(ilm (Gluteus Medius, TFI.., QL) Coordilla-
mises less lhon 6 inches. if hip externally rolates.
(lOll Test ~l,(.(, (Fig. 5.27)
pelvis rotates. or hip hiking occurs
Patiem side lying with lower knee nexcd and upper leg
extcnded
Isometric Te.'il
Pelvis placed in slightly umucked position
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
A Purpose
To identify coor~ination of hip abduction
To identify tightncssJovcractivity of quadratus lurn-
borum (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 cx-
B
tension)
Fig. 5.21. Pelvic tilt (hook lying). Posterior (A) and anterior (B). To identify weakness of gluteus medius

j
A
Fig. 5,22. Double leg raise with posterior pelvic tilt. Correct (A) and incorrect (B).
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 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 • NOJ1t.'

I;
>

I!
!i

Fig. 5.23. Trunk flexion tesl.

."i

i
II
I -"j

I ~
Fig. 5.25. Sternocleidomastoid lest.

)
.";

I
A
)
-,
1

I
}

...?
• ,V
tl

A j
,
B )
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 l
adduclcd while hand of lower arm rests on upper shoul-
der
DOt.:1Or anchors bOlh feel ,
P;llicnt ~lltcmp[S to wise trunk ofr wblc witholll using )
~lrIns for assistance B
Paticl1l i~ askl.:d lU hold for 10 s('('omJ!; Fig. 5.26. Respiration lest. Correct (A) and incorrect (B).

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CHAPTER 5 : OUTCOMES ASSESSMENT IN THE SMALL PRIVATE PRACTICE 91

• •• •• •Ii
II i j i
A B
Fig. 5.27. Hip abduction test. Correct (A) and incorrect (B).

A B
Fig. 5.:8. Trunk side raising test. ~ (A) and incorrect (8).

Qual Uica ri Oil Qlwntijicalio/l

• Pass/fail • \Vith dynamic ck<':lromyography

Purpose Ql/{/lificaliol/
To id('lllify ~trcnglhf:.aabilily of trunk side bending JIlUS- Pass/fail
ek:,- (qu~ldr;ttus lumboflllll) Fail if erector spina~ comracls before gluleal max.imu:,
Record activation sequence Of liring order of gluh:al
PRONE maxil1lll."'. hamstrings. lumbar erector spinae. thora·
columbar crcctuf spinae (ipsilateral ~\1H.l contralatcr:ll)
Hip Extension Coordin(lt;(}IlIStrellgth~1(Fig. 5.29)
Note if contralah:ral shoulder/neck Illusculature contr~lC(s
Patient prone
Patient attempts to raisc Icg into cxtension with knee
Purpm;('
held in extcnded position
Positive lesl ifercctor spinae musculature contracts be- • To idcntify incoordination of hip ~x[el1sion
r. fore gluteus maximus To determine if gluteal rnaximus is weak or inhibited
,:.) Doctor should observe activation sequence of (I} harn~ To determine if l.'rL'ClO( spinae is oYL'rac!ivc
~rings <Inti gluteus rnaximus (2) contralateral lumbar To detcrmine if hamstring is ovcral,.'livc
cn:clor spiOjlc <mel 0) ipsilawral crc.etor_~pinac To dctermine if hip joilll h.IS rcd\1l't.~d extension l11ohil~
Palpation lIsed only [0 confirm rcsuhs ily or if psoas is :,hnncncd
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 Ht:HA~ILIIAIIUN OF THE SPINE: A PRACTITIONER'S MANUAL ..• "
,
Trullk Extension Strength Test .. .M1·1l (Fig. 5.30) QlluliJinltiOtI
Patient is piOne with hands bt:hind head and elbows Pass/fail
held horizontally Pass if p:lli~nt can perform 15 repetitions and th~n hold
Patient is instructed 10 Ii n chest off table (about 2 position lor :~() seconds
inches) 15 times (with 1- to 2-sccond pause) nod hold
15th repetition for 30 seconds
Purpose

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

strengthlendur;.mcc
If patient can r~ise
trunk into extension
Shaking or twisting
OTHER TESTS
• If feet raise up off table
Simple tests that identify whether a certain movement pro-
Quantification vokes symptoms have been found useful c1inicnlly. Morc :ltl-
vnnccd upproachcs have proven valuable for cstablishil1~
Strain gauge tcstingl3.7~
trunk flexor/extensor nllios. lifting capacity, neck tkxor
Alaranta et al described repetltIve and isometric en-
strength and cndur<1nce, mld cardiovi.1scular litncss.
durance tests. " In the fonner, patient nssumes slightly
flexed position and raises trunk to neutral position until
Provocative Testing
no more repetitions are possible. 'l A normative database
has been established. The isometric test is a predictor of Movements that provoke. relieve, or are staWs quo with re-
recurrences..!1 Alaranta ct 31 reported both reliability and spect to presenting symptoms represent .1 reliable WilY to tcst
a nonnative database for this timed endurance test. paticnts.15 These tests have been used clinically to classify pa-
tients 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
., f

isometric trunk flexion and extension strength. A ratio of

1.3: 1.0 extension: flexion is normal for this tcst.'·U-.l.~~ ~11­
lhough reliabilily is questionable.

Lifting
STRAIN GAUGE TESTING OF ISOMETRIC LIFTING STRENGTH

A simple. low-cost protocol following the NIOSH guidelines

Fig. 5.29. Hip extension lest exists for quantifiably measuring lifting strength.5~

A B
Fig. 5.30. Trunk extension lest. Correct (A) and incorrect (8).
'-=
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-~
 CHAPTER 5 : OUTCOMES ASSESSMENT IN THE SMALL PRIVATE PRACTICE 93

ISOTONIC TESTING OF LIFTING STRENGTH DOT thus, has defined the demand minimum functional ca-
~acity of most jobs in the U.S."l\·\ Jobs arc funha categoriz.ed
l Mayer and co·workers developed the P.LL.E. (cst.~) and
as scdcntaI)', light, mediuIll, heavy. or very heavy according
Matheson developed the E.P.I.C. test (sec Chapter 8), both of
to Ihe maximum weight lifted during lifting or ci.lrrying.I'~·Il(·
which arc low-cost, quantifiable methods. They orrer stan-
Unfortunately, strength factors have not been defined for any
dardized protocols with nomlativc dalabasc.~ established.
other job factors. An additional problem with WCE is thm a
one-time test docs not reflect an indiviclu'll's ability to per-
Neck Flexor StrengthlEndurancc .
form a task O\'l:'r the course of an 8·hour day.s,1
Watson and Trott found that decreased isometric strength and These problems aside, tiS many job factors us possible
endurance of neck flexors along with a forward head posture should be included in the FCE. Silting tolcrancc can be
,j ") could differentiate headache from nonhcadachc sufferers.1! tracked as an outcome. \Valking can be evaluated for pain
~
Trcleaven and colleagues described the same distinguishing provocation (sensitivity) and ex.amined qualitativcly. Lining
Ij f)
features of poslconcussional headache patients. Xl Trcleaven can be evaluated as described by Matheson (sec Chapter 8).
I• () and co-workers showed that observation of supine. neck flex- Squatting can be assessed using Alaranta's lcst or ns shown in
ion. as just discussed. was as reliable as thc strain gauge for this chaptcr." Standing can be evaluated for pain provocation
J.
I 0 identifying neck flexor weakness. and qualitativcly with postural analysis (sec Chapter 6).
Stooping can be assessed with trunk flexion range of motion
I
.~
Cardiovascular Fitness tests and by pain provocation (see Chapter 12). Balancing can
be ~valuatcd quantitatively with the one-leg standing test.(,<}
I Simple protocols exist for measuring aerobic capacity using Kneeling Ciln be assessed with the lunge test. and rC2ching
I 0 treadmills, bicycles. and other ergometric instruments. sa.1I1 with the shoulder abduction test. Carrying can be ex.amined

i 0 High Technology Tests

with specific protocols.8S.S9 Pushing. pulling, and other job
factors can be evaluated as well.u.s<}
IJ High technologic quantification of functional deficits can cost During functional testing and exercise training. it is im·

II C}
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
portant to evaluate an individual's performance potential for
activities of daily living (AOL). athletic activities. and de-
mands of employment. Many of the lraits just described
,!, 0 these units prohibitive for most small private practitioners. should be objects of rehabilitation that can guide the func-
Elcctromyographic units arc also cost prohibitive for the aver- tional training of patients. An individual who can sit. stand,
li
'"} balance, walk, squat, climb. carry, reach, grasp. kneel. etc,

II
\;", age field practitioner. although in medicolegal practices or re~
search settings. such equipment can be beneficial. with minimum discomfort and adequate strength, endurance.
~.

"
nexibility. and coordination is an individual who is not im·
Work Capacity Evaluation paired. He or she therefore has little or no limitation in ADL
0 or work capacity. Functional restoration should strive to pro-
It is the duty of the occupational physician to rate impairment. mote the development of these functional traits as the final

II
.~ determine functional limitations, and establish the patient'S goal of a successful rehabilitation program.
work capacity.8~.8) Translating functional capacity into work
.) capacity has been a great challenge. Fishbain et al outlined the CONCLUSI07>
reasons for this difficulty: (I) normal values for functional ca- Functional restoration addresses the deconditioning syn-
pacity arc needed for the individual (for age and sex and type
,~ of worker): (2) many functional capacities arc diflicult to
drome. It docs not require expensive testing or training equip-
ment. Small practitioners in private practice C'lI1 begin to tr.lin
~ 0 translate into job skills or trailS (i.e., isokinctic abdominal patients with customized exercises progr:.lms lIsing simple
~ strength): and (3) it is hard to translme functional capacity equipment. Measurable functional outcomes are of growing
0 inlo a "demand minimum functional capacity" for a specific

I
importance both for patient motivation and reimbur.;cment.
job or job category.~·\·14 Directing the focus of"thc patient toward functional outcomes
0 To correlate functional c:'lpacity with work cap<.lcity, the rather than pain relief is essential to this process. This ap-
Dictionary of Occupation:'ll Tille (DOT) may bc used as the proach is appropriatc in the subacute phase of care as well as
",) standard of physical demands of a specific job or job fac- with patients with rccurrent or chronic pain.
,J.ii {)
tor.K~.K~.K(. Twenty job factors detailed: standing, balancing
walking, sitting, carrying, climbing. squatting, lifting, kneel- REFERENCES
ti ing, stooping, crouching, crawling, reaching, handling, fin- I. Spitzer WOo Le Bl:mc FE. Dupuis M, et :II: Scienlific :lppro:lch 10 the as-
(~ gering, feeling. pushing. pulling, talking, seeing. and hearing. scssmCI\\ :lI\d managcmenl of ;Iclivi\y-rclated spin,11 disordcrs: A mOllO-
u 1;r.lllh for cliniei;llls. Repon of the Qucbct,' T;lSk force on Spinal
A sl:'Hldard WCE delineates a worker's readiness to return to
* ()
~ Disorders. Spine 1:::!(Suppl 7):,51, 1987.

I () work based on their ability to perform job factors. lll

The DOT lists the job factors lhat arc important for most
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.

I <
~
0
jobs in the United Statc~s.s~.Il(. According to Fishbain et ai, "the
19R1
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J.
Of; t:~':l
~
•,~
 ~9...:4 ...:R~E::.H:.::-:A::B::.IL::IT:.:A.:;T.:;IO=N...:O:::F~T:.:H-=E~SOINE; A PRACTITIONER·S MANUAL

3. Hazard RG. Fenwick jW. K:tli~ch S~·t. ct ;11: FUll~'lhlll:III\:"lur;\linn \\ nil .r~. \\·:t,lddl I;: .-\ 11\."\\ dUll,.: 1:10 ...1.'1 !tlr Ih~' tf,·:llllk·llI ,II h.\\ .j-.".I. paill.
I 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· .-n.
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II'Hl DI.. 1,.... mhagl·1l SJ. '\L:h.·.Ptl L:\: (juiddlll~" lor fUI1,1:"Il.,] ,':IP:Il'-
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5. Rcadin~ AE: A cOlllparis('n ()( I~lin r.llin~ s..:ak.... J I'sydn'snm tho, .q_ ;\lil\'hdl 1{1. C;lrUl"nl;~l J..i~·'llih •• f ,I Illullk.·ll!.·" In;cllhlll:-' .Ill \1l,,'n·
24:119.1979. ,i\,' ·.1,11\,: .... \~·Il·i"l.· 1'11';.:1 .. ';: :",'r Ibl' lll':lllll~'lll ,.1 :Il'U'" .. '11 ,l"n,' aud
6. Moone)' V. Clin1.~ D, Rohcrt'(lll J: A syslcl1\ t"llr ~'\aJllaling alld lr~'al:ll~ b,,\'I, Inlur,,:~, Spill" 15:::'1,~. l'"lI1
chronic bad, dis,lilility. West J .\kd 12·1::nO. 197(1, .':' ...\ndl·I~"'I\ GB.I. I'I'p': .\Ill. h~:llnY"r J\\": EP1dl:llliplll,-~:- 11: l\,p" .\IIL
7. ~'lcll:Kk R: The shurl-for1L1 .\kGill Pain Quc'li\lllll:lirc. Pain .1U:l\)1. hyllh':l'r )\\'. And,'I,,"I: (; ,,',hl: (J..'n11';lli"ll:d I.n\\ 1I,I,k 1'.:1:1. \,,·w
1987. '·llrl... Pr.\.:~"r. 19S·l. pp 11';-II.t.
8. Beck t\: Ikpro:ssion: eliai...a!' b:pcrillh':lllal ,,1111 lhcllrcli"::ll Asp..·..· I'. .'11. Fr~·lIl\':,·r JW: Ejlid,·ll\h,i,,;:-. hI Fr:lllu:o:r j\\" Gnrd"H SI. ll'd,):
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9. Zung W\VK: .-\ !'elf-rated. lkprcssion sC;lk. Arch GCll PSYl,:hi;ttr J:=:(•.~. AIlI~·ri,·:m .-\....:llkllly ,.!" Ou!:.·r.ll·l!k Sur;:.... '.lh. I'JSlJ. pp I<)-.~.:.
1965. .n. (julI~kl\;11I IL Lilj..:q\i'l .\1. Ibtl'~"ll T: "tilll"ry pre\"l'lllll'n "f h:ld.
10, Main CJ. Wood PLR. Hollis S, el al: 'nle dislres~ and risk ;ISSCS!>lIl.. . 1Il .~YIllPhlll\' ;ll1d ah!i"Ilt:l· IrPIll ·,\url.. Spilll' IS:5S7. ItJ9.'.
melhod. Spin.. . 17:42. 1991. .'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.
II. Lea\·in F. Garron DC. Whiskr WW. et al: ,\ "l,llllparisnn of r:lli~'ll"'. :Ull! h:u.:l.. P:lill. Spin.... 1·1: I":'. IIJS9.
tre;tlcd. by chymopapain and lalllilh:C(Olll)' (ur low l'l:lCk pain usin~ a IIll1l, .N. M:tth.... ,,'ll l.: Ib!ii~· r"'lui/"::I"nh fur ulililY ill Illl' a"'·.. ."nwll! "i ph: ,il'al
titlimcllsion:11 pain scale. Clin Onhop 146:136. 1%0. di.,ahilit:. :\I'S j(luru:ll .'. !').". 111'14.
f)
12. Bt:rnslt:inlH, Jaremko r..'IE. Hinkley BS: On Ih" IJlilily of tht: SCl.-l)O.R 40. Grabill..'! .\ID. Kolt TJ. GI1.:/.,'.,i l\f:: D,·.. . uuplin:: of hibt..':·.d i,.\I",I~pm;ll
Wilh [ow-l'lack pain patiellls. Spine 19:42. 199·l, ..:xl'ilalilln in suhj.. . ClS wilh 1"\1 h;ll'k pain. Spilll' li:1211J. I<I<J~
13. W'll.klcll G. Newloll M, Henderson I. ct al: A (e;lr-:l"oit!ann: hdi"fs tllll."- .11, L"wil K: ~bniplllati\'1,' Ttl . . r.:py in Rdl:I1'i1ilalit11l (l[" lh..: \11'h11" ~Y'I""ll1.
titlllllairc (FABQ) and the rok of fear-;lvuit!:\IH.:C h\:1il'fs in dlrl11lil· h~·.\'­ 2nd Ed. Londllll. B\llll·C\ll1r!!h. 1IJI) I.
back p:lin and disahility. i':lin 52:157. 199J. -12. taR'M,:....;1 1-1: A ta\UIlIIIlIY \'1 ... hrnlli~· p;lin 'YllIlr\lllle,: 1991 Pr,·..hkllli,,1
14. \Verne!':c ~·1\\'. Harris DE. Lidllcr RL: Clinic.. 1cffecli'·elless (If 0.:11:1\ ii" ..\t1dr....". C~r\·il·al Spine k,··".:'r.. . h S()\:i\·ty .·\nulla! Meclin~. n,:~·,·ll\h,·r :'.

1 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;,
1991. Spine IOS:S-'4J. I'JIJ:
4.';. Newton \1. \\'adddl G: Trunk ,trt:nglh l..:.,tillg wilh i...()m;l... iHn~·., !';Ift t:
Review of a dccalk of !>ci,'il\iiic e\·ilkn....e. Spin.... 18:801. 1~N .:.

1 ability questionnaire. Physiolherapy 66:271. 19&0.

16. Vernon H. ~tior S.: Neck Disability Indl,':X. j M:tnipul;llin: PhY$iol Th....r
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.~.

i 14;..HJ9. 1991.
17. ~. tjllion R. Nilsen K. Ja)'~on MIV. ct al: Evaluation of low back pain and
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

i assess men I of lumbar co~elS with and wilhoul back suppol1s. Ann
Rheum Dis 40:449. 1981.
Rehabil63:171. 1982,
..\6. M,lycr T. Gatchel R.. Ki",hinll N..... 1 al: Ohjl.'cti\" ;ISS .... S... llh.'lll ,'.1' spilll~

i
18. Vermont Rehabilitation Engineering Centcr: Low Back Paill fun . . tion following illdu"lri::i injury::\ prtlspel'li\" 'lUd: \\illl ,"'lilpari-
Questionnaire. Universit), of Vermont. 1988. Sllll J;WuP and ollt:-ye>lr follo\\ -up. Spillt: I o:·1~2. IIJX;i.
.'.k'>.
19. Roland M. ~·1orris R: A ~tudy of the natural hislol')' of back pain. Spine 47. Bicring-Surenscn I:: I'hY'I.::::l lIle:lSlU~'Ill\'llts :1' ri,k illllk,lh~r~ f,'r Itl\\"-
..J
8:141.1%3. h:li:k lrouble o\,er;1 un~'-ye:lr (lC'ri{ll,1. Spine I): 106. I<)S4.
20. Lawlis OF. Cuenca... R. Sclb~· D. el al: TIle dC"elopmcnl of Ihe Dalla.' .Is. TrnupJDG. Manin JW. L1(1~d DCEF: llal'k 11:,ill in illdu'lr;o: ..\ P""'P~'.:­ ,)
..

I
Pain QueMionn3irc for illness bch3\'ior. Spine 14:5 !I. 1989. li\'e stuuy. Spine 6:61. 1'}1i1. '-
21. Deyo RA. Diehl AK: Measuring physical and ,",ychosocial funclion in 49. Vcmlln H. Aka P. ,'\t"Jrth::nKu M. 1.'1 :,1: Evalualioll PI" n.."·~ 11Illsl'k
patientll wilh low-back p:lin. Spine 8:635. 1983. strl,':llglh wilh a nnxlilied 'phygn\l\l\lan\tm"k'r dyn:.IIIIlIll,'I"r: Rl'liabilily
22. E\·;ms JH. Kagan A II: Dc\·clopmt::nt of functional rating scale to mea· ;lIld \·alidity. J M:mipul;sli'c Phy"iol1l1l,'r 15:343. 1992.
sur.: IrC:ltmcnt OtllComes of chronic spinal paticnb, Spine II :2.77. 1986. :'0. Ct..."idy JO. Lopc.:s :\A. Yvn::·Uing K: Tlt\· inllllcdi:lt.... dk.. l "f lll:llllpU·

I, ;
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.
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'!"
24. Bigo.~ $ .. Banie. Spenglerc OM, et al: A prospective study of work pl,':r- 15:570.1992.
"t:ptimls and psychosocial factors :Iffecting the report of b:lck injury. :'1. Toppenhcrg R1\·1, Bullod-. ~II: Th.... inll.'rrdalion of .~pitl:11 <"111"\.· ..... I'l'I\'il.'
Spine 16:1, 199L lilt anu !l\u'cllo.' lengths inlhl.' :Jdn!c.Wl,'nl kl1\:Lk. A\I... I J Ph:-'ll'lhl'r .~~:6.
25. \'011 Korff M. Oe)'o RA. Chcrkin D, et ;tl: Back pain in primar)' care: 1t)~6.
Ou((.'ollles at I year. Spine 18:855. 1993. 5~. Knill. S: :..:iIOSH lifling ;:uid::lille..... Am Ind Hy~ .'\"u~:.1 ..l_~.,l.: I. I'J~~.
~6. D\\\'rkin SF. Von Korff. Whittlcy we..... t al: Mea<"url.'lltl.'lIt of chJractcr· 5 .. , :-.-I:tycr T. Barnes U. Ki:-Iuno .". 1.'\ al: I'r\':;f,·."i\·e i,uin.. . rti.l! htllll:: ,'\ :11-
iqi,... pain intcn~ity in lit:ld n:~earch. POlin 5uppl ;:5290, 1990. ualiorl. I. A st:llltl;lrtli/.cd rrtlil ....lll a11l1 1I\'rm;lli\'I.' datal1a.'l'. ~!,llll' 1.~:'J9.'.
27. \i,lll Korff M. Onncl J, Kecfe F. et al: Gr:n.ling lhc ...t:vcrilY of ehruniL; 19H5.
pain. POliti 50:1:33.1992. 5.t. Guide<" 10 the E\·;llu:llion III i'o:rm:lIll,'nl !ll1p:lirllll·1I1. :>rd E,:. Chll·a:;ll.
28_ W;lldorf T, Devlin L. N,tlI<"ct 00: -nle cOlllpar,tti\'c ;)!'!'.... sslllent of American ~kdic;tl Assodo:llfm, 1l)~K
par;lspin:.! tissu.... compliance in a..<;Yllljllolllalic female and male subject... 55. N.Ulscl D. Jans..:n R. CrCfIlo:la E. 1.'1 :II; Elk~·ts of l..'erviL·,,1 :IJ.llhlll\l·llb un
in both prone and slanding positions. J ~'hlnipulati\"e Physiol Thcr lateral-flexion pa...si\"c cnd.r~lllge asyrlllllt:tr)' and un hllll,ld l'r..'~~llfl·. h....arl
14:-l57.1991. rate and plasma cateehol<llninc lewis. J Manipulali\"I.' Ph:~i,,1 Th.... r
29, \\\ll(c F. Smythe HA. Yunnus MH, et :II: 'nlc American College of 14:450.1991.
Rhcum:lI(llogy 1990 Criteria for ClassilieatiOIl of Fihromyalgi;l. Arthriti .. or
56. Ellison JB. Ro....... S.I, S:lhnn,mn SA: Pall":fll.~ rotation ran;: ..• "f Ilwliol\:
Rh,,:ull1 J3: 160. 1990. A comparisoll between hc::1thy xuhjel'ts :Illd palicn .... Willi 1,'\\ 1-.1,1.. pain.
30. Hubbard OR, Berkoff GM: ~·1Y(lfascial trigger points show spontilncous f>hys 'Oler 70:SJ7. 199U.
1t~·l.'dlc EMG activity. Spine 18:180J. 1993. 57. Reid DC. Bumhalll RS. S;JhllC LA. cl ;11: Luwcr eXlrelllil~ Ik\lI'i1il: 11;11-
31. \\":!dddl G. M;lin CJ: Assessment of sl'\'crity in low-had.. dison.lcr,. terns in c1:l..."i....:,1 h:lllci d:ltlcef\, :lt1d lhl'ir ....nrrel:lliun It.' 1.It.·f.ll hil' :lml
Spine 9:20J. 19~. knec injuries~ Alii J Spc)n, .\ktl 15: ....17. 1t)~7.

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 CHAPTER 5 : OUTCOMES ASSESSMENT IN THE SMALL PRIVATE PRACTICE 95

( . '\ 58. B;SIr:lnd J. Gillquisl J: The (r.:quenc)' of mu~l(' ligll1ncss ,lOll iiljuri~'s in 7-t Sill:lkl \1. (inl"'''':, N: Bad :-lfl'n;:lh..-nin;: n.l....:i,,:s: Quanlil;lli\-..- c\'<llu:I-
socc..:r 1l1;1~·crs. Am 1 Sj'I('"S ~kd 10:75. 19$2. tiun .'f :h..-n dli"-.I':y r.,r \'tllll,'n ;If:...d -111'(1:\ y..';I1". Ardl Phy.. ~h:d
,i"\, 59. Inamur.t K: Rc·'lsscssmcnl of Ihe Illclhod of an:dysis of ch,.'(;(cogmviw· Kt.·hahl -O:lh. 19S9.
I;.r::Iph and Ihe one fool les!. Aggn:ssologic 24: 107. 1983. 75. Ikliull ..\. Cil111I"a MT. Erh:lrd RE. ct al: Evidclll:l: rur U.\I: uf all 1:.'l:I<:n_
,- ) 60. Nelson RM: NIOSH Low Back AlIa... of SlandJrilcd Tcslsll1lo:asun:s. sillll-m.,t'olli/;lliull C:lh.:gnry ill ;ll:lltc low had: ~ylltlrtlnh':: ;1 prcSl,:ripli\"!,:

I -,
U.S. IXpanmcnt of Health ;md HUlllan Ser\'ices. Nationnl Ins[i[Uh: for valid;IIlI'n pilllt sHuty. I'hy.. Th..:r 7:':21(,. lIN.\.
. (kcup:lIional Safe I)' :llld H...allh, December 19$8. 7CJ. Erll.JrJ RoE. D.:Iiitll A. Cihulka MT: l<datiH' cffl:l'liv":llc~s "r ,Ill 1:.\len-
61. Hir.Is..J\\'J Y: l...efl fOUl to suppon hum;l1l stand in:; and \\'alking. Sci :\m :-illll rr.,;:r.lI11 ;ulIl :1 ~·tllllhirll'l.l pro~r.llll til' 'll'lIlipulaliun ami lh:x.iull amI
(Japan) 6:~~. 19S;1. cXh:n~h'n ..:\\·t<.:i~.,:- in pati..:nt\ wilh ;I":UI..: low had: s~mlnJlIl"', Phy\ Thcr
f-" 62. M;lycr T. thad)' S. Ihw:lSMI E. CI ..I: Nunillvasi\'c ntcasurcmcnl of ccrd- 74:1093. Iq9~.
c:lllri-pbnar llIUliull in nomla) suhj\.'Cls. Srin.: IS::!191. 1994. 77. '-Icll:;.inf ..\ L. LilltHII SJ. ":'a(.,·O:II1;lrk r...t: A prI1sp..:cti\'1: siudy of p:lticnl<;
63. Youdas J, CLre)' J. Garrel T: Rc:liahilil)' t,f me3.!'ourcmcnts of cervil:al with acutc o;lck ;lllllnl·..:k pOlin. Phys TIl..:r 7~: 116. 1994.
0 spinc range l)f mOlioll-comparison of Ihree methods. Phys 11ler 71 :98. 78. Bcimlx1m DS. i'>·1()tTi.~scy 1l1C: A review or the Iitenlturc related to trunk
1991. muscle r..:rt"orlllallc,,:. SpillL' 1.1:655, I t.l8!\.
64. Gajdosik RL. Rieck MA. Sullivan DK, Cl :\1: Comparison of four c1ini· 79. Trelca\cn.l. Jull G. Alkinsoll L: Ccrvicalilltlsl:uluskckwl dysfunction ill
cal tests for :lssessing halllqring muscle length. JOSPT 18:614, 1993. po-sl-concussi(Jn:r1 h..:adachc. Ccphalgia 1.1:27\ IC)94.
65. Gricc A: l.umbar cxercises for kinesiological harmony and stability. 80. Parker DC: A l\l':W suhmaxilll;ll trc;ll!lllill ror prcdil·tillg V02
JCCA. Del:. 1976. ma~: Ratiomllc mId Y~llidalion. I\nn Spnrls l\'k~l. Sllhtlliltc~t fill' puhH·
~
,,
•, ", ". 66. Nelson RoM. NcslOr DE: Standardized asscssment of indu:miallow·b:lck
injurks: DeveloJllllcnt of the NIOSH low-hack atlas. Top Trauma Acutc
cation.
81. Aslr.md P·O. Rooahl K: T..:~thook of W,lrk I'.hysiulogy..\nl E\J. New

I
Care RehabiI2:16. 1988. York. ~lcGraw-Hill. 19S(J.
0 (17. ~'hlffroid MT. Ihugh LO, Henry SM. et :II: Distinguishable groups of 82. Sp.:=klor S: Chronic p:lin .md p:lill.rdatcd disabilitks. J Disaoility 1:98.
llIusculoskdetal low back pain pilticnts and a.<;ymptomalic control sub· 1990.
ject:. based on physical m~;'i$UrCS of the NIOSH low back alias. Spine 33. Fishb:i.i" DA. Khalil TM. Abdcl-~'lol)'A. el al: Physici;ln limitatioll when
1 '-: 19:1350.1994. assessing work cap:lCity: A review. J Back MIl~culoske1ct Rchat:oil 5: 107.
I ') 61'. Riss::mcn A. A1J.r.mta H. S3.inio P, et 011: Isokinctic and non-dynamomet. 1995.
~ ric teSls in low back pain patients related to pain and disability index. 84. Batistol \1E: Dis.lbility cvaluations: EXpecl:llions of insurers and payor!'.
I
•l t)
~
'C.
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
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.
i a p;lin palienlS. Pain 58:367. 199~.
70. Trdea\'en 1. Jull G, Atkinson L: Ccrvi(':lllllu~culo;ke1ctaldysfunction in
DC_ CS GO\'crnmcnt Printing Office. 1986.
86. U.S. Do:partmcnt of whor. Emplnymell! and Training Administration:
post-concussional headache. Cephalgia 14:273. 199~. Selected Characlcristics of Occupations dcfin..:d in the Dictionary of
71. Alaranta Ii. Hurri H. Hc1io\"aara M. ct :11: Non-dynamclric trunk perfor- Occupation:ll Tilles. W;I.~hingtol\. DC. U.S. Go\'ermcnt Printing Office.
m:lllcc tcst~: Reliability and nonnati\'c data. Scand J Rehab Med 26:211. 1981.

I 87. Isemhagen SJ: Phy... ic:lltherapy and ol.:eup;lIiol\;1l rehahilitation. J Oceur

1994.
n. W'ltson DH. Trott PH: Cervic;11 headache: An ill\'estigntion of natural Rchabil 1:71. 1991.
() hC:ld po~ture and upper cervical lkxor muscle p.:rformancc. Cephalgia 88. Fishbain DA. t\bJcI-Moty A. CUller R. et ;,1: t\ lIlethod ror 111":;lSIII'11Ig
ii
; 13:272. 1993. residual funelional capacilY in duoni<: low back pain palil:nts l>ased on
n. Tri;mo JJ. Sko£sth:rgh DR. Kow;alski fl.UI: The u:,c of inslrumenlation
I
~
;;) ;and Iaboralol)' ex.:uuinalion procedures hy Ihe chiropractor. Inlialdeman
Ihc diclionary of Ol:Cululional tilles. Spicn 19:972, 1994.
89_ Moonc~ v. ~(athssol\ LN: Objecti\'e Measure!llent of Soft Tis'::'u..: Injury:
S h..-d): Principles and Pr.3.clice of Chiropr:lCtic. ::!nd Ed. Norwalk. CT. Fca..<;ibility Sludy Examiner's Manual. Industri~ll Medic", C(\llllLil, 51"le

I () Appleton & l..lnge. 1992. ofC.1iifornia, 1994.

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 6 Evaluation of Muscular Imbalance
VLADIMIR JANDA

I
I
I,
I Muscle imbalance describes the situation in which some mus-
cles b~come inhibited and wsak, while others become light.
pelvic or distal crossed syndrome. <lnd the shrtlldcr girdle!

I
neck region. associated with a proximal or shoulder girdle
losing their ex.te~sibililY. M.~crat.cly tight muscles arc usu- ero~sed syndrome. •
ally..str.OllgGOh!.1.IJ.JJQDP~L although in the case of pronounced (Th~, proximal cross_cd, syndrome is char<lcterized by
dcveiop~ncnt- of·].~hiilc·~~~in·-illc-"u·l;rc~ trapezius. ~tor.

10 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 pos-
and pectoralis major and. on the other hand. inhibition in the
deep neck flexors and lower stabilizers of the scapula~.

I sibly 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
Topographically, when the inhibited and tight muscles art
connected, (hey form a cross. This pattern of muscle imbal-
ance produces typical changes in posture and motion. In

I also results in improved strength of inhibited ant<ig9D.iBic

mu~s, probab'iiii~ediated via t~~~~herring!.Q~~s-.I~~~:.~ e­
ciprocal hmcrvatioih
standing, ele\,?:£~l and protraction of the shoulders are .cvi-
dcm. as well as counterclockwise roHuion and abduction of
the shoulder blades and a p'ush-forward head position. This
altered p~s"ture is likely to stress the cCTYiCocranial and the

I
The terms muscle tightness (stiffness, tautness, loss of
ncxibility) and muscle spasm should not be confused. A de· cerviso.!!!t?racic junctions~l~;lddition. the stability of the
tailed differential diagnosis is necessary because each condi· shoulder blades is decreased and, as a consequence. all move-
tion requires a different type of treatrnent. 1 Unfortunately, a ment patterns of the upper extremity arc ailcred.
precise and adcquate analysis is often neglectcd. The distal crossed syndrome is ch.lnlcterized by tightness

I
The tcndcncy for somc muscles to develop weakness or of the hip nexors and spinal creclQrs and inhibition and weak-
tightness docs not occur randomly; rather, typical "muscle ness of the gluteal and abdominal muscles. Again. connection
imbalance paucrns" can be described. Further, the develop· of tight and inhibited muscles form <l cross. This imbalance
ment of these pauems can be predicted clinically and. there· results in an anterior lil~()r.thc pelvis. increased flexion of the
,AA
forc. preventative measures may be taken. hips, and a comp.g.l.l.~ato.rY "t~Yp~r1()rdo:-;is. TIllSsltuatTQ'~ is' a
"prcsumption to overstress of both- i:;Ip'~ioillts as \vell as of the
~ Muscle imbalance docs not rcmain limited to a certain
part of the body. but gradually involves the whole striated lower back.

I
muscular systcm. Because thc muscle imbalance usually pre- The examination of joints must pr~ccdc llluscle c\-aluation
cedes the nppcarance of pain syndromes, a thorough evalua· of flli:I~"c1cs. -----~ "". - " . - .
tion can help in introducing preventive measures. In clinical practice. it is advisable to st~lrt by analyzing
Muscle imbalance develops mainly between muscles erect standing and gait. This analysis requires ex~rience,
prQ& (0 develoP..!J.g!!t'I<!~'i.c~.(f!lc;!2?s surae, hamstrings, one-joint however. and an ob~ervation skill in p;.trticular. On the other
~ hand, it gives fast ~\lld reliable information that C:lI1 :,a\'c time
! t'!iJ?~.~gg_~tors, r~~_s_~~rr:t0ris.' iliopsoa~, tCI."!~sH:.f~~fiae latac.
piriformis. quadratus lumborum, erectors of the spine. pee· by indicating those tests that need to be performed in detail
tor~TI~nl.ajor"andminor, upper trapczius--and levator scapulae. and those rhat can be omitted. The observer i~ at'fordl.:d an
s"t~_f!!Q.C;.I~idoIJ.lastoidcus, short deeprneck extensors. nexo~~ of overall view of the paticnls muscle funclion <lnd i:, encour-

1 the upper extremities) and muscles prolle to develop inlfibi-

ti01;-(iibiaiIS-an"terlor; vasti, in particular the medialis; the en-
aged to think comprehensively about the patient's entirc
motor system and not to limit attention to the local 1C'\'cl of the

I
tire gluteal group; abdominal muscles [the obliques, however. lesion.
are controversial): lower stabilizers ohhe scapula; deep neck Evaluation of nluscle imbalance in a patient with an acute
nexors {they tend to spasm, however, which is oftcn misdiag- pain syndrome is unn::lia~J~~nd I1!US[ ~_~~~e~.~ken ~1i!!Jie­
nosed]: mainly the extensors of the upper extremitics). saution. A precise evaluation of tight muscles illld movement

I
~
Although muscle imbalance involves the whole body. the
imbalance is more evident or starts to develop gradually and
predictably in thc pelvic region, whcre we speak about the
patterns can be performed only if (he patient is or is. almost
painfree. Its usc is typical in the chronic phase or in p<Hicnts
with recurrent pain after the acule episode has subsidcd.

I
I www.bodywork.su 97

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"---'-,---. ."~." -,-~,
~o REHA81l1TATION OF ,-= 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. \l\1:;h P'\!p;ltioll. L\ .:i~:,!ii\lll or till' .\IO'lIo('/CitlOIl/c1S/oiti is 1I0l
the head p:lssivcly tk\yd ;.tOt! illl'lillcd 10 Ihcl."lllllralatcl':t1 rdi;lhk hCi:;WSl' it ~'r\'''l'S loom;lllY ~l'.:;rnellts {I;·ig. (lAl.
sid~: Fr-oin Ihi";Z-j;-u:..ilit;n. II~c- ... iullll-d~i-ill~(Ik· i;-ri~;hl..~T.~~;lall y. lIil'110pl"." lilt".:, .. ,:.... lhg. 6.:'1. n'!'wsll'llloris (Fig, ()J))
N(fnh~l1y. a soft b:uTil."r i... at tilL' I..'nd or tile pnsh: \\hl'll the ;lrl' !L·~lt.·d with thl' ",:::..'l1t in:\ llHldilil.'d Thomas position. Till.'

1ll0VCIl1('ut i:- rcstricll'd. il is hard. prl"l"IlI,:d llIodilic:lh':1 ,11"'0 allows l'\,llnin:ltioll or till: ....hon
L(·\wo,.S("OIJll!ac lFi:::. (l,:!1 i......· ,aulillt:d in:1 silllil:lr man· f'"::); addrw/ors ,lIh: ::::.' [I'llsor fiISf';" !:if{/("
lll'r. only (hL~ had is ill ;lddili\~J,~,r{.1,1_;11.\':~!I,~lq.1_l,'~.~,!n~r:ll;l!c{alside. Till' p:lIil'llt i... 'll;~:tll' with thc tm~(l on the plinth ,1I1d till.'
Peclomli.\' 11/0)0" I Fi~. (1.:\) i... \J..'stt.:d with thl' patient ll'"ll'd k~ h)\\sl'l~ h_::,~ill~. The 110111l>,te(l leg is 1ll:lxilllally
supine. the ;lrIll I1U~\ctl p;'l:-.si\'dy inlo abdm:liull. The tnlltk Ikxl,.'d to sl"hilit:I,.' Ill;: ;'l.'h·is and tlall~n Ih~ IlImb;II' spine. TIl('
must be s(;Jbili".cd hcf(ITI..' the :mll i... pl'lced into ;lhdllL'tion hc· Ikxion pllsitioll in (h~' hip joint indicatt:~ the tightness or thl.'
cause a possihle (\Vbl of lilt.: trunk might mimic 11k' normal iliop,oa", th~ nhliqu;.: position of th~ lower kg indicates Ihe
range of 1ll0VCllH:nl. Thc arm should reach the Iwril.Ontill tigh\lh:~S of the IS:'lU'. ThL: inability' 10 ;lchicvc passively thl.'
level. To estimate Ill!,; d,l\icul"r jJllrtion. the ilnll is alll1\\Td to hYPL:I\~.\tcll.'iioll ill Ill:.: hip joint .111\.1 thl.' in<.lbility 10 a<.:hicvc full
hang down loosely :1I1J the ex'lminer pushes Ihe :-.houh.kr llexil)ILOf the kncl.' I i.~5~) conlirms the lightncss of thc iliop-
downward. 1 ormally. {lIlly;'1 slight soft barrier is felt. ."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.

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 CHAPTER 6 : EVALUATION OF MUSCULAR IMBALANCE 99

1
!

Fig. 6.4. Screening test for stern-

ocleidomastoid tightness.

Fig. 6.5. Iliopsoas.

adduction to 15<J or less indic.ltcs the tightness of the tensor of the groove on the outside of the thigh is noted.
fascia lata (Fig. 6.7); abduction less than 25° indicates short- Hip abduction-less than 15 to 20o-shon hip adduc-
ness of the short one-joint thigh ..lddllctors. This lest can be in- tors. The tendency toward compensatory hip flexion
nucnccd by the stretch of the joint capsule. however. and thus should be controlled during the ICst.
the more specific (cst should be used to confirm lhe tightness
J-!wrlJlrillgs (Fig. 6.9) tightness is evaluated by the
of the adductors (Fig. 6.8).
Confirm.nion of tightness is clear when excessive soft lis-
leg raising test. To avoid the inllucnce or tht: eventually
light iliopsoas on the position of the pelvis and thus 011
Sllt.: rcsis,!al1cc and decreased range of motion arc encountered
the range of hip ncxion. the nomested leg should be in
on applici.ltion of pressure in the following directions:
l1exion. Under these circumstances. the noonal range of
Hip flexion-less than 10 [() 15°-iliopsoas. A simultane- mOlion is 90"".
ous extension of the knee joint points out the shortening , Thigh adductor,,· .Ire tested with lhe patient lying supine
of the rectus femoris.
Knee flexion-less than 100 to 105°-reCLus femoris.
_.
at 'O:C edge of the plinth (Fic. 6.10). The passive abduction
in the hip joint should be at least 45.... Iight.._~~~~lgs
Compensatory hip flex.ion Jll~\Y occur during the tcst. 1l13y__c_onLribulc..JQ,.J~.~_ mngc limitation. If this situation
Hip adduction-less than 15 to 20°-tensor fascia occurs, bending lhe k;~~-·-Siloufd-ilU.:·rease tht: range of
lata and tht: iliotibial ballc!. An associated deepening movement.

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lUU REHABILITATION OF THE SPINE: A PRACTITIONER'S MANUAL

M. !);rUilJ'llli,1 i, !~"\L'd willi tlw paliL'lll ~llpill"'. TilL' Icst~d trunk side bending i~ (csted while the patient assumes a sidc-
h:~ i~ pla~(.;d willI Ilk' hip.~\lilllll\ 11,'\1\1l1IHJl tl\,Cr(,()". Il1m;!X- lying position (Fig. 6.12). The refcI~J),S:_~""p.pin.t.is (IJ~.Jcvel of
imal adductioll. and 1!1;.' pl'h-i" j" ,,!;thili/.l'd by jlushing 11lL' tilt..' inferior angle of thc scnpula. which should.be q~~~S(~ frolll
knee in lhe loll~ :l:-.i .. \\f lhe fl.'lIl11!" lFi~. (1.11 K ThL'll. lh~ iUh.:r- IhJ...· HOOf 1~'.!_~)Ollt ~ inches.
- . ~

Ilal rotation in thl..' hi;' I ' jlcrfornh:d. :'\onn;lIly. soft gr:l<.lually .')/);1101 at·(·tl1l·.~ ~Irc again diflkult 10 examine. As a
illlTca~in.:; rl..'SiSI;llh:~· i ... llOh:d ;li ti ...: clld of IhL' rangL' of mo- ~cfl..· ':lIing h:sl. fllf\'~lrtj hending ill ;'1 short sit ;'Illows obscr·
lion. Iflh\.: llIuSl.'k I' il~llI. lhl' l"lhl.I\:dillg is h;m.l ;\Ild Illay hI.' \'~lIi'll1of th.: ~r;'IJu;)1 (.·Ufvallln: of the spine (Fig. (l.I.').
assoCi;th;d wilh p:llll ,h.·cll in tlh: hUH\II.:b. ).,ll>re rdi:lhk. 110\\1.."·':r. is Schober's test. AllY incrCilSC of
QuctrintfUS [limi t
·,Wl i~ diflil"uh to L',x;lI11inc because ((10
/ · .. distance 1I11i.kr :' elll should he considered as limiti.ltiull of
many :-:pilh: "'1':;1Il~·1l1 . . I..'llh:r tht' play. III prinl'iplc. passive the range of motion.

Fig. 6.6. Rectus femoris. )

,
J

)
.C'

.J

Fig. 6.7. A screening lest for tensor fascia lata

tightness.
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.
 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 begin-
ning 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 pat-
tcrns 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
'''1; Fig. 6.9. Hamstrings. activation \?.!..~l~~ gl.~teuSJ:na~ill!.l.ls. ha!n~lri_!lgs. spin_aJ" exten-
V
sors--:-ancrstlOulder gird!~__ "~n~"s"c1~_~js observed. The first sign
'C.
~
of altered pattcrn"in"g' is when the hamstrings and erector
7i·ice".~ surae <Irc tested by performing passive dorsiflcx¥ spinae arc readily activated during the movement and con-
ion of the fool. Normally, Ihe thcmpisl should be able to traction of the gluleus maximus is. delayed. The poor~sl pat-
achieve passive t1or7'>illcxion to 900 (Figs. 6.14 and 6.15). tern occurs when the erector spin'lc 011 the ipsilateral side or
,''\ More detailed description of the tests is available e1se- even the shoulder girdle muscles initiale lhe mO\'~mt:1l1 and
<~

where.:\ 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
EVALUATION OF,INHIBITED MUSCLES
the Icg lifl is achieved through pelvic forward lilt and hyper-
To examine tht.: inhibited muscles is difficult, because the lordosis of the lumbar spinc. which undoubtedly o,'crstrcsscs
classic.1i muscle strength testing docs nOI give sufficient ,lnd Ihis~gion.
reliable information. The focus of this evaluation is less on Hip abdltC:rio!l (Fig. 6.17) gives information about the
the strength of the p<lfticular movement and more in sequcnc- quality of the laleral muscular pelvic brace and tlHls indirectly

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 102 REHABILlIAIIUN Ut- I Ht: ::»1"'11\11:::'; M 1"'" "'" I I 1 IVI'O"'" , ,~

Fig. 6,10. Thigh adduClors (A): tesl if hamstrings are

tight (B).

I
A
-~

ahOUI thr..; stabilization of the pch'i~ in walking. II is tested movement is thus performed mostly in the hip joint rathl..'r
with the patir..;nt in the si(lc~lying position. The gluteus medius than by kyphosis of the trunk.
and minimus together with the ten~or fasciae latac act· as P/lsh /II' (Fig. 6.19) from the prone position gives iJlrl'r~
prime l1lover~ while the quadrmus lumborum stabilizes the mation about lhe quality of st<lbilizmion of the shoulder hl.u.k.
pelvis, The lirst sign of an altered abduction pattern is a ten~ If slabiliz.ation is impaired, the scapula glides over the thorax.
sor mechanism of hip abduction: in~tcad of pure abduction, shifting upw<lrd and/or rotates. and/or winging of the scaplll:I .,
thc,.movc}llcn( is combined a~ abduction. lateral rotation, and occurs.
,Jl{xiun..:The poorest paUern of hiIJ al)uucllOll occurs when the l1i'od.flexioJl (Fig. 6.20) is tested with the patient supine. Till'
quadratus lumborum acts not only to stabilizc the pelvis. but slIbject is requested I{) raise the head slowly in the usu.lI w'ly. If
also to initiatc the movement through a lateral pelvic tilt)This the deep neck flexors arc wC;'lk and the slcnHlCleidolllaSIOitlc:u:, i:"
pattern again can cause excessive stress to the lumbilr and ~trong. the jaw juts forward :ll the beginning or the 11l0Vel1ll'lH
lumbosacnll segments during walking. with hyperextension in the cervicocranial jUllction. The tesl pl'll-
Trunk cll!'lup (Fig. 6.1 S) is tested to estimate the interplay vides information <lhout the intcrplay between lhe stenHx:lcidl\~
between the lIsu<llIy strong iliopsoas and the abdominal mus~ mastoidcliS <md the deep neck flexors. This information is es:"~ll·
des. With the patient supine, the test involves active plantar ti~1 in cSlilll<lting (he dynamics of the cervic.:al spine.
llcxion of the feet against resistance. Initially, the examiner SIIol/ldcr abduction (Fig. 6.21) provides information
observes the paticnt'~ spontaneous pattern of silting up. If the about Ihe coordination of muscles of the shoulder girdle. It i~
iliopsoas is strong and domimllll. curling movement of the tested while the patient is silting, wilh Ih~ elbow flcxl.'d h\
Irunk is minimal anti the movement will be performed with an control undesired rotation. Shoulder ahtltH.:tion is a result l'l
almost straight back and anterior tilting of the pelvis. The thrce components: 'lbduction in the glenohumeral join!. n\la~
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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).

Fig. 6.12. Screening lest for QllZldratus lumbo·

rum tightness.

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104 REHAIjILlI AIIUN UI"" I Ht ::::'1"'11"'1::: f'\ t"hAIv 1illUI'H:n .... IV'''''''....... '"' ....

Fig. 6.13. Screening test lor ereclor spinae

lightness.

"',

')

Fig_ 6.14. Gastrocnemius.

-,
)

Fig. 6.15. Soleus.

()

,
.• ii'

,
.•. J>

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....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.

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 ,vv

lion of the scapula, and elevation of the shoulder girJk. Tlte may lleed 10 be l".'Olllli :::;.'l! Ill' lh:~;lh,:d III ,uh~-=qtll:lll l\llIS~'k
; decisive movement is identifying im:oordil1;11ion is lhe deva- Icll~th lesls.
6 lion (hm normally starts to occur at ..thou! 6()" l}f . lbdtKliml. 'Ill Tht' Il/lric-III is .lin; ·hH'lTed .fi'(l1Jl behind ilnd ;1Il oYl'r;dl
I .111 individual with shoulcJcr dysfunction. e1c\'aliOl~ 51.u'ts C~lr­ Impression of posture ;... dCh:rmined. Allcnlion i" 111\.."11 di-
\.Jic:r or may even inilialc the movemenl. r~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':
ANALYSIS OF MUSCULAR IMIIALANCE .. ~
joinls. and lower lind", .:r;,'. ;IS ;\ rule. rl.'tll".'\,'!\,'d in p;:h"il' po:-.i-
IN STANDING
lion. An il1cre;lse or lk·....... "sl." in :-agillallill. a lah.:r;t! :-.hifl. :111
In "Ul an.dysis or sl:.Illuing. all ;ltlcmj1t is maue to diffcrcn~ oblique position, rol;tih'll, and lorsioll :-houl<.l bl..' \,lbsl.'rwd.
tialc bc(,,,,'cclI possihk provOL:<ltivc CIUSCS. including struc- The peh-ic crossed s: nJi\ll11l." Illay 01.' rc:-pollsible for tht.: in-
tufal variations. age. altered joint lllcl:hanics.•mel residual creased anterior tilt of In.. .
pelvis. This condition is usually as-
effects of pathologic processes. In this chaptcr, only mm;· sociated with il1l:rca~l'J lumbar lonJosis. The pch'ic (wist is
cular changes arc described. In muscular analysis. the Illain usually associated wilh . . hortness of the piriformis amI/or il-
concern is with size. shape. alllI tone of the supcrficial iopsoas: an oblique pthHion or (h~ J1d\"i~ i.. i.ISSlleialcd mostly
muscles known 10 react by hyperactivity and tightness or with leg length asyml1l~lry. Shortness or thigh :'H.lc.lu... tms and
by weakness and inhibition. The role of deeper muscles liglllI1CS.S. of the 411aur:..:llIs 11II\\borlllll and of 'th~ . iliopsoas

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

"incc"cct" (B).

.,
..J

,
- . . ...J

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 --", CHAPTER 6 : EVALUATION OF MUSCULAR IMBALANCE 107
--_.. ~._--------------

A 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.

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- - - - - - - " .. "" _
..... ....•. _....__..- ..•••.. _ .......•...
 i 108

I ..,,

I
shonen the leg, whereas ligllll1CSS of th~ piriformis makes 1111..' Tlll' ,hal'l.." III IIll· lin,' ,II" 1111.: llll'tli;t! ;"pect \11' tilt.' Ihi~1t
leg longer. ~i\y, impllrl;lIU inl"llflll..::"1l :lhtlUI Iill' lhi~h ad,.hl\·lof~. III in-
Next, the shape. size. and IOlle or the hutto!":k ;[t'l: ob- di,·idll;l!, wilh addul,,·h'; \l~hllll''''S. the llllC-joilll :lddllclor"
,
j
served. Usually, thc gluteus is hypotonic and inhibited 011 thl' hll'l11 :1 di'lilll.'1 hlllk ill ;:1,' lIppl'r (lIW lhird 01" thl' 111i~11. Thl'

I~
side where the sacroiliac joint is hlocked.
The hamstrings arc usually well de\'e1opcd. hUI it is im-
portant to look at their bulk relativc to lhat of thl.: glutei. b~·
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";'

I C,lUSt: wh"':Ji i.b,,; ::lttcr is inhihited, lite hamslrings (ln~lI be· 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
I c.:ome prcdomin;'lllL This (hangc is rc'ldily cvkklH if the
impairmcllt is unilatcr.l!. addition. Ih.: lower k~ k:,·\lll1l'S l'ylindrk (I'-ig. (l.~~).

I Fig. 6.24. Abduction and winging <?Ilhe

1
. right scapula.

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~
1

I )

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~
I
'~
()
:;

)
Fig. 6.25. Tightness of the levator
scapulae.

)
,)

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 .... " .... VM. IVI~ Vt<
--------_ ..__._._---_... _...• -
MU::i(.;ULAH IMBALANCE 109

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:- Fig. 6.28. Touching the hands behind the neck.
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 sta-
bilization ill the lumbosacral region (Fig. 6.23). Tightncs ... of lhe upper trapcl.iu\ ,llId kv"tol' s<.:'lpulat..' (Fig.
Tht..' illh:rs<.:apular span: and the position or the shoulder 6.25) <.:;111 be "'Cell 011 the llc~k ,houlder lim;. III ;m;'IS of tigllt w

blade=, give infornl,ltiotl ;lhoUI the quality of the lower stahi- ness. the c.;5~nt(Jur sU·;liglllens. If tightnl..'.';o;"of the !l;valOr prt:-
lizcrs or 111l..: scapu!;,!. If these muscles ,Ire weak and/or inhib- dominalcs. the' COn(~Hlr ur the 11i.:<.:k line 4lppl::lrs as it duul\k
ited, slight 'lhdlH.:tioll. ekvation, and winging of the slwull.lcr w;lve in the.: <':fl,;";J of insl..'nioJl 01 thl.: lIIH~t..·k Oil th~ Sl:;lpUlJ.
blade <Ire ohserved (Fi~. ().24J. This straightening uf the ned: . . houldt..'f lille is sOlllctilllt.'S lk-

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110

sl:ribcd ;IS "Gothic ~holllth:r" ill tll;ll H i... rl:lll1l11:-~'~'Il\ llf the 11,111',. lli:-lilll..:1 ~11"'\ " .~ dpparCll\ t)11 thc l,tlCra] "idl' or the
form or Gothic chull:h l(l\~'CC 1\'1,',; iili ... lilldin~ 01-;: ..,,\.',,-
a pll.. . sibk 1.!t'I.:rca'L' ill the slahi-
Vie\\'illg rhe pmi('/I! FOI/1 ,!lc' /""111, lhe q\l:llil~ pf Ihe ah- hllil;': i HIll'! ion Ilf Ihl' r,', u in Ihe allll.'rop{lsh.:rior din:l'l iOll. ;1Il
dominals is obscrn.:d lir:·a. Id\'·:lll~. 11h..' :thdoillilla! \\:111 i" nal. illl!".n.tll\ r:ll'ltlr hlr 'i.>til/alioll oflhc "pine (Fig.. (1.2(1).
A sagging and pn,lIrudcd ahdoll1l'l1 may 1"I.'I\""l'1 '::l'lh.:'r:dilcd nh' l\\p :lll\,.:rilll ;:',:;:lllHlsCk's Ihal (:Ill inlluCllCl.' lllc llllll-
weakllc~s of thl..' ahdomill:lb. \\'!il'll Ihe ohliqul" .n...· dllllli- bll:~~·1', I,' pu.. . ltl.l· ;11~' :::: lel..... llr fa~\.:i:lL bl;IC alld the rcclus
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·..·,:luralisllIiLJor is charactl.'ri"l.cd hy :t
IIh Ir..:- pftllllinClI1 lllu ... (k' 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·
,j

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 addi-
Fig. 6.29. Extension of [he elbows. liOlWI daw.

)
Fig. 6.30. Hyperextension of the thumb.

,]

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 1'.\l'l\:i~\' d,'~" Illl! k<ld 10 t'\ llknt hypCflWphy. The muscle
()
hlllL' is \k... rl·.:~;:d when a:,sc:.scd hy palp;ltion and the range of
\111,,1.:1..-;0. \";Ill h\.' iun)I\".'d !i1 llIany (lfhL'!' ;lfIL·'!\lI1S. One {If Ill:..'
EllOV!..'l1h:1lt ::: lnillb is l.:ompari.llivdy iuncascd. In Spill,,' of
lll\lSI (\Hllllhlll :-.ilU:llilllb I ' ...· 'lllSlil11li()ll;t1 h~ ;',-'n1Hlhilily. Till'
joinl illst;l('il::~. it has llot h~~ll conlirmco that "hypamobilc"
va~llt.:. IHHlpn1gn:ssi \ l" \'lilli..:;l1 :o..yndnlllll'. It. 'I rl':llly a dis,:;.,\".
'UhjlTh arlO ,,,,,r\.· pr(Jll~ 10 t!c\'c!0P musl.:lllo~kdclal pain syll-
i.\ lit' 1l1lKllll\\1I (lrigill. 11 i_, ,:haral"tcfi'l.cd j\~ .: '::l·Il.:r:lll;l.\il~ ,II dn 11lll·S.
li"'SIlC:'. 111 p:lnintlar ill' li~;lIl1l,,'ll\:'. l\'lust.:k <;-~'1l~11l ill ;L!"k\'h:d
('llll,lllt,i:"Il;1! hypl:fI1Hlbility involves [hl: l:rHir~ hody. <11-
illdi\'idll:d ... u"llally i.. ltm. ;llld e\"en II \'i~\":"'H' "'1n.~ll~lhl'llIll~
thuuglf ;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
C) 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 l1ledla-
nistll to . . t;lbilil.e:. in panicular. the: weight-bearing joints.
Thcn.::forl', 'lrctl.:hing. if necessary. should be performed
-~ 0 gelllly unu lllliy in key lllu . . t:Ic . . 1hal ..lfe: supposed [0 be dcci·
I sive in ;1 p:mh:ul;lr syndrome. Because the IllllSCIe:; gcncri.llly
,
I, 3,. afe wC<lk. th;:~ may be easil~ o\'erused ano. therefore. trigger
points in mu:-d~s ~nd ligamems develop c;:lsily.
~ ~.
') Assessment or
hypermobility is in principle bas~d on es-
~, timation of muscle [one by palpation ;md range of motion of
i 0 the joints. in clinical practice. orientation tests usually ;lre suf-

i0
~
,C)
licicnLln the upper pan of the body. the most useful tests <Ire
he~d rOHltion. high :trill cross (Fig. 6.27), touching the hrmos
behino the neck (Fig. 6.281. extension of the elbows (Fig.
I
-~
(l.19). and h:, paexh.:nsiol1 of the thumb (Fig. 6.30). In the
lower pan of \h-: hody. the bcq choices <lrc the forward bend·
.
I:<j
t
ing test (Fif. 6.31). lateral tlexion test. leg raising tcst. and
dorsiflexion e,f the foot (Fig. 6.32).
R

SUMMARY
j\'hl.""h.:: illlb;:lJn,c is an c . . 'cmial comp0J)cnt of dysfunction
Fig. 6.31. The lorward bending test. synorume:~ or' thl' lllUS'lllo_~kcletal syslem. Important ap-

Fig. 6.32. Dorsiflexion of the fool.

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 proach~~ ill Ihe o\'crall therapL'lIli . .· progralll lie in lh~ recog- HEFEREfI;CES

nition of factors that p.:rp.:lll<lI.. .' tilt' dysfunclion ;l11d norma!· 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.
ization. This fact is :ruc rL'g:lrdk~~ llf whether lllllSl'k imbal-
Chur..:hill Li\'inpllllh.'. 199,1.
ancc is considered I,' callS': thL' jl'int dysfunction ,)r 10 occur bnda V: r..1 usck ~P;I'lll-;l pmpl1scJ 11n~c\lurc for diffcrclIlkLl di:lI~no·
p~lr..llcl 10 it. ,j,. J i\1;1Il1l:11 i\1.:,1 (,: 1.::(" 1991. ~
lUllla V: i\tusd..: Fun,lion Tc~tjn~. Uultcrworlhs. L(lndon. 19S;\.

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 I ulagnosis of Muscular Dysfunction
--:,
by Inspection
LUDMILA F. VASILYEVA and KAREL LEWIT
,
1
t.• r';
~
•

This chapter is devoted to the art of iDspcction. On thc basis b. Of particular importance if these points are connected
of work by Janda concerning 11l0VCIllcnt patterns and that of by a single joint or belong to the same motor segment
Travcll and Simons dealing with the musculature. the authors (Inspection alonc, howevcr, is not sufficient to make a
show how much can be g~lincd by inspection. It is no coinci- complete diagnosis of dysfunction, e.g., joint move~
dence that findings prim:triiy concern muscles, for [hey .Ire ment restriction)l
most in;portanr for the shape of (he hum:tn body. Their hy- 3. Inspection is ncvertheless most important in directing our
peractivity ;:md shortening rcsllhs in visible hypcnonus. their attention to the most relevant lesion
weakness in flabbiness. These clmngcs not only arc patent but
Thc dysfunction that is most important tends to dctennine
also significantly change posture. Le.. body statics. and. of
the asymmetry. I.e., deviation from midline. and should be
course. move me III paucrns_
distinguished from compensatory excursions.
The aim of this chapler is to show that changes in body
shape or statics (Le.. body contours) arc so specific and relc-
Normal Body Statics
V:\nt thm often it is possible by mere inspection to identify the
single muscle involved. movements affected. and related joint The main criterion of normal body statics is to maintain bal-
dysfunction. This proficiency speeds up the difficult and la- ance with minimum expenditure of energy.2 The visual critC-
borious diagnosis of dysfunction of the motor system. The ri<l must be assessed from the front, side, and back and from
importance of diagrammatic sketches and photographs is em- above. In all thcse views. vertical and horizontal reference
phasized. lines connecting important points can be established for use in
The focus of this discussion is on inspection. i.e.. with vi- measurements and comparison. If body statics are normal, the
sual charactcristics. If used judiciously. inspection allows us lines should be parallel (horizontal or vertical).-'
to assess changes in individual muscles. thcir relative weak-
ness or hypemctivity. and/or shortness. This }nfomlation is BACK VIEW (FIG 7.1)
important for the a~$essment of not only muscle function as
The Spille
sllch. but also body "t;.Hics. kinematics. and joint function.
3. The plumb line from the occipilal protuberance passes
through the spinous processes (at the ccrvicothoracic.
DIAGNOSIS BY VISUAL INSI'ECTION: thoracolumbar, and .Iumbosacral junctions) to the coc-
AIMS AND I'OSSilllLITlES
cyx between the feel.
Main concerns when assessing the motor system arc as fol- The most important horizontal lines arc:
lows: b. between the ear lobes (tips of the mastoid processes) (2)
c. between thc acromia (3)
I. Identifying dysfunction
d. between the lower margin of the 12th (last) ribs (4)
<l. By analysis of body contours; first. bony prominences
c. between lhe iliac crests (5)
.1Ild their relative position examined from in front. from
the side. from the back, .and from .above
r. between the posterior superior iliac spines (6)
g. between the isehial tuberosities (7)
b. By comparison of findings with "the norm" (or a
model) The Upper Extremity
c. By identifying the arcH of the most important asym- h. The plumb line from the greater tubercle to the
metry humerus passing through the olecranon and the middle
d. By drawing horizonlal and vertical lines through the of the wrist (8)
most important points to locate maximum distonion I. The horizontal line between the major tubercles (the
(see Figs. 7.1 to 7.4) lateral angles of the scapula (9)
2. Visual criteria of dysfunction of individual muscles j. between the oleerani (10)
:t. Attachmcnt points arc closer togethcr if the muscle is k. between the styloid processes of the radius and
shortened or hypcractive. or further <lpart if it is weak ulna (II)
113
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 2
9

6 3
9 3

.10
§l4
~~m~~
iW~--jf\-\-lH-6
._1.3
7

14
.~5:=-
t~ 7

J.!L. ~ 6

Fig. 7.1. Important reference lines for the assessment of body Fig. 7.2. Important reference lines for the assessment of body
statics (back view). statics (side view).

The Lower Extremity condyle of the femur, (he. tibia down to a point a lin-
I. The plumb linc from the lower scapular angle through ger's breadth in front of the lateral ankle (I)
the midpoint of the iliac crest between the femoral b, The horizontal between the occipital protubcr;ulI..'e and
condyles to the midpoint of the calcaneal tuberos- the lower margin of the zygomatic arch (2)
ity (12) c. The line between the medial cnd of the spina :,c;'lpulae
TIl. The horizontal line between the greater trochantcfs of through the head of the hUlllerus to the medial end or
the femora (13) the clavicula (3)
11. between the femoral condyles (14) d. The horizontal lines connccting two poilH:' in the
o. between the condyles of the tibia (15) course of each rib: one 011 thc vcrtical below Ihe mid-
p. between the malleoli of the tibia and fibula (16) point of the clavicle. the other on the vertical trl)\l1 the
lower angle of the scapula (4)
e, The line from a point just bellm: the anterior :,uperior
SIDE VIEW (FIG. 7.2)
iliac spine to the prominence of the posterior :,up,,'rior
a. The plumb line from the external auditory canal to the iliac spine (5)
acromion. following the axillar line to the midpoint of f. The line from the upper edge of Ihe palella I" the I,>"er
the iliac crest, the greater trochanter to the lateral edge of the lateral femoral condyle (6)

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\.-HAY I "H I ; UIA(jNU~IS OF MUSCULAR DYSFUNCTION BY INSPECTION 115

3
5

Fig. 7.3. Important reference lines for the assessment of body Fig. 7.4. Important reference lines for the assessment of body
statics (front view). statics (view from above).

Fig. 7.5. Normal body stat~

A B ies (diagrams).

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116 REHABILITATION OF THE SPINE: A PRACTITIONER'S MANUAL

g. The linc from the upper edge of the tubcrosit<l5 tibiae tion (Fig. 7.5). Typical changes from normal body stillics are
tn the upper surface of the fibular head U) illuslrntcd in Figure 7.6.
h. From the lower edge or
the outer malleolus to the ai-
I;lchment point of the Achilles tendon (8) DisturIJcd [lady Sta'ics
I. The plumb line from the external ~ludilory canal
The main criterion of static function is that muscles maintain
through the hC<ld of the hUlllerus. slightly in front of lhe
bal~tIlcc with minimum activity. Therefore. vbual ~vidcnce of
ulnar epicondyle to the midpoilll of lhe wrist or the
increased tcnsion or hypcrtonus is of !lrc~H importance.
sliglllly llcxcd first interphalangeal joint of (he fore-
NOiieei.lblc signs of IllUscul;'lr ilnbaiance also imply aSYlllllle-
liilgcr (9)
try. and thcrdorc vism!} signs of hypotonus and <lsymmctry 01"
FRONT VIEW (FIG. 7.3) tonus arc also significanl. Direct signs of dislUrbcd equilib-
rium. such <IS a forward-drawn posture or deviation to onc
<l.The plumb line from the center of the forehead passes side (sec Fig. 7.6). illustrate clearly that the patient would
through the jugular notch of the sternum. the xiphoid. indeed lose his or her balance if muscle activity did not
the navel. the pubic symphysis. to midpoint between prevent it.
the feet (I): Because muscular imbalance manifests in individualll1u~­
b. The first horizontal line passes through the lower edge c1es and therefore (primarily) in cenain regions. but is fol-
of the auricles (or the lower edge of the zygomatic lowed by compensatory reactions in other areas that restore
arches) (2) b<llance. it is most important to determine which muscle
c. The second line through the acromia (3) (muscles) and which region arc plimarily affected and when~
d. The third through the lower margin of Ihe last rib~; {Ill compensation takes place. Unfortunately. pain rek!ted to ovcr-
c. The founh through the anterior superior ili<1c spines (5) ~tmin may occur in both areas and is therefore ~\ most unreli-
f. The plumb line [rom 'he midpoint o[ 'he c1"vieul<t able symptom, It is logical to infer that the direction in which
pilSSCS through the midpoint of the patella and of the the body (with the ccnter of gravity) deviates should be an im-
,alocrural joint (6) portant guide line. The horizontal lines in the illustrations
serve ,IS an additional guide to show the direction tow~1l"(1
VIEW FROM ABOVE (ASSESSMENT OF ROTATION) (FIG. 7.4)
which equilibrium will deviate. If these lines ~\rc not parallel
u. The line connecting both auricles (I) ('owing 10 spinal curvature, the side where these lines diverge.
b. The line connecting both acromia (2) or in the case of several curvatures where the sum of di-
c. The line connecting the anterior ends of the ribs (3) vergence is greatest. corresponds to the direction toward
d. The line connecting both greater trochanters (4) which the patient would fall if muscular contraction did nN
e. The line connecting Ihe outer condyles of the fcm- prevent it.
ora (5)
f. The line connecting the midpoint of the heel with the Disturbed Statics in Dysfunction of Individm\1 Muscles
second toe (which ought lO be symmetric in relation to or Muscle Group~
'he midline) (6)
These criteria in a shorleJwd tII11xde include allachrncl1l
Drawn on the basis of the data and illu~trations described points that arc closer togcther than norm<ll and increased
in lhis chapler. the diagram in Figure 7.5 represents normal prominence of its contours owing to hypcrtonus. In a u'(,ilk-
conditioll~ and is used for registration of muscular dysfullc- cne,1 IIJlucie. criteria include increased disl;lncc betwcen

-~

;;
Fig. 7.6. Abnormal body
statics (diagrams). a,b: Mus-
cle dysfunction. Dotted lines
stand for dysfunctional mus-
cles. c-f: Disturbed body sta-
lies. Black, devialion from the

·:··
vertical; gray. divergence 01 \
horizontal lines; angle 0". '\ ,
~L
open in the direction of body
j
deviation. g. h: Joint dysfunc-
tion. Black. restriction; gray. :
hypermobility (see also Fig.
, f i
7.36).
" B c o
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E H
 CHAPTER 7 : DIAGNOSIS OF MUSCULAR DYSFUNCTION BY INSPECTION 117

.<
< :.Iltachmcnt points and flattening of its contours owing to Dircclion of movcment is dctermined maiotty by Ihe <lg-
hypotonus. onists and also by thc synergisls
The imbalance just described results in the <lsymmctric Precision of movement is guarantecd by the I1cUlralizers
position of the salient parts of the bones to which the muscles Fixation of auuchmcm points is guaranteed by lixator
\ attach. It .1150 goes hand in h:md with articular dysfunction. I muscles. excluding motion in the vicinity
Those cases in which the attachment points were closer to- Smoothness of movement is guamntccd by the eccentric
g.ether were ..ssoci;ucd with a preponderance of movement re- contr.lction of the antagonists
striction. Hypcrmobility was found in neighboring segments
of joints where movement restriction was fountl. DISTURBED LOCAL MOTOR PATIERNS BECAUSE OF
SHORTENED MUSCLES
Diagnostic Criteria of Body Statics
The shortened muscle is also hyperactive <IS a rule. Its irrita-
These criteria include the following:
tion threshold is lowered and therefore it contracts sooner
The direction in which the body deviates from the nann than normal; i.e., the order in which muscles contract in
Diagnosis of the region (muscles) primarily affected the normal pattern is altered. If. therefore, the agonist is

,,~ Diagnosis of the individual muscles affected

Dirlgnosis of the individual joint dysfunction in the re-
shortened, the relationship to the synergists, neutralizers, fix-
alars, and antagonists. is. out of balance and the local paUenl,
i 0 gion of affecled muscles and attachment points I.e., Ihe direction, smoolhness. speed. and range of motion.
I, o"'~

... ,} Diagnosis of hypcrmobilily. in pal1icular in lhe vidnil)'

of movemclH rcstriction
are disturbed in a charnclcrislic way. (See subsequent section
for discussion cC'ncerning visual assessment of individual
i r} muscles.)
i Assessment of Disturbcd Motor Pattcrns If Ihe synergists. neutralizers. and fixators arc shortcned.
I,, ~
.J NORMAL LOCAL MOTOR PATIERNS'
it is again the short synergists. neutralizer. or fixators that con-
lract first and distort the pattern. If the antagonist is shortened,
i ")
'<.;
The crilcria for normal local patlcrns, such as in onc exlrcm- the entire pattern is altered and substitution occurs (see dis-

i, ) I
I
ity joinl or concerning one section of lhe spinal column. are
as follows:
cussion concerning weak musclcs in subsequent section).

DISTURBED LDCAL MOTOR PATIERNS BECAUSE OF

~
:) Movement is carried out exactly ill lhe. u(;",;!"(;J direction
£ A WEAKENED MUSCLE
Movement is smooth and of a constam speed
(1 Movement follows the shortcst possible path The threshold of irritation in Ihe weakened muscle is
~ Movement is carried out in its full range raised and therefore. as a rule. the muscle contracts I:.Her
\~
-I ,)
,\,..

!J
I, )
I ,)
,J• J
~
,•,
•
~
~)
~,',

%
'"
i

:~
f"
~ q,

II
}

"j

• {) Fig. 7.7. Normal

movement patterns
() (diagrams).
Ir
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'<~J
110 REHAtilLlIAllUN OF THE SPINE: A PRACTITIONER'S MANUAL

than normal or, in some cases. not at all. Hence. the order dr;'lwn by a dott~d lin~. Agalll. 1m tile s<.lkl: III \.:iarity. tht:
in which muscles contract is nltered. :.IS is coordination. The changes havc purposefully bcen exaggerated.
most characteristic feature, however. is substitution, altering
the entire' pattern. This change is particularly evident if the
Gluteus Maximus
weak muscle is the agonist. If. however. the nClItr;i1ii'-cr:-:
and/or the fixators 3rc weak. the bi.lSic pattern persists but
GENERAL CHARACTERISTICS
there is ;:\cccssory mOlion~ if the antagonists arc weak. lhe
range of movement is increased. 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 Origin Inserlion
:JUachmcnl:
I. Upper part of the in- I. Tbe supcrlicial
)
Typical synkinesis in distam regions with primary
movement in other parts of the motor system nominatc tillers cross over ,..
Smooth propagation of motion from one region to other 2. Lower pari of thc Ihe gre:lter lro-

part' of the body sacrum challlcr ,Ind atl:lI.:h ~

,.. J
A constant (optim4J!) rcl;'llionship between lhe speed of 3. Cocc)'x-I<lteml surr;l(c 10 the i1iutibial
1t100ion initialed in one region with the speed of synki~ 4. lumbodorsal ;lpO- (ract.
ncsis in other regions neurosis 2. The lower pari (\1
). Sacrolubcnlll"; li~;lInclH Ihe lihers atlach ;!l
If local pmlcrns arc changed. synkinetic patterns rCIll<lin
6. The fascia or the glu- (he gluteal tuher-
inHlel. as long. as substitution docs not take place
(eus medius osit)' of the 1i..'lllUf , fi
The results of assessment of local molor patlcrns arc
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
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
DISTURBED STATICS BECAUSE OF WEAKNESS (FIG. 7.8)
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~
Direction of 1. Upper p:Jrt of the in-
cned muscle.
pull at the nominate dOTSOl1lcdio-
:Ht:lchIllCllt c;.sudall)'
VISUAL CRITERIA OF DYSFUNCTION OF poill1s on 2. Sacrum: 1(I\\,cr p,lri
INDlVIIJUAL MUSCLES ("(llltr.lctil1ll: mediodorsoc;l\Idally
3. Coccyx: mcdiodor...C1-
A key c1emcnt in diagnosis is a sct of tcsts that show wcak~
Possible caudally
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 change ill I. Innominillc: i1ntcn;r-
call change body posture and in particular the contours of the position ,...( ..ion. cXlcTIlal rotaliun
human body. \Vc also provide the visual criteria of somc mus- ana{(lInie 2. Sacrum: '\lHc\'cr~i(.rn.
c1cs prollc [0 such change that arc noted frequently in clinical MTLIClllres ipsilatcml flexion. and
practice. (owing tll rot;.stion 10 the same
In this chap[cr. ccnain key muscles th<lt arc prone to short- wcakncss"l: \ide
ening are <lddrcssed. The)' ;'Ire the biceps femoris. the tensor 3. Lumbar spine: hyper-
fasciae I~ltae. the piriformis. the quadr;'llus lumboruill. the lordosis with SCOIII)\;",
upper trapezius, and the sternoc!eidoIll<lsIOideus. f , Muscles toward the ipsil:lIcral
with a tendency to weakness thai arc discussed .Ire the g(ut~us ...ide
maximus ;:1I1d the reclUs abdominis_ A more comple.; list is .:I Lower p;lrl of Ihe
given in Chapters 2 and 6. ...acrum ;.md cocc)'x:
In the following illustrations. the nonnal position is in contrJI"tcr.a1 devi;llioll
black and the ;'lhered position. the result of dysfunction. is in Joilll Sacroiliac joint:
white. Where the abnormal hides the normal. the normal is mohility: IpsilalCr;tl movement

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I",n1'\t" I t:.N I : UIAt.,;iNU1;iI1;i OF MUSCULAR DYSFUNCTION BY INSPECTION 119

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, glu-
teus maximus.

B
,

c ;r D

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120 REHABILITATION OF THE ~I-'INI::: A t-'HAc..;lllIUNI::H~ MJ-l.I~U"""L

CHANGES IN BODY OUTLINE BECAUSE OF WEAKNESS DI~ I uR~eD MOTOR PATIERNS BECAUSE OF WEAKNESS
(FIG. 7.9)
If there i~ wcakness of lhi~ IllUSCIe. Ihe halll'\trings and hlln-
Qrigin In!'cnioll bar cxten~or~ become m(\fC activ~ (see Pig. 7.12).
Front vicw: 1. Increase in tf'-lllSVCrSC 1. Increase in truns-
diameter of pelvis, verse diameter of Biceps Fl'Oloris
GENERAL CHARACTERISTICS
mainly in c<ludal hip.
portion 2. Gre.lIer trochmucr This musclc has a Icndcn.. . y III bc(.;olllc shoflcncd and ovcr-
2. Upper margin of iliullI is displ:lccd .1ctivc.
is lowered. anterior suo upward and
pcrior ilia,=, is depressed protrudes FUNCTIONAL ANATOMY
3. Ramus sup. as pubis is 3. Valgosity 'It knee;
lowered and protrudes patella is shined Puints of
anteriorly medially attachment:
I. Long head: poslerit1!' I. Long head is joined
Side view: 1. Buttocks protrude pos- 1. Anterior shift aspcct of i~thial hy short hcad and \ll-
tcriorly and pel ....is is mainly of distal tuberosity f!ethcr form it CUIll-

naucncd anteriorly pan of thigh. fOf- "J Short head: lataal lip mOll tendon lhal rum:
2. Increased lumbosacral ward protrusion of of linea aspcra of along latc"ll condyle:
lordosis knee femur :lIld eSlablishes ;l lri-
2. Slight flexion of partite 'lIlchor It) bl·
all major joints of era! aspect of libular
extremity head

Back vicw: 1. Increase in vertical di-

nmClcr 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:

Qrigin Insertion

(
Direction of I. Ischial tuberosity is I. Fibular head is
pull al lhc pulled in caudal-Imcr;:ll· pulled in craniu·
attachment dorsal direction dors.1! direction
points on
contraction:
Possible
changes in I. Innomini.lte retrol1cxion J. Flc;r;ion adduction
position of adduction and imcrnal and eXlernal rt1I;I-
analomic rolation (ion of leg bdow
'L
structures: knee (vcnlrof1h.~·
dial shift of di:H.1I
end of thigh)
Joint I. Hip c;r;tcnsion (Iighten- I. Knee. joint: Hex·
mobility: iog of sacrotuberous ion. exlernal rola·
ligament) lion. anutorsiOIl in
relation Iu Ihigh.
A B (i;r;alinn of tihio-
Fig. 7.9. Changes in body outline because 01 weakness of fibular juilll:
the gluteus maximus. Front view (a), side view (b), back view (c). valgosity

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\",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). . fro m above (d),
view (c) view r" 3 tibia; 4•
. . 2 femu, .
1. pelvIs, .' ps femoris.
libula; 5. blce

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 1 <:<: REHABILITATION OF THE SPINE: A PRACTITIONER'S MANUAL
,j

I CHANGES IN BODY OUTLINE BECAUSE OF SHORTENING

(FIG. 7.11)

Ori~in !lI'l'rtioll

From I. Decreased transvcrsc I. Increased tr;llls-

Vic\\': diameter of tlppt.·r pan \'c,":'e di;ullelcr (If
of bcmipdvis lllwer pan of
, [nnolllin;lh: is hl\\"crcd hemipdvis
and com:a\"e: antcrior
, L:lleral cOlltour (If
:mpcrior ili:lc spinc thigh at lcvel (II'
raised: upper edgc of trnchalller is more
j
1
I1
pubic bOlle is r..lised
and less prmninen! ,. prolllincill
Knec lics morc
1 medial and su dnes -'1

I,
~ Side View: I. Pelvis is drawn forward
patella: medial
condyle protrudes
I. Distal end of thigh
{,. ;md its dorsal outlinc is thrust forw;ml
%1 flattened and patella
A B
i protrudcs
Fig. 7.12. Hip eXlension in a patient with a shortened biceps
I Bilek I. Increased concavity of I. Protrusitlll of IlH>
femoris. Back view (a). side view (b).
! View: pelvic outline above dial fClmw.l1
~

I
buttocks and increased condyle
DISTURBED MOTOR PATIERNS BECAUSE OF SHORTENING
prominence of buttock 2. Dor.-;a[ protrusioll
AND OVERACTIVITY
ami g.rc.lIcr tuberosity of libul;lr head Jild
j of biceps muscle This paucrn may include an altered activation sequence of
Ig Icndon muscles during extension or the hip joint (Fig. 7.12).
~
The order of muscle contraction during hip extension is
!l

I I. Hamstrings
2. Glutcu~ muxillllls
J. COlltr~l<ttcral erector "'pinaL' "

\)
4. Ipsilateral erector spinae

DcI<lycd activation of the gluteus maximus may occur

when the biceps femoris is o\·cractivc. ,
f

Tcn.wr Fasciae Latac

GENERAL CHARACTERISTICS

This muscle has a tendcncy to becomc shortened and over·

nctivc.

FUNCTIONAL ANATOMY

Points of
att:ldllllent: I. From ,Interior part of
-"'(
I. Antcromedinl h:lldi- ,oj
OUler lip of iliac crest mlus fibers lerminate
to ;,mtcrior ~upcrior in I~teral palcll:lr
iliac spine retinaculum
2. Posterolateral half of
musclc tcndon :11-
taches below knee
A onlo later.lliubcrclc
Fig. 7.11. Changes in body outlines because of a shortened bi- uf tibia via iliolihial
ceps femoris. Back view (a). side view (b). truet

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,
I ' CHAPTER 7 : DIAGNOSIS OF MUSCULAR DYSFUNCTION BY INSPECTION 123

I
1
~ Fig. 7.13. Disturbed body

1 statics because of a short~

ened tensor fasciae latae.
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

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

IMPAIRED BOOY STATICS BECAUSE OF SHORTENING DISTURBED HIP FLEXION MOTOR PAITERN BECAUSE OF
(FIG. 7.13) SHORTENING (FIG. 7.15)

Changes at lhe ipsilateral sith.:: Din:Clioll (If ~"lovC1llelH

I. Hip j\lint: Ilcxiull. I. Ipsil;lter31 innominate is lowered ;lIld

Origin
;lhductiUl\. internal rnt;lIes: pelvis shifts toward ipsiJm-
Direction of I. Caudolah:nHlnrsal Pill! I. Cralliolalcro-t1ursal
l"(ltaliol1 croll sidc
pull at the at ;llltcrillr :'\lp~rior pull ,il proximal end
2. Knce joint: l1exion. , Lumbar spine extends and side bends
attachment spine of tibia
"
abduction 3. Hip flexion and :lbduction
points VClllroll1<:di;d dc\'i:l-

I
Oil '"'I
~. Lateral deviation of paldla and toes
contraction: lion of thigh is
resull or muscle's
Piriformis
tendency 10 approx.·
illl.lIe tibia toward GENERAL CHARACTERISTICS

I,
8
Possihlc
changes in
position of
;lIl:ltomic
J. Innominate- ahductioll.
;mld1cxi(lll. ami cxlcr-
nal rotation
2. Flexion. uddllctiotl. and
pelvis
J. Vcntronicdi.11 dcvia·
liun uf disl;tl end uf
thigh: abduction.
l1cxion. and eXler·
This muscle
active.

FUNCTIONAL ANATOMY
hits a tendency to become shortened and over-

structures: internal rotation of llal rotation of pmx- Poinls of Ori<1in J~rtiQn

proximal end of thigh lmal end of tibia attachment:

I. Anterior lateral surface I. Fibers run through
Joiu! J. I-fip joint: abduction. I. Knl;C joint: stabi· of sacrum between grc;ltcr sciatic
mobililY: ncxioll. intern:ll first and founh sacral for.mh~n and alt;leh
lii'.:ltion. Ilc:-.:ion. ro-
rotation t:ltilln for:lmen to grc;lt~r

2. Pall of fibers aHach to trochanter of 1

CHANGES IN BODY OUTlINE BECAUSE OF SHORTENING margin of greater sci- femur on medhll
(FIG. 7.14) atic foramen at cap!'ule side of its superior
Origin In<icniOll of sacroiliac joint and surface
sacrospin:tl ligament
Front vic\v: I. Increased trJnsverse di- I. Increased trans-
ametcr of upper part of verse diameter in
hcmipclvis hemipclvis
2. Iliac crcst is raised and 2. Lateral contour of )
protntdcs anteriorly
3. In addition. tense mus-
thigh fonns
straight line: tensc
,
.J
cle belly of tensor fas- fibers nf iliotibial
ciae latae fonns round band visible
protrusion 3. Lateral (emordl
condyle protrudes: )
.'
p.neHa deviates
laterally.
Side view: I. Pelvis dc"i.nes posteri- I. Knee slightly
i _.~
,
orly; relative concavity nexed ;lIld pro-
at level of hip joilll and
increased convexity at
trudes anteriorl)'
f
level of coccyx ')
2. Increased lumbar '.J
lordosis
Back view: I. Superior deviation of I. Protnlsion at level
posterior superior iliuc of contr;\cted mus-
spine appears deeper de: pelvis is in-
and at greater distance c..'-lined to the Si.lnle
from sacrum side
2. Ischiill tuberosity. how- 2. V':llgo:-ity at knee A B c .j
ever. approaches omd abduction of Fig. 7.14. Changes in body oulline because 01 a shortened ten-
sacrum tibia sor fasciae lalae. Front view (a). side view (b). back view (C).
www.bodywork.su

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 CHAPTER 7 : DIAGNOSIS OF MUSCULAR DYSFUNCTION BY INSPECTION 125

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:j Fig. 7.15. Hip flexion in a pa-

I tient with a shor1ened tensor

fasciae latae. Side view (al,

i
A B front view (b).

IMPAIRMENT OF BODY STATICS BECAUSE OF SHORTENING

(FIG. 7.16)

!i () Changes at the ipsilateral side:

Qtigjn
CHANGES IN BODY OUTLINE BECAUSE OF SHORTENING
10 Direction of I. Latcrocaudo·\'cntral I. CraniulIlcdio- (FIG. 7.17)

I
pull at at- pull at lower part of dorsi.ll pull <It
Q.tigin Inscrtion
,) tachmcni sacrum greater troch:.lOtcr
poim on producing approxi- Fronl I. Anterior superior iliac I. Latcral cOntour of gre.ucr
contraction: Illation of ~acrum Vic\\': spine lies higher and trochanter is nallcncd
I and greater is less prominellt
ur
2. Leg is in abduction and

i trocharlil.:r. causing
laicrovclllral devi-
ation of caudal
2. Upper edgc pubic
bone devi,llcS crania-
medially
external wt,Hian
3. PatcH,••Uld {()C$ arc dcvi.
ated laterally
part of pelvis 4. On changing weighl 10-

I
ward ipsil.ltcral leg. posi-
Possible 1. Sacrum is tilted hack I. Thigh: abduction.
tion of loes rcmains un-
changes in <lnd bent to opPo!loitc OUI\vard roWtiOll
changed. but \'algosily at
position of side, resulting in flex- and flexion; leg
knee bcnmlcs cvidellt
anatomic ion of sacrum and knee deviate
f, structures: 2. Pelvis is thrust back: 10 side and for- Side I. Pelvis is thrust b.\(;k- I. Knee .\flO ta\ocrunll joilll
tendency to "f:lll" witrd with ten- Vicw: ward and both sacr:d arc slighlly ncxed
backward dency to varosity kyphosis amI lumbar
3. To compcIlS~l1C, the pa- al knee lordosis arc reduced
tient slall(.I~ on COIl-
Back I. Trans\'cr.;e diamch.::r I. Knee deviate!' I:llerally:
tralatcrallcg. View: of hcmipclvis is re- laleral cdge of popliteal
Joint I. Hip joint: Olll\vard rota- duced: poslCrior supe- rossa in a lllorC dorsal
mobility: tion, abduCli\lII rior iliac spine lies and mcdi'll in more vl.:n-
2. Sacroili<lc joint: ne,lrer to S.lcrum ,Hld tr:.ll posilil\l\
cOlllprcssi(lll is more prolllinclll

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126 RI:.HAIjILlIAIIUN VI- I HI:. :;)t-'INt:: A PHAG 1IIIUNI:.H~ MANUAL

Fig. 7.16. Disturbed body statics

because of a shortened piriformis.
Front view (a), side view (b), back D
c

"
view (c), view from above (d); 1,
pelvis; 2, femur; 3, piriformis.

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Fig. 7.17. Changes in body outline because of

a shortened piriformis. Front view (a), side view
A B c (b). back view (c).

Fig. 7.16. Hip flexion in a patient with a shortened

B piriformis. Back view (a), side view (b).

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 DISTURBED HIP FLEXION MOTOR PATIERN BECAUSE OF CHANGES IN BODY OUTLINE BECAUSE OF SHORTENING
SHORTENING-HIP FLEXION (FIG. 7.18) (FIG. 7.20)

Din:Clion of Mm"Clllcnl Visual Crill'ria Insertion

I. Shcarill~ force at I. I)l1r;ll~ ~;1it. P~llil.;l\l raises ipsilateral Front I. Tr;.lIlsn:rsc diameter of I, Increased transversc di-
s<lcroiliac joint wilh inrwmin;ltL' wilh intcfIlal rotation View: ipsihlterallowt:r part amcter of ht.:lllipeivis .
compression .., FI:llICIK'd lateral outline at hip of thorax is dimin- mainly lower part
., Extcmal rotation. 3. Leg is fined. abducted. and in olll- bhed 2. Antt.:rior superior ili"c
abduction. Ocxioll at ward wlalion with (Onl and loes de- 2. Waist is narrower spine deviates latt.:rally
hip joint viated l:llcrally and is more promincllt
3. p.lticnt puts weight
mainly on ipsil:ltcral leg:
Quad~atlls Lumhorum contralateral leg is ab-
ductcd .md slightly
GENERAL CHARACTERISTICS
flexed
The qu.tdr..ltus lumborum ll;ls "l lendency to become shorlcncd Side I. Increased lumbosacral I.Decreased sagittal diam-
and overactive. View: lordosis eter of pelvis
2. Sacrum with coccyx tiled ---..
- J
FUNCTIONAL ANATOMY dors<tUy ;md protrudes:
P(lims of ventral contour of pelvis
au~chlllcn[:
is nattened
I. Vertical iliocostal 1. Posterior part of
fibers: medial half of iliac crest llnd ilio- Back I. Lumbar spine deviutes I. Apex of sacrum with
12th rib lumbar ligament View: to side. resulting in coccyx and ischi.l1
2. Iliac crcst and. fre- scoliosis tuberosity approach thigh
2. Diagonal iliolumbar
fibers: End of fina three quently. iliolumbar 2. 12th rib and innomi- 2. Transverse diameter of
buttock is diminished
of rOUT lumbar tmlls-
verse processes
ligament
3. All lumbar trans-
nate approach lumbar
spine: transverse di- ,. Gluteal foid is r.tiscd
verse processes ametcr of trunk at 4. Posterior superior iliac
3. Di3gonallumbocostal
llbcrs: 12th rih waist diminished on spine closer to the
that side: lateral con- sacrum
tour more concavt.:
,_ Frequent compen·
IMPAIRED BODY STATICS BECAUSE OF SHORTENING
satory thoracic scolio-
(FIG. 7.19)
$is to opposite side )
Changes at the ipsilateral side:

Dirct:\iOll Q.rigin
il of pull
'I I. 12th rib caudolllcdially: I. Iliac crest: cranio-

I at attach-
mcnts on
\riln~Vcrsc processes

later;.lly
tllediodorsally
DISTURBED HIP EXTENSION MOTOR PATIERNS BECAUSE OF
contraction:
SHORTENING (FIG. 7.21) ---~

1 Possible
changes in
I. Lowering of 12th rib.
increa~cd hunbm lordo-
I. R<lising. external
rotation. and
The quadratus lumborum contracts before the hamstrings and
'-J

I
.~
posi\ion of
anatomic
sis and thor:lt:ic kypho-
sis: IUlllbar scoliosis to
rctroOexion of in-
nominate
lhe gluteus maximus.
Direction pf Movement Visllal Criteri,j
'~! strUctures: Samc and thoracic sco- I. L.umbar spine: extension. I. When <ltlcmpling. to extend leg.

Ii Joint
mobility:
liosis to oppositc side
i. Fixation of the 12th rib.
increased pressure on
intcrvcrtcbr.tl .md lum·
I. Flexion and ad-
duction posilion of
side bending
2. Pelvis: laterol1cxion and
antcnexiol1
p;lticnt lirst t.::c:tel1ds and side
bends lumbar spine instead of
hip joint
2. Innominate of same side is

i:~
bosacr.tl joints
2. Thoracolumhar hyper-
mobility
hipjoillt r<liscd and (hura:c: is lowered. ar-
pro,Jcbing the pdvis: "S"-scolin-
t!
~
sis results

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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.

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

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~ shortened quadratus lumborum. Back view (a),

II
side view (b). A B

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 ~ ,•• _ ,,,>,,;>,.. Vv•.,:) vr MU~VULAH uytil-UNCTtON BY IN::iPECTION 131

DISTURBED TRUNK FLEXIDN MOTOR PATTERN (IN THE IMPAIRED BODY STATICS BECAUSE OF WEAKNESS (FIG. 7.23j
STANDING POSITION) BECAUSE OF S: :ORTENING OR OVER·
Changes at the ipsilateral side:
ACTIVITY (FIG. 7.22)

The. quadratus lumborum contracts before the iliopsoas and Qris.in

rectus femoris. Direction of I. Ctrlil;tginous end of I. Pubic bone Cr;,l-

force at 5th-7th ribs :lIld nially

Dirl'ctiun of r-.·1Q\'cment Visual Crileria
atlac1ullent xiphuid caudally
I. Lumbar spine: extension. I. On trunk anteflexion. lumbar points of
side bending (s;,unc side) spine goes into extension and contraclion:
2. 111Or;lcic spine: flexion. bends to same side; thorJcic
Possible I. Rib" and canilages I. Caudal shirt of
side bending (opposite spine goes into flexion and
change in with xiphoid deviate pubic bone pro-
side) bends to opposite side
position of crani;,lIly and contralal- duces anteflexion
3. Hip joim: nexioo 2. Flexion lakes place mainly in
anatomic crally, resulting in ex· of innominate
hip joint; enlire body shifts
structures: tcnsion and side bend· 2. Pelvis deviatcs
forward
ing of thoracic spine in dorsally and con·
Opposile direction tralatcrally result·
2. Compensatory scolio· ing in incrc:tscd
sis and increased lordosis of lumbar
kypho;;is in upper tho- spine and in scoli·
racic spine osis Iowards ip:'ii·
liltcrul !'ide
Rectus abdominus
Joint l. HypcmlobililY at tho- t. Hypennobility:lt
GENERAL CHARACTERISTICS
mobility: racolumbar and lum- symphysis: pelvic
The rectus abdominus has a tendency to become weak. bosacral junctions obliquity

Fig. 7.22. Trunk flexion in a

patient with a shortened quad·
ratus lumborum. Side view (a),
back view (b).

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A B

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Fig. 7.23. Disturbed body statics because
of a weakened reclus abdominis. Front view
(a). side view (b). back view (c). c

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 _,,, ....... " , ..... ,,...~ .... v.::U;;;) ur- MU~I.;ULAH UYSFUNCTION BY INSPECTION 133

CHANGES IN BODY OUTLINE BECAUSE OF WEAKNESS

(FIG. 7.24)
GENERAL CHARACTERISTICS

---
Qrigin Insertion
This muscle has a lcndcncy to becomc short..:n..:d and over-
Front I. Increase in vertical di- I. Increase in tran~\'cr~c di- "clive.
Vic\\': .lmcter of abdomen amcter of lower part of
2. Trunk deviates (0 con- pelvis IMPAIRED BODY STATICS BECAUSE OF SHORTENING
tralatemi side 2. Pubic bone dcvi,lIcs (FIG. 7.25)
down ano w sidl:
Changes.H the ipsilater~1l side:
Side I. Increased protrusion I. Incrcased lumbar lordo-
Qrig!ll Insertion
I CJ View: of abdominal wall;
sternum is lifted and
sis and prominence of
end of sacrum Direction 1. Occipital bOlle: cmllJo- I. Acromion: in era-
xiphoid is close to of pull at vcntrally and slightly lat- niollwJial direc-
skin surface attachment er'llIy ti(ln
Back I. Scoliosis toward ipsi- I. Innominatc is lowcrcd points on 2. Uppcr ccrvic:il spinc:
View: lateral side mainly in and waist is flattcncd; contraction: mainly Iater.lIly ,1Il0
lumbar region deeper on oppositc side slightly caudoforw'lro
Possible 1. Head deviates to side, I. Clavicle with
DISTURBED MOTOR PATIERNS BECAUSE OF WEAKNESS changes in forward. and into acromion deviate
position of rClroflcxion wi.h rotation CfaniOllledially
As a rule. the psoas substitutes for a weak rcctus abdominis.
anatomic to opposite side resulting 2. i\·lcdia: pull pro-
The iliopsoas. erector spinae. quadratus lumborum. and rcctus
structures: in increased cranioccrvi- duces compression
femoris may all become overactive when the rcctus abdomi-
cal lordosis of clavicle against
nus is weak or inhibited.
2. uter.ll pull at spinous sl~mum

Directinn of Movement Vi... ual Critcrin processes results in lat- 3. T(l compens:lIc.
eroflexion on upper cer- some side benJin,g.
I. Lumbar spine: eXICIlSio!l I. While stooping, the paticn(s
vical spine coupled with ;\1 shoulder girdle
,,;i;", ;Ji~I"'Jn~.\ioll iO lumbar spine remains lordotic as
rOl<ltion in opposite di- hl opposite side
same side the patient side bends 10 the
rection owing to C'IU- Wilh r\Jt,ltiull (() ip-
Thoracic spine: flexion SClme side: flexes thoracic spinc.
dolateral pull silataal side
wilh side bending to op- and side bends to the opposite
3. To compensate, some
posite side sidc.
scoliosis at cervicotho-
2. Pelvis: l:lleroflcxion to 2. Also flexes hip and entire body
mcic junction (0 ipsilat-
opposite side is shifted back
cr.11 side with incre'lscd
3. Hip joint: flexion
kyphosis
Joint I. Fixation at cervical and I. f-ix;uion a[ s[erno-
mobility: upper thoracic spine; hy- c1a\"icular: hypt:r-
pcrmobilily at cr:lnto- mobilil)' at acf<.\-
cervical and cCfvicotho- mioclaviculm joint
racic junction

Fig. 7.24. Changes in body outlines be-

cause of a weakened reclus abdominis.
A c Front view (a). side view (b). back view (c).

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134 REHABILITATION OF THE SPINE: A PRACTITIONER'S MANUAL

-",

Fig. 7.25. Disturbed body statics

because of a shortened upper
trapezIus. Front view (a), side view ()
(b), back view (c).
)

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Fig. 7.26. Changes in body
)
outline because of a shortened ,J
upper trapezius. Front view (a),
side view (b). back view (c). C '~_A'
·1

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 CHAPTER 7 : DIAGNOSIS OF MUSCULAR DYSFUNCTION BY INSPECTION 135

CHANGES IN BODY OUTLINE BECAUSE Of- SHO,HENING

(FIG. 7.26)

f-rolll I. Hc.u.l inclined to ipsi· I. Shoulder girdk rt)lah;S 10

View: lateral and rotatcd 10 ipsilalcml sidc and is
opposite side; car is r;liscd: decrcased Irans-
seen ,lI1d lowered; verse diametcr A
other car IS partly hid- 2. Acwmion dcviale:-;
dell <lnd raised mediocnuli:llly
.. ' ...".
"
1! U 2. Nose devialcs con- 3. Prominent upper contour

It tralater.Jlly of shoulder; fi:1Ucncd

() outline of latcr.J1 part of
dnvicula
,)
'-. I. Acromi<;m dc"iah::s em-
~
Side I. Head is thrust forward
Vic\\': .lIld benl back; ipsilat- nially
t 0
~ er;1I car points antero- 2. Increased dislance be-
j; inferiorly tween acromion and
;~~

I1 humeral he'lt!
:<1
3. Flattened cervical lor-

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Back I. Head and neck in-
dosis and prominent
cervicolhoracic junction

I. Shoulder girdle is raised;

~
~ 0 Vic\\': dined to ipsilateral decrca<;ed transverse di-

,• side ameler

~ ") 2. Contralateral car is 2. Raucncd latcr.JI contour

t raised and more of neck and shoulder
;1
3. Lateml outline protrudes
n visible Fig. 7.27. Arm abduction in a patient with a shortened upper
trapezius. View from above (a). back view (b).
t1 3. Horizontal fold (sign at level of acromion
l]

I
of cx:tension) .It em-
""',
niocervieal junction
,~) 4. "S" scoliosis noted-
contralatcr..tl in cervi-

I J cal ;)nd ipsilatcwl cer- DISTURBED MOTOR PATTERN DURING CERVICAL EXTENSION
(FIG. 7.28)

I
\·icothor.lcic region
) The upper trapezius bilaterally contmcls before the spinal
~ DISTURBED MOTOR PATTERNS BECAUSE OF SHORTENING extensors.
'>
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\~,:fI ON SHOULDER ABDUCTION (FIG. 7.27)

The upper tr~lpczius contracts before the deltoid (clavicular

Jj
Ii portion) or the supraspimltus. creating a dysfunctional scapu~

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lohumcr:lI rhythm.
Direction of Movcl1lelll Visual Criteria

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I. Acromioclavicular joint: I. Elevation and oUlward rolation
i ...J
move men1 of shear be- of shoulder and arm Direction of Movement Visual Criteria

,ff 0 tween clavicle .1Ild

shoulder blade
2. Head is inclined to ipsilaler.11
.tnd rotated to contralateral side:
). Head eXlension: ipsi-
latefonex:ion. contralat-
l. On back bending the head. pil-
ticnt side bends it 10 same side

i$ () 2. Head: extension. ipsi-

lateronexion. c(lntralat~
head is thrust forward and in ex-
tension
eral rotation
2. Cervical spine: forward
and rotates it (0 Opposile side
2. Cervical spine drawn forward.
h
'Ii
eral rot4ltioll 3. "C" scoliosis of cervical and shirt. latcronexion to the inclined to ~'lI11e side and ro-
3. Cervical spine: forward upper Ihomeic spine same. rotation to OPPO- lated to opposite side

I 0
shift. ipsil,Her:tl flexion.
contralateral mlation
4 Shoulder girdle: upward
sile side
3. Shoulder girdlt.:: clc-
v,ttion
3. "C" scoliosis of ccrvicolhoraci-.:
SPIIlC
4. Shoulder rai~cd and rotated with

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(,l1ll,:ill
Stcrncoclcidomastoid
1'\l.v,ihl,; " {·\;I\"Il.1': "lcl"llal ~lld I, Hcad: l1('vialc:-> for-
GENERAL CHARACTERISTICS c!l;lIlg,;, III 1;II\nl, '·':"'UIUi.:f I!.ir- ward to opposilc sidc
The sternocleidomastoid 11l11~dc has a (l:IlUCIlCY 10 l1C(OmC pnsili1ln hll Ilk p...·.;,':'l hack (if and rOl;:lh:s also In op-
shortened and ovcracti\°t::. Clllllr;IlII' III' 11\·;ul,'.:: ':;<1,; sli,t:hl posilc siul'
'"lall',I, ',~ \hllllldcf 2, Ccrvkal spine:
FUNCTIONAL ANATOMY 1~1l,.lk I', ';rlle sid~; lordosis limited ttl
lllWI'IJI'~' 'If lal!.:ral craniocel"vic,d junc-
Points of "I r_)~·.idc with
\'1111 lion: cCf\'ic<l1 verlC-
allachm~nt: 1. Cl:\\"iclilar division: I. Both di\'isinn:- attach
""'11I1<1,;; ::nd ;lrlll brae are thrust for-
1 sternal end of clavi-
cle
to lateral SlITf;.!I:c

mastoid prnccs:- and

of

I. 1(1'''1''';11' ,n ;11 sh:rnn-

ward ,\nd <Icvi.He to
opp(lsitc side .>.
2. Sternal division: an- 10 hller"l half ('If su- J
Joint ddVi'.llh: ~rid Slcl'- I. Rcstriction al cranio-
terior surface of perior nw.:hallinc of
ll)obillly: II'" ,,..1;;: :'Ilnls on ccrvical ,md cervi-
manubrium sterni occiput
- ',:1111'" ',1':': 'J/ith hy- cnlhnr.lc;c junction
Ih'"n"i, .,';, 'lllUJl-
IMPAIRED BODY STATICS BECAUSE OF SHORTENING
1"'··Ik .
(FIG. 7.29)

Changes al the ipsilateral side:

Q.tigjn
I. Sternal eno of ckl\'i- I. :\'taslOid rnl{:c!>~: cau-
Direction
of pull at cle: craniodorsolat- dovcl1lrolllcdially

points of crally
attachment: 2. Medial surfJcc or
manubriurn slcmi:
cran i odorso I ate rally

()

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Fig. 7.28. Head extension in a patient with a shortened upper )

trapezius, Side view (a), back view (b),
J
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Fig. 7.29. Disturbed body statics because of a shortened slernoc1fwlf'llIrltllnhlllllli I I'Jr<' I I, II / '1/ • "'J,
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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
B view (a). side view (b). back
view (c).

CHANGES IN BODY OUTLINE BECAUSE OF SHORTENING

(FIG. 7.30)

.!.illWiill.l
Front 1. Decrease in transverse I. Head deviates to ~idc
Vicw: diameter of shoulder and rolales 10 oppo~i(c
ginJk. less prominent side
shoulder outline 2. Ear on thai side i~ low-
2. Both heads of short- ercd. turned forward.
ened muscle and upper well visualized
and lower clavicular 3. Lateral conl<.ll!f of neck
fossa clearly seen on ipsilatcml side flat-
under skin tcned and at right angles
3. Shoulder £irdlc wim with shoulders
thorax slightly rotated
to same !oldc Fig.7.31. Head anteflexion in a patient with a shortened ster~
nocleidomastoideus. Front view (a). side view (b).
Side I. Sternal end of clavicle I. HCild thrust forward.
Vicw: wilh manubrium slcrni chin r.. iscd. occiput
r:liscd :md tilted back. lowered
xiphoid process on 2. Ipsil:.slcral cur rOlated DISTURBED CERVICAL FLEXION MOTOR PATTERNS BECAUSE
olher hand prolmdcs forward and lo\\-ercd OF SHORTENING (FIG. 7.31)
2. Acromion with shoul- 3. Reduced cervical lordo~
The slernocleidomastoid and ~calcnc~ will sllb~titu(c for the
der and ilrm lowered sis. but increased c:'(ten-
longus colli.
and thnlst back sion at cranioccfYlcal
junction Directiun of Movement Visual Criteria

B'lek I. Luer.Il angle of I. Occiput dcvialc~ to op- I. Ell;tcnsion at COil and I. HC;ld of patient is lowered. chin
View: sC;lpula lowered. infe- posite !'ide; ipsilateral CII2 ipsilatcnd inclina- thrust fOr\vard and to opposite
rior ;lI\glc raised. arm mastoid process lower tion wilh rotation to <:011- side
close to trunk and anterior. contral;.tt- tralatcr.tl side 2. Ipsilalcrnl car lowcred and dcvi-
eraJ raised and poslcrior 2. Allie· and JatcruOexion ates (0 opposite side
2. "C" scoliosis of cervical of neck J. EXlension of upper cervical and
and \lppCr thoracic spine llcx.ioll of low~r cervical spine

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 REHABILITATION OF THE SPINE: A PRACTITiONER'S MANUAL

PRACTICAL APPLICATION viatcs frol1l1h~ (ideal) midline to the left, with maximum dc~
viatio[1 at the level of the navel. the point at which the (zll·
Case History leTed) vertical line between the legs and thaI from the head in-
! Patient K., male. cOlllpl:\ill~d of gnawing p:lin in his h:ft tersect. 111e horizontal line diverges toward the left to the
shoulder that I.Idialcd O\T!" lhl' ;1I11crior Surl"KC of the thor'lx. right} with maximum divergence between the lower margin of
the rih cage (4) and the greater trochantcrs (6).
ANAMNESIS Note, hOWC\'CT. the divergence to the right of the line be-
tween the acromia and the lower margin of the rib cage. As
Six months prcdously. \vhcn paticllt K was Iihing <I small n>
dcvi.uion from tlie plumb line is dearly to the left and diver-
frigerator. puin started in Ihe right bUllock and mdiated down
gence of the mentioned lines is grealer to the left than to the
the posterior surface of his [high. Pain disappeared within a
riglll (sec angles ex and {3), it can be inferred that deviation of
fortnight without treatment. He then began to complain of
lhe pelvis 10 the left is primary and deviation of the shoulder
shoulder pain. mainly while standing. which grddually wors-
girdle Lo the right is secondary (compensatory).
ened. Standing with feel apart lessened the paui. but pain in-
Side View
tensified when he held his feet close together. Pain disap-
Pigurc 7.J3b shows forward deviation of the patient's body
peared when lying on thc llonpainfu1 sidc.
from the plumb line. particularly noticeable at the legs. Note
lillie deviation of the trunk, but, again, forward deviation of
ANALYSIS OF BODY STATICS (PAIN-PROVOKING POSITION)
the neck. The horizontal lines diverge mainly in front, mostly
FrQut View between the lower margin of the rib cage and the crista iliaca
The changes in body staLics an: illusLrated in the diagrams in (4,5). The horizontal lines between the spina scapulae and
Figures 7.31b to 7.32b by vcnieal'lfld hori1.ontallincs. Figure c1;wiclc and the lowcr margin of the rib cage (3,4), cor·
7.32c illustrates muscle dysfunction. The vertical line 0) d~- responding to the mainly straight thoracolumbar spine.

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12'1 't,

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Fig. 7.32.
muscles (e).
A B c
Front view of Patient K. in the pain-provoking position: photograph (a). diagram (b). and diagram of dysfunctional

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....... ~, 'C'" f • VI/,\UI\lU;:.I:;' U~ MUSCULAR DYSFUNCTION BY INSPECTION 139

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11
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+--18
12
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-_-17
~ 16
13

14 -1+-16

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c

Fig. 7.33. Side view of Patient K. in the pain-provoking posi-

tion: photograph (a). diagram (b), diagram of dysfunctional
o muscles (c). and (d) photograph of upper part of profile.

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14U REHAtjlLllAllUN Ur 1 Ht: tWINt:: A !'JHAG 1IIIU!'lt:H'~ MANUAL

converge dorsally. It can be inferred thaI body statics (bal- the lower iliotibial band. This tension contrasts with the hy-
ance) arc disturbed. with a tendellcy to fall forward. The angle potonus in the gluteus maxim us. producing flattening of the ;~

between the lower margin of the rib cage and tilt:: crisla iliaca buttocks and lowered gluteal lines. Also noted are lum- ::
is therefore primary ,md the :-;houldcr is the secondary com- bosacral hyperlordosis and increased thoracic kyphosis with
.

1
pensation. some tension (prominence) of the erector spinae and a pro-
,
Back Vicw truding. flabby contour of the upper pan of the abdomen. The
,
In Figure 7.34b. lhe paliclll stands with his legs apan. i.e.. in head ;md neck arc thrust fOf\vard and tension is evident in the
the relief position. Lillie dc\'j;'lIion from the vertical is seen right stcrnocleidomaslOideus and upper trapezius. Lordosis is
,
between the legs; deviation is limited llluinly 10 the cervi·
cothoracic spine. with ;,\ maximum :.11 the lc"c::1 of the lower
prescnt at the craniocervical junction. In Figure 7.33d. the
contour of the acromion is clearly outlined when the arms are ., j

angles of the scapulae. Maximum divergence of the horizon- hanging down, and, again. note the step-like prominence of
tal lines is between the biacrumial line and the line connect- the acromion in relation to thc head of the humerus. \\'e also
ing the. klwcr margins of the rib cage (3,4). The line between see better the cervicothoracic kyphosis with a raised lower )

the troclwnters is now almost parallel lO the lowcr margin of angle of the shoulder blade. The lower cervical spinous " .~

the rib cage (4.5) (compare Fig. 7.32b). 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 .;

ANALYSIS OF MUSCLE FUNCTION
dorsally. and there is visible tension in the biceps brachii. The
(pAIN·PROVOKING POSITION) '\
relative flattening of the thorax with a prominent xiphoid
Frolll Vie ... (Figs. 7.32c 7.34c)
10 process is also clear.
What can he secn on thc body outlincs is in keeping wilh the Back Vie.. (sec diagram in Fig. 7.34c) I
disturbance of stati~s (sec Figs. 7.32b to 7.34b). The pelvis The patient stands with his legs apan in the relief position. "

deviates to the left and tlte spina iliaca antcrior superior ap- Outward rotation of lhe foot is more pronounced on the Icft s;
pears highcr; the trunk devialcs to the right and the shoulder and tension is greater at the Achilles tendon on lhe left. On the .~

is lowered. The head is slightly inclined to the right with left left side. prominence of the triceps surae is greater and the dc-
rotation. pression below the knee on the medial surface is dcCIXf.
Closer inspection reveals outward rotation of the left leg. The popliteal fossa is deeper on the right (with th< knee
which is adducted; the right leg is flexed at the knee. Note the flexed) and the patella: is rotateo inward. The lateral outline of
tension of the sartorius on the right and protrusion of the shon the biceps femoris is more prominent on the right, the contour
adducrors on the left,..The shoulder is closer to the pelvis on of the semimembranosus and semitendinosus is more promi-
the right and the thorax to rhe left, which is in keeping with nent on the left, and there is a concavily on the medial surface
increased tension of the obliquus externus on the right where above the knee. Above this concavity is the prominence of the
its attachments to Poupan's ligament and the iliac crest arc short adductors; the gluteal lines arc lowered on both sides.
seen. The abdof,TIcn protrudes more on the left and hypertonus The pelvis deviates only slightly to the left. but rotation to ,
)
of the pectoral muscles is visible on the right side. Also 011 the the left is apparent. The transverse diameter of the hemipelvis
right side.-ffic mpple I~ lowered, the outline of the pectoralis is therefore greater on the left side, and the outline of the glu~ ,,
m.illQr ~.l.Jhe. axilla is sharper. the shoulder is drawn lorward teus medius can be seen. Abovc the pelvis. tcnsion is in-
and protrudes anteriorly. the supraclaVlCUiaf fossa is deeper. creased in the paravertebral muscles on the left; hypertoous. )
.and the outline of the sternocleidomastoid and trapezius mus~ principally in the latissimus dorsi. is visible in the craniolat-
c1es is clearer. The acromial end of the clavicle is raised on eral direction. Below the axilla. oo\e the .promiilcnce -of the
the right side. and there is a step between the acromion and tcres major. The convex outline of the infraspinatus belo\\' fhc
(he head of lhe humerus. spinae scapulae can be secn only on the left side. Here. too.
On (he left side. the contours of both the trapezius and the upper extremity is adductcd and slightly ncxcd on the left
sternocleidornastoideus arc vaguc. The head is not only in- side. The contour of the left shoulder forms almost an angle,
clined. but deviates to the right. The transverse diameter of i.e.. hypotonus of the deltoid muscle is noted. On the right
the .shoulder girdle appears smaller on the right. The head is side. on the other hilI1d. the waist line is deeper. and alxn·c it,
,
.J
rotated to the left, the right ear more visible on the right. The tonus of the latissimus dorsi appears diminished. The lower
right ann is slightly flexed and the hand is pronated; the con- anglc of the scapula is more prominent on the nght sid~ and
tour of the biceps is more prominent. the shoulder is drawn forward. Increased kyphosis in addition
Side View (sec diagram in Fig. 7.33c) to scoliosis are evident at the cervicothoracic junction. The
The main feature is the forward drawn position. particularly he.ad and neck arc inclined and rotated to the left; [h(' car is
of the lower extremities and the neck. This posture results in clearly visible. There is also some hypenonus at (h(' upper
tension in the triceps smae and the hamstrings. in the muscle trapczius on the left side. but the lower fibers of thm muscle
belly of the tensor fasciae latae. and. to the lesser degree. in as wcll as the middle trapezius ;lrc flattened .

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........- . - - - - - - - - - - zIa
 .....,"'.. ,....UOl" vr- MU;:)l;ULAH DYSFUNCTION BY INSPECTION 141
ANALYSIS OF RESULTS
The numerous asymmetries of muscular tonus described
From Ih.: ('hall=:~s in hody sl:lli(:~ and comp'lnson of the p;Jin- arc mostly compensatory. In the legs, it involves the biceps
provoking and rdid' POSiliollS. it follows that the main and femoris on the right, the adductors on lhe left, and the ham-
prillwry disturb~lI1l'c is al th~ pelvis: the parallellincs (sec Fig. strings and triceps surae on both sides. In the trunk. it in-
7.:l2b) show maximum divergence toward the left. and pch'ic volves the pectoralis on the right and the latissimus with the
dc"imion is signifk.mt. In the relief position. on the olher (eres major on the left. Othcrs include the slcmocleidom<ls-
hand (sec Fig. 7.34b). less deviation is noted. consistent with toideus on the right and the upper trapezius on both sides, but
increased lension of the obliquus cx(crnus abdominis on the more so on the right. The asymmetric position of the anns
right side ;Illd of the qU;ldrmus lumborul1I on till; len side (see goes along with incrcased tension of the biceps brachii on the
also Fig. 7.20), right and adduction on the left. These findings are illustr<1tcd
The other important change in body statics is the for- in Figure 7.35 (sec also Figs. 7.5 and 7.6).
w;mj·drawn posture wilh lumbar hypcrlordosis. It can be In " similar way, it is possible to eX3mine movement, in
infcrn.:d thal)hc straight abdominal muscles arc nOI primar- particular gait. as shown in the preceding discussions con-
ily wei.!k. out arc inhibited becausc of the shortcned lum- ccrning disturbed movement pattcrns for each muscle. It is
~i.Ir :-;.cclion of the back extensors (including the quad- even possible to infer from typical changcs in body statics
ratus lumhorum). Spasm of the external obliquus on the lef, which movement pattcrn will be affected. and from the dis-
side is clearly visible. and it is spasm of the abdominal turbed movement, which muscle is either shonened or weak.
fllusdcs that is the most frequent cause of the forward-drawn Visual diagnosis is also useful when checking therapeu-
posture. tic results by comparing findings, such as in photographs,

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12
1./ 13

4 13
-22
5 ,.
15
6
16
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17
20
18 21

7 !\
8
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19

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Fig. 7.34. Back view of Patient K. in the relief position: photograph (a), diagram (b), diagram of dys-
functional muscles (c).

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)

Fig. 7.35. Diagrams of patient K: (a) Dysfunctional muscles in the pain-provoking posilion (dotted lines, changed muscle con-
lours): (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 dis- 6. Janda V: Muscle Function Testing. London. Buttetvlorth, 1993.
tance. Its results. however. must be checked by using other 7. Koga.n OG. Va~i1yeva LF: Atipichniy lokomotomiy pattern. diagnostik;l i
Iccheniye. (Atypical locomotor patterns. diagnosis and treatment).
methods of clinical cxamination~ in panicular. palpation. test- No\'okuznelsk. 1990.
ing of aClive and passive mobility-the full range of physical
examination.
Acknowledgments
REFERENCES
I. Lcwit K: Manipulati\'e Ther.Jpy in Rehabiliution of the Locomotor I am grateful to my teachers for their contribution to the ideas
Systcm. Oxford. Bunerworth. Heineman. 1991. pp 23·25. of this publication, particularly concerning the role of the mus-
2. Rash PJ. Burk.e RK: Kine$iology and Applied Anatomy. Philadelphia. Lea culature. il.. functional anatomy. and biomechanics. i ant gr.t1cful
& Febigcr, 1971.
to Dr. Lewit. who firM opencd the door of m.mual medicine to
3. Kogan OG, Schmidt JR. Vasilyeva LF: Visualno-palpatomaya dingnostika
Russia. I am indebted greatly to the work of Janet G. Travell and
patobiomeck.ani$tiehcskick iSll1cneniy posYonochnik.a (Diagnosis of
palhobiomechanical spinal disorders by inspection and palpation). David G. Simons: to Vladimir Janda for his ide.ts of muscular P;lt·
Manualnaya Medicina 3:10.1991. terns: and 10 a.G. Kogan and I.R. Schmidt for their help in analysis
4. Janda V: (1990) Differential diagnosis of muscle tone in respect of in- of slatic dysfunction. ,
hibilOry techniques. In P:Uerson JK. Bum L (cds): Back Pain. an I thank Karel Lcwit and I. Lcwitova for their painstaking and
i
Intcmation;ll Review. Bostoll. Kluwer Dordrccht. 1990. p 196.
constructive criticism and active editing of the text. Last. but cer-
5. Vasilycv:I LF. Kogan 00: Manual diagnosis and manual therapy of atyp-
ical motor p;mems. Presented at the IOlh International Congress of the tainly not least. I thank I. Litvinov for the wonderful illustrations in
Federation Intcrnation;lk de Medicine Manuelle (FIMM). Brussels. this chapter.
September 1992. Ludmila Va... i1)'cva

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 t5 .t;valuatlOn of Lifting
LEONARD N. MATHESON

, '

CHIROPRACTIC FUNCTIONAL
variable because lifling tasks appear to be relaled 10 both
CAPACITY EVALUATION
increased frequency and increased severity of industrial
As the chiropractor assists the patient in restoring pre-injury injuries. 2- S
functional capacity, periodic functional capacity evaluation is
necessary. Functional capacity evaluation (FeE) denotes a
LII'TING AND LOWERING
form of work cvalumion consisting of a battery of tests that
focus on selected work tolerance areas. Matheson' defined Lifting is defined as the vertical displacement of an object
work tolcr~nccs as the observed and measured physical capa- with mass that is accelerated vertically through the applica-
bilities of the cvalucc thilt affect competence to perform the tion of force along the direction of the lift. Lifting is generally
physical demands of work tasks. The term jUllctional con- considered movement of an object held by onc or bolh hands
notes purposeful, meaningful. or useful activity. implying a in opposition to gravity. Le.. lifting upward.
definable task that has a beginning and an end with a result Some FeE systems consider lifting separately from low-
that can be measured. The term capacifY connotes the maxi~ ering. Lowering is a distinct task and is dell ned as the con-
mum ability of the individual. beyond the lcvcl of tolerancc trolled movemcnt of an object vertically downward. The force
that is measurcd. Capacity is the cvalucc's potential. The tcrm applied to initiate movement is gravity. The individual's max~
el'(l!uar;oll is a systematic approach to monitoring and rcport- imum lowering ability is taken as his or her ability to resist
ing performance that requires the evaluator to observc. mea- this force so that the object remains under control or. at the
sure. and interprct the cvaluec's performance in a structured least. is controlled at the tcnnination of the vertical move:'
task. Thc information gathcred in thc FeE is descriptive and, ment. By contrast. vertical movement downward of an object
when standards of performance arc available. normativc. accelerated by gravity without resistance applkd by the
Descriptive results arc used to compare the cvalucc's ability worker is considercd a "drop" rather than a lowcr.
with thc physical demands of ',vork or with thc evaluee at a In practice. when lifting and lowering arc evaluated
previous point in time. Normativc rcsults arc used to compare jointly, the maximum lifE-lower usually is the individual's Iift~
the evaluee to a reference population. ing capacity. People gcncr'Jlly arc able (0 lift approximately
An FeE requires lhallhe cvaluee put forth maximum vol- 20% less than they are able to lower. ahhough this percentage
untary effon for the dcfined- task. The dcfined task may re- varies from person to person and depends on the swrting
quire full strength, full velocity, endurance. a target number of height, the vertical displacement of the lift or lower. and the
repetitions. a maximum nUe of responding. or some other frequency of the task.
"full effon" performance. When the measurement of function
is less than maximum. the evaluator must bc able to dctermine
LWflNG CAPACITY FACTORS
to what degree this deficiency is a function of the biochemi-
cal. cardiovascular. mctabolic, or psychophysical limits in- Several factors inherent in the lifting (ask innuenc~ the max-
herent in the cvaluec. imulll load that can be lifted.

Horizontal Displacement of Load

LlI'T CAI'ACITY TESTING
The distance belween the center of gravity of the load held by
For scveral reasons, the cvaluation of lifting capacity is a key
thc hand or hands and the cenler of gravity of the worker is a
ingredient of most FeE. Lifting is an important component of
crucial dctcrminanl of maximum lifting capacity for ~evcral
many jobs. because of either the proportion of job activities
reasons:
that require lifting or the criticality of the lifting task as a
component of the job. Lifting is important because it is a cell· I. The human biol11cchanical sy:,tem exponcntially mulli-
Iral organiz.ing wlr;lIble that provides an excellent estimate of plies the effect of the load on the human body :'0 that it
general work capacity.' Additionally. lilting is an important rapidly increases as horizontal displ~lcel11enl inl.:'rcases.
143

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144 REHABILITATION OF THE SPINE: A PRACTITIONER'S MANUAL

2. The stability of the worker-load system is maximized of his or her biomechani("al couplings. A linn stance 011 a sta-
when horizontal displacement is minimized. blc surface and a strong and comfortable grip 011 thc object
3. Risky lifting~lowcring maneuvers arc minimized or arc the two most imponant issucs with healthy workers.
eliminated as horizontal displacement is minimized. \Vhen thc evaluation con("crns an individual who has one or
Certain behaviors such as torquing of the spine when more impaired biomcchanical components in thc linkage. that
moving an object through a lateral arc of motion can be linkage may becomc critic:.:llly limiting. depcnding on the de~
eliminated entirely if the horizontal displacement is grec to which thc task and/or the posture and mo\"Cnl\.~1l1 of the
sufficiently slllall so ,IS to place the object against the worker stress this component. If the task and/or posture and
worker's abdomen or pelvis. movcmcnt of the worker do not stress the impaired compo-
nent, the effect may be negligible. Conversly, if the compo-
nent is stressed. it may be the primary limiting factor.
Location of the Hands at the Origin of the Lift
The common reference point for lifting and lowering is the Aerobic Capacity
position of the hands on the object. This positioning is taken
For tasks that arc prolonged at loads that arc signifkantly less
as the point of origin of the force and the center of resultant
than the worker's maximum lift capacity, the aerobic capacity
force vectors. Lifting is accomplished most easily through in-
of the worker becomes important if the frequenc)' of the task
temlediate vertical ranges so that the biomechanical system
is sufficiently high. Generally speaking, aerobic capacity be-
can be used most efficiently. At the extremes of the range up-
comes important if a light load is lifted once every 2 minutcs
ward or downward. workers arc less capable of full,muscular
or more often or a heavy load is lifted once every 5 minutes
exertion. Different muscle groups arc called into play de-
or morc often. In regard [Q tasks that involve lifts more frc-
pending on the starting height of the litt some of which are
quently than six to eight times per minute, aerobic capacity
more inherently powerful or fatigue-resistant than others. In
may begin to be importam after the second or third minutc of
addition, secondary limitations occur that depend 011 the start-
continuous activity.
ing height of the lift-lower, including cardiovascular demands
and effects of various strategies of trunk stabilization on the
Anaerobic Capacity
cardiorespiratory system.
This capacity of the \vorker is important in high frcquency
Vertical Displacement of the Lift tasks involving loads below the worker's maximum single lift
load and in low frequency tasks involving loads ncar thc
The vertical range over which an object is lifted or lowered
worker's maximum load. Anaerobic capacity is a function of
affects the workers's lifting capacity in the same way and for
the load of the task relati\"e to the worker's maximum and the
the same reasons that the starting height of the lift affects lift-
mix of \l>'Ork to recovery time in the task.
ing capacity. In addition. however. the vertical displacement
of the lift affccts lifting capacity in tcnns of the amount of
Metabolic Capacity
work that is required in the liftMlower. Work is a product of
force applied over distance. Muscles have the capability to This capacity of the worker is important in repetitive tasks
produce power, which is force per unit of time. The biome- with a frequency of once every 5 minutes or greater than
chanical system is limited in terms of both power and the abil- are sustained for more than I hour. Tasks perfooned less
ity of the system to sustain that power to produce work. The frequently or of shorter duration generally are not affected
amount of work performed is directly related to the distance by the worker's metabolic capacity. unless it is substan-
over which the object is lifted or lowered. tially impaired as a comequence of illncss or severe dietary
problems.
Frequency of the Lift-Lower
Test Instructions and Performance Target
Because of the inhercnt power and endurance limitations in
the worker's bi0111cchanical system. the number of times a The type of instructions provided to the evaluee significantly
lift-lower task can be repeated is limited. This limitation is di- affect their subsequent performance. Coaching during the
rectly related to several factors that interact: activity affects thc evaluec's consequent performance. Al-
though few studies ha\'e addressed this topic. the effects
Degree to which the load approximates the individual's
they have reported have been substantial. l • As one compo~
maximum single lift capacity
nent of the instructions given to the evaluee. the "cogni~
Duration of thc individual task
tive target" provided in a maximum strength task is an im-
Rest period after each individual task
portant component of demonstrated liftMlower capacity. The
Duration of the task set
difference between "your maximum possible lift.. and "your
maximum dcpendable lift tha! you can replicate sevcral
Biomechanical Couplings
times per day" is subst<lI1tial. Evaluators must provide a spe-
Both the maximum load and the consistency of the worker's cific cognitive target so the eyaluce docs not select his or
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ability to lift and lower arc directly affected by the adequacy her own.
 _.. •..__ .... .. '-', ...... ",.\,;;1
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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 tatSCl
Fig. 8.1. Factors that contribute to
Gill MusculoskelctAl strength maximum performance in a lift capac-
ity t.est.

Musculoskeletal Strength
worker also affects the level of effort and. th~reby. the
The worker's strength is the largest single contributing factor worker's performance.
to his or her ability to perfonn a maximum lift. Depooding on Three general classes of strength testing have been identi-
the other factors listed, however. the contribution that museUM fied. They are differentiated in terms of the effect of the test
loskclctal strength makes to the ability of the worker to per- on muscular contraction, considered in terms of both the mus M
fonn to a particular level will be limited. In the simplest case. cles' force of contraction and the rate of shonening.
musculoskeletal strength is limited by the "weakest link" in
1. Isometric. Under load, the muscle length does not
the biomechanical chain that cxists between the surface on
change. Force is measured in one biomcchanical posi-
which thc cvaluce is standing and the grip that the evalucc
tion.
maintains on the joad.'·~ This factor, however. presents only a
2. Isokinetic. The muscle lengthens or shortens at a fixed
level of the potential performance that cannot be exceeded.
ratc as a consequence of external control of the veloc-
This ceiling can be approximated in lifting tasks that arc in M
ity of movement of thc biomechanical unit. Force is
frequent. or that arc performed over a limited vertical range.
measured throughout the range of movement.
involve holding the object close to the body, and with good
3. IsoineniaL The muscle shortens at a variable rate in re-
biomcchanical couplings and tcst instructions that are per-
sponse to a constant external resistance. As the biome-
fectly understood by the evaluee. Figure 8.1 is a graphic de-
chanicaI trigonometry changes to accomplish move-
piction of the author's estimation of the degree [Q which each
ment. changes in muscle length occur at varying
of these factors contributes to the ability of the evaluee to per-
velocities. Constant resistance is inferred from the con- .
form a maximum lift in a work setting.
stil,ncy of the mass that is moved. Acceleration is as-
sumed to be negligblc.
CLASSES OF STRENGTH TESTS
Various technologies have been developed to assess these
Lifting and lowering is a synthesis of the worker's biomc- general classes of strength tesL'i and arc identified by namc in
chanical. cardiovascular, metabolic. and psychophysical ca- tcrms of the type of function that each iwends to assess. Some
pacity. The development of tests has been innuenced by confusion results in that, because of the complexity of the bio M
progress in hardware technology. so that the focus in this mechanical system involved in lifting and lowering. the ex-
early phase of the development of lhe science of lift capacity ternal system .used to tesl the biomechanical system may not
testing has been on the biomcchanical system. Anyone of the be able to control the tcst at the level of the individual mus-
four domains. however. may be the most limiting in any sin- cle's function so that the intended mode of tcst is actually
gle tcst for any given evaluee. Usually. strength tests are lim- achieved. For example, although isokinetic testing intends to
ited primarily by the cvaluec's psychophysical capacity. evaluate the strength of the biomcchanical system at a set ve-
Psychophysical factors affect the worker's ability to lift in locity, accelerative movement occurs carly in the task up to
tenns of the degree to which maximum voluntary effort ap- the point at which the desired velocity is achieved. Even after
proximates inherent biomcclwnical, cardiovascular, and thm point. a rebound phenomenon may occur before stabi-
metabolic capacities. Factors such as fear or anxiety about the lization at the desired velocity is achieved, As a result. each
task or confidence in his or her ability to perform it directly of the modes is inexactly sampled by the technolog.ies lhat it
I innuence the level of effort that the worker is willing to put
furth. Other attitudinal fnctors, such as the relative risk-tOM
is intended (and advertised) to test.
A lifting task usualiy involves a combination of types of
i J reward ratio or work-ta·value ratio as perccived by the muscle contractions. depending on the biomcchanical scg-
~
~O www.bodywork.su
!
j-J.L,
~-=-.Ao-_~ _
140 RI::HAt::SILlIAIION OF THE SPINE: A PRACTlTIONER'~ MANUAL

ment that is considered. These lypeS will change dunng jlt:r(t:pi~'.Ill of the difllcully of the task. Informat ion abollt task
the task. For example. a "squat lift" from floor (0 knuckle, difticuhy is supplied through feedback loops that provide the
whether accomplished in an isokinctic or isoincrtial mode. indi,"iduJ.1 ,vith inform:nion concerning, initially. the biol1le-
usually involves the upper extremities in isometric actiyity if chanical demand. and socm thereafter, the cardiovascular de-
the worker's style of lift emphasizes IO\\'cr extremity exten- mand 0f the task. The biomechanical demand depends on sell-
sion. Conversely, with a lifting style such as that used by com- sors that function best when joints and muscles are in
petitive weight lifters. this same vertical range might be un- 1ll0\"Cment. Thesc scnsors arc less fUllctional and. thereby.
dertaken with the bwcr extremities perfonning isometric less useful when the biolllechanical system is static. Thus.
stabilization whik the upper extremities provide :m accelera- isometric strength testing has proven useful for differentiating
tive force to overcome the inertia imposed on the mass by individuals who arc pUlling forth various levels of maximum
gravity as it sits at rest With these ca\'C3ts in mind. the de- voluntary effort because it is difficult for the individual to
scription of each lcst technology is grouped in terms of the gauge the degree to which he or she has put forth ef1'011 and.
type of function that each is intended to address. thus. maintain consistency with less than a full effort trial. It
is precisely for this reason that isomctric strength testing, un-
less used carefully, ha.s the potential to place workers who
Isometric Testing
have inherent defects in the biomechanical system at risk for
This form of testing is the simplest type of technology and stressing the defcctive segment to the point of strain.
tends to be the most reliable in that. because the body is tcsted A second issue COllcems the unusual nature of the isomet-
in a static posture. the geometry between the biomechanical ric task. Whereas isometric tasks with the fingers and hands
linkages (termed "kinematics") can be controlled and. thus, arc relatively common in everyday lifc. isometric whole body
replicated. tasks are extremely unusual. Thus. the worker involved in an
In terms of safety. however, isometric strength testing has isometric "lifting" evaluation is performing a task that has lit w

prompted debate. On the one hand. Garg. Mital. and Asfour,'> tie familiarity. Although posture is controlled. the psy-
Chaffin,1O and Caldwell. Chaffin. and Dukes-Dobos ll reported chophysical skill brought to the task in terms of achieving
that isometric strength tests are safe. Because it does not maximum performance efficiently and with safety is less than
allow acceleration and. thus. the increased inertial loads that it would be in a task that is more familiar. For example. the
are a consequence of acceleration. isometric testing should first trial in a particular posture is often wasted because of
place less stress on the body and inherently be more safe than problems with balance.
other methods that allow acceleration. On the other hand. The third issue relates to the care and precision with
Kishino and co-workers. 12 describing their experience with which instructions are given. Because the technology is rela-
isometric strength testing of individuals diagnosed as having tively simple. clinicians may tend to use less care in its appli M

spinal soft tissue injuries. found that most reports of muscle cation than otherwise would be appropriate, Rather than be-
strain or prolonged soreness occurred as a consequence of ginning the lifting task gradually with a "ramp liP" to full
isometric testing. They hypothesized that this result was at- effort. many evaluators allow the evaluee to increase explo-
tributable to the longer period of time that peak force must be sively to full effort before the mechanical system's inherent
maintained in an isometric test (typically 3 to 5 seconds). elasticity has been entirely diminished. This situati011 results
whereas the peak force in an isokinetic or isoinertial test is in inertial effects that greatly increase the force within the bio-
transitory. Battic et all; and Zeh et all": raised the same issues mechanical system.
after finding problems with prolonged symptomatic responses Isometric strcngth testing has been demonstrated to be
and a small incidence of reported back injuries after testing highly reliable, with test-retest correlation coefficients ex-
nominally healthy people in an employment setting. ceeding r = .90. 5 Coefficients of variation have been in the
Three important issues with regard to the safety of iso- neighborhood of 10 to 13%.15 \Vith regard to validity. one dis-
metric testing have not been fully explored on a scientific advantage of isometric strength testing is that force values arc
basis. The first issue relates to the value of psychophysical mcasured only at a specific segment in the arc of motion.
limits in terms of producing safe lifting performance. Selection of the segment to replicate is an important consid-
Psychophysical limits arc developed throughout the individ- eration to allow results in an isometric strength test to predict
ual's lifetime as he or she is involved with tasks that place de- performance in a dynamic task. Perhaps more importantly. it
mands on the biomechanical. cardiovascular. and metabolic may be that the spine responds differently to an isometric task
systems. The learning proceeds through trial and error so that than to a dynamic task. Marras. King, and Joynt It· found that
the individual develops internal controls. termed "work func~ electromyographic (EMG) activity was highest in the latis-
tion themes:' which in essence are rules that the individual simus dorsi muscles during an isometric task, whereas the
follows to remain free of injury while involved in work tasks. erector spinae group produced greater EMG activity during
These rules are applied unconsciously and require input from an isokinetic task.
the individual's sensorium in terms of the degrce to which a In spite of concerns about safety and validity. isomctric
task places demand on the individuars functional capacity. tests can be useful because they arc brief and so are the least
This feedback is applied as a consequence of the worr..cr's costly type of tcst to administer. The ARCON ST is an exal11-
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.1
 Lo,,,.,...,V"" 'v''! vr Llr 111\ll.:J 147

Fig. 8.2, ARCON 5T (Advanced Re··3.:'~ IilZl-

lion Concepts, Irvine. CAl.

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 ina-
tia. 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~·.
<lppropriah:l~ g~lllgC his or 111::1' effor! level. One meI hod 10 il11-
pron: rcliabililY is 10 pftwiJe I.."ardully c.kn:lppcd :nslnlCliOib
thai ;lre well undcrstood h~ the c\'i1lucl:, Both of Ihese ;:11'-
pro;ldlcs ha\'c bCl'll lls~d ill lhl.." ERGOS \Vor]..: Simulator £Fig.
:(:;l, The ERGOS is a Illultip!c"la:-;k c,,;l!U;ltiOll itlstrulllLllt
thai prcscnh ins[l'lll..,ti()ll~ til the cvalucc ill three ways. sup-
plcnll:lIlt:d hy inpul from ;lll :::\";11\1;11111" who i.. prescIH c.I11rin~
Ihl.: l..·\';llu;llillll. Primary in"lful.."tiol\:- art.,' pn..... l.:llIed ;lIIdilori.tll~
lhrllu~h lhl..' lhl' \11':1 :,ynlhl'.. i/l.."d "\"l\kc" in (lllllbinatioll wilh
lext pre~l.:ll1cd {Ill ;l l..'olor \ iLko di~pl;\y Icrminal. Sl.'eOlH.I;Jr~
instruction . . arc prl..'sl..'nll'd pl(torially foll\l\\ ing the II.:X! pn....
scnt;lliol1. u"in~ synlhl..'si/ctl rhOh1~raplls lh~:l c.lepil'[ (he po .,
lun.' III usc \\ ilh thl..' cvalualioll task. Suhscqu~ll(ly. during the
isol11etric lil"]..:", the l..'\,;l!Ul:I..· h pnn-kh.::d "1'L:ill (illll.'" feec.lbal"k
l.:OIKcrning lC11'0,' ~I.'lh:f:lli(Jn thrnu~h Ihe u.. ", 01" a f(m..:c CllJ'\'C
Iha[ l'l\.'SI..'111'" pcrt"lll'lllalll.."l.: on tht.' basis or a ~J cycks per ;.,tc·
(Jllll ;dong ,I !og;lrithllllc "'(:llt:. III tile hill1:lI111tll. isomctric.
whole body "'lrcn~lh 1a']..: .... ri~hl hand pl.'rformancc is pn.>
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:
~hllnl.:llillg or kl1~thl.'lIillg or a llltl:-dl.: ill cOl1traclioll pCI''' Fig. 8,3, ERGOS Work Simulator {Work Recovery :3-:. ~;e:ns,
fllt"llll:d at a 1..'011"(;1111 "d()cit~ rcg:lrdk'ss (If llie fon.::: ~CIlCr;I(l;d Tucson, AZj.

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-~----------------
 ... _._ .••.•. _ •• ~ •••. _ ...... ,~. " , I ,'''''--' '" ' ..... '~ .... ' ,..., ,y,""U .... ""L..

Fig. 8.4. LIDO Lilt (Loredan Biomedi-

cal, West Sacramento. CAl.

by the muscle. Accelcration is minimizcd so thatlhc force CX~ constant resistance ~i1ong a vector. The constam-resistance as-
crteu is equal to the force necessary to move the object at a sumption is violatcd in !i(ting and lowcring because of the ac-
constalH velocity. Because the inertial effects of force appli- celerative nature of fr.::.\:iEY. Thus. [he force imparted by tilt:
cation arc controlled. maximum force can be measured person performing the ~ift is ~Kl·derativc. As a consequence.
throughout the entire range of elongation or shortening. true isoincrtial lift (t"';lng is nOl possible. Various testing
Isokinetic testing has been found reliable in several stud~ strategics have been de\ doped. howcver. to cOl1sTraillthe op-
ics."l - n Isokinctic lifting simulation was shown to be reliable portunity for rhe evalui':c to us~ acceleration. One such strat-
in studies done by Porterfield and colicagucs. 1J Frykman. egy involves testing (l\-:r limih:d vertical ranges that com~­
Harman. and VogcL:!~ and Alpen described the reliability of spond to lhe range of rr'<Jtion ayail<lblc to (hc cvaluec to usc a
isokinctic lifting stimulation.:6 The Janer researchers used the single biomcchanical ,egmcm (c.g.. from Iloor to knuckle
LIDO Lift, presented in Fig. S.4. level or from knucki:: level to shoulder Icvd). This quasi-
Some critical issues have been raised regarding the usc of isoineni<tl str~llegy he;' been dcveloped because it more
isokinctic testing of Iifting.l:!.:~ Although isokinetic testing is closely replicates the <:~iUal d~l1lands of lifting than do either
dynamic. it docs not mimic functional activities because work the i"omctric or isokin~'\ic stralL'gics.
is not usually performed with a fixed speed. Kishino ct aJl~ rc- Isoineniallift cap-=.,:lty typiC~llly is ICs!cd using one of two
ported that although isokinctk equipment can be ~\ useful tool similar "lppro"lches. SrFJok ~lIld Irvine.'ll." Garg. Mita!. and
in industry and rehabilitation. it had important equipment lim- Asfour,'.1 Kahlil anti <:{J,·.:.orkcrs:'~ ~Uld Pytel and Kamon·1.\ ad-
itations that limited its ability 10 predict pcrfonnancc in an ac- vocate the "psychoph: .,icaJ'· approach. which involves thl:'
tual work setting. Til11m~'~ reported that lifting is composed of concept of 111.lximum i.:.cccptabk weight (MA\V). The maxi-
various combin<.ltions of isometric. isotonic. ~lOd isokinctic mum accepwhlc load h adjusted by the cvaluce by adding or
effort that isokinetic technology may not mimic sufficiently rcmoving lead shot fr•.,m a tote box that is lifted at a particu·
to be effective as an evaluative or rehabilitative 1001. Mayer lar frequency to determine the acceptability of the load. The
ct nl"'J compared isokinetic lifting on the Cybex Liflask with a load is adjusted llntillnc cvaluec determines that thc load rt>
Progressive Isoincrtial Lifting Evalu.llion (PILE). and fOllnd fleets his or her MA\'·. given th~ frequency. size of the box,
the correhuions between the two tcsts were low_ They con- and both Ihe: stOlrting hdght and venical I'~mge over which
cluded that thc tests do not evaluatc the same pamlllc1cP.' and {he box is lifted. K<l.r"\\fJ\Vski-'; found this approach was reli-
~anl1ot be substituted for each other. Alpert e1 al.: tJ however. able only for low and Illolkrate lifting frequencies (not
found isokinetic testing a valid predictor of subscquent pro- grc"Her tl1"111 six Iifb per minute). MiwP:; rt:portcd th<Jt tht:
gressive lift capacity testing. psychophysica~ IIlcth(,d tCl\(kd 10 ovcrcstimah: the MAW of
lifting.
M,llhcSllll'I', dcsl.:ribcd the WEST Standard [~vaillation
Iso inertial Testing
(WSE), a progressive lift~loweril1g tcst proct:durc in which
Isoincrtial dellotC:-i :a dynamic lest of lifting capacity in which h.md is il1<:1'casc<.l incrementally while providing the cvaluct:
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the muscle is cOlltr<lctcd in orda to move a m<lSS imparting an opportunity 10 <.h.:crt<.t-\c vl.'ni",."al range as he or she approx-

_ .. _._----------
i..
 14~

I
I, illl;IlCs Lll.IXiIllUlll •· .. 1I1~C "I' IlIUliUll 1Illljl.:!" iUdd.'· The \\'SE j,
the most widdy used c(l1l1nh:rci~11 tcst of lifting cap:u.::iIY. \\ illl
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 slan-
approxinwicly IIO() units ill usc in 1991 throughoul Nnnh d,tnl" ;1~;lillSt ,dlidl to measure the v;llidity ll( othel" more ex-
America and Auslr;t1ia. I'vlathcsOll n reponed Ih;1l Ihis ;11" pl:lIsin: t~ p\..'~ or lil't lest tedmology. Tilt: dl.:\'ell)p~rS (11' the.
proach has good inlrah:st rdiahility wilh l"(lI:fIiciCnls of \;tri· EPIC I.ifl Clp:lI..'ily lcst implemenled a lr"ining ,lIId ccnilica-
:llioll of k:'\:\ than Y·k. Jacobs. Bell. and PopcJ~ lIsL'd a .... illlil;lf liOll \'1"\1;;1";1111 I'll!· lesl II."C!'S that provides l:l:nilk,lIiol\ 01" pro-
progrcs!'i\"c lifting cap,Kity appro"lch in lhe: Opcr;uional I.ift li..'ssillll:II, and (11" lcdlllil·i'lIh. PmlCssion;lls tire ccnificd 10
1 Task (OI.TJ. III lhis [CSt. \\\:ight in a craIe is illLTCiLSt.:d illl.:I\,'- pcrfo1"ln Iht' \..,,·;t!Il:lIiOIl within theil: area or tr:lining and ex-
] mentally until the subject is unable to lift thl' load. pl;nisl'. Tlll.:y Ill"y ;dsu Stllk'nisc h:dllli\.:'i'llls. Technici;lll:-; arc
I Another pmgn.:ssi\"c lil'! c.tpacil)' ;tpproach to isnincni:li cenilil.."d (0 prm'ide lhe CY"lu'llion under the supcrvisiolll,f lhe

i mt:asurcl11cnl or lifting pcrfonn<lncc dc"dopcd by Kroclllcr'"

involves a progressive lifting Glp_lcily prouK:ol in whid} lht:
ccnilil.."J profl.."ssioual. The primary issuc that distinguishes the
profession'll from the lechnici'lll is the prokssional's lraining.

I!
evnlucc is presented with gradually incre:\sillg loads lIsing iI
weigh[ machine {hm captllrcs the weight :llld maintains a li.xed
tr'ljectory. The stu~y reponed a coefficient of vilfi'llion of ),2
whidl pro"ides the ahility to make correct judgments COll-
L'crning Ihe appropriate rcsponse to s)'lllpiolllS that occur as
lhe lesl pmgr~sscs.
I to 3.9% in an overhead lift and 5.2 10 7.Sq.. in il knuckh.'- In lhl: isoim:flial approach. till.': ohjcL'IS lIsed arc similar to
thosc found in re:t1-world l;lsks. As .1 cunscquence. this 'Ip-
in height lift. The smne subjects showed higher v,lriahility wilh
proach is gellcr,lIly considered 10 have good validity. SOllle
I, 1
static tests. The coefficielll of vtlriation willt the s[atic lcqs
ranged from II.() 10 15.4<::'t. researchcrs. however. havc raised concerns about thc safety of
Mtlycr ct al JII lllodilicd the progn.:ssi,·c lift capacity 'Ip- this ;lpproacb: 1 Others noh: that tllc practicality of lhe tcsl is
() proach to c.k"c1op the Progressive 1s0inCrliai Lift Evaluation limited in that it typically requires 20 10 30 minutcs to dc·
1
. . (PILE), which requires four lift-lowers over a standard veni-
cal range wilhin a 20-second period before the evalucc is
asked whether the load is cquivulcnt to a MAW acceptable
weight. If noL the load is changed 'incrcmcntally. Different
weight increments arc used bascd on gendcr with IO-pollnd
inCrCI1lCiHS for mcn and 5-pound incrcmcnts for ''''·omen. The
PILE ulso involves an age-based hean rOlle limit:'llion and re-
slricts thc c,·a!uce to loads of less than 55 to 60% of ideal
body weight based on gender and height. This approach has
been foun(i reliable in a smull sample. Test·rcicsi reliability of
tht: PILE ~howed a corrcl::llion eoeflicielH of r = .M7 for lh~
lift from noor to 76 cm :.md r = .93 for the lift from 76 em to
137 CIIl.
Matheson ct al JI provided further elaboration of this ap-
proach. 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 expe-
rience 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 re-
searchers. 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 <lnd
intcr-rater reli:Jbility:n reporting test-retcst reliability that de-
p~nded on the test and rdnged from r = .62 [0 r = .87.
Subsequent modifications to the PLC protocol have becn
undcrt:'lken by Matheson and colleagucsJ.l.44 in the EPIC: Lift
C<tpacity Test (ELC). Thcse changes include standardi7.ation
01' Ihe load incrcments across gcndcrs, determirmtion of the
vertical liflillg ranges bascd 011 lhe evaluec's height. and de-
Vel(1pmellt l)!" six subtcsts in lile test battery, with later tests Fig. 8.5. WEST-EPIC Uft Capacily Test (Work Evaluation
using informatioll from the cvalucc's perfonnal1l:c on e<'lrly Systems Technology, Signal Hill, CA).

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 'vV MI:t1P.OILil PI IlUN Vr I Nt:: ~!"'INt:: A ~HACTITIONEH'S MANUAL

\
Factor
Safety
Isometric
Low> High
Isokinctic
ModernIC> His:.h
Isoincrtial
Modcr.:nc
I
Rclbbilitv High Low> High Low> Modernte

Fig. 8.6. Comparison of lill capacity _.__ . Validity Low > Modcrmc Low > Modem!c HiRh
evaluation technologies using !lle Na- Cost Eauiomcnt r-,'lockrJlC Hi~h Low
tional Institute 01 Occupational Salety
and Heallh test selec!lOn crileria.
Cost· Administration Low l\1odcr.llC High

tcnnine the MAW for any p'H1icul'lT cOlllbin;:llion of fre- ~. Ma~or.t. A: In\'eslig;uionfo. of the relation between low back pain and oc-
cupatiun. III. I)hysical rl.'<)uiremcnls: sitting. standing and weight lifting.
quency. starting height. and \,(:nic;:,1 displacement. and lhat
InlluSl Med41:5. 1972.
both the time \lnd effort expended by the worker is SUbS!im- 5. Bigos SJ. Spengler OM. ~fartin NA. Cl al: Back injuries in industry: A
tially more th"l11 is found using an isometric or isokinctic rClTOspcelivc sludy. II. Injury factors. Spille II :252. 1986.
'lpproach.~h _ 6. ~~atheson L. Moone)' V. C.:liOl1.O V. ct ;II: Effect of instructions on isoki-
The potential value of isoincrtiJl ~lrcnglh (esting with a n.:tic trunk strength \·ariability. i'diability. absolute value. and prcdicti\"e
valid!I)·. Spine 17:914. 1991.
disilblcd population depends on it . . relinbilily .!Od validity.
7. Andersson Gll1, Ch:lffin DB. Pope MH: Occupational biomechanics of
With lhis nppro'H:h !O testing. bOlh lcsl-retcst aod intcr- the lumbar spine. In Pope MH. Andersson OBJ. Frymoycr J\V. (cds).
rater rdiability depend on lhe C'Irl; with which the lest Occupation:11 Low Back Pain: Assessment Treatment and Prevention.
is COOdUCICd. Within-test "rdiabililY checks" in the ELC S\. Louis. Mosby Year Book, 1991. pp 20-43.
arc available to conflrm the e\'alll~e's performance reli- H. Ch"nin DB. Andersson GBJ: Occup:'Ilionat Biomechanics. New York.
John Wile)' & Sons. 19S4.
ability through a comparison of pal'orm<lnce at different
'J. Garg A. Mil:l! A. Asfour SS: A comp;lrison of isomelric strength :ll1d dy-
frequencies or .It diffcrclll ranges of motion. These COI11- namic Ii fling cap;lbilil}'. Ergonomics 23:13.1980.
parisons among individuals are dependable and provide a 10. Chamn DO: Diomcchanic!< of manual malerial handling and low b"c:k

I
reasonable benchmark with which to compare an c\'aluce's pJin. In (Xcup:!lional Medicine:: Prindples and Pracl;c31 Applie:'Ilions.
performance to dClcrminc whether or not it represents a best Chicago. Year Book. 1975. pp443--467.
effort. 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.
The cvalui.uion of lift capacity can be accomplished 1974.
,,~ in many wayg. Selection of the appropriate test depends 12. Kishino ND. MaycrTG. Galchc1 RJ.'::I al: Quantificmion of lumbar fune·
~
'~ 00 several factors. A hierarchy of factors has bcen estab- lion. P,I" 4: Isometric and i~okinetic lifting simulution in nonl1a!lIubjccts
,I lished by the National lnstitulc of Occupational Safety and 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:·
Health.':~ The author has applied this hierarchy to the vari-
diclOr of industrial back pain reports. Spine 14:851. 1989.
)
ous types of lechnology thaI arc availabk to cvalualc lift ca- 1.... Zch J. Hansson T. Bigos S. el al: Isometric strength testing:
pacity 10 produce a comparison of thcse approaches (Fig. 8.6). Recommendations ba~ed 011 a slali~lical antilysis of procedure. Spilll'
Figure 8.6 depicls a comparison or lif! capacity evalu- 11:43. 1986.
ation systems that can be used to s~lect the technology 15. Chamn DB. Hemn GO. Keyscrling WM: PrccmplO)'menl slrength lesl-
that the evaluator \vishcs to purqlC. \Vhen a r<loge of ing. An updated posilion. J (Xcup Med 20:403. 197~.
16. 1'.larras WS. King AI. Joynt RL: Mcasurcmellls of loads on the lumbar
ratings is listed. the evalu~\tor can improve the ratings spine under isomelric and i~okinetic conditions. Spin.c 9: 176, 1984.
through training and the applic.ltion of diligence ;lOd a high 17. Hislop HJ. Perrine JJ: Thc isokinctic (onccpt of ex.ch.-isc. Ph)'s Tlicr
degree of professional skill and acumen. In most cases. the 47:114.1967. )
range depends on the evaluator's training. experience. and IK. Aitkens S. Lord J. Bernauc:r E. ct al: Analy~i!i of the \';1\;dity of lhc UlI(l
skill. DigilOlllsokinclie Sptcm fresearch p;1pcr). Da"is. California: Uni\'cr~ity
of Califomia. D'I\·i~ School of r.kdidne. 1987.
The evaluation of lift capacity has developed beyond clin- 19. BurdclI R. V:m Swearingen J: Rdi"bilily of isukinetic muscle em!ur:lllc,:
ical art to have i.\ firm base in science. aided by well-thought- Ic.~IS. J OCClIp Sports Phy'- TIler R:4S4. 1987.
out and appropriately designed technology. The intent of this 20. L:lIlgr:lIla NA. Lee CK. ,\1cxander H. e! al: Quantiwti\'c :lSSCSSIlICllt of
chapter is 10 present an overview of the technology and ap- back strcngth using isokinclic testing. Spine 9:287. 1984.
plications to .Issisl the clinician in using this technology more 2 I. 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<lll
effectively.
SysiCIll. Mcd Sci SPOn!> Exerc 21(Suppl}:SS2. 1989.
22. Rose 5. Delitto A, Crandell C: ReliabililY of isokinctic lrunk muscle pcr-
REFERENCES form;lOce. Phys lller 6S:H24. 1988.
I. M:uhesOIl LN: Ill1lu~triill Rehabililalion Resource Book. Sanla 23. Smilh 55. Mtlyer TG. Gatchel. RJ. el al: Quanliflcation of lumb;lr func-
Margarita. California: Performance Assc~~lIl(~llI & Capacit}' Testing. lion. Part I: Isometric and multispeed isokinelic trunk strength mcasure:.
1991. in sag,iHal and axial planc~ in normal subjects. Spine 10:757. 1985.
2. Pheasant S: Grgotlornics. Work and Hcahh. Oailher:<>bur£. MD. Aspen. 24. Porterfield JA. MO!'lardi RA. King S. el al: Simul:lled lin te.sling lls;n~
1991. (oll1puterizcd is(lkinelie.\. Spine 12:6:'0. 1987.
J. M,lgOTa A: Illveslig:1110tlS of the rdalion Ix:lweclI low bad: p;lin :md O{'. 25. FrykTll:l1I PN. 1-l;mn;1O EA. Vogel J: Using a new dynamometer to Ctlll\·
cupalion. Indust Med 39:31. 1970. rarc Ihree lift stylc... (abstraCt!. Mc~ Sci Spon..<; Exerc 10:87. 1988.
www.bodywork.su

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~h. :\1(11:11 J. \1.1111":,\111 I.. Beam W, <.'1 al: The r<:liahility and v;!lidily of ~7. M:llhcson l.N: Evaluation of lifting & lowering c:Jpacity. Vocational
tWI> Il~"\ l,·.h tit' lIl:tXillllllll liflm~ ~';lp;l.... iIY, J O . . ~·llp Rehahil 1:13. [ ....:llu:ui(ln :lml Work AdjL"tlltcnt Bulletin, 19: 107. 1986.
1991. 3S. J:u;obs I. Bdl DG. Pope J: Comparison of i~okinelic and isoillCnial lift-
~7. I{ulh...h.'lll J\1. LUll!> tH., ~b~h<'\\' "1"1': Clini.:al u~.::' \,1" i~l,kil\ctic nll::'- ing. tcsts :IS predictors of maxim.:ll lifting c.:lp.:lcit),. Eur J Appl Physiol
.'lln:lll('rH~, l'hy~ Tiler (J7: IS.1O, JI)S7. 57:146,1988.
~S. Tillllll KI: l"lbl1clk linill~ "imubtillll: t\ ll\1rl\\;lli\'~' data '\llIdy. J (kl"llp W. Kn)ClIlcr KilE: ;\.n isoincniallcchniquc to a.<;sess individuallifling capa·
'i
I
~ r)
Spun:-I'hy .. Tlk'r III:I~(,. 19:-;S.
~IJ. ~lay ....r Tf;. B;t!llc, I). Nidl"l... G. 0.:1 :11: Pro~n:~ ... i\·.... i:-I,illcni:ll liC.info
hi'it)'. HUIll Facturs 25:493, 1983.
40. Ma)'er TG. Barnes D. Kishino ND. ct al: Progrcssh'e isoincnial lifting
1 l·,";.IU;t,i"I:, II :\ "'\llllpariM'll \\ 1\h i~\lldnclic lifting ill J. di..ahkd ..:hroni..: evaluation. I. A standanlizcd prolocol :\IId nonnativc dataha!Oc. Spine
! It\w.h:u:ll'.lllI indU.'lri:ll [ltlPlll:\li\ln. Spin\.' 1~:99R. 19SR. 13:993. 1%8.

,
t
.'11. Smluk SII. In 1II1' 01: ~bxil1lum :1":"'Cpt:lhk wcit:hl of lifl. J\.m Intll-lyg
,,~
41. lvblheson L. ~. 1ooncy V. Jarvis G. CI al: Prog.ressi ...c lifling cap:lcily witlt
~ As.,o\: j ::-~ .'~1. 1%7. masked wc,:ighIS: Rdiahi!it)' study (abslract). PAR Rcsc:m;h Found:ltion.
~
31. Snouk Sit: I'.,y..:huphysi"::ll "·Imsi~kr;tliuns ill r..:rmissihk '(lads. Physical Assessment ;tnd Reactivation Ccnt~r. Irvine Mcdical O:nler.
f ~ ErgIlI\1I111i..· ~S:.l~7. 19S5. Irvinc Califomia. Presentcd .It lhc 1"lt'nllltim",1 Society fi)r t"c' Study of
, Y!. Kh:llil T~t. \\"aly SM. Gcn:lidy :\\1. 1.'1 :II: Oclenllin:llion of lifting abili- ,he: Ul1JllJur 5I'i/l('. Bosloll. MA, June. 1990.
1, ..-"'t..
< .I lies: A cllmrJ!:,1i\'c stully of f'lur lechniques. ATIl Ind lIyg A~soc J 42. Golden NS: An .:lssessment of inlerr:lter reliability .:lnd inlcrtest correl:!·

I,
4~:1)51. II}~i. tion of a progressive psychophysical lifting evaluation which me.:lsures
:\.1. P::::lcl JL. K:llllon E: Dyna1l1it' .qrenglh lest :IS a prediclor for 1Il:lxjlllal and oceasionalliftinf:, cap'lcily (thesis). University of Iowa. Augusl. I99{).
al'l.:,:plalll.,: hlling. ErJ;ollolilks 2~:6(,3_ 19&1. 43. Malhe!OOn L: EPIC Lift Capacity EvalU.:ltion Manual. S.:lnta '\03, CA,

•, -,, J.1. !\:trWt\w"i..1 \\": \.bxilllll1l\ IO:Jd lifting .:ap:Jcily of rn:Jk~ OInd fCIIHllcs in
le:lIllwu,l. !.·\b.,u<t.:Ij. Prnl:ceJing, uf the Hum:1Il FOIclors Socicty.
Employment POlcntialllllprovemell1 Corporation. 1991.
44. Matheson L. Moonc}' V. Grant J. el.:ll: A test 10 measure lift Cap.:lCil)' of
~ LOlli,vilk. I\\.'mm:ky: LJl1in'rsil~ of L(luiwilk. 1985, pp 6S0-699. physically impaired adults. Part I: De... clopllI~nl .1Ild reliability testing. In
.j .'. 1\lilal :\: Tlw p'y.:hophysic:11 ;\ppro:tdl in m:lIlu:l! lifting: A verilic:l1iof1 press, Spine 1995.
j ...tlldy. HUlll FaclNs ?5:.1~;;. 19~~. 45. N:Jtional Institule for Occupational SafcI~' and Health: Work Pruclices
~ .\(,. 1\·lallle1.111l I..": WEST:! Examincr's Malluill. Work [\·.:llu:llion S)'SICIl1S
"
Guide for ~'bnu.:ll Lifting {Technical Rcpon 81.122]. Cincinnati. OH•
, .,
M ·Ii.. chl\o'(l~~. 19M:!. Division of Biomedical and l3ehavioml Scicnce. NIOSH. 19S J.

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 9 Back School
PAUL D. HOOPER

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NEW PERSPECTIVES IN BACK PAIN EDUCATION to describe some of the better known back school pro-

I
grams
'.--J Research over the past several decades has provided much
to discuss the various formats used in presenting a back
new infonmuion ubout back pain. During this lime, dingnos-
school program
tic procedures have improved considerably (c.g., magnetic
to discuss the physical requircmcnls for presenting a
resonance imaging. compulCd tOlllogmphy. electromyogra-

I
back school program
c'"--~

~, §
phy), <IS have methods of (rcalmenl. Likewise. our under·
to discuss the various applications of the back school in
standing of spinal anatomy. mechanics. and pathology has in-
a private pr.:tctice. as a public service, and in the work-
",) creased. Even so. ccnain aspects show no evidence of change.
place
The overall prevalence of back pain remains around 80%.
to discuss the most common problems and the limita-
I with 'Ill annual incidence of 5%. The number of people dis-
tions of the back school

II
abled by back pain belween 1971 and 1981 incrcnscd by
(i 168% (14 times fasler than the population growth). The an-
nual cost associated with back pain in the United States is es- PURPOSE
") timated to be in excess of S50 billion. I Although the signifi-
The back school is a panicular method of teaching back pain
I cance of past advancements cannot be ignored. no single
prevention and self-care. It is a precisely directed presentation

I procedure has been shown to alter the long-term outcome for

patients with back pain. Even procedures. such as surgery,
thm positively affect the short-term course show little lasting
conducted in a setting designed and supplied for the sale pur-
pose of educating the patient This process of education may
take many directions. The programs used by the author are di-
benefit. 2

I
.~ rected at patients with back pain and at workers with back in-
-.J As the problems and costs associated with back pain con-
juries. These programs include the following categories:
tinue to increase. it is clear that we must approach back pain
with a different altitude. Clinicians providing care for patients Introductory back orientation program (Basic Train-
with back pain must accept the responsibility to promote self- ing).' This type may be used as an introduction to back
reliance and resist the temptation to make patients dependent safcty for patients and/or for employccs <\s part of an in-
on ·carc. Employers must assist the individual in obtaining dustrial safety program.
care and make every effort to hasten the injured individuals' Back training and exercise program for all patients and
return to work. The third·party provider must promote pre· employees wi"th a history ofb.ack pain-the classic back
vention programs. in both the work place and the clinic. school (Put Your Back Problems Behind You!!!)'
Finally. the patient must accept the responsibility for his or Intensive back training and exercise program for pa·
her own recovery. The single 1110st important aspect is the mo- tients and employees currently receiving some form of
tivation of the p'lIieIH to get beltcr. disability or compensation for b;lck problems-back
The purpose of this chapter is to take a look at the use of school plus specific rehabililation procedures
education programs as one factor in reducing the incidence Back safety and injury response training for manage-
and severity of back pain. 'In this are'l. education programs ment and supervisory personnel. An extended program
have developed into a formal presentation commonly referred designed to acquaint those involved in \Vork~rclatcd in-
~ to as the "back schooL" The specific objectives of the follow· juries with the realities of back pain.

I iog discussion arc as follows:

I
The principal goals of the back school program arc education
to describe the general purpose of the buck school and and self-responsibility. A necessary step in decreasing Ihe im-
the role it plays in the prevention of back pain pact of any health problems involves improved understanding
u 1O describe the historical development of the back
school
through patient education. In addition. to resolve the problem.
patients must accept responsibilily for their own health.
to review the literature regarding the effectiveness of

II ~ I
As a practicing chiropractor. I have treated many patients
the back school with back pain. Most recovered quickly. but as so often OC-
I 153
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154 REHABILITATION OF THE SPINE: A PRACTITIONER'S MANUAL

curs, many had rCCllrrcncc~. Like many authors who have ad~ back school.13·1~ Thousands of back school programs have
dressed the topic of back pain. Ill)' interest in prevention be· since developed; some are fonmil and involve the use of spe-
gall after personally experiencing recurring back problems. cillc audiovisual aids and materials. whereas others are more
As my interest grew. I suc("cssfully applied the principles that informal and involve readily available props.
I learned to my own back. Pleased with the changes 111<11 I
experienced. I implemented a back school in my private STATISTICS
practice. The impact that patient education programs havc on the out~
My initial .ittcmpts (0 educate patients in back pain pre-
come of any disease is diftkuIt 10 gauge. Some l·\iJcnce illdi~
vention were based on existing programs described in theiit-
catcs that certain diseases. such as measles and typhoid. have
cratufC. Over the pas! decade. I have lllodihcd my ideas COI1-
been positively impacted by these programs. Objective evi-
cerning 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 cooper-
is 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 tradi-
tional approaches. HI In an extensive review of the literature,
HISTORICAL PERSPECTIVES Linton and Kamwendo state support is limited for the
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 sup-
education 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 ob-
cost effectiveness of a 6 Mweck 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 "ground-
costs as compared to a control group. A key finding in this
dwelling" population when compared to industrialized soci-
study was that back school participants had half as many rein-
eties. 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 de-
workers for at least 6 months. The back school group had a
creasing the lumbar lordosis would assist in preventing prob-
savings 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 indi-
ion 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 ex- American Biltrite saw Workers' Compensation claims
ercises in an effort to increase the lumbar lordosis. 9 drop from $ ISO,OOO 10 $40,000 annually at the end of a
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
veloped in an automobile factory in response to an increasing and a 43% reduction in lost work time. They calculated
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 treat- the 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
first statistical studies regarding the effectiveness of these cd· and 3500 were not. Although the overall incidence of
lIcation programs in 1977. 12 The next few years saw the devel- back 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.
www.bodywork.su
 ..... ' ,,...r en ~ ; ;:>lVHUUL 155
,, I 0"'..... "

When one COllsitkrs tht.: staggering costs of back injuries (15 10 20 subjccts) and a variety of professionals serve as the
011 the work forec. even a small reduction in injury rales or instructors. including an orthopedic surgeon. a psychologist. a
lost work time hilS a signilk;.lllt impact psychiatrist, and a physical thcrapist.
One aspect of the back school that appears to be con- Class I. This session is taught by an orthopedic surgeon
sistellt in the literature is the positive impact of this type and focuses on anatomy, mechanics. and lhe aging process of
of program on the patient"s attitude. Dutro and Wheeler the spine.
cite different slUdics (h'll indicate that most individuals Class 2. In this session. a physical therapist leaches proper
i
attending back Sl:hool progrmns found them useful; in addition. body mechanics. First aid methods for obtaining temporary
.
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most felt the program hold indeed lowered their level of pain. ~~ relief from back pain are also included.
i UCC,lUSC much evidence points to a variety of psychosocial fac- Class 3. ll1is session addresses the psychi:Jtric aspects of
~
.~
, tors. including motivation and lack of control. as key factors in chronic pain and the influence of emotions on back pain. The
~ the development of chronic back pain and/or disability, this ef- instructor is a psychiatrist.
I , fect on patient attitude. may be the most important role for the Class 4, The final class is team taught by a physical ther,
1 back schooL In fact. I contend that lhe b:lck school is morc usc- apist. who leaches basic back exercises, and a psychologist.
I,
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ful in changing an individual's attitude about their back prob- who demonstrates relaxation techniques and discusses stress
lems than it is in changing the way they lift management.
~
)
! PROGnAMS The California Back School"
f
,% Sevenil programs h.lvc been eSlablished as major contribulors This program. developed by White Matmiller, includeS three
!
~ to the evolution of the back school, including the Swedish
i 90-minute ~essions held al weekly intervals. A fourth follow-
,I J Back School. the Canadian Back Education Units, and the up session is scheduled I month later. Class size is small
C.alifornia Back School. Although many other programs exist, (4) and most classes are taught hy a physical therapist.

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including modifications of those listed, it is worthwhile to
view the format of these programs. .
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
& The Swedish Back School daily living (ADL) is included, Each patient is evaluatcd us-
§ ")
ii .~)
Developed by Zachrisson-Forsell. this program consists of
four 45-minute sessions conducted over a 2-week interval.
ing an oh<;'f;ldr: cOIln;e and an exercise tolerance tes!.
Class 2. This session concentrates on ADL and'coordina-
;<:
? J
Each session includes a IS-minute sound-slide presentation tion exercises. The obstacle course is used to train pntients in
~
followed by a 30-minutc presentation provided by a physical lifting techniques and other ADL. Participants learn back ex-
'I ~.)
ercises and on·the·job safety procedures.
t therapist. Class size is relatively small (six to eight subjects).
Class 3. This class includes a quiz on [he information pro-
~ Specific goals of the Swedish Back School are to (1) in,
\1
~ crease pntient self-confidence; (2) understand the role trcat- vided. along with a second texl on lhe obstacle course.
•,
• } mentplays in the condition. and (3) reduce the costs of carc. Instruction is given on more complex ADL. and individual

I An outline of class content follows.

Class I. The focus of the fir!:t session is on anatomy and
problems arc addressed. Patients arc given a stress tcst.
Personal Concerns Inventory (PCI). and instructed on its use.
~'" biomechanics of the back. the development of back pain, nnd Class 4. This session focuses primarily on problem sol\'-
l ) lhe types of trealment available. Emphasis is placed on rest- ing. PatieOlS are once again tested on the obstnc1c course. The
I
•••;:;1

ing positions and some trcnlment advice is given. PCI is rcviewed and suggestions arc made for reducing stress.
Class 2. This session focuses on the stresses imparted on Each of the programs discussed provides participants wilh es-
the back from poor poslure and improper daily activities. seOlinlly lhe same basic information. including anatomy. pos-
Exercises arc demonstrated for strengthening the abdominal lure, body mechanics. first aid, exercise. stress reduction. nu-
musculature. trition. and lifestyle habits. Although the format varies
Class 3. In thb more practical session. participants nre slightly. each has similar goals. To be dfective. a back school
asked to apply infonnution gained during the first two ses- should be able to adapt to the panicular environmcnt (i.c.. pri-
sions. Various activities of daily living (ADL) are demon- v<.He practice, industrial, etc.) and to the needs of the partici-
strated and practiced. pants.
Class 4. This session includes a review of lhe first three
classes and patient is provided with a written summary of the THE BACK SCHOOL IN A CHInOPRACTIC PRACTICE
information presemed. Pmicllts arc encouraged to become Although the back school should not be viewed as the solu-
physically active. tion to back pain. it is an essential component in the {rearment
and prevention of back pain. It should be an integral part of
The Canadian Back Education Units :l'1
any encounter with patients with b~lCk pain. Bccause so many
This program. developed by Hnll. consists of four 90-minute patients seen in a chiropractic oflicc have a primary complaint
!
'Y, ,--', lectures hcld at weekly intervals. Class size is slightly inrger of back pain. the back school should be a standard part of
i J

www.bodywork.su
 156 REHABILITATION OF THE SPINE: A PRACTITIONER'S MANUAL

treatment. Anhur White staled. "Back school is the center of derstands that, although the episode may have been
the fastest moving specially in health care today ... \Vc will triggered by a particular activity, the activity did not
see chiropractors using bO\ck school in all of its forms and it create the problem. Ii is imponant to understand that
may change the face of the chiropractic hCJ.lth delivery sys- back problems arc like heart disease, they don't just
tem. Chiropractors have lraditionally delivered their lreal- happen, , , they develop,
ments .md moved quickly to their next palicnls. They have Causes of back pain. Back pain has no single cause.
1,, nol, in general. spent time 011 cducntion and prevention. If and Rather. il is the result of an accumulation of stresses
when they do so. the public .\Od olher health care profession- over a period of time. These factors include ~tress. poor ,
I
~,
als 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:t-
posture, poor living and working habits. poor body me-
chanics. loss of flexibility, and an overall decline in
health. To minimize the impact of future episodes of
)
i

licllts. the back school should playa role in preventing back back pain, each of these areas must be addressed.
I, problems. As costs for health care continues to escalate, the
role of prevention is increasing in importance. As an example,
First aid for back injuries. One of the most important as-
pects of any back school program is first aid. Because
I the National Institute for Occupational Safety and Health many people with back pain arc likely to have future
(NIOSH) has SCI, as a priority, a national health objective for episodes, it is imperative that they know how to respond

II
)
the year 2000 10 implement back injury prevcntion and reha~ when problems do occur. The response may have a sig-
bilitation programs in at least 50% of worksitcs. As of 1985, nificant impact on Ute severity and duration of the
only 28.6% of worksites with 50 or more employees offered episode. When a patient sprains an ankle, the.y typically
back care activities.-\{) apply ice. For some reason, however. when a back
A description of (he back school programs used by the au~ sprain occurs, patienls often apply heat, many times at a
th?r follows. Although the focus of attention is on the work- doctors advice. In the event of back injury, patients
related back injury, each of the programs is readily adaptable should be instructed to: (I) stop whatever they are do·
for a general practice setting. ing, (2) relax in a comfortable position, (3) perform
some type ofUfirst aid exercise" (Le., press-up, knee-to-
Introductory Back Safety Orientation for Industry chest, or standing back bend), and (4) apply ice.
Self-responsibility. Ultimately. the solution to back pain
The purpose of this aspect of the back school program is to
lies not in the doctor's hands, but in the patient's.
provide all newly hired employees with an orientation course
Consequently, the primary goal of the back school
in back safety, Topics to be addressed should include the fol-
should be to provide the individual with enough infor-
IO\\ling:
mation to allow them to take an active role in their own
Basic back anatomy and biomechanics. This section is back care and to encourage them to accept the responsi-
structured to reduce the fear of the unknown. Anatomy bility to do so.
is presented in such a way that those attending back
,,
school have an appreciation for the unique design and This orientation program may he presented in a classroom
function of the human spine..The role of the muscles. style format and should last approximately 30 minutes. It
bones. discs. and nerves is presented. The nature of in- can be adapted to accommodate small, medium. and large
juries to each of these tissues and the type of treatment groups.
lIsed for various injuries are discussed.
Cost of injuries. both to industry and to the worker. Back Safety Program for Industry
Individuals should appreciate the impact of back pain The purpose of this componenl of the back school is to pro-
on everyday life. Most estimates p1:lce the toral costs of vide all employees with information necessary to avoid seri-
b,lck pain at greater than S50 billion annually. but this ous back injuries. Topics of discussion arc similar to those
number is unmanageable for most people. More practi- covered in the orientation program (sec previous section). The
cally, discussion should include the average cost of vis- content is expanded and the fonnat includes active participa-
its to the dot::tor. the loss of wages that oflen result from tion on the pan of the employees. It is suggested that two sep-
back injuries, and the costs on home and family life. arate sessions be included in this section. Each should be ap-
Overview of how back injuries occur. Too often patients proximately 30 to 45 minutes in length and scheduled within
view the onset of back pain as rapid. In fact, many doc~ 2 weeks of each other. Class size should be limited to 20 to 25
lOrs also look at back pain in much the same manner. participants to allow interaction. J
For example. when an individual bends to pick up a box ,
and develops back pain, she or he tends to blame the
Back Training and Exercise Program
box. The patient is often cautioned about picking up
boxes in the fUlure. In contrast. an individual who picks Those individuals who have had back pain previously :lfC tit a
lip a box and has a heart attack would not consider high risk for future problems; in fact. a positive hi:-lory of
blnl11ing the box for their heart problem. The patient un- back pain is one of the most signific<lllt risk factors for future
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0HAt-' II.:H 9 : BACK SCHOOL 157

problems. J' ·)! In addition to the increased risk, these individ- Management issues, how to dcai with the injured
uals typically arc more interested in prevention programs. For worker (e.g., referral process, liglll duty, company <ltti-
Ihese rc.~asons, this group requires more extcnsive training. lude, etc.)
It is suggested thai this group enroll in an extended back • Legal considerations
school program consisting of three 45-minute sessions. Class
Recent infonnatioll indicatcs that managcment education
size should be limited to 10 to 12 individuals to allow indi-
and support may be one of the most effective ways of mini-
vidual auention to specific needs and problems.
mi1.ing the costs of back injuries on the job. Fitzlcr and Berger
CI<lss I. Topics discussed include the causes of back pain.
describe ;]11 industrial progr<lin in which management w;]s
anatomy and biomechanics, first aid for back injuries, and re-
taught to accept low back pain and workers were cncourtlgcd
laxation techniques.
to report all episodes. Treatment was immediately available
Class 2. Topics include lifting techniques and instruction
and included worker education. Every effort was made to
in ADL, safety lips, and specific flexibility exercises.
keep the worker on the job. \Vorkers compensation costs were
Class 3. Discussion includes the risk factors for back
reduced tenfold in a 3-year periodY·J..l In another study, Wood
problems, good health tips, stress management. strengthening
described the effects of a personnel program designed to min·
and coordination exercises, costs of back pain to industry and
imize the impact of back problems. The program stressed
to the individual, and self-responsibility.
early .access to care in addition to changing the attitude of
management. n
Intensivc Back Training and Excrcisc Program Management should make every attempt (0 provide in-
Those individuals currently receiving care for a back injury or jured employees' with reasonable access to care. Programs
those currently receiving some form of disability should en· discouraging early return to work should be dis~ontinued.
roll in an intensive program to address their condition and Employers should explain fully thc employee's rights under
their problems. This type of training consists of three classes the Workers' Compensation guidelines and work to devclop
as described in the preceding section plus any follow-up ex- an atmosphere of cooperation. Prolonged disability from back
ercise and ADL training as indicated by their condition. It is problems is often associated with adversarial situations be-
important to appreciate that those patients who may be dis- tween the worker and the employcr. litigation, and lack of fol-
abled need to be in some form of rehabilitation or exercise low-up .and concem.~ (This topic is discussed in greater de-
program. In thc case of an injured atliktc, vuc ;:"'oiild nm ex- taillatcr in this chapter.) Only through cduc<.ltion, of both the
pect full recovcry without some fann of directed activity. It is injured worker and the employer, can we take the necessary
equally unlikely to expect an injured "industrial athletc" to re- steps to reduce this aspect of the back pain problem.
cover unless they arc active.
FORMATS
Back Safety and Injul')' Response Training Over the years. I have taught back schools in a variety of for-
mats. including lectures to large groups, small group sessions
Until rccently, the use of education and training programs
with 6 to 10 individuals, and one·on-one instruction. Each
(0 reduce the incidence of low back pain has focused on
particular fonnat has advantages and disadvantages and the
the injured worker. One of the most significant components
design of any back school program should be adapted to the
of any back safety or injury prevention program. however, is
specific audience for which it is intcnded. As stated previ-
the training provided to supervisory staff. The way in
ously. many industri<ll back safety programs arc bcs.t pre-
which lhe "compnny" responds to an injured employee
sented in a lecture fomwt. A program intended for patients re-
has a great deat to do with the scriousness of the injury.
covering from a reccnt back pain episode requires a more
With this in mind. one must look at a somewhat unique
personal appro'lch. such as small group sessions. Some pa-
aspccl of the back school. The purpose of this portion
tients with particularly difficult or chronic problems may need
of the program is to provide the supervisory staff (e.g., man-
individual instruction.
agement. store managers. union stcwards, etc.) with Ihe
Before addressing what is necqcd to implement a back
infonnation necessary to deal effectively with the injured
school in private practice, it is important to take into account
employee when an accidclll occurs. The class is designed
the rcquiremenls and demands of your particular situation.
to consist of one full day of 6 hours duration; class size is
Many well-meaning individuals h.we attempted to establish
limited to 30 to 40 individuals. Topics to cover include the
some type of on-going patient education program only fo
following:
find that the logistics were complicated and the demands
Risk factors. both occupational .tnd personal impractical. As with any patient education program. the
Anatomy and biomechanics back school will change along with your time. energy. and
Costs of back injuries, to the individual and to industry experience.
Types of back pain Many different formats for the back school have been at-
Causes of back pain tempted. The most successful for p:llicnt care has been a se-
• First aid for back injuries on the job ries of three classes, each belween 45 and 60 minUles in

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 158 REHABILITATION OF THE SPINE: A PRACTITIONER'S MANUAL

length. In OUf facility, c1.1sses afC scheduled on Mondays and condition. Paticnts should learn to respond to any future
Thursdays and participants arc scheduled on three consecu- problems by relaxing. assuming appropriate 1l10V~111el1ts
tive nights (i.e., Monday, Thursday. Monday or Thursday. and positions. pcrfonning first aid exercises. and apply-
Monday, Thursday). Consequently, the entire series of cl3SSCS ing ice and suppon.
is completed in a period of 8 days. Cla...s size is limited (0 six Exercise. One goal of a back school program should be
to eight individuals to allow individual illlcntion. 10 teach exercises to minimize future back problems.
These exercises will vary with thc background and phi-
Group Versus Individual Training losophy of Ihe inslructor. hut they should include rdax-
ation techniqucs. flexibility and stretching excn.:iscs.
At times. certain patients may require individual attention. As strengthening programs. balancc and coordination pro-
a general rule, however. small groups of patients arc more cedures. and endurance exercises.
productive. The advantages of lcaching back school in small Stress reduction. Many back school progmms have in-
groups include that the friendly environment reduces intimi- cluded specific ,mcmpts to reduce stress in back pain
dation; patients learn from each others' mistakes and experi- patients. Efforts [Q reduce stress ~nd tension arc a most
ences; the variety of expcriences and questions is greater; productive 1001 for the management of many muscu-
those in the group provide psychological support for each loskeletal problems. including back pain. and should be
other; in any state. it is encouraging to realize they arc not a focus of the back school.
alone; tcaching several individuals at a single session is cost Nutrition and lifestyle habits. The relationship bel ween
efficient. lifes.lyle and health is described to raise the level of pa~
tient awareness in this area. Topics covered include
Curriculum good nutritional habils. smoking, alcohol. regular exer-
cise. :lod relaxation.
Although the curriculum varies from one location and pro-
gram to the next. certain basic clements arc found in most ,i
back school programs. The infonnation provided should in- Needs
clude the following:
To determine the oplimal back school program that is both
Anatomy-basics of spinal anatomy. It is imporwnt to effcctive and practical. the following wamlO[ consideration:
describe the anatomy in· tenns that are clear to the pa- (1) patient population, (2) available space, (3) personnel,
lien!. Understanding the parts of the back enables the (4) availahle time, (5) available equipment, and (6) fees.
,6
'.II
paticnt to better appreciate the role each part plays in
their problems and in their recovery. In addition. the PATIENT POPULATION
marc an individual understands aOOm the back. the less
One of the primary considerations in developing and design-
, ,
.--").

fearful Ihey become.

'",
ing a back school is the nature of tile intended participants and
Posture. Many authors have suggesled that poor posture
the demographics of the community in which the program
;Jlays an important role in the develQpmcnt of back pain.
will function. Those panicipating in a back school may be
Although not everyone agrees on which posture is most
current back pain patients. a general patient population. back-
detrimental or most helpful. it is clear that any posture
injured workers (Workers' Compensation). participants in an
[hm is sustained is. at the very least. a contributing fac-
industrial safety program. managemcnt ,md safety personnel.
tor to back pain. Patients should learn how to recognizc
school-age children. or pregnant patients. As stated pre\'i~
both healthy and harmful postures. They should be able
ously. it may be helpful (0 develop sevcral different formats
to identify positions and movemcnts that allevi.ltc their
aimed at rcaching diffcrent groups.
symptoms and be trlught to modify their work habits to
improve posture.
AVAILABLE SPACE
Body mechanics. The relationship of acti\'ities of daily
living to the development of back pain is an important The back school docs not require a large amount of space
aspect of the back school program. Patients should in which to function. It is possible to use separate facili-
be encouraged to use their bodics in safe ways. lies specifically designed for patient education. or you may .,
-__J
which is accomplished by teaching safe lifting tcch- want to "double up" an area that is used for other activities.
niques and by demonstrating and practicing a variety If space is a problcm. teaching back school principles to
of everyday movements and activities (c.g.. lifting. small groups or evcn one-oil-one is marc practical.
pulling, cle.) Scheduling back school sessions at a time when the office
First aid. Thi~ aspect of the back school is one of the is not involvcd in patient treatmcnt activities is another
most impol1anl. Even if patients understnnd how to use consideration. A b'1Ck schoolth.1t includes an obstacle course
their back and establish good back habits. accidents and and an exercise arC'l rcquires an open room with ;approx.i-
injuries slill occur. \Vhen they do. the reaction to the in- mately 200 squarc fCCI of noor sp'll:e. The only rcquircmcnts
jury has a great deal to do with the seriousness of the are that the room he c<lrpc[cd and clean. If the back school
www.bodywork.su
 159

-";.,
follows a large lecture fonllat, you may want to consider
renting a small meeting room in a local hotel. at the local
• 97\OO-therapeutic exercise
, public library. a nearby public school, church. or fitness cen-
ter. In one instance, I found a nearby dance studio ideal for
97540--ADL and/or job-related activities Irainin~
• 97708-ADL evaluation
our purposes.
)
!
~
-' . PERSONNEL
READY. FIIlE. AIM!
In planning a back school, consider the options thai arl.· llHlst
~
; .< , One of the most important aspects in developing a b~ll.::k
school is dctermining who will provide the instruction. Some
pmctic'll for your situ<'ltion and BEGIN! Anticipate changes ~tS
yOll gain experience. Many questions will remain llllans\\"en:d

,
!
~ ()

")
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, particu-
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.
!, larly those who have a history of back pain. The next option
is" to look for help in the community. Every community has
Certainly. the chances of success arc much better once yOll
begin!
.~ (j

,
people with some health and/or education experience (physi-
~
• '1 cal therapists. licensed practical nurses, registered nurses. re~ Promoting the Program
tired teachers. etc.) who are eager and willing to work a few
hours a day and enjoy interacting with peoplc. An advertise- To be successful. the back schoollllllst reach the intended au~

tI .")
./
ment in a local newspaper should provide a li~t of qualified
pcapic. It is also possible to find the right person from among
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.
~ your patients. Whoever is selected. she or he needs to be
e friendly. uninhibited. and willing to listen and learn. (Note: they simply need to enroll in back school. If the program is in-

i., This search should not be viewed as an opportunity to recruit

new patients. Being serious about finding the right person for
tended as a public service. making the necessary comacts with
local service organizations or groups is required. Any interest
~ )
,~ ,J
the job increases the likelihood that the back school will be in presenting this information to industry necessitates active
"marketing" of these serviccs. The following information is
" "<-
' )
successful.)
I. provided to assist in the latter endeavor.
t AVAILABLE TIME
Note: The back school will be ,an effective public relations
t program for your practice. Most people contacted. and cer-
;(
,,- The time schedule for back school sessions wilt vary. tainly most participants in the back school. will h3\'c a posi-
! v('""'1,
Sessions that take place during the nomlal work day while pa- tive feeling about the program and about you. Th~ back
t
1
tient care is being administered. necessitate both space and
personnel dedicated solely to this purpose. Scheduling 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
~ )
school sessions during nonpcak office hours, during evenings. those individuals wilh back pain and this fact must remain the
! or on weekends places less of a burden on your facility and primary focus.
~ personnel. Use in industry remains one of the primary functions of
,,
;~

-0;
this type of educational program. The chiropractor is widely
recognized as an expert in the area of b;lck pain. and the: back
AVAILABLE EOUIPMENT
1 -:#
..~

school allows the professional to positively impact the indus·

~ One advantage of a back school is thal no sophisticated or ex-
~
:;;
trial community. To introduce a back school into local indus·
~., pensive equipment is required. Most items needed are found tries, the chiropractor must first make contact with the neces-
• J around the house or on the job. such as a vacuum cleaner. sary individuals. She or he must establish themselyes as an
i suitcase. floor mop. grocery sacks. etc. It is helpful. however,
to have n slide projector, a cnssctte tape recorder. and/or a
expcrt and be able to convincc management that this program
will be lIseful. This relationship bct\\'ccn the chiropractor ,1Ild
television with a video cassette recorder. industry. often develops gradually over a period of tim~: once
established. however. it should prove to be of bene lit to every-
FEES body concerned.
An initial contact is made with a representative from the
Perhaps one of the most practical questions concerns how
company or industry. This first contact will hopefully lead to
much to charge and who is to pay. Fees vary from location to
a most important step. the interview. which is used to cSl<Ib-
location. but a reasonable fce is the cost of an extended office
lish what type of services 3re needed.
visit. Many insurance companies P~\Y for these services and
sometimes the patient's employer is willing to pay. \Vhatever
The Interview
the cost. and whoever pays the bill. il has been stated that, for
everyone dollar spent Oil education and prevention. nine dol- After armnging 3n appointment with the :'Ippropri~ttc company
lars arc saved! representative. the real wOik begins. This first mecting is an

www.bodywork.su
IOU REHABILITATION OF THE SPINE: A PRACTITIONER'S MANUAL

opportunity to leave a lasting impression with the company to the company. tilt: illl.:atioll ur job description wh~rt: lhe
and that impression should be first class. It is important to injuries occurr~d, and th~ manner in which the cbill1s wt:rc
know as much as possible about the company before this handled.
meeting: The following information is helpful. Once this evaluation is accomplished. it may be helpful to
do an on-silc evaluation or analysis or any problem arc;,s Ihal
What is the nature of the company. Le.. manufacturing. arise in lhe records review. or particular iillcrcsi me areas 111at
heavy construction. material handling. high-tech. cIC. have holO a high il1<:idt:IK~ of injury, especially back il1.iuri~s,
How many cmployct::s docs the company have locally Other areas of interest induoc slips .ll1d falls. knee injuries.
Docs the company have olher facilities or branches .1011 and shoulder injuries. and wrist and hand problems.
How long has the company been in existence and at this As with patient care. once problems have been c1ci.lCly
location identilied through a thorough case history and exmnin<ttion.
What is the fUlUre market for the products or services of the clinician is in a position to offcr suggestions to address the
this company problems idcntifled. This advice may include the usc of back
school programs.
This infonnation is available through a variety of sources.
The local library has demographic infom13tion on most in-
dustries, as docs the local chapler of the Chamber of NEW PERSPECTIVES
Commerce. In addition, a receptionist or some other contact
The significance of past advancements cannot be ignored. yel
at the company will often provide a grcm deal of information.
no single procedure has been shown to alter the long-term
It is useful to vicw this first· meeting in much the
outcome for patients \Vilh back pain, As stated previously,
S<.1mt: way as we look at an initial pcHicm inh.::rvicw. This
even procedures such as surgery. show little lasting bcnent..\~
first encounter is the time to identify the primary problems
Similarly, the back school has not been shown to provide any
and to establish if there is a need for prevention services and.
long-term changes in persons suffering with back paill:1'I,JII
if so, what type of assistance is needed. For example. if
Consequenlly. our approach to the back pain problem needs to
a company has a large number of repetitive stress claims
change,
for wrist and hand injuries but no significaJ1[ problems with
One of the newest arC<lS of back pain prevention programs
back pain. it may not help them much lO provide a
is education of management <lnd supervisory staff. This type
h<l("k "choot. Another company may have a real problem with
of program involves addressing methods of prevention and
noise pollution or with exposure to toxic chemicals. It is help-
worker training and. perhaps more importantly. developing
ful to have a list of individuals in the vicinity who deal
appropriate management skills for supporting the injured em-
with other work-related problems. If you arc unable to
ployee. The emphasis of most industrial back s;'lfety progr.lIns
help directly. perhaps you can refer the company to someone
is on preventing injuries. Hcre. the emphasis is on minimiz-
who can.
ing the impact of the injury on the injured worker and on pre-
In addition to identifying problem areas. it is important to
venting drawn out litigated cases th.lt often end in disability.
establish the attitude of the company in health-related areas.
Several studies have shown that the manner in which a su-
This informalion is crucial in developing a clear understand-
pervisor, company doctor. or employer responds to the in-
ing of the health-related problems faced by the company and
jured workers has ~I significant impact on the seriousness of
the role that a prevention program may play.
the injury.JI.J~ Chronic back pain .lOd disability arc not solely
a result of physical injury, but arc ;,lssociatcd with a complex
INDUSTRIAL CASE HISTORY
interaction of factors, including psychosocial issues. )
The Industrial Case History is designed to provide informa- Management and the clinician must make every effort to un-
---~

tion about the demographics of the company. the nature of in- derstand the impact of injury on the individual. ,)
juries and problems Ih31 arc common in their work environ- Industry can facilitate worker recovery by providing c<lrly
ment, and the manner in which they view health issues. h is a return-to-work policies. maintaining contact with the injured
most useful resource for this first meeting, It is unlikely that worker, and accepting his or her injury as real. Efforts should
any company rcprcsemativc will have the answers to all of the be made to reduce the likelihood of liligation. Onc study by
questions on this form: they will need to do some homework Ihe California Workers' Compensation Institute showed that
to provide all of the information required. This situation af- lhe most crilical element in reducing litigation was inform<l-
fords an opportunity to schedule a second meeting and also tion. Most injured workers went to an attorney because they
helps to establish the nrst way in which one can function as a felt they did not properly understand the Workers'
consuhant 10 the comp:my. Le.. 10 review thcir Workers' Compensation systcm.JJ Other studies clearly demonstratc
Compensation claims. that the presence of an attorney delays the "hculing" tirnc.""I,J;'i
One of the first steps in developing a prevention program With these factors in mind, an innovative educational pro-
\vith <I company is evaluating their p,ast on~the-job injuries, gram was established that was designed to teach the manage·
Rt:vicw of the workers compensation claims for the past mcnt team how to deal effectively wilh Ihe injured worker.
2 ycars provides informalion on the type of injuries common Topics covered include the following:
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 _ •• , .. ' .... I V , ...." V l ' uvnVUL 161

Costs of back injurics-to industry and to thc Individuai Sinlrt h.·llflh or time Oil th~ joh~l.~~

ClUSCS of back pain/types of back pain Lm:k nf .h';' satisf;\ction/p<lll[' supcrvisnry ralin~<> <.:
Risk factors. both occupational and personal Hig.h str~ .." levels at work"
Anatol11Y and biomcchanics of the back Poor g~Ilc:r:.I1 hC;llth~l·/smoking·\1
f-irst aid for back injurics on thc job
Management issucs-how to deal with the injured RISK FOR DEV"_OPING CHRONIC BACK PAIN
worker (e.g., rcfcrr'll process, light dut)'. company ;lui-
Other raL'lor.. ,hml1icily JJ1"('clic:/ol's) lIlay 11:1\"1': rc!l:v.ll1ce·
tude. etc.)
ill c\'aluating .: ~rollP of patients with aculC low hack p:lin
Legal considcrations
to <.lclincate Ilh',e :; or I ()tIc who will (h.:vclop a chronic
problcm:
THE "10%" FACTOR
Clinil:al rrt:>,clltation of a palicm ovcr the initial weeks
One of the predominant statistics in the litcntturc pertaining to
after injury Illay be a valuable guide in determining
back pain is that approximately 10% of workers account for
chrollicit~. Fal:wrs indudc:
80% of the coslsY' To gain control of the back pain problem
-Leg pain. particularly the.: presence or root tCI1SLOIl
in industry, we must take a close look at this small group of
signs~' ;.
individuals to try to dctermine why their situations arc so dif-
-Nonorpnic signs. whkh may he assOl:iated with
ferent.
symptom magniticoltion syndromc. hypochondriasis.
and/or malingcringl • l
The Injured Worker
-Pain self-report. A pain complaint thal docs not con-
To understand bettcr the back-injured workcr who becomes form to known physiologic patterns. particularly
chronically disabled, we must take a look at the situation from when coupled with om abnormal pain drawing"l
a ncw and different perspective. No longer is it adequate to -Nonspecific diagnosis. The lack of a specific
equate the impact of the injury with the "seriousness" of the pathoanatomic diagnosis is associatcd with a le~s f;j-
physical ailment. We must inslead differentiate between the vorable outcomc('!
disease of low back pain and the illlless associated with low Age. Indi\·iduals younger llwn :lge 25 years ;m: at
back pain.-I7 greater ri5-k of injury but usually l'elUrn to work sooner,'"
The process of disease is defined solely as a biologic dis· Those injured workers betwcen the age.: of 30 and 55
turbance. The illness is the subjective experience of the dis· tcnd to h<:.\·c higher incidences of chronicilY and dis-
case by the person in his or her environment. As such, under- abiliti-":'
standing the behavior of an individual with a disease or a Sex. Eighty percent of back injury cOlllpens~Hioll
disorder in the context of that environment becomes crucial. claims ar~ tiled by I1)cn."\ although an occupatiOll~l\ly
Two individuals with similar disease.\· often respond lotally injured \\oman is more likely to remain disablcd.~"l·
different ways, One patient may be (O[ally disabled. whereas Educmion. An inverse relationship exists between edu-
I
~
~
J the other may be merely inconvenienced. In spite of the nurn·
hers provided previously. there is some thought that the ,U...•
cational le\"d and tow back pain and disability. with the
most pronounced incidence in the least cducatcd.~··"~
;.,) ease of low b.lck pain has not incrc.lsed in incidence during Context of the injury. An ;lcute cvcnt related to lifting-.
"'i the past several dec.ldes. whereas thm of the illness has in- bcnding. or (wisting or an accidclH such .IS'I slip or fall.
creased dramatically. has a predictive \"alue for chronicity.-I·-
Part of our efforts in preventing. or managing industrial Inconsi!'h~ncy of medical carc(~1
back p"in should be directed at identifying individuals al Lack of <.1\·ailability of interim light duty workJ,~
risk ..l,~
RISK FOR BECOMING DISABLED
RISK FOR INJURY In addition to the factors just mentioned. 'l1lother set of pre·
In the gcneral uninjured pop·ulation. certain factors (injury dictors (chronic' olltcolJle predictors) might be helpful in idcn·
(JfediclOrs) may serve to differentiate the group at risk for a tifying those individuals for whom trcaUllL'11l or intervention
back injury: is likely to fail. It is this poHienl who 1110st contributes 10 thc
"high cost" of industrial back problems. Thesc racwf:O: in·
History of back pain is the single most important pre· elude:
dietor l '!
Trunk strength deficits. The probability of injury Compcmation and Iitigation 111
is [hree limes greater when the job lifting require· LIS time. The longer it takes for an injurcd Wllrkcr to
mcnts approach or exceed the individuals' functional receive care. the longer it takes for a referral to a spe-
co\ll<lcity!ol1 cialist lO occur. and the longer she or he must wail for
Individuals involved in heavy manual labor, vibration procedure, such as surgery. A chronic outcomt: i:- nK,rt:
and driving. heavy lifting. and prolonged siHing l likely in this situalion.

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 100::::: REHAl:.illll A lION OF THE SPINE: A PRACTITIONER'S MANUAL

\Vhcn surgcry is suggestcd but not pcrlorlllcd 6. I'dtlcr t: Til,' l>:ld ...:hl,,,1 ,'I Iklpcd\ ill ~·I0111pdicr. elin Onhllp 179:4.
1<):\.'.
Lack of availablc work upon rcturn~"
I. F:lhrni \VII: B;td,;;t<.:hl· ;t1ld I'rilll:lll'tlsllm,::. V;l\Icou,·cr. ~hNlucallll'uh..
1.1.1.• 197{1.
11 Total Management of the Back-Injured \Vorker s Willblll~ PC: 1.0\\- Il:Id;, ;111\1 S...•...·k Pain: CI\ISCS <Ind COllscr.... alin,::
Tr ·;lll1'...·I11. Sl'rlll~lidd. C!l;lrh:, C'I"""Has. 1974.

I Success in this task includes an unders!:.mding. of the fol-

lowing:
'J. ~1 ·",·lI/k It: ·\11...• l.umh.l! Spin,·: i'..lcch:mical LJia~l1l1:-.i:-. ,mil 11\1,::rap~.
Wcllinghlli. 1':C\\ h·'lbn,!. Spl1l:lll'lIhlic;ltinns. 11)8;'\.
Ill. Z.•dIrlS'-llll ~1: ·fh · 1.• '\\ Ibd. S...·h,KII. 1):lIIdc~·d.·Swedeli. 1):llllkryt!'"
...,
The injured worker-whal Iype of worker is injured iI'hpil;tl SI'"l1d Ih · ,Iill...· phl;:!';lIll. 1'J7~.
The injury-hO\\' docs the injul)' occur. \\-'hal types of II. Zadlri':-'''n-Fllr,cll ~I: Thc SWt:di.,h B;tt:k. l'ehool. Phy:-.iotherapy 66.
activities arc associalcd with hack injuries April. 19Stl.
Thc response to injury-what happells .lIlhe time of in- I~. Ikrqui:o.I·Ullm;lll ~l. l.;INm U: :\CIIIC' low back pain in i1H.luslly. :\cla
Onh.l Sl';mtl (Supp1J:170. IlJ77.
jury, to whom docs she or he report. who docs. she or he
1.\. Hall II: The C;lll;ldiall 11;11.;1\ EJII~'ali(1ll Units. Physiolher;Jpy (l(l: 11 S.
see, what help docs the company offer ItJXlI.
Return-to-work factors-what is the company policy. l~. ~1:11111ilh:r AW:Thc C:llifurIli;1 Hack school. Physiother;lpy 6l1:115.
what is the employee. attitude and expcrience. Illodillcd IIJXI I.
work program. who arc the slake holders 15. lIali II. kctOIl JA: Ibck sc!lo(,ll: An overview wilh spc...·ilic rcferclIce In
Wlmt makes an injury serious Ihc l'an:l{Ji;lII n:lek blucallUll Units. l'lin Orthop 179: 10. 19S.'\. ")
1(,. "Ial\t:r·~-hll"fell JA. Chasc S:\-l. Portek J. CI al: A C(lntmlkd perspcctin-
'ludy lu cvaluatc the cffeclivclles" (If a l't;u.:k school in the relief Il(
SUMMARY chrunk low h:lCk ~in, Spine II: 120. 1986.
17. ~l;lll1lilkr ;\\\': The California !lad; school. Physiolhempy 66: 115. I()SO.
Patients must lake a morc activc role in their n:covcry. IS. K\'icn TK. Nilsen H. Vik P: EcluC:llion and sclf-care ofpaliellls with low
Clinicians are being asked to abandon passive treatment in fa- b;tck p;lin. SCilnu J Rheum<ltol 10:320. 1981.
vor of mcthods that encourage patient activity and participa- 19. Linton SJ. Kamwcndo K: Luw hOlCk schools::\ critic:ll rc\·icw. Phys
tion. After three decodes of interest. however. controvcrsy Ther 67:1.375. 1987.
surrounds the effcctiveness of the back school as a means of 20. Berwick OM. Rudman S. Feldslein M: No dinkal dfecl (,I' b;lck sdlQols )
in an HMO: A r::lndomi"lcd pro~p<.'Clivc trial. Spine 14:.'38. 19R9.
combatting back pain. The back school is treated by somc as 21. Fclclslein A. Ualanis B. Vollmcr W el ;11: lllC Back Inju~' Prevt:lllitlll
an important part of the solution to the growing problcm of Projcct Pilol Sludy. 1 Ckcup Mccl 35: 114. 19<13.
back pain. By othcrs. it is considered unnecessary and unpro- 22. Brown KC. Sirles AT. Hil)'cr JC. el al: CosH:ffeclivcne:-.s of a back
ductive. school intervention for lllunidpal employees. Spinc 17: 1224. 1992.
23, I'looper PD: Prcvcnting Low B;u.:k Pain. Ballilllml·. Williams &. Wilkins.
After 17 years of active involvement in back school
1992.
programs, I havc ~een interest in this topic increase and de- 24. DUlro CL, Wheeler L: B;H.:k ~Ch~IOI and chiropraclic proH.:tke.
crease. The substantial commitment of timc, effort. and ~'lal1ipulati\'e Physiol Ther 9:209. I n6.
energy needed to establish and continue a successful b'lck 25. DUlro Ct. Whccler L: B;ld sdmnl anti chin'l1r;lt.:tk pr:....·lk"e.
)
school program in a chiropractic pr<lcticc or any other ~lanipu1:ltive Physi{ll 'nler 1):209. 19~6.

clinic may account for the current decline. It is clear, how- 26. Zachris...on-Forscll M: 'nle Ibd school. Spinc 6:1t).J. 1981. )
27. l·faUII: The Canadian Back Edul;;tliull Unils. Phy~iolh"r;IPY ()(d IS.
evcr, that efforts to decrease the incidence and impact of back
1980.
poin have failcd. and J am convinced that the back school 2H. While AH: B:lck School and Olhcr Cuns.cr\,;,tive Approaches III L{lw
is a vital and necessary step toward recovcry for all patients Back Pain, 51. Louis. c.\'. i\·!oshy. 1%3.
with back pain. 29. While A: The Baek st.:holllt,f lhc FUlllfc. In While L (cd): Bad Sclu.\.!.
)
Appropriate management of back injuries, particularly Phil;lddphia. Hanley antI Bclfu<;. 1992.
30. J)cpanlllellt of Hcahh and lIuman Rcsourccs: Dr.lfI Obj...· cli\'cs f(lr Ihc
those sustained on (he job. must includc a cooperative effort
YC:lr 2000. W3!ihinglon. DC. U.S. I'uhlic Health Service. 1989.
ilwolving the injured worker, the company. the clinician. and 31. Pederscn PA: Prognoslic indicators in low back pain. 1 R Coli Gell Pr:ICt
the insurer. This coo~ration is achic\'cd only through proper 5:99.198l.
education. Thc individual who providcs this information is in 32. Lloyd DeEF. Troup 1DCi: \{cClIrrclll hack pain and il:-. prcdictivlI. J SlX'
a uniquc position in the industrial arena and in (he treatment (kCllp Met! :'3:66, 1910
of back pain. B. Fit~.Icr SL. Bcrger RA: The Chelsca back program: One )'ear latcr.
Occup He:llth Saf 7:52. Il)1\2,
34. Filzkr Sl.. Berger Rt\: Alliludillal I.:hange: The Chclsc;l h~lck pw~r;\I1l,
REFEHENCES ,. 1
I. Haldeman 5: Prcsidcmi:d addrcss. Nonh Amcrican Spine SociCly:
OCl.:l1p Health S;lf 3:20.1. ]\)l:O.
3;. Wont.! DJ: Design and cvaluation of a h:ld injury prc\'cllliiJn pro~r;ltl\
.,',.'"
Elilurc of Ihc pmhology modcllo prcdict back p<lin. Spinc 15:718. 1990. wilhin a geriatric hospilal. Spine 12:77. 1910.
2. Wcber H: Lumbar dj~ hcnlialion: A cOnlrollcd prospeclivc !>Iudy wilh 36. Nordin M. Crilcs-Batlie M. "opt.: MIL el ;11: Edul-;llion and Irainin.;!. In
,)
len year:;. (If oh~cr"aloin. Spine 8: 131. 1983. l'opt.: ~·lH. Andersson GnJ. Fryllloycr JW. CI :11 (cds) OcCU[hllioll:t1 Luw
3. Hooper PD: Ba."ic Training. Di:uuonu Bar. CA. Injury Pr.:;\'cmiun
Tcchnologies. 1992.
Hack. Pain: Assessmcnt. Trc;IIIllClll al',J t'rcvclIIiull. $1. Louis. Musby J
~. Hooper PD: Put Your Back Prol:tkm." Behind You!~!. Diamond Bar. Ct\.
Injury Prevcntion Technologics. 1992.
Year Buok. 1991.
:17. S;lUndcrs !-If). Iscrnh;lgcn SJ: Back Schools. In lsernhagcn SJ (cd): Wwk
Injury. RllCkvillc. MD.A:-,pcll. 19HH, [l '17.
.,.-
5. Br:mdt-Rauf PW. Rrandl·F;'IufSI: History of occupation,,1 medicine: Rel-
e\';\1\(e of Jmholcpand Edwin Smilh papyrus. Or J Jnd Med 44:68.1987.
38. Weber H: Lumbar disc hcrniatiulI: A commllcd prtlspccli\'l; SIUtly with
len YC:lrs of obsen.'alioll. Spinc 1'\: I J I. 19M3. ,
-~

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, ..... HAI-' II:H 9 : BACK SCHOOL 163
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
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:
.-l1(,'lIi..- Ihl'. Spill'" II' J ~(l. I"X(•. ..\ rL'lrn",pcl.:li\"e sludy. I. Overvicw and cost Oln:llysis. Spine II :241.
,
1
.11. B.lrn..':- D. Smith I). (;:lld,..:! R.l.'l ;\1: 1'.. ~ ..I"h.r•.:inl:l:"n"ll1i.: ph'IIKbJ" 1'J:'h.
~ "r Ir-::IIIll<:llI \lll:,:..-, •.tf.ldml· ill ..:1U"I1I' t",\·b:td.. pail! I'ali"'lll-, Spill~ :'i. Fr~mnyer JW. PIll"'" .\IIi, Clemcnls JH. et al: Risk f.,Clor." in low back
1.j:.l~7. JlJ~i'J. p:lil1_ J BOlh: Jninl Sllf~ I t\1lI I 65: 184. 1983.
.12. Fr~lIluyl'f J. (':,h·B.llll \\-: I'r..'di..'ltlr, ,.1 tn\\ h.ld. tlisahility. ('lin Orlh,." 5S. Iham~.S"r":Il~1I F: A I'h"'pe..:li".... study of low ha..:k p:lin in :l gCIl":w!
~2U\'). II/Xi. !"rul:l1il'l\. Sl':ll1d J Rd1:lh f\kd 1):81. 1(8).
.,1.__ r..· hh 11\ \\"ulka:-' Cllllll'.:n',tlJ<>ll. I'J\'so:nl~·t1 at lh~' St:ll..:
:\: l.ili';::lll\'ll :"). Tr...up J1)G: Slr.lifill-Icg·r:lising tSLRI :Illd the qualifyint;. tcsts for ill-
\\·"rlltl~·u· ... C"l1I!,":Ih.lli"n :\d\ i_'"r~ C"lllllliH~'\', S:lll Di\.·~". CA. rr~"hed rUllt tCllsiun: Thcir predi,,·li\'!.: value afler back :lml s~iadc pain.
Cklllhcr. J 97.t. Spill\' 6:526. 19S I.
.\-1. B1o,:k AR, t\1''':Ill'':l' E. Gaylor \·1: Ikha\i,'r;d lfl.'atlll\·l1l Ill' ... hrpili,· paill hO. W.I..l\kll G. M..:Cul1ou~h JA. KUlllmd EO. CI OIl: Nonorg:lnic physic:ll
\ari:ll:oks afli:.:tin;: (r'::lllllelll cfli..·a.:y. I':tlll S:Je.7. 19SII, "'l~n... in lllw h:Kk pOlin. Spine 3: 117. 1980.
-1~. Whilc !\\\'M: l.ow h:ll:k p:lin illlllell l'..''':",I\ Ill;: workl1'cns· ..·nmp..·n':llioll. (d. Kirkaldy·Willis WH: Thc dinicOII picturc-introduction. IN KirkOlldy-
em ~kd :\~~(lC J 9~:;\(J. 1966. Willi~ WH (cd): M:m:.ging Low Back POlin. 2nd Ed. Ncw York.
-1(,. Frymlly....l' JW. Pop..: ~IlL I{oscn 1. ":1_,<1: [rid.. . lllioillgi'" slllllie, of low Churchill·Livingstonc, 198R.
h:li.:k rain. Spin.. . 5:-119, 19HO, 62. F~mo)'cl' JW, C:lIs-Baril W: Prediclors of low hack pain disahility, Clin
o -17. '",: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\"\:
Onhop 221:89, 1987.
63. Bigos $1. Spengler D~1. ~'larlin NA, Cl :II: Back injuries in industry:
Ph~ ...itllllll:r 1-1:Ji ). 1991. :\ rclrospcctivc study. 111. Employee-related (;tctors. Spine 11:252,
'
.IX. 1'01:l1il1 I'll: I'r..'diclHr... III' low h:1d. p:un disahililY. In Whit..: AI-I. 198b.
Amkfsoll R kd"!: Clllh.. . rv:llivc Cll'\.' (11' Low Back Pain. B;lllirnorc, M. F~'moyer JW: Back p:tin and sci mica. N Engl J Mcd 318:291,1988.
Williallls..'\: Wilkin.... 1'1'11. 65. Klein BP, Jensen RC. Sanderson LM: Assessment of workers' compen-
JIJ. Uigo~ 5J . ..:1 :11: A pro...p..:cliv.... ":\';llu:llilJn uf ,,:olllfllunly used pr..:-cm- salion claims for back !'ilrain.slsprains. J Occur Mcd 26:-143. 1984.
ployrncnt s.:rr:cning trio!... fIll' anile intlu"'lrial hack pain. Spine 17:922. 66. Dzioba RH. Doxey NC: :\ prospectivc investigation imo lhe orlhopcdic
199~. :lnd pS)'chological prediclors of outcome of first lumbar surgery foUoww
50. Chaffin DB, Park KS: A longitudinal sludy of low-hack pain :I~<'()ci;llcd ing industiral injuiry. Spine 9:614. 1984.
wilh occup:lIional weight lifting f:lCl\lr<" .-\tn Inti I-lyg A"slx- J ,1~:51~. 67. Dcyo RA. Tsui·Wu Y: Descriplive epidcmiology (11' low h:ICk p:\in :\nd its
1973. rdatcd medical C:lre in Ihc U.S. Spinc 12:264. 1987.
51. B'~I\' 5J. 51'..:ngkr ()~1. .\-laflin r\A. Cl ;IL B:I,,;I.: injuries in indu'lry: ..\ 68. A"lr;lnd NE: Medical. p...ychologic:ll. and soci:!l factors OIs.~ocjatcd with
rclrlhpc(·ti,·.... ~Iudy. III. [mpllly,,'e·rd:lt..:d fa~·h)f:'. Spine II :252. 1986. back abnurmalilks and ,e1f-reporled hack pain. Dr J Ind r-,.·Ied 44:32"1_
52. --"trand NE: ~·1cdical. p'ydwlvgil.:;tl. 'Illd ... ~~ial f:lCtors :lssociall:d with I%i.
hack abnorillalilic~ ;IIlU sclf-n:porlcd hack p.lin. Hr J Inc! ~'1cd J-1:J27. 69, \\'ci~d SW. Ferfer HL. Rothman RH: Indll.~lrial low b'ICk pain-:!
1987. pro'pceti\'c c\'illualion of a sl:l1ltlarizcd di;)~nosli..: and tr..:atmelll prolo-
5:;. ~1:tgora A: Ilwcstig:tlion of Ihe rd:lliull,hip between 1(lw hack pain alld col. Spine 9: 199. 198-1.
occup:lIioll. Scand J Rehah l\kd 5:191. I<JB. 70. Robertson LS. Kc....vc JP: Worker injuries: The dfccts of workers'
5~. Wc<;lrill C. H1rs..:h C. Lindcgard B: 11le flI.'"NJnality of Ihe I:o:t;:k p:.ti":lll. compcns;ltion .1Ild OSHA inspections, J He:lhh Polie Polk)' L-lw R:~81.
Clin Orlhop S7:20{,j. 1972. 1<J10.

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 IU YatIent ~ducation
CRAIG LlEBENSON and JEFF OSLANCE

Pmicnt CdUC.l1ioll is as csscmiallO successful rehahilitation as lic\·ing. that c;'lrly aggressive conservntive care is not neces-
afC exercise or other trc~HmClll stri.Hc:gics. Sometimes educa- . ~sary for patients with low back pain. Experts and emerging
tion. advice. :.lnd training arc all that a person lh:cds. Im- consensus-based guidelines disagree vehemently with this
proving a pmiclll's sining posture or recomlllending J llcadset lfodilional approach. sloling lhal the lypical managemenl ap-
for prolonged ll.:lcphonc work arc jUq two cXi.unplcs. Patient proach of bed rest with medication is responsiblc for fostcr-
,I
cducmioll is prdcm.:d over cxcrcisL' bee use once a person ing disability in those prone to it. Troup. an esteemed British
lc;mls how to rcdll<..' c strain. that Klwwll'dgc is with them for- orthopedic surgeon. stated that, "The first attack is the ideal
ever. whcrc<ls exercises must be performed over and over time for active and perhaps aggressive treatment but if it is
again. tacitly assumed that the vast majority of patients recover-from
Traditional subjects for patient education include spinal back pain whether or not they are treated then the opportunity
imtltomy. pain sources, fir~;( ;Iid for acute recurrences. body may be missed."lO It is essemial to pursue rapid resolution of
mechanics. and preventive exercises. We place the most im- symptoms aggressively to minimize the likelihood of recur-
portant areas to cover into four c;.uegorics. First. reassurance rent symptoms as well as the development of a chronic. dis-
that the natural history of most pain syndromes is toward a abling pain syndrome. The Quebec Task Force on low back
speedy resolution. Second. body mechanic!' lhat arc univcr- pnin disorders said. "Management strategies should be di-
sally applicable (i.c.. workstation ergonomics. lifting advice). rected at maximizing the number of workers returning to
Third. the importance of focusing on function in addition to \.. ·ork before I month and minimizing thc number whose
pain relicf as a goal of care for the subacutc. chronic. and high spinal disorders keeps them idle for longer than 6 months."t'>
risk patient Finally. explaining the dilTerencc between hurt Prolonged disability or pain will lead to both physical and
and harm so the patient is less likely 10 immobilize them- psychologic dcconditioning. which we should 'strive to pre-
selves and become deconditioned in their attcmpt 10 <lchicvc vent through appropriate care of acute episodes.
pain relief. In the early managemcnt of back pain episodes. manipu-
lation is the single most effective treatment strategy. I:
Rehabilitation with exercise 1m!' also been shown 10 hasten re-
NATURAL HISTORY
turn III work tInct reduce the rate of recurrenccsY·l.1 Radicular
Close to 90% of back pain episodes resolve within 6 wccks:· liI syndromes arc associated with a less favorable outcom~.
This excellent prog.nosis should not. however. lead to a negli- Nonetheless. ovcr 90% of individuals with pain below the
gent approach to managing this problem. A review of 1989 knee and nerve root tension signs recover without surgical il1-
\Vorkcrs' Compensation low back pain claims revealed that. tcrvenlion.. ~·wrhe length of time prescribed for bed rest may
"cases that go on to have prolonged disability arc the primary be longer (up to I week), the value of manipulation less cer-
contributors {O the cxpense of low back pain.'''' It was deter· tain, and the overall length of time required to achieve symp-
mined thnt "25% of low back pain cases accounted for 96% tom resolution more than 6 weeks, but the prognosis for re-
of the costs'" Persons who are still suffering ..,ftcr 6 weeks arc covery is still good.
at considerably higher risk for 1;lsting disability and chronic. Thc prognosis is poora for chronic pain syndromes.
pain. According to Nordin. " ... there is a very small window Patients may henefit from a trial of manipul;Hivc therapy. but
of time in low back pain care: we must .Icl quickly within 11 biopsychosocial approach is detinitcly indicatcd. Exercise.
4·6 weeks to bring paticIHs into an active reconditioning pro· education, and encouragement arc the mainstays of success-
gram if we expect to return them to productive lives and pre- ful carc. Psychologic intervention may be needed as well.
vent recurrence."11 With recurrence rates around SO(k and the Focusing on function and reducing the patient's fear about
high costs associated with chronic disabling pai-n, aggressive movemenl arc critical to succcss. Carefully explaining that
conservative C.lre focusing 011 restoration of function and pa· hurt docs not equal h;lrm and that wc do not follow a "no
tienl education should be the standard of carc. pain~no gain" philosophy is an important prelude to rehabili-
Unfortunately. because of the excellent prognosis for tation. Functional goa.ls must be clearly cst;lblished and ob-
most patients. many health care providers arc misled into be· jective outcomes used to monitor and demonstrate progress.
165

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166 REHABILITATION OF THE SPINE: A PRACTITIONER'S MANUAL

in cnronic pam m.uwgcI1lCIiI. il j, \.'sscnti;111O t'\)(US I.Ul control Table 10.2. Risk Factors for Chronicity (British Management
nnd nol cure ;,md to place )'(lur:-df in tilt: role of hdpcr rather
lhan healer. n
Guidelines lor Back Pain)
,
Previous history 01 10\'1 back pain
Rarely is back pain 11ll: prl'''l'luing symptom llf .1 serious • Total work loss (because of low back pain) in pasl 12 months
disease. A thorough history and clinical cXillllin;l\i\l\1 should • Radiating leg pain
• Reduced straight leg raising
be obtained. howc"cr. to ruk oul inrcclions. 1ll1l10rs. and other • Signs 01 nerve rool involvement
serious disease=, (Iwt t;tIl mill1ifcs( with spin'll pain. • Reduced trunk strength and endurance
Reassuring p:nicllts lhal their prohlem is IlIcl...'hanic:'l1 .llld not • Poor physical fllness
• Sell·rated health poor
.1 sign of inlcflwl disCilSC is an important step in p;Uicnt edu- • Heavy smoking
catioll. • Psychologic dislress and depressive symptoms
• Disproportionate illness behavior
• Low job satislaction
Standard of Care and Identification of • Personal problems-alcohol. marital. financial
High Risk Patients • AdversarLal medicolegal proceedings

Over 80% of the population will cxpcriclltc hack puin Juring (From Waddell G: The Low Back Pain Guidelines (British). Clinical
$lnndards Advisory Group: Back Pain. London, HMSO, 1994.)
their Iifelime. Only:; to ISCJ( of these individuals. however.
will become chronic suffers. lkcause of thr: disproportion-
ately high cost associated with chronic C:ISCS. much altention
has been placed on linding bellcr treatment ~lnd prevention 1I011Y MECHANICS
strategies for this minority. The :IlHhors of a large re"iew of
Reducing strain is essential to preventing recurrences.
worker's compensation low back claims concluded that. "the
Tcaching office workers to take frequent "microbreaks" every
primary goal of low back pain management should be the prc-
20 to 30 minutes can help immeasurably. Studies havc shown
vention or reduction of prolonged disability"'"
th<.ll tissue creep occurs after just 15 minutes. IX Also. if just
A question posed by guidelines panels is. How many
4% overload is encountered. a negative metabolic state is es-
treatments 3re appropriate and for how long? The Mercy
wblished. I".~O Propcr chairs and workstations arc a must for
Guidelines concluded that 6 weeks of carc is usually sufrl-
patients with low back and neck polin as well as those .suffer-
ciem for "uncomplicated" cases.-' Three to Ihe sessions per
ing from upper extremity repetitive strain disorders (i.e..
week for 1 to 2 weeks is appropriate. followed by "Progres-
carpal tunnel syndrome).
sively declining frequency is expected to discharge of the pa-
Work station ergonomics is a practical place to get started
tient ..."$ Spinal manipulalive therapy has been shown to
when looking for sources of mechanical overstrain. Go
lead to a 34% better rmc of recovery (at the 3-week mark)
through the workstation checklist with your p<.lticnts (sec
when compared to other traditional forms of Iherapy.l"
Appendix 10.1). )
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<ltions lasting up to a Lifting Technique
month."I~
Lining technique is often debated; typically. squatting.is rec-
ommended over stooping. Unrortunatcly. Illost workers fail to
Risk Factors
follow this advice if repctitivc lifts arc required. Garg and
The various factors lhm may lead [0 a slo\l/cr course of re- Hcrrin lloted the increascd encrgy expenditure associ:ucd
covery arc presented in Table 10.1. The factors associaled with squalling versus stoopin£.~1 What appears to be an at- )
predictively with chronic or recurrent episodes arc listed in taintlble goal is maintolining the lordosis. independent of thigh
Table 10.2. and trunk angles.~~ Adams and Hutton reported thm less
According to the British Guidelines. low educational compressive load on ..I fully flexed lumbar disk (i.e., stooped
attainmcnt and heavy physical occupation arc lesser risk posture) is needed to cause posterior herniation of nuclear
factors. but will interfere significantly \vilh successful reha- materi'll than would cause end plate fracture in the uprighl
bilitation. s positipnY According to McGill. "Because ligaments arc not
rccruilt;d when lordosis is preserved. nor is lhe disk bent, it

Table 10.1. Factors That May Predict a Longer Recovery

appears that the annulus is at low risk f"r failure.":: This J
statement was supported by thc work of Hickey and Hukins. ~~ .,
Past hislory of >4 episodes Lifting while maintaining lordosis allows the further benefit .}
> 1 week of symploms before presenling 10 doclor of activming the musculature and thus prov.iding for neuro~
Severe pain intensily
Pre-existing structural pathology or skeletal anomaly (i.e .. spondy~ muscular control to protect ligamcntous tissues.
lolisthesis) directly related to new injury or condition Lifting technique is important, but when you lift may be
evcn more significant. As a result of the increased fluid con- .0
(From Haldeman S. Chapmiln·Smilh D. Pelersen OM: Frequency and dura·
tcnt in the disk after lying down al night, disk bending stresses
www.bodywork.su
tion 01 caro. In Guidolines lor Chiropractic Quality Assurance and Practice
Parameters. Gailhcfsburg. Aspen. 1993. pp 115. 130.) arc increased by 300% and Slrcss (0 ligaments is increased by ,

L
',Y
 ......... , ... n I U . n.,l I l:. 1'1 I t:.UUCATION 167

XO'./r in thl; t1Hlrnin~.:'

Thus. th",' ri~k of injury during. forw..ml Thc proper dcsk hcight is normally about 27 to 30 em
klldill~ ;\~{i\·itil.'''' ;~
inl:rcascd in thc early morning.. above the seaL"~ The shoulders' should be able to relax with
Prol\H1~eu n".':\il\ll. SllC.::h as in sining. can rcnder the back the elbows bent 90° and the hands relaxed on the desk sur-
'·ulner'lole 10 liftin~. ~-1cGill ,lUll Brown (ound lhat after jwa f.cc. A slantcd dcsk (10 to 20°) may also be hclpful for rc-
3 minutes of full tk.xion. slIhjecls lost half lheir stilfncss.: h ducing neck str'lin.
AJall1.'i anti Hutton nclievc thaI prolonged full flcxion nwy
l';\USC ligalllclHoll.. neep and fender lhe spine sllsceptiblc to
FOCUSING ON FUNCTION
lkxioll ()\'crlo~~d dming liflil1g.:~ According to McGill. a brief
I..'\lUrs~ of CXh:lbion exercises hcforc lining may prc\Icnt Functional restoration gels to the heart of a recurrent disorder
injury. ~.: more effectivcly than searching for the technique to "fix." the
CO-""olllr,K'tion of thc lumbar erector spin;lc muscles dur- problem. Pain relief is enough of a goal for many first-time.
ing lifting app;;;lr... 10 redistribulc compressivc forces 011 the pain patients. When pain is recurrent or chronic, however. or
spine by adding guide }\'ires In a nexible rod. like rigging on lhe individual is at high risk for a chronic. disabling condi·
a ship's masl.:: The i;lCrcasc in compressive loading on the tion. enabling the patient to focus on function becomcs a high
spine is slI,!"lstmnial if even a small :Jmoullt of IOrsion is re- priority for the Ireating physician. \Vc should help the pmient
quired during lirting. 22 To prc\'~nt injury. objects should nOl to understand that a more fit back is less likely to become in-
he lifted if they \\'ere awkw"lrdly placed. To reduce the exten- jured; whatever the cause of their pain (disk, facet. myofas-
sor J1l0Il\elH. the load should he held as close as possible and cial, etc.). they will be marc stable if function is restored. In
lifted smoothly.:: :\ jerk lift is only appropriate for highly fact, 80% of the time. an exact cause cannot be identified. but
trained illdividu;ll~ who must lift light. awkwardly placed ob- clusters of functional changes can .,ddrcs~ their symptoms.))
jects. The purpose of this lift is to avoid loading the spine in A deconditioned individual has lWO options for achieving
flexion for any longer tl};;lll is abs.olutcly nccessary.~~ Table lasting pain relief. First. they can avoid all strenuous activi-
10.3 !'llllllllarizes current advice about lifting. ties. Second. they can increase their functional capacity (Fig.
10.l). These options arc really the only means available to
Ergonomi<:: Factors prevent spinal problems. Either the load is reduced or the ca-
pacily to handle that load is increased. Convincing a patient
One of the JllO~t delelerious activities people engage in is sit-
to reduce external strain is optimal, because once they change
(ing. Erect sitting ill\'olves disk pressures significantly higher
their workstation or learn better biomechanics. they have that
than th.it of normal standing, Sitting slumped forward (ante·
knowledge forever. If. however. only limited reductions in ex-
riar sitting) increases disk pressure cven morc. and the great-
ternal strain arc possible. improving their intrinsic functional
est increase in pressure is associated with slumping back-
capacity or performance is the only remaining option.
wards (posterior sitting),:!"~s Using a lumbar support or back
Exercise is always more difficult (0 accomplish than educ:J-
rest reduces disk prcssurcs.~l A scat-backrest angle of 95-
tion because of problems associatcd with motivation and
105° reduces both erector spinae EMG activit)' and disk
compliance.
{""\ prcssure.~'u"
'\..;7
The chair ~C<tt ~hould provide a stable base and yet not be
!Oo constraining. 'I The height of the chair is imponant. A scat PATIENT MOTIVATION
~~)
height that is lOa low places too much slrain on the ischi:JI
Achieving compliance in patients asked lo shure rcsponsibil-
C} tuberosities, Too high a sc..ll increases pressure on the thighs,
Chairs lacking variable height adjustments m.lY necd to be
ity for management of their pain rests on convincing them
that body mechanics and functional improvement arc essen-
"""
\,j
complen1t::nted by <L footrest. The scat edge should not touch
tial for long·tenn success, No amount of persuasion is ade-
the popliteal fossa: this situation leads to too rigid a sitting
, posture. A slighl dcpression for the buttocks is beneficial for
quate. however. unless their fears and anxicties arc also ad-
'OJ
()
I slability. A concave seat increases weight bearing through the
greater trochamcrs <lnd intcrnally rotates the femur. again re-
dressed. Most chronic patients fear that aClivity will cause
them more pain. Explaining the difference between hun and

i
harnl will help considerably (sec Chaptcr 2).
stricting movement of the legs. Seal angle is controvcrsial. nl-
•...
\'..J'
" though it is apparc'llt th,H a forward sloping scat increases
Exercises that stretch stiff, shonencd tissues may in fact
cause pain or discomfon but are not injurious, In facl. pa-
lumbar lordosis during sitting and maintains the erect siuing
(\ tients will learn how to stretch safely and to feel a comfort-
'-v position.
able "good hurt." Also, strengthening exercises arc best
Table 10.3. McGill's Rules for Lifting'12 performed in a pain-less range, with pain only felt (he fol-
lowing day (sec Chapter 14). This postexercise soreness
Ma[ntah normal lordosis should involve only the lrained muscles and not be felt
00 nollill immediately alter prolonged flexion or rising from bed
Lightly co·contract the back and abdominal muscles before and in any symptomatic spinal or postural arcas, Occasion>tlly.
during lilting "McKenzie" exercises CJ:lllse some discomfort, but this pain
Keep Ihe load as close as possible as long as lordosis is maintained should be local. These exercises arc avoided if any radiating
Avoid twisting
pain is perceived, Learning that they can control their symp-

www.bodywork.su
168 REHABILITATION OF THE SPINE: A PRACTITIONER'S MANUAL

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.
"c 9. Webs!cr ns, Snook SH: 111c COSI of 1989 Workers' COlll(lCnsation low
,
'"E Injury hac\: p;,in claim!'. Spine 19: 1111. 199·t

"n'";
c
10. Troup JOG: The perception of Olu~uloskclctill pain and incapacity for
work: Prc\'cntion and carly IrC:Il111ent. Physiother.lpy 74:435,.1988.
~x II. Nordin M: Early findings of NIOSH-CDC model back clinic reveal sur-
W prising 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
Non-injury 54:353. 1993.
1-1. Lindsaom A. Ohlund C. Eck C. et 31: The effcci of gl"3ded activity on pa-
lientlO with subacule low back pain.. Phys Ther 72:279, 1992. )
15. Saal JA, Saal JS: Nonoperative trcatment of lumbar herniated disc with
Functional capacity I"3diculopalhy. Spine 14:431, 1989.
16. Bush K, Cowan N. Katz DE, el al: The natural hislOry of sciatica associ-
Fig. 10.1. Relationship between external demand and functional att.-d wilh disc pathology: A prospccth'e study with clinical and indepcn-
capacity. dc-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 me 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
toms becomes a liberating experience for 1110st patients. As the Study of the Lumbar Spine. Philadelphia. WB Saund.:,:;. ! ')90,
slated previously, the rehabilitation specialist should teach pa- p213.
tients how to control their symptoms and not promise to 20. Sato H. Ohashi J. Owanga K. et m: Endurance time and f.3tiguc in st<llic
"cure" or "fix" the problem. contractions.. J Hum Ergol (Tokyo) 3:147.1984.
21. G<lrg A. Herrin G: Stoop or sqU:lt: A biomcchanical and metabolic e"nl-
Patients need to know the exact goals of exercise. For in- ualion. Am lost Indus Eng Trans II :293, 1979.
stance, a goal might be to strengthen the "big muscles" (i.e., 22. McGill SM, Norman RW: Low back biomechanics in industry: The "J
abdominals. glulcals. and quadriceps) to take strain orf the prevention of injury through Nlfer Iifting_ In Grabiner M (cd): Cur·
lumbar spine. \Vhen proper goal setting is aCl:omplishcd and rent Issues in Biomechanics. Ch..mpaigll. IL. Human Kinelics. i' J
those goals are mutually acceptable. patient adherence and 1993.

compliance 3fC easier to achieve. If excessive fear and an-

23.. Adams MA. Hutton We: Mechanics of the inter...enebral disc. In P )
Ghosh (cd): The Biology of lhe Intervertehral Disc. Boca R.3lon, FL.
xiety persist. then referral to a pain psychologist may be eRe Press, 1988. pp 39-71. ~
needed. A psychologist may be able to teach better coping 24. Hickey OS, Hukins OWL: ~c1aljon belween the structure of lhe annulus .~

strategic!' or relaxation techniques and can uncover hidden fibrosis and the function and failure of the inte","ertebral disc:. Spine
obstacles, such as drug or ~llcohol dependency. job dissalis- 5: 106. 1980. ;
25. Adams MA. Dolan P. I-Iutton we: Dirum<tl \';Iriations in the stresses on
f"ellan. or family stress, ..)
the lumbar spine. Spine 12:130. 1987.
26. McGill SM, Brown S: Creep response of the lumbar spine to prolonged
.'
fiexi()n. C1in Biomech 7:43. 1992.
27. Amkrsson GB. Murphy RW. Onengren R. el al: 111c inllucm·(.· of J
hack rest inclination and lumbar support on lumbar lordosis. Spine -1:52,
REFERENCES !979.
I. Aenn RT. W('I('Id PH: Pain in the back: An aucmpt to eSlim;l\e the ~izc of 28. Andersson GS, Jonssoll B, Onengren R: Myoelectric activity in individ-
the problem. Rhl:umalol Kclwbil 14: 121. 1975. Ilal lumbar ereclor spinae muscles in silting. A study Wilh surface and
2. Horal J: The clinical appc:ar'Lncc of tow back p;lin disordcrs in the city of wire electrodes. Scand J Rehabil Mcd J(suppl):19, 1974.
GOIhcnourg. SWc...d cn. Acta Onhop Scand Suppl 18: I, 1969. 29. SChuldl K, Ekhnlm J, Hanus.Ringdahl K. el al: Effects of ch:lnge~ in Silo
3. Ruwc ML: Low back pain in industry. J Occup Mcd II: 161. 1969. ling work poslure on static neck and shoulder muscle aClivity.
)
4. Bcrqui!'t-Ullman M. L..l rsson U: Acute low hack pOlin in industf)·. Acta Ergonomics 29:1 525. 1986.
Orthop Scand Suppl ; 70: I, 1977. 30. Andersson GS, Onengrcll R. Nachemson AL. c.( al: The sitting poslUrc:
S. Haldcman S, Chapman· Smith D, Petersen 01\·1: Frequency and uurOltion An clcctrornyographic :lnd discomelric swdy. Dnhop Clin Nonh Am
of care. In Guidelincs for Chiropractic Quality Assurance and Practicc 6:105.1975.
Parameters. Gaithcrsbag, Aspen. 1993, pp 115. 130. 31. Oniz D, Smilh R: Ergonomic Considerations. In Basmajian JV, "'yb...-rg
6. SpilT.cr WO, Lc Blanc roE, Dupuis M. et al: Scientific approach to the as- R (cds): Rational Manu"j TIlempies. B;I\timore, Williams & Wilkins.
~!'i!'men{ .ll1d 1lI0lnagement of activity-related spinal di~orde",: A lllono- 1993, pp 441-450.
www.bodywork.su

".-
...... 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 sim-
ple 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 move-
Fig. 10A.1. Spinal column (side view). (From Basmajian JV:
ments. such as sitting or bending and twisling. This advice typically
Primary Anatomy. 8th Ed. Baltimore, Williams & Wilkins. 1982.)
consists of prescribing limited activities and the usc of pain-relicv-
ing methods (i££, hCal. uh~d. electrical muse;..:: stimulation. ma-
nipulation. massage. tmction. etc.). A support may be given and bed drome. which is resulting in pressure on a nerve. a diagnosis will be
rest recommended. but this regimen is used fOf the minimwn time madc and appropriale treatment will be initiatcd.
possible to decrease the danger of dcconditioning (becoming execs- Thc sccond goal of care is to get yOll aClive agilin. This process is
sivel)' weak or stifn. called rcmobiliz.ation. which is accomplished by reli.lxing tense 1ll1lS·
Perhaps most important is the reassuranc:;c thal you will receive C$S ',ocl loosening stiff joints. Gmdllillly and safely. you will be in:
that ),our condition has been evaluated thoroughly and that you do creasing the activitics you perform with Icss and less fear of reinjury.
11m h<lvc ally scriolls medic'll conditions. If you do havc a disk SYI\- Stretching and light cardiovascul:lr exercises. along with nmniplll:l-

Table 10A.1. Stages of Care

SliJgcS: Stabilization Remobilization Reconditioning

Goals: Pain RcliCJ. Reassurance. Proteclion Acslore Mobilily Improve Strenglh and FleKibility

Treatment Find relief positions Manipulation Strengthen ~big muscles" (abds. buttocks.
Strategies: Limited bed rest Stretching thighs)
Supportslbraces Ergonomic advice (i.e .• how to sit) Stretch postural areas (calves, back)
Physical agents (ice. heat, ultrasound, Cardiovascular exercise Biomechanical advice (i.e .. how to tift)
electrical muscle stimulation. etc.)
Manual therapy (manipulation. mas-
sage. traction)
Analgesics or anti-inflammatories

www.bodywork.su
 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
\1
)~
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.... Unless addrcs~cd, this condition
--- ~~. ~. '"",=---
prcdisposc~ yOll to future rccllm::nccs. You willlc.arn a combination
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.
Ii
The stages of C,Ire arc shO\\ n ill Table 10A.I.
Nucleus
WIIlII.DO('J tll(' Spine L(/ok Like? pulposus
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 thai serves as a shock absorber betwecn
each vertebrae. It has <.I lough criss-crossing network of liga- Fig. 10A.3. The disk. (From Basmajian JV: Primary Anatomy.
ments (;.mnulus fibrosis) famling a prolective ring around its gel~ 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' NERVES

Fig. 10A.4. Relationship 01 the disk and spinal nerve roots.

t
~
Fig. 10A.2. Lumbar vertebral joints. (From Basmajian JV:
Primary Anatomy. 8th Ed. Ballimore, Williams & Wilkins, 1982.)
(From Kirkaldy·Wiliis WH: Managemenl of Low Back Pain. 3rd
Ed. New York, Churchill Livingstone, 1994.)
www.bodywork.su
I"l .--,
.~

~
I
.L
----------------------------
 .... , 1r'\1 1 ~n IV: t"AlltN I eDUCATION 171

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 rcprcscn-
,, latiuns of pain referred from certain key muscles.
~~ I Joints and lig;,unclIls arc also able to cause local and refcrrcd TP,
:~
(somc distance from its origin) pain. Figures IOA.14 and IOA.15
1, show typical refcrred pain pauems from irritated vertebral facct
,, joint!' in the ccrvical and lumbar spines, respectively.
t)
i The most famou!' culprit of severe pain is the "herniated disk"
•
,I ' ; <'~ 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
I~ () i bulge or ~ssibly [car, causing gel (nucleus pulposus) to herniale inlo

!• {) II lhe area containing lhe spinal ncrycs (Fig. IDA. I?), A bulge is com-
Illon ,md oftcn does not cause pain. Hcmiatio~s Ciln pinch on nerves

,
§

~
II
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
Fig. 10A.6. Referred pain from the upper trapezius muscle.
•
~ -,
actually causing your symptom,s.
(From Travel! JG. Simons DG: Myofascial Pain and Dysfunction:
The Trigger Point Manual. Vol. 1. Baltimore. Williams & Wilkins.

I
" .,~ Another structuml problem occurs when arthritic spurs (dcgener A

1983,)
j ,Hive joint disease) jut out from lhe. vertebral. joints and either pinch
q i

,
1 nerves (stenosis) or restrict our normal mobility. Here too. it is con ' -
Whor COli I Da?
man for degener.ttive joint changes to occur in the spine and be pain-
q !,
'~ less. In f:lct, arthritis increases with age. as docs graying of the hilir Back and neck p,lin are interwoven into our lives, They arc normal
I ,md wrinkling or'thc s~in. yet back pain peaks between ages 28 ilod yet unpleasant experiences that. if mismanaged. can become chroni-
50 years. cally disabling. In the past. docto~ believed bed rest. pain relievers.
!

I,
and perhaps somc physicallherapy (hC'l1. ultrasound. etc.) were all
<)! that was needed to lide someone over until the problem receded.
r~-,.
I, Most of lhe time, such an approach succeeded in alleviating the pain.

'--'I, But. <llltoo often (up to 20% of the time), it failed. According to re-
cent independent. gO\'ernlllent studies from Canadil. lhe United
..~ ~
:1:
, Slates. and Great Britain concerning the back pain problem, eonsen~

II ~:
'-,
"} l
sus has emerged that this poor rcpon card is largely rcl~lled to the
ovcrprcscription of bcd rest and medical ion ,lI1d l~lilur~ to focus care
on quickly restoring funcliOlwl integrity to your muscles and joints.
,~"
"I =
What is the solution? Today. we know that manipulation (i.e .. chi-
ropractic adjustments) is the most effective trCillmcnt for quick pain

°1"}I '"
i
relief. TIle Rand Corporation. British Low Baek Pain Guidelines.
~llId the U.S. Agellcy for He,llth Care Policy and Rcse,lrch have con-
cluded that Illilnipulation is olle of till..: Illost cffective (onns of early
intervention for back pain. Milnipuhuion in combination with ~~r~
D' cisc :md simple educ<llion have proven to be far superior to tmdi-
tional prcscripliOl\s of prolong~c;..d_U:ji1Jlm!.I!Lc..ill£illion.
0 When you are in pain. the first rule of pain relief is 10 avoid :Iddi-
tiona I strain. Figures IOA.IS .1Ild IOA.19. show the different
() arnOUfllS of muscular effort required to slabilize different postures.

I! You should minimize assuming strenuous postures all the time, bu[
they should be avoided completely when you are suffering an acute
cpisode.
I If we <lrc involved in high risk 'lctivitics. such as repetitive lifting
i
>, Fig,10A.5. Dangerous bending and twisting position. or prolonged .~itling. it is impnrl:liit tn learn how 10 modify 0111'
~
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172 REHABILITATION OF THE SPINE: A PRACTITIONER'S MANUAL

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.)

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 CUUL;AIIUN 173
.
.......... 'LoI' IV. rMllt:I't'
.'.....
,:

• 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

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174 REHABILITATION OF THE SPINE: A PRACTITIONER'S MANUAL

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.)

~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.)

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 175

.t I
/~\ .
.,
!
j ~

I j
II
1 (')
~
I ", ..
\, "J
I
I .....,
,"~

Ii n ,~ /
1
,f,, ""
,j

1;

1l ,)
,,
~
~ Fig. 10A.13. Referred pain from the gluteus minimu5 muscle. Fig.l0A.14. Referred pain from the cervical spine joints. (From
I (From Travel! JG. Simons DG: Myofascial Pain and Dysfunction: Dwyer A. April C. Bogduk N: Cervical zygapophyseal joint pain
~
I ~
") The Trigger Point Manual. Vol. 2. Battimore, Williams & Wilkins, patterns: A study in normal volunteers. Spine 15:453, 1990.)
1992.)
~ (}
~

I, ':)

.~
~
I () v
~ v
< v
"'2" "
"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.)

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§ ~'-.':.
~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
l
~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\'-

I
j
~ Jf I .~

i
i
I
I
1
Fig. 10A.16. Referred pain from an irritated or "pinched~ sciatic
nerve root. (From Cox JM: Low Back Pain: Mechanism. Fig. 10A.17. Herniated disk. (From Kirkaldy-Willis WH:
~ Diagnosis, and Treatment. 5th Ed. Baltimore. Williams & Wilkins, Management of Low Back Pain. 2nd Ed. Edinburgh. Churchill
~ 1990_) Livingstone, 1992.)
i
!
ij
~
jJ;

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I;
i
"I;i 200 Ibs. Pressure 150 Ibs. Pressure 100 Ibs. Pressure

I ~
~
..J

I 55 Ibs. Pressure
i~
t
11

iI 200 Ibs, Pressure 100 lbs. Pressure

25 Ibs. Pressure

Fig. 10A.18, Effects of posture on lumbar disk pressure. (Adapted from Dutro S and Wheeler L: Pregnancy and exercise. In White A,
,
!

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Anderson R (eds): Conservative Management of Low Back Pain. Baltimore, Williams & Wilkins. 1991.)

~
,1--------------------------
~ _________~L~·
;;;
~'

.",

I
 ·. . . . ~., • .., . • ,..,.,,-,,,. CVUI",M.llVN 177

m.:.; tlpri1;ht puslur..... The n:sulting forward drawn or slumped pos-

lur~' 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-
-~ lilm.'· which willmo\"y-you hack in the right direclion. A good rule
Z r •
,, (\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
1)(
C\-r.:~ 20 milltlles as a way of "fine tuning" our posture until it il11-
2)(
() pro\'6 :Iulomalic;l,lIy. Aftcr just a few months. our new posture wilt
3X 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
-rolling your shoulders back and down-··
-----_._
-llallcning your low back against a chair or wall
..
compressive forces on the lower neck increase by the additional
weight of the entire head. (From CurIO: Head Pain. Baltimore. -tucking your chin in whilc ),ou glidc your head backward
Williams and Wilkins, 1994.)

111... ~iuillg poslure IS fatiguing because of the pressure it places

c 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 impor-
t'-tnt thing to remember about sitting is to keep the low back str..light
or '-lightly <Irched. This po~hro'llTili~vTir'p·rc~ci;lu·s··trom siurnp-
ing.thus preventing both lower back .md neck slr.lin (Fig. IOA.22).
Drh j'ng or sitting in :I car is onc of the situations cncounter~lmost
fr~qu~ntly. The best way to sit in :1 C,I( i.s witl12.~~.~~~.,!~~_cll
wpponcd and lhe seal back Slightly reclincd. The seat should be
at ;I height such that your hi;~';-r~levcr\vith or slightl)~ highcr
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<lrd. As
we grow. our spinc extends ill both our lower back ,uld neck. which
allows us to look stmight ahc:ad. walk upright. :ll1d usc our hands.
Unfortunately. modem occup'\lions and lifestyles. by overusing the
sitting position in C;Jrs. while C:;\ling. w;Jtching tclevision. :lnd work-
ing al desks and computer workslations. have imbalanced ollr nor· Fig. 10A.22. Poor driving posture.

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 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.

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,
.~

'."

----_._------- ._----
 179
,I \,.,M1'\1"" I t:.H lU : t"Allt:N I t:UUCATION

I
1, c
,,
:<,

l
L l
A B
Fig. 1OA.27. Improper sitting posture (a) and proper silting posture for reducing finger, wrist. elbow, shoulder, neck, and back
strain (b).

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<l~ily fmigllcd and IxCOIllC strained. M:Il'y hc,Jdaches, neck. shl)ul-
der. arm, and shoulder blade pains result from this posture. A simple

Table 10A.2. WorR"station Ergonomic Checklist

Chair ~- YIN
-seat height adjustable

A
I
Fig. 10A.28. Proper head/neck posture (a) and slumping and
B
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
Ihe dowager's hump (b). 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
When typing or imputing Oll'a computer keyhoard. your hands relaxed (not shrugged)
should rest on the keyboard without your wrists bent, your elbows Other ~
"""DOCument holder
should be bent ~ll a right ang.le (90"). and your shoulders should be
Head set
completely relaxed (not shmgged) O\g. IOA.27), Table IOA.2 is a

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 180 H~n""OlL.. 1 , ,'U,'1 u r I n..:; v, IU'-. '"' , , ' " I ."-',~ ,_

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Fig. 10A.29.
(
Postural exercise lor round shoulders and head forward posture.

I exercise can be performed frequefHly throughout the day for just 2() you will need n larger pillow than someone with narrower shoulder.s.

I
lO 30 seconds C"lCh time {(l pre\'cl\I Ihese ill effects of the ~ Finally. it is important to placc your pillow betwcen your neck and
pmaurc. As shown in r:i,gUfl.' 10.-\.29. you can roll your shoulders shoulder. not under your shoulder.
~~k Jnd down (by squeal"!! \"Our shoulder blades together), rotale Lifting is probably Ihe area of greatest concern for all back doc-
your hands outward, and 1\lck your chin. This same exercise can also lars. The mOSI import,mt rule is 10 "keep your back straighl."
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
abdomen.
Your posture for sleeping is abo impoftanl. The ideal sleep pos-
ture 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 ac-
commodating both wilhout distoning Ihe position of your neck is the
key. Sometimes. a bohlcr or spcci<ll onhopedic pillow is helpful to
fill in this space. If you ;lH: a side sleeper and have broad shoulders. Fig.10A.30. Fetal position.
www.bodywork.su
 CHAPTER 10: PATIENT EDUCATION 181

Fig. 10A.31. Sleeping with a pillow between

the knees.

Fig. 10A.32. Sleeping with a pillow under

the knees.

()

C)
A

I - Fig.10A.34. Proper lifting technique from the ground.

\
c
- 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
Fig. 10A.33. a, healthy neck/pillow relationship; b, too small of a
of straight Table lOA.:; slllllrnarizes the key components of proper
pillow; c. too large of a pillow.
lifting lechnique.
Reaching for things above shoulder h:vd is another strenuous ac-
Second, .\Void twisting when you lift. The combination of bending tivity for your back. Usc of a fOOL stool is an excellent w.IY tl) rl.'ducc
and twisting I!> the death knell for yOllr lumbar disks. It is also im- the strain (Fig. IOA.361. If a stool is un;l\"ailablc. then a trid;. is to
porlant to try 10 lift objects as dose to your chest as possible; the far- tighten your abdominal and buttocks llluscks so you flath.'ll your
ther the object is from you. tile greater is its "mass," Another reccnt hack (Fig. lOA.}?). This maneuver will pr~vellt the tcndency \() :-tiek
disto\,cl)' documents Ihal the back is especially vulnerable immcdi· out your buttocks and ovcnlreb your back.
ately after sitting for a prolonged period (just 15 minutes will do it) Carrying suitcases. groceries. or a baby ;lrc all chalJ~n~C':, for a
or .1her;'1 night's sleep. Remember 10 usc good lifting habits. espe- person with a bad back.. When p;'lcking. for ;1 vacation. it is Ixttcr to
cially 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 espe- Table 10A.3. Proper Lifting Technique
cially difficult bec::Iusc they obviously do not sit still like boxes do. lift with your back straight
Nonetheless. because we will do lots of bending and lifting if we Never bend and twist while lilting
have kids. the sooner we learn to do it rig.ll1. the less likely we arc Keep lhe object as close to your chest as possible
KJ:>J:>["Ithings that need to be moved at waist level whenever possible
to have recurrences of disabling back pain. Pigure IOA.34 shows

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---------------------._----------_.
182 REHABILITATION OF THE SPINE: A PRACTITIONER'S MANUAL

,,

) Fig. 10A.35. Improper lifting

A B technique from the ground.

.,,

,
..f

/
I
B .J
L
Fig.10A.37. a, Incorrect overhead reaching with back hyperex-
Fig. 10A.36. Use of a stool for overhead activities. tended; b, Correct overhead reaching with back flal.

j
pack (wo smaller suitcase!' Ihan one oversized one; you can thell baby c~c (0 you, you arc less likely 10 injure your b:'lck (Fig.
h;llancc the loads and .\Void straining your back (Fig.. IOA.38). IOA.40).
Avuid carrying a bahy or any other object with outstretched ;arms. Pushing and pulling can be yet ,mother source of lumbar str'lin.
By holding the \\'cighl close 10 your chest. you greatly reduce Given a choice between the (wn. pu:,hin!; is preferred bcc;ltIsc lhe
the pnlenlial sIr-lin (Fig. IOA.39). This :'Idvicc is particularly legs can be used more effectively (Fig. IOA.4I). When huying. a
impOJ1ilnt when pUlling a baby in a car scat. By holding the carriage lor your baby, try 10 find one that is lilted 10 your heigh!.
www.bodywork.su
 CHAPTER 10 : PATIENT EDUCATION 183

Heat is generally avoided in the acute stage because it can <lclUally

im:rease swellinr: or infl,unm:uion in the back. Anti-inflanlJ11illorics
may be helpful for the first few days to reduce the swelling quickly.
Your chiropractor or other specialist may fit you for .1 lumbar br.lcc
;lnd give you sp.:cilic therapeutic exercises to try. Some of the safest
exercises arc simple strctches or lumbar extension excrcisc~ (Figs..
lOA.47 t() IOA.50). Walking l1l<Jy also be suggested. Gcntle lreat-
ments may bc applied thai will also speed the process ;tlong. As soon
as your ",cute pain bcgins to case. morc aggressivc conscf\,;lIi\,c
treatmcnts will follow Ihat will gct your back functioning again as:
quickly as possible.
In order for your back to cillm down. you must Ie am ways to per-
form normal activities without placing any unduc strain on the back.
Sitting should be minimizcd and sometimes ;Ivoided altogether. The

()

() A 8

Fig. 10A.38. a, Too heavy a suitcase; b, Balanced carrying.

If you arc rull. the carriage will need longer amlS (Fig. IOA.42). In
0' 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.
A
cUHing vcgetables. folding laundry. and brushing your lccth arc just B
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 some-
times possible to bend your knees <md lean them against the cup-
bOilrd (Fig. IOA.45).

Pi nil aiel for (lll (lell/c' ('pisoc/(' of bad pain

One of those acute. disabling e~odcs of back pain Cim easily pro-
voke 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
Fig. 10A.39. a, Incorrect carrying of
not mushroom imo a severe. disabling episode. Try to reduce ,lilY
a baby with outstretched arms: b,
source of c~tcmal sWlin on your back. Assuming proper rest posi. Incorrect carrying of an object with
tions is of vital importance. L}'ing~ your b,!S=k wi_tiLy.ou(.kQe_e~b£nt outstretched arms; b. Incorrect carry·
CJ js...one...oL1h~clief" p2.ili.i.ons for the spine (Fig. IOA.46) in thaI ing 01 an objecl wilh outstre.tched
it r@ces pressure on the di~~~.'.l.l1d r~t;!'~~lUh£_~~~i;~tNii~iyTng
o ie~__ ~2 minutes four to six times per day normally is a~"i~;lb'::J
arms; C, Corre!;t carrying of.. an object
held close to the chest.

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 184 REHABILITATION OF THE SPINE: A PRACTITIONER'S MANUAL

danger comes when leaning forward over the sink. In this situa-
tion. it is pruden! 10 bend your knees or usc a foot stool so that

I
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.

II
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 sim- ."1
ple 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
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 nourishes all the tissues of the spine and increases Oc:x.ibility <Hld
stiffest then. but also~r disks arc swollen from not bcine com- strength. When recovering from an acute episode of pain. exercises ." )

pr~scd by gr.1\'ilY. Getting Out of bed safely by avoiding doing a actually h~lp the tissues to heal faster. Unfortunately Do! all exer.
sit-up is absolutely crucial. It is best to get up on our side and try cises arc appropria,,' (or lb.- bjlck jlD.(tw:d>...s.nm.Ul\CJsi:i,~.sJh~ ac- ')
to avoid twisting or bending at the waist (Fig. lOA.5I). The next tually..caD.....CMus.c.llaffil are as follows:

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Fig. 10A.41. a, Unsafe

B pulling; b, Safe pushing.

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 ,-,nl"\'" I t:H lV: t-'AllcN I EDUCATION 185

4- Lat Pull Downs. A great exercise. but not the way it is com-
monly pcrfoml~d. You should nO( have to crane your head for-
ward 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<? f~cus on improving the func-
tion 0f.y<?urJ>a.c1. Reconditioning involving stretching and strength-
ening is CVC!)' bil as important as learning how to sit or lift. Beforc

c 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~ .:xer-
cises commonly performed today. 11,e four mas! l.:(}n~tnon er-
rors 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
.} A 8 commonly include the foilowing:
Fig. 10A.42. at Stroller arms of proper height: b, Slumping be- t. Hypcrcxlcnding the low back
,} cause stroller arms are too low. -sitting leg extensions
-hamstring curls
-Iat puB downs
\ Toe touches. TIley stretch the back and hamstrings simultaneously. -supine f1ys
which is too dangerous (Fig. IOA.~4). -()vcrhcad press
2 Sit-ups. Never come up alllhc way because the disk pressure is (00 -lunges
) high. Also. they can be bad for the neck if you pullan your neck -squats
as
or. poke your chin rorwar~ you come up (Fig. IOA.55). -trunk curls on an incline board*
J! 3 Hamstring curls. The tendcncy is 10 o\'erarc:h (hypcrextcnd) the lum- -sit-up)
bar spine during this excrcisc (Fig". IOA.56)." -Roman Chair
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A ( Fig. 10A.43. a, Changing stalion height

too low: b, Correct changing station
height.

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 186 REHABILITATION OF THE ::;I-'INt:: A PRACTITIUNt:.H"::; MANUAL

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Fig. 10A.44. a, Typical ironing posilion; b, Use of a footslool to Fig.l0A.45. a. Brushing teeth with both knees bent; b, Use of a
reduce a low back strain. footstool to reduce low back strain.

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B Fig.10A.46. Back relief positions.

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Fig. 10A.47. Back extension "sphinx exer·

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cise.

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; ..... n1'\t'" I eM IV: t'J\IICN I t:.UU\,;AI"ION 187
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Fig. 10A,48. Single and double knee(s) to chest exercise.
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-cxcrci~c bicycle
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",~~ -hmmtrillg :-;tn.:tchcs (toe touch or on floor)
-stiff-legged di:,ld lift*'
t) -bent forward rowing*
''') 3. I-Ic;ld forward po~aurc' with chin puked fon.. .md
.J -sit-ups
{'t -stairll1:1stcr
'iJdJ Fig. 10A.50. Prayer stretch.
-exercise bicyck
~ -l:It pull downs
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-pllsh-ups
-st;lirclimbcr 4. '-liking or shnlgging of lhe shoulders
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-push~u\ls -rowing m;lchinc
" 2. Slumping at the w"isl -hem o\'er rows
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·~sitling leg extellsiolls -latcf.11 arm raises
-sitling chest press -overhead press
() -push·ups
-stairdimbcr
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Fig. 10A.51. Technique for gelling out or in

bed with a bad back,

A
Fig. 10A.52. Sale back options for putting on pants, socks. elC.
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chair.

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Fig. 10A.54. Dangerous toe touches.

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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 fur-
tha 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 tn-
w;lnllh...: L·;lt·...

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[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:'. The long-term solution illvol\'e~
learning h'lw to rcum:..: strain lIlld improve poswn.::. Tht: advice
yuu rel."..:i\"t._· from your rch,.bilitation spcei~llist and that is indudc:d
Fig.10A.55. Improper sil-Up. ill Ihis handuut b llcsigncd [0 help you (0 hdp yOllrself. Back

t[ ...,"1 Fig. 10A.56. Harmful ham-

string (back 01 thigh) exercise.

These ftlUr cardinal error.> elll (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:x-
tcn~_ A g~nllc cQ·contr.Klillll of ~ (lUI' abdolllin:tl!'o <llld your hUltocb.
is usu~llly sufficicllI to is(lIlH:-irtc:illy hold your spIne 111 a st~ll;lc posi'--
-:----- - -------------_._-----------_.-
tloopr !~!~_o-,h~!!~l}-'l!:,Y.~lf 1.'-~XQ<;.i2.!:'~.i!~_I11Cnlioncdc all hc pc!::
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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!'. -------- -------
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When your hC<ld is forw<.lrd of y{IUr tor:o;o. it is vulnerable 10 in-
jury. Thi:;: position fatigul.:s your neck Illllscies and place:- the eer- ,)
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 ver-
tebrae \11' tbc fled (<l11;Is). It .d~v creatcs a "~lIillotinc"-likc effect
between the tr;lll~ili{lll or the 10\\1.:1" p;trt (If your neck and the up-
per pan of )'uur thoradc spine. By silllply making slife YllU <Ire
not slumping ;tt your w,li:-t and kl.:epiu!; yuur shouldcr~ hack t{l
prevcllt them from rolling forward. your head POSilicllI will oftell cor-
rect itself.
Excessive shoulder :o;hrugl;illg j ... a COIIUlHll1 probkm. EJtHltinnal
tension kads to shoulder ;lIld neck tension. which results ill "hav-
ing-;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::,;~.

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 191

\11' fwd, p;till ;Iri:-l':- frlHIl l'XPO~\ll\" In mCCh:lllic;ll slr.lin Ihal I\lay abll lIc.:lI to sian a lhcrapclltic stretching and strenglh-
~r;tdtl;dl~ :tl·..:tlllllll;lll·... yuur lifetimc. If you karn
Ihrl1u;;holll eniftg program. Learning how 10 perform typical .t\.:tivitics of
ttl ~il. li(l, hend. l·"n~. :llld :-kep ~lll;lficr. tile likdihlll1d Ilf di~­ d;lil~ life without incn.:asing strain, and also training mus-
,:tHl1(WI ;llld ri:'l~ uf ,\'.injll1')' is fl..'duccd. If yOIl 1l;ln.' d.:cou- ck~ In he lll11n: fit. will enable yOll 10 control your symp-
diti,llll:J :I' ;\ I"o::-ult ,If kadil\;; :l "'l:,kllwry lift::~ayk Ilf frlllll fe· hllllS ;1IIt! pre\'ellt the likelihood of lIlore seriolls problems in the
:-It'il'lill~ ~t'llr :ll"tl,iti\.', ;1:- ;, cOllsequence of pain. thell ynll fUlUro.: .

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 IV
FUNCTIONAL RESTORATION

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 11 Role of Manipulation in Spinal Rehabilitation
.KAREL LEWIT

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!, Rchabilit.nion is dcfined :.IS the restoration of function in thc also true of othcr methods o!" what may be called "relk.\ ther-
!I ,.. motor systcm. This definition implics rec..:upt::ration of Jctivc apy:' e.g.. acupuncture or local anesthcsi~l. Sudl iUHI".cdiate
~
I, 7 voluntary motion. To place emphasis on activc exercisc effects would hardly be possible if the underlying !.;;.I\lSI,;" Wl;rc
j is therefore justified (0 achieve normal active control of a pathologic change of structure that requires hc..:alill~ and
~ movement. Structures that move passivcly, howevcr, such as could not be reversed immediately. This concept is casily UIl-

I, ')
joims. li,g.llllcnts. fasciac. and tcndons. frequently playa key
rolc in this recovery. and passive tn:a(mcnt of these struCturcs
derstood. however. if the existence or real it)' of c..:hant!.es in
function is recognized. For stnlclUre ill the living org<:ln~slll ill
i C,IIl be effective. c\·en for severe muscle spasm. In fact. the general. and in the locomotor system in particular. b no mort:
•! ') usc of pnssivc manipulative therapy by a qualiflcd individual real than is function:'musclcs in spasm (with TrP). incapabk

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may enable <:1 patient to c..:arry out .lctive motion. whereas
omitting thesc methods would result in frustrmion and loss
of time.
of lengthening; restricted joints (perhaps because of lllcnis-
coid entrapment and/or spasm): and short muscles or r;'lsciac
rcquiring stretching (shifting):-iC'
Manipulative treatment is an important factor in the An examplc of an even l1lor~ elementary situation is'ten-
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restoration of passi\·c motion. particularly now thal up-to-date sion ano muscle pain thai Jccompanics an uncomfortable pn-

I techniques affect not only joillls but <llso the soft tissues. in
p.t:nieular fasciae. <I~ wei; as muscles in spasm and with trig-
silion: discomfon improves imlllediately with a change of po-
sition..l-;\s observcd by Brugger. if ,I person sitting in a
I '. ) g,er points (TrP). Many of these techniques also make lISC of round-shouldered position is examincd. the l1luscles of the
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thc paticnt's muscles and therefore may be considered scmi· shouloer !!.irdk.. 'Irms. and even of thc IC2s arc tcnse an.d~n­

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acth·c. Such methods are perhaps a link between passive and
active trealll1cnt. I - J
Evcn more important is the diagnostic v'llue of thc tcch-
niques dcscribed by professionals who use manipulmion for
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 sUll-
ics. but relicf has been obwincd.

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Ihe assessment of changes or lesions in [he tis!'lues and .,truc-
tures that constitute the locomotor syqcm. These 'Isscssment
techniques are useful not only for joints. but ,llso for soft tis-
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 prob-
~ "J sues. including muscles <HId fasciac. No less important is the
• contribution of these professionals to the diagnosis or dislUr- lem'. In il1lcnml medicine. some changes in function ;'lpp:lr~
J, .J bances in spinal stalics (e.g.. short leg. poor posture)...:,r• ently arc accepted. e.g.. cardia(; arrhythmia or ~ndocrine dysw
function. but such acceptancc remains an inSUrtllOUllWblc
t~ obst<tclc in the motor system. where funclion is p"ramount.
)\ iv ) CHANGES IN FUNCTION
~ Anatomic verification at <:IlHOpsy has become the obsession.

iR ,) The condition affecting the motor system that most often re-
quires treatment. including rchabiliwtion. is not the obviolls
as though physiology was or little import'IIKc. it being, in-
deed. unvcriliable post mortclll. I therefore like to lise a sim-

i"s ;J loss of 1110tor (;ontrol or motor function. bUI poil/. also termed ple example from engineering.

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lIIyofa.\'Ci(/f /W;// (i\'1 p). Use of (his descriptive term seems jus- If an ,1lJ(olllobilc stops fUllLtioning. the L·'H1Se ITwy be a
oj
tified in so far as thi!'l pain. whatever its tlll~ origin, is ex- broken cylinder or b..tllbcaring. Alternatively. the problem
~ pressed or felt mainly in Illuscles and their attachment points. lllay result from maladjusted combustion or ignition. In the
;
cl\ .~" ) Despite its enormous incidence, this 'lfIlictioll is poorly un- lirst case. therc is ~ross pathology. BCGllI!'lc a machine cannot
11 'J
• derstood: flO pathologic structur<ll changes have so far been heal. we must repl'lce the damaged p'lrt. In [he SC(;OIH.I case.
~ d conlirmed as relevant. and it is the secret hope of many the ~tructure is intact. we have only 10 adjust the ignition or
~
r~searchcrs thal discovery of such changes i~ just round the c..:ombustion (i.c .. jlmerioll) and the m;H.:hine pt.~rforms again,
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"':i, corner. An importall\ warning is appropriate ill this point: just as
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, One of the features of mallipulation ~lI1d other techniqucs
u.....:d to treat MP is that they :lct inullcdi'ltdy. This feature is
it lllOly take l:qual effor( to adjust" complicated engine as to
eh.mgc SOIllC sparc pans. trcaltllclH of changes in locol1\otor
~
.:. 195

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 196 REHABILITATION OF THE SPINE: A PRACTITIONER'S MANUAL

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 ."--''h
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the sitc of pain is usually losl." This fundamental change in
approach threatens the c1inici'l1l with the loss of firm ground: I
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in fnee Ill.my who .In: involved in treating dysfunction tend 10 . }
;lpply these methods (e.g .. manipulation) mainly to the ! ')
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painful area and not In the.: re.:al source of dysfunction.
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Fig. 11.1. Brugger's relief (lordotic) posHion. Chain Reaction in Functional Pathology
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~ Experience has shown lhal changes in function follow' cert<lin
I function is sometimc!' quite involved. Unfortunately, physiol- pmtcms; <lS .1 rule. if we lind one change. there is <lnulher
"'~-< ogy is no less complicmcd than anatomy. As, however, connected wilh it, i.e .. we ubservc CCr1:.1in chain r('([c:films.
?
-:: changes of function arc by definition reversible. treating func- At first, this observation \V.IS purely the outcome uf clinical
tional pathology of the locomotor system is a rewarding chal~ expcrience. On closer scrutiny. however. it W.IS possible to
Icngc. show that these chain reactions fo\l(w/ certain rulcs that
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.The ra~[ that some changes ill function are imm~d.iatcly correspond to the ba.,ic funclions of lhe locomotor sys~
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revcrsible provides a rational explanation for some "miraclc tem:"\ (I) gait. invoh'ing mainly the lower eXlrClllities and ,")
~ cures" after treatmCnl by manipulation and other "rencx ther· the pelvis with the lumhar spine: (2) body stalics. involving
,~ apy" methods. Unl.<munately. locomotor dysfunction has ll1<1inly the trunk :.md neck: (3) respiration. involving mainly
f rCllmincd a medic",1 no man's hmd.lost belwccn such special- (11(' thof<lx; (4) prchen ...ion. involving In<linly Ihe upper ex~
i ties as rheumatology. onhopedics. ncurology. and rehabil- tremitics. the shoulder girdle. :.md Ihc neck: and (5) food in~
i
-~ itation medicine. In \'icw of its importance. a clear distinction take, involving mainly the nrofacial system and Ihe ncck. Th.:-
iJ bctween structural and ··functional" pathology (dysfunction) llrst of these l:hains i... presenled with a detailed cOlllmcntary.
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is fundamcnral. for di~gnosis and managemellt as well as for
c1assificalion. It can be compared only {() the distinction be~
thc rest in Tables 11.1 10 11.,'l Ihat the rcader \\fill undersland
by analogy.

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tween Iwrdwarc and ~oftwarc. These ch:lins not only illustmte a different :lppro.1Ch in
If we accept c1wngcs in function as relcvant in MP, then the dhlgnosis of Wh'lt we l'all function;]1 pathology of tilt:' :,1
;£ we should be able to explain why and how dysfunction can motor system. hut .t1"o :Lrc important in therapy. The point i~
f; truly cause it. This explanation seems relatively easy: what- to determine the mo\,( r('{('l'Oll! link in the t:hain and (0
b
ever the type of dysfunction we trcat-a muscular TrP, a rc~ choosc the most approprhlte mcthod of trealmcnt. When suc-
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strictcd joint. a change in soft tissucs, or altered body statics cessful, treating the key link should improvc Ihe l:hain as a
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or movement patterns. we invariably meet increased tension. whole.
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~
In fact, impaired function of the motor systel~l is associated The cau:-;c of di:-.turbed futll'tioll is frequelltly in the motor

I~ 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
systcm itself: it may. howcver. lic outside. in parti<.:ular ill the
viscera. triggering charactcristic patterns or ch;lins.
The chains prcscllled in Ihe tables do not c1ailllto be eom~
,•••
~
strenuous work, the common JCl1omin:uor is increased ten-
sion (strain).
plele, constant. or lixcd. In Olddition. renex ch~lI1gcs in the skin
and (if chronic) changes in !",\sciac and pcrioslcal p'lin POillh
I The link between strain and pain should be rCi.ldily under~ must be considered. but their indusion in the tahles would

,
~-
-f stand able. Pain is. in lhe first place, a warning sign of im~ make them too invoh'cd to he USci'll!' It is W0l1h nOling. ho\\'~
~ pending danger and. in the locomotor systcm. is an indicator e\fer. that these chuin... ;\fl.~ char.lc(eristic;t1ly formed on one
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I of the need 10 proH.:ct 'lgainst overstrain. The role of pain in sidc of thc body.

:t
i1

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 ..... nl"\,... I en II : NULt: ut" MANIPULATION IN SPINAL REHABILITATION 197

Table 11.1. Galt: Stance Phase and Swing Phase- Table 11.4. Upper Extremity tJrehension

Stance Phase Extension

1. Increased tension: Toe and plantar llexors. triceps surae. 1. Increased tension: Finger and wrist extensors. thenar.
glutei, piriformis. levator ani. ereclor supinators and biceps, deltoideus,
spinae supra and infraspinalus. upper lixa-
2. Tender attachment Calcaneus (plantar aponeurosis and tors 01 shoulder blade. interscapular
points (referred pain): Achilles tendon), fibular head (bi· muscles
ceps femoris). ischial tuberosity 2. Tender attachment Proc. styloideus radii and latera! epi·
(hamstrings). coccyx (gluteus max· points (points 01 condyle. attachment points 01 supra-
, lmus. le....ator a;;:), mnc crest (glu·
teus medius. lumbar erecior
referred ~<l;i:l}: and infraspinatus, attachment poinls
01 levalor scapulae. and spinolls
iI spinae), greater trochanter (gluteus process of C2 (referred pain)
medius, piriformis), and spinous 3. Joint dysfunction Elbow, acromioclavicular joint, mid-
processes L4·S1 (erector spinae). (blockage): cervical spine, cervicothoracic junc-

Ii
3. Joint dysfunction Midloot joints. ankle. tibiolibular join!, lion. upper ribs
(blockage): sacroiliac joint, low lumbar spine
Flexion
Swing Phase·lIexion and internal rotation 1. Increased tension: Finger and wrist flexors, pronators
1!
1. Increased tension: Extensors of the loes and foot, tibialis ,subscapularis and pectoralis. sler-
anterior, hip flexors, adductors, recti nocleidomastoids scaleni
abdominous. Ihoracolumbar erector 2. Tender atlachment Medial epicondyle. medial end of clav-
spinae (upper extensors) points (points 01 icle. sternocostal junction, Erb's

I
2. Tender attachment Pes anserinus (adductors), patellae referred pain): point. transverse process 01 alias
() points (referred (rectus femoris, tensor fasciae 3. Joint dyslunction Carpal bones (carpaUunnel syn-
pain): lata e), minor trochanter, symphysis (blockage): drome). elbow, glenohumeral joint,

~ 3. Joint dysfunction
(upper and lateral aspect), xiphoid
Knee, hip. sacroiliac joint, upper lum·
cervicothoracic and cralliocervical
junctions

Il
i
,, (blockage): bar spine and thoracolumbar junc-
tion, (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
Table 11.5. Head and Neck: Food Intake, Mastication,
and Speech
i functional sequence 01 muscles to become involved. Group 2 lists attachment
points (or relerred pain) olthc above muscles that are likely to become tender
I 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
1. Increased tension: Masticatory muscles. digastricus. ster-
nocleidomastoids. short extensors of
craniocervical junction. trapezius and
muscles. their dysfunction is lhe result of changed static and dynamic lunction
levator scapulae, deep neck flexors,
as a result of (mainly) muscular dysfunclion.
pectorales
2. Tender attachment Hyoid. posterior atlas arch and trans-
() points (points 01 verse processes. spinous process

Table 11.2, 8~S referred pain): of C2. linea nuchae, medial end of col-
lar bone. upper margin of scapula.
and angle 01 upper ribs
Tension in muscle parts 3. Joint dysfunction Temporomandibular joint, craniocervical
Sternocleidomastoid: short craniocervical extensors (blockage): junction. cervicothoracic junction,

Ii 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)
upper ribs

I Posterior atlas arch. transverse process of atlas, spinous process

of C2. linea nuchae, medial aspect of collar bone, upper and Structural Versus Functional Pathology

i
vertebral margin of scapula, xiphoid. symphysis, lowest ribs.
ilia~ crests . . A short survey of the main chamctcristics of dysfunction as
Joint dysfunction (blockage) cOl11rastcd with structurill pathology may bc useful to demon-
Cranioc:ervical.junction, cervicothoracic junction, upper ribs, thora·
strate (he fundamclltal differencc in approach.
columbar junction. !umb.osacraJ anp sacroiliac: junction
I. The step is to decide whether the probkm de·
first
scrib.cdby Ihe patient results I1winly from dy~rul1t'­
Table 11.3. Lifting the Thorax at Respiration (Typical lion or from structural puthology.
Respiratory Oysfunclion) 2. A strucwrallesion frequcntly c<lusesdysfunction (hat
then produces the clinical manifestations; on the
1. Increased tension: Upper section of abdominal muscles.
pectorales. scaleni, sternocleidomas· other hand. dysfunction by itself Ill;',y cause clinical
toids, short extensors of craniocervi- manifestations.
cal junction. levator and Irapezius 3. The reversibility of dysfunction makes immcdiate
2. Tender allachment Posterior atlas arch and transverse pro·
point (referred pain): cess, spinous process of C2, linea cure a possibility. whereas structural pathologic
nuchae, medial end of clavicle. upper change requires hcaiing.
margin 01 scapula. sternocostal june· 4. The aim of structural diagnosis is to IOC:'lliz~ :.mtl dc~
lion (referred from scaleni) and upper
ribs termine th(: nature of the lesion: in dysfunclion. it is
3. Joint dyslunclion Craniocervical junction. cervicolhoracic csscmial to illvcstig;'l!c correlations and interplay. i.c.,
(blockage): junction. upper ribs, thoracic spine the chain n::''1l:tiollS.
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 S. Structural diagnosi~ aims at the organ at fault, func- ity of soft tissue structures one against the other: skin against
tional diagnosis at tht.~..J.).rgi1!Jj~ a whole. muscle, musck:s and fasciae against bone, not forgetting the
6. In cases of Jysfunc!ion. structural diagnosis gives important task of movcment palpation in joints and mobile
ncgalivc results. whereas with functional diagnosis. segments of the spinal column. In this effort. we use not only
we typically lind lllMe than we expcct from the pa- our sense of touch but also proprioception.
ti~nt's history. One of the most degam methods of diagnosing superficial
7. Tile aim of therapy of pathologic change involving a hyperalgesic zones (HAZ) is skin drag: we move ovcr thc
structure is hcaling or excision; in dysfunction. it is 10 skin, and in areas with more moisture (s\vcat). resistance
treat the rclcvant link of the chain'. (dr::~) is in~rcascd. Most ~nlethods have-(}Jlc thing in
S. In slructural pathology. modern technology plays an common: during palpation, we move our fingcrs or hands.
evcr-increasing role. whereas in functional pathology, The diagnosis of a TrP. which is discussed in anothcr
clinical methods rcmair} unchallenged. section. has another important feature, which is more pro-
9.. 1n structural pathology. the relationship betwccn nounced in this case yet common to other methods of palpa-
. cause and effect is unambiguous. whereas in dys- tion: provoking a twitch response, i.c.. we establish ill-
function. cause and effect arc frequently interchange- teractioll 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 "comple- providing a we?lth of information and at the same ti~lC ProM
mentary" medic inc arc relcvant mainly in disturbance viding the basis for effective therapy. This relatiomhip devel M
of function. ops when_ applying all typ~s of massage, and the good thera-
pist. whether consciously or not, profits by this feedback,
DIAGNOSTIC UTILITY OF PALPATION AND sensing the refjction o(the patient's tissues and correcting his
THE BARRIER PHENOMENON or her moves accordingly.
As statcd previously. dysfunction causes increased tension in
various structures (tisslles) of thc motor system. and this ten·
Barrier Phenomenon
sion relatcs to pain. The main tool in the diagnosis of changes To make both palpatory diagnosis and treatment more etIee-
in tension is palpation. Palpation is an art that was once im- tive and better understood. we must be <l\l,'are of the barrier
pOl1ant in medicin_e. T02ether-·,-,viih--inspection-'andausculta- phenomenon. It seems to be common to most ~trllctures and
lion. wa-slhcbasis of clinical medicinc; regrettab-Iy. it is tissues of the motor system, and thus plays a key rolc in ma-
nmv Iargcly neglected. For this rcason. it is necessary to gjve nipulative therapy. It was first described by ostcopaths in
a concise analysis of palpation in relation to manipulation. 1-t-1I joints. but it is relevant wherever manipulation is applied. Il'
Moving a joint from a neutral position involvcs flrst a
Palpation range of motionin\~hic,hresistanc~i~, ~ll,ifor!~~ar~(,Lt.lt;gljgU5le.
The flrst step is to apply our fingers to the body surface and to
As \ve ~lP~p~.ro;lch the-end'(j(t-ilc-·r:i;lge-. ·hO\~'~\'c·r. we mcct rc-
sistanc~. which gradually incrcases. The moment rcsistance
conccntrate 011 what we want to investigate: resistance to
starts to increase~ i.c., whcn wc meet the slightcst resistance.
prcssure. temperature. moisture. smoothness or roughness of
we have reached the barrier. In other \I,-'o[(.\s: thc sooner we
skin. and tissue mobility. If we intcnd to proceed from one tis-
sense the barrier. for diagnosis as \vcll as for therapy. the bet-
suc layer to the next. we never simply increase the pressurc.
ter our sense of palp~ltion and our techniquc. It follows that
but shifl our attention and apply small movements, i.e., we
the normal barrier is soft and resilient and can be easily
ch<!ngt;Jl 9_th intensity and dircct,i~n ?.r_prcssu~e, u_sing dis,crecl,
il!otion (Fig, 11.2). We may want to palpate' the 'sll~ipc '01' a sprung. On the other band, a palhologic or rcstrictive barrier
struciurc:-thc transition of muscle to tendon. or where the ten~ is one that is n~et too soon and feels abrupt (Fig., 11.3). In the
diagram in Figure 11.3, we sce that the anatomic barricr is
dOll is allachcd. Thcn. we want to palpate the relative mobil~
nevcr rcached under normal conditions: thc ·ptlYsiologic bar-
ricr corrcsponds to the normal rangc of movcment. The patho·
logic barrier signifles movement restriction. The neulral point
(N) may shift to the normal side (N I ). if there is such a patho-

Barrier

A Ph Path N~ N, Ph A

CI?~~~r-~-'--------,.
Fig. 11.3. Barrier phenomenon: anatomic, physiologic, and patho-
Fig. 11.2. Palpation. logic barriers.
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 CHAPTER 11 : ROLE OF MANIPULATION IN SPINAL REHABILITATION 199

Fig. 11.4. Palpatory changes pre-

and posHrealment.

logic barrier. Barriers arc found not only in joints. hut also in soft ti~:,ut: techniques. symllletry is readily reswrcd. :llld yet·
tissues that call be stretched or shifted against each other. r'ldiographic cX<llllination shows 11(,1 chang.e has ul."~·lIrred. If.
However useful the barrier phenomenon may be for di .. g~ howc\'t:r. the radiographic image includes the palpming lin·
nosis and trcallncnt. it also has an important protective func- gers. it i:, clear Ihat the position of the lingcr~ ha~ changed
tion. This role is Illost obvious in joints: resistance increases (rig. IIA). Hence, lhe chunge lli.~s occurred in the ~ort tissucs
before full range is reached; however fast we may stretch our or "media" through which the bony landmarks wl,,'r(' palp;:llcd.
"rm: the antagonist SlOpS the movement in lime to prc\'cnt This obs.ervation provides evidence that Illost '·adjustments"
damage. Other protective mechanisms come into rlay \.. . hcn noted by chiropr'lctors or osteopaths after manipulation to re-
we stretch connective tissue or cause shifting between diffcr- store '·:-ymmctl)':' as indeed they sen~e. me in the :,oft li~sucs.
em tissue layers. e.g., fascia against bone. The stretch renex is because joint renligllmcnt is not cvidelll radiogr<.lphicall)'.'·'
part of this protective mechanism. rvkaningful research in palpation hns rarely been under-
To usc the barrier phenomenon for diagnosis and trem- wkcn. in PLirt because of the complexily or Ihe task.
ment of pain and dysfunction. take the following steps. By en- Interpersonal reliability studies have so far been frustrating.
gaging the barrier (taking up the slack). wc determine the because no one person knows exactly whnt the olher i~ doing.
range of movement (shift or stretch) and recognize the loca- Ncverthdess. palpation yields invaluable inform~\tion that is
tion and quality of the barrier. After engaging the (pathologic) essential for diagnosis and thcr;'lpy. in the same W~l~· the blind
barrier. we wait: after a few seconds, the barrier "gives" and rely on the inform'llion gained from p;.dpation all through life
myofascial releasc is obtaincd. Release may last from a few (Figs. 11.5 and 11.6VI'.~'"
seconds to half a minute (or even more); this release must be
sensed. making sure we havc normalized the barrier. i.e.. nor- DlAG:\OSIS AND TREATMENT OF
malized tcnsion and thereby obtained relief of pain. As shown SOH TISSUE LESIONS
subsequently in discussion of specific techniques. this release
In a simple outline of the IllOst useful techniques. lhc bmricr
is as true for joint mobilization or muscle rclax~tlion as for
phenomenon offers the most useful basis. The simpk~{ model
skin stretch or shifting fasciae or subperiosteal tissues. using
with \\ hich to stan invol\'es the soft tissues, lk'~il111il1g with
the bmTier phcnomenon as common denominator.
the skin.
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 ob-
wined 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 COI1-
siantly moving, changing both intensity and direction. mean-
ingful 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 Fig. 11.5. ~Low·tech" medicine.

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L _.'-'.-_._-_ ..---- - _ ... ---------

 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 bar-
rier without increasing stretch. the barrier gives after a hllcncy
I 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
I,
~
nonnal barricr (like on the normal side) and skin drag is re-
stored to nom1al. This reaction is found regularly: if there is
an underlying cause of the HAZ. it soon recurs.
!
I Connective Tissue (Fig. 11.8)
,\
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 bar-
Fig. 11.6. "High-tech" medicine. rier 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)

~' J
Hyperalgesic skin zones (HAZ) arc found most convcnicmly J
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 Fig. 11.6. Palpation 01 connective tissue changes. j
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1
I '_,';

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 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.

, Pressure (Fig. 11.9)

l
Even if pressure is used. it is most important (0 eng~lgc the Fig. 11.11. Stretching (shilling) the dorsal fascia over the shoul-
barrier with a minimum of force: after waiting for a few sec- der blade.
onds. the finger will sponwncously sink deeper into the tissue.
This method is most effective in muscles with superficial TrP.
Sitc:s of restricted fascial mobility also occur on the chest
where it can replace postisomctric rel~xatiC?1! (PIR). \Vllen the
finger sinks into th"cnluscle:"it
-will'-reach the nonnal barrier
(charactc:rislically in mastodynia): on the buuocks. frequently
in a cranial direction: in the groin: around the elbow and knee;
after approximately 10 to 30 seconds. but if the direction of
and around the ankles .lIld wrists. In addition. some structures
pressure is slightly changed. funher release may be obtained.
bcha\·c like fascia: the scalp should move easily in all direc-
Such change in direction is important in large muscles. e.g..
tions in rdation to the skull. Restriction in any direction is fre-
the gluteus maximus.
qucnlly linked with headache, and treatment mcthods that fol-
low 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 pa-
When using this import<1nt technique. the most chamcteristic tients with headache and/or vcrtigo. Another such structure is
finding is thaLmusc!cs (or all the soft tissues) on one side do the SOfl tissue pad at lhe heel. which should shift easily in all
not ~.Jlli.S_asily on th~ underlying bone ~s those on the directions on the calcaneal bone. Rcstriclion is characteristic
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.
painful sidc. A "tight and loose complex," i.e.. one sidc is rc· and resistance to this shift is characteristically incr~ased in
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 cau- is 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 re-
the 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 seg-
muscle fibers. frce mobility of f'lscia is essential for norm<ll ment. This fmding. too. can be di<1gnostic and can be treated
muscle and joint function. It is in chronic pain patients that with skin stretch accordingly.
mobility of fascia is frequently impaired; in such cases. joint
(spinal) mobility is as a rule restored by moving the fascia. It
Shifting Periosteal Tissue
also follows that unless we restore normal mobility of the fas-
cia. muscle and joint dysfunction wiII recur. This principle is Restrictive barricrs arc also found at painful pcriosteal points.
particularly important in fasciae that arc cornman ta a great By palpating such Icnder points. we can shift the s.urrounding
number of Illuscles. like the lumbodorsal. tissues close to the bone and compare mobility with 'hat of

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202

A B

c o

E F

G H
Fig. 11.12. Stretching (shiiting) the cervical fascia,
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 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·.
1
1 Unlike pcri\l~[l..'alll1assa~1.'or "deep fr;l·tion:· Ill!,.',\,.' sofllis.'lh.'

~,
IcdUliqul.'s arc gentle: pressure is lIot dircdl·d 10 the p;lin
point. but l"allll'l' t<lllgl.'ntially Ill\WCS thL' pl.·ri\l"ll'allissllL' ;I\\';l~
from (he p\lilll of pOlin. P;linful SpillOll.'" pnH:l':'o'''''S ill tile hUll-
hal' spill\'" off\-'" a ,good cx;nnpk. They an: palpah:d ill lIIidlinl..':
lltlwevcr, il" 1hL' palpating lingL'r l11tl\"L'S sidc\\;l~ S. \\'1..' lind Ihal
only one sid\..' of the spinolls prnl.:css is n.·ally lender. 011 Ih:1t
side. We l11eel resistallce if we try to eXert del'fl pressure par-
;llIcl to Ihe spinous proceSS. AI this poinl. Ihe sl:u..:k is takcn up
,
".--">.
} and release follows. pnxlucillg relic!'.

Soft Tissue Syndromes

Two "soft ti~suc syndromes" arc or
grcat practic<l1 impor-
[;.mcc. The lirst goes h;md ill hand with;1I1 ;.lpp<.lrCll( shin :11 the
o pubic symphysis ,Iud the ischial tuberosity. caused by in-
crcascd tension (TrP) of the straight abdomin.i1 muscles and
their .1It:1chmcnl at the symphysis. and in the £lute;'11 muscles.
causing restriction of (he cranial shift of the buttocks on one
or both sides. Typic'llly_ the most prominent sign is a forw:.trd-
drawn poslllrc. which may be noted at lhe pcl\"is in rdation !O
the feet. at the shoulder girdle in relation to the pelvis. <lnd
with the head thrust forw<lrd when looking at an object al eye
\) levcl. We then also lind increascd tension in the back museu-
latun.~ with the patient sumding. as well as in the neck lIlU:--
() des. Tension in the neck (and b:'lck) muscles .,ubsides. ho\\"-
evcr. when thc patient is sC:'lted. If we engage lhe b;:uTicr by
shifting (he bUllocks (111. glutei maxi mil in a crani<ll direction
Fig. 11.13. ForNard·drawn posture (left); after soft tissue treat-
nnd then obwin rclc:.lsc. or if we usc pressure \\"hcn~ we sen~\.'
ment (right).
hypcrtollus in the buttocks and obtain release. we normalize
mobility at the bUllocks ;'IS well as lcnsion in lhe abdomin;tl
muscles and at the ..utachmcnt points :'It the symphysis. and
symmetry is restored. The luberosities then appear symmetric Both these :;.yndromcs affcct most of thc postural muscu-
on palpation. The forward-drawn position also disappear" lature. and lherefore symptoms may arise in any pan of thc
and. therefore. tension in the neck and back muscles reverts (0 motor system. including headache with restriction in the cran-
normal. However striking this effect Ill'l)' be. the condition iocervic;.11 junction. and even tension in the masticatory IlllIS-
) tends to recur if tlK~ abdomilliJl and gluteal muscles arc wcak des. back<lche. and p:.Iin in lhe arc" of lhe coccyx. Sacroiliac
(Fig. 11.13) (sec Chapter 14)."\1.1 involvemcnt I~ pica II)' is not part of these syndromes. but it
(J The second soft tissue syndrome. dcscribed by may occur. The pathologic barrier al the sacrotuberous liga-
Silverstolpe and Helsing.'\I.·\~ can be detected because ofa ten- mcnt is probiJbly attributablc to a TrP in the Ill. coccygeus.
o der TrP in the midthor;:lCic region. more frequently on the left
side. On mechanical stimulation. this TrP causes a twitch re-
I'OSTISO~IETRIC RELAXATION (I'IR) IN THE TREAT-
o sponse in Iht.: low lumbar arC;'1 of the spinal ereclor ,md may
even cause contraction of the hamstrings. producing sharp
",iENT OF MCSCLE SI'ASM (TRi'J'-'-'·'-·"
dorsillcxion. Typical findings include a lender point III the lat· Postisolllctric relaxation produces rclc:.Jse in Illuscles in
eral gluteill arca at the height of the upper end of the inler- spasm. the moq frequent type of spasm in myofascial pain
gluteal fold and all c"cn morc tcnder point at the s<lcrotllhcr- (MP) being the Irigger point (TrP). This technique w~s intro-
ous ligament. When the indcx linger reaches this puint duced by Mitchell for joint mobilization. and it is in its
(slighlly vcntral and craniao on the latcral edge of the tip of essence a type of son tissue rnanipul<Hion. Just as in the tech-
thc sm;rllrn). rcsi~tancc is mcl. After taking up the shick. we niques described prcviously. the lirst step of PIR is to cng:.lgc
oblain rc1c<lsc after a latency of scvcral seconds. Both the Trl' the barrier by lengthening the muscle to the point at which the
in the thor:'H':ic spinal erector spinilc and lhe lateral gluteal ten- first. slight rC3iswnce is met. After this point. however. the pa-
der point (TcP) arc gone. ticnt is wId to exert slight resistance in the opposite dir('ction.

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 ~U4 REHABILITATION OF THE SPINE: A PRACTITIONER'S MANUAL
,

holding it isometrically for about 10 seconds. followed by the sought alll.! illclllilied. C1illl,:;i1ly. thl:)' m;lllifest thL'l1l.. . dn.~ . . hy
order to relax. (lct go). After a few seconds (wailing at the h<lr- referred pain. which call ~ far from its SOlin.:..::. and il is im-
rier), release takes place and the muscle lengthens (dccol1~ portant to know the sitcs (,f pain referral. Palpation ll.:('ht\iqtl~
tracts) for anything from a few seconds to half a minute. must also he mastcred. L' "ually. slight hypenolllls is no Led

i
Clearly, a subtle, yet important differcnce exists in the mcdl~ ;lhon.: a muscular Trl'. hut it is frequCl1lly so di . . creet ;IS 10
anism of release in PIR rdati \Ie {O olher techniques of IIl~Ulip­ avoid tktcl.:tion ;lIItl'di;lglllhi,. By making the lllu:,de harhor-
ulation: whereas connective tissue must be' pas!'iin:ly ing a TrP slip 1I1H..!L'r our lill~as. howc\"L'r. we prodlH':c a fL';lC-
1 stretched during rclca:-e. ~llthnl1gh wilh lillie force. muscle de.,;. lion in precisely those 1i~. ·. rs thai arc perceived as ;1 ""tau!
Ij conLrilction is an llct;I'e process. just as is muscle cOlllraclioll. band'" The rrP lies within Ihis band. and at this point. we
and is only monitored by the therapist. "You cannot relax the should be able lO evoke refared pain and the twitch reactio[\
t. patient's muscles for him, he has to do it himself." The mo- (Fig. 11.15). Interestingly. the mOTe superficial a TrP, perhaps
{

ii
ment the therapist tries to stretch the musclc, the patient pro- in the forearm or the erector spinae. where the pmient is Illore
duces the stretch reflex, which is counterproductive. If PIR is likely to be aware of it. the better he or she tolerates exami-
not satisfactory at the first attempt, we repeat the procedure nntion. The hidden TrP. such <IS in the m. psoas or sllhst.:apll-
(from the barrier reached after the first auempt) and prolong laris. arc most painful on palpation or when merely touched.
I: the isomclric phase. in its b'lsic fofln. as ju~t described. PIR has some serious
:~ Post isometric relaxation is highly specific. tlnd it is im- drawbacks. Many patients. even when. instructed. have diffi-

I
portant during the isometric phase to contract precisely those culty putting up minimal resistance only and show their C<l-
muscle fibers that are in spa!im. especially fal1~shapcd mus- gcrncss to cooperate by a display of strength. Other~ have dif-
cles such as the pectoralis major. It is also essential to usc'- ficlIlty rclaxing. although prolonging the isometric phase to
minimum force, because we then increase the likelihood of 20 seconds and more prO\'cs effective. Finally. many practi-
,;
I stimulating selectively those fibers with a low threshold of tioners find it difficult to distinguish the patient's relaxalion
~ stimulation. Le., those harboring TrP. Relaxation of the mus- from "gentle stretch,"

I
cles brings aboUl relief not ani)' of the painful TrP, but also of
the painful attachment point. as well as regions of referred
Using Eye Mo\'cmcnl'i, Respiratory Synkinesis. and
pain (Fig. 11.1.4).'·

I
Gra\'it), with PIR
As stated for the techniques described so far, accurate di-
agnosis is essential to the success of PIR. In some types of For these reasons. combining the lise of PIR with other "neu-
muscle spasm or cramps. the diagnosis may be obvious. Some romuscular techniques" ha, improved our results and is par-
TrP. however, may be excessively painful on palpation and ticularly of value in promoting self-treatment. The Iirst such
yet are not felt spontaneously by the patient; these must be combination is with eye movements. If the patient looks to the

I ,
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~
,
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I
I~
I .. ~
p

¥
It
I
~ Fig. 11.14. Post isometric relaxation of
J
~
wrist extensors (left); self-PIR of the
ii wrist extensors (right).

I1-----------·-.--------.- ----
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1 >. CHAPTER 11 : ROLE OF MANIPULATION IN SPINAL REHABILITATION 205
I and to inhal~_Whil.e_§looping, This principle is equally lrue for
side bending, and even during backbending. maximum exha-
lation is required to obtain synkinetic contraction of the tho-
racic 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 re-
verse 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 but-
tocks 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 pa-
tient'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 in-
halation. In contrast. the digastricus and mylohyoideus are fa-
cilitated 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 re-
{) sistance at inhalation and relaxation at exhalation-when the
thumb sinks toward the midline-witham exerting prcs-
sure(!) (Figs. 11.2010 11.22).
Fig. 11.15. Palpalion of a trigger point by identifying the taut Respiratory synkinesis is <1lso noted in regard to eye
band. (Fmm Travel! JG. Simons OG: Myolascial Pain and Dys-
D function: The Trigger Point Manual. Baltimore, Williams & Wilkins,
movement: looking up is coupled with breathing in and look-
ing down with breathing out. This correlation i~ c;J,sily ex-
1963. p 61.)
:,) plained. because under natural conditions. looking up is fol-
lowed by straighlening up (the body follows Ihl: eyes). and
looking down by stooping. In fact. it is diffkult to exhale
right. he or she facilitates rotator muscles th<ll can be resisted while looking up and to inhale while gazing downward.
during (he isometric phase: if the patient looks in the opposite Therefore. combining looking up with inhabtion (double
direction. Ihese muscles will relax. If he or she looks up. the facilitation) would be effective for lreatment. whcrc;J,s com-
muscles in the ba<..:k and neck contract and can be resisted; bining looking down with inhalation would be counterpro-
when looking down. they will rclax (Fig. 11.16). Here. too. duclive.
Ihe pmicnt must lir:·a sense the b~lrricr.J7 Whenever possible. Ihe force of gravity i~ u:-;cd for both
Respiration plays an import:',"t role in PIR. inhalation isometric resistance and relaxation. Gmvity is lI:-;~d for rcsis-
having a fncililalivc and exhalation an inhibitory effect, par- lance when the pmient isometrically contr'lets tht:' muscle h'lr-
ticularly as it affects structures in the head, neck, and trunk boring a TrP, and again for assistance as the patient relaxes the
and less so the extremities. The effect of respiration is partic- tense muscle. According (a Zbojan. when gravity·induccd re-
ularly evident in rcspiratol}' synkinesis. This term dcscribes laxation is used alone, the contraction and relax:ltion ph.lscs
when movcmcnt in onc dircction is coupled with inhalation, should each last for at least 20 secondsYlf thi~ tt:'chnique is
whereas movement in the oppositc direction is coupled with combined with respiration. however. the timing of contraction
exhalation. As an example. straightening up is linked with in- and relaxation should coincide with that of tht:' rcspir.<.\wry
hal.ltioll whereas bending down is linked witlfexhalation, in- phase. Therefore. respiration must be slow. The patient is told
deed because it is difficult to exhale while straightening up- to hold his or her brealh after inhalation and. if necessary.

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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 .,,,
'..7
relaxation phase (right).

Fig. 11.18. Isometric manual traclion 01 the pelvis.

Fig. 11.17. PIA 01 the thoracic erector spinae using respiralory Fig. 11.19. PIR traclion of the cervical spine using respiration ,
'.J-.
synkinesis. www.bodywork.su
only.
CHAPTER" : ROLE OF MANIPULATION IN SPINAL REHABILITATION 207

Fig. 11.20. PIR ollhe scalenes.

even after exhalation. Gravity-induced PJR lends itself natu-

rally 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 Fig. 11.21, PIA of the maslicatory muscles; self· PIA of the ma5~
physiologic stimuli. making the entire procedure automatic. ticalory muscles.
so the paliem <.:an apply treatment 'even morc than once
a day.
However adval1lagcous ,lOd effective the combination of rehlXCs (sec Fig, 11.28). In both c;IS~~. looking up f;h:ilil~ltCS
methods m;ty be. it requires careful thinking'to identify the inhalation. which in turn racilit::lte~ the muscles in yucstiOll
mOl-a dfecti\"c method ;.md to avoid incompatible or useless and lifts the head and straightens the- trunk. The fon.'l.~ 1...... ( grav-
combinations. An ideal combination to obtuin relaxation of ity is adcqu~te for r~siSlimcc and for obtaining rcka:,l.' during
the stcrnoclcidom;.\stoid (also sclf-Illobilii'.lltioll of occiput! relaxmion.
atlas) follm\.'s. The patient is supine. with the hcad rotated Wheneq:r the combination of eye movemcnt <llld rt.'spinl-
over tile end of lhe table acting .1$ a fulcrum. The patient is in· tion is lIsed. the eyes should be direl.'teo lirsl. In thi:, way. the
structed w look ww,ud the forehead i.lnd to breathe in: at II direction of muscle pull is de(cnllill~d ;lI1d lhc-fc :,lh\ulu be
cCr(<lin singe of inhillalion. lhe sternocleidomastoid contracts. timc for th~ isometric ami the rL'iaxatiol1 phases. t-!l..\ldil1g lhe
slightly lining thc hcud. \Vhen the p'ltieot looks down (toward brc~lth is helpful for the same reastl!l.
lhe chin) and bremhes out. the Illuscle relaxes and the head is An illuSlration of how to .\Void mistakes in l"llllli:'inalioll
lowered (scc r-ig. 11.27). Another example is gravity-induced involves the upper trapezius 1ll1lSI.:!C. The head is fir:'! side-
PIR of the m. quadratus lumborum. The pnticnt stands with bent away from the involved muscle to take up the :,Lh.:k. The
legs apart and leans to the opposite side until the slack has patient is then instructed to look Illw;lrtlthc affccted :o:.ide and
been taken lip. The patient then looks up and breathes in to breathe in (sec Fig. 11.29) whik' the operator rcsi:,(:, his or
slowly uOlillhc quadratus lumborum automatically contracts. her automatic attcmpt to cxen pressure tow<lrd till.' ;lfkctcd
slightly straightcning Ihe trunk. The patienllhcn holds his or side. During the rckixatiofl phase. h(lWCvef. the thefari:'t must
her breath. looks down, and slowly breathes out: during ex· not tell the patient 10 look to the l)thcr side. bccml:,c the re-
hill at ion, side bending increases automatically while he or she sponse \\'ould be (0 rotate the head and no rehlxati('n \.If Ihe

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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 (ji ihc lJpper irapel.ius

l.sing gravity.

Fig. 11.24. Sell-PIA of t!1e infrtlsplnalus using

gravity.
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 CHAPTER 11 : ROLE OF MANIPULATION IN SPINAL REHABILITATION 209

Fig. 11.25. Self·PIA of the subscapularis us-

ing gravity..

()
o Fig. 11.26. Self-PIA of the piriformis using
gravity.

tnlpczius would occur. Therefore. the correct command for by relaxation for at leas.t an additiOlml 20 se<.:onds (sec
the relaxation phase is: "let go ;lIld breathe OUl.'· Figs. 11.23 to 11.26).
For l1lobiliz;uioll in the ccrvicOlhoracic or thoracic region
inlO side bending. the operator instnlcts the pmicnl to look lip
.JOl:\T \IOBILIZATION (MANIPULATION
and to breathe in (after ttlking up the slack into side bending).
WITHOUT THRUSTING)
followed by "hold your breath" and then "relax and breathe
our.'· The oakr to look down would make the patient bend Joint mobiliz~ltion without thrusting makes usc of the same
forward. which would be incompatible with ctTcctivc mobi~ principles tlwl·apply to all the manipulative techniques so far
lization in Ihe ccrvicothoracic .uH.lthoracic regiolls. dc~cribed. namely. engaging Ihe barrier (laking up lhe l'lack)
For gravity.induccd PIR in trunk muscles. we make usc of ,lIld obtaining release. This goal CUll be achien:d by simply
o the facilitative cffcl.:l of inhal;ation during the iSOI11Clril: phase waiting and ~\pplying slight pressurc or by repctitive spring-
and of the inhibitory effect of exhalation during lhe relaxation ing of the barrier. Many practitioners lind these techniqlll'~
phase. beginning by telling the patient 10 look up. to fadlit'lte time consuming and in the end less effectivc than Ihrul'l-
inhalution. and thcll (wilh a few exceptions) to look do\vn be· ing (front Ihc barrier!): it has been Ihe mcrit of oSleopaths
forc breathing out and relaxation. To make the rhythm as slow to COll1illllC with their usc. This situution hal' changed greatly
<IS possible. Ihe patient holds his or her breath after inhala- since {he introduction of neUI"OI1111SclJlar techniques into ma-
tion ilnd possibly after exhal:ltioll. In muscles in lhe extremi- nipulation. m<'lking mobilization more clTcctivc ;lIld work-
lies. howe vcr. the effect ofbrculhing in or out is doubtful. ;jml ing within the barrier gelltler. safer. and Icss time consum-
so we rely 011 the patient to hold the extrcmity (or part of ing. The reason for this result is that in a restricted joint. il is
it) slightly raised for abolll 20 st.:<.:onds (or lllnn:) follmved Illusck spasm that is first met at the harriL'l". making slo\\'
www.bodywork.su
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-mobiliza-

tion 01 CO-C 1 using a combination 01 methods.

.~

<J

--~-
Fig. 11.30. Mobilization ollhe sacroiliac joint. )

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.'dl-
niqul..'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'
Fig. 11.28. Self·PIR of the Quadratus tumborum using a combi· "';\l,:roili"c anti other juinb, ". ;'.
nation of methods. 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'-
IIh 1bilizaiioll less SllCCC ......J ul. Wilh the ;.tid or IlCUHlllluscular nating in<.:rc;'lscd rcsistar\t:c ag;lil\:'1 sidc bcndill~ ill lhl.' i'l'('//
Il·..: hniqlll:.... this muscle :-.pa";lll i~ ~l\'crcomc :'\lIo. in some ,\'C',l.:I1I('III,\', sudl as CI (1I1In"Clllelll helween oc<:ipul :lnd albs)"

\.';1:'1.':". the p;'lticn(s l1lu\ch;" may even help in lllobilizOl' C2 (lIloVclllcnl bl.'I\\'t.'t.:l1 C2 allli C:;l. ('4" dl·". \\ hi.."1i ,-dax
IiI 111. i.e.. WI.: make lise (If the 1110,,1 phy\iologil.: means-the lI';,lt I'.rlwlcllhm, ResiswllCl: illt.TI.';Isn. Oil IhI.' \'IIII,,'r hand.
illh..'n:lll I"nn':l;S or the patient's nr~;\nism. Exceptions han; :lgaillst side hl:lldill~ al exhalatillll in thl.: odd SI'.<..:III('/IfS \C \.
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 ...... no"'r 1 c:n II . n""l-l- vr IVlfW.jI/""ULI-\IIUl~ 11'1 ::Jt""INAL Ht:HAtlILlIP.IIUN 211
I
•, (rig. ! L~J~. Th;~ cffc::t !~ ~!r,:,~~g('''1 in the upper cervical re-

..
I gion 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
::1 "look up (toward YOLlr forehead) and breathe ill:' followed by
,"
j

l
, .
"look dO\\'I1 (ww,m! your chin) and breathe OUL" except into
.1 .) rClroncxion. in which eye movements \\lould he ;,It \'ari,l1H':c

IJ ,: ";
,
;
......... .;
.........
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
I; thal usually no or only one repetition is required.
I"j in rotary mobilization. we combine inhalation with the
isometric phase and exhalation with the rclax:.uion phase. In

I
I
Fig. 11.31. Mobilization of the upper part of the sacroiliac joint. the cervical region. however. it is usually more appropri:ltc to
give the order "look up" during the isometric phase and "look
.~)

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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 junc-
tion (from C6 to T2) increases during inhalation. and rclax- Fig. 11.33. Mobilization of the lower part of the sacroiliac joint.
:.ltion occurs during exhal.ation. From T2 onward. increased
resistance during inhalation is again noted in the cven seg-
ments (T2. T4. T6. T8. and TIO) followed by relaxation dur-
ing 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):'"
"~i
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
! J out:' In the cervicothoracic and thoracic regions. the com-

Ii) I mand again is: "look up and breathe in:' followed by "relax
and breathe out:' to avoid increased Ocxion of the cervi-

lUII
Ii
cothoracic junction and the thoracic spine. which is most un-
favorable for mobilization. In the odd segments. however.
·ii , combination with eye movemcnts is unsuitable. bec:'lUse look~
~~ I ing down would not increase resistance against side bending
and looking up would not help mobilization into side bending Fig. 11.34. Side-benning mobilization of the cervical spine.
l
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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 re-
gion (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 usu-
ally 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).
Fig. 11.37. Mobilization of CO·C1 lateral flexion.
The original Muscle Energy Technique (MET) as de-
scribed 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· Fig.

Fig. 11.38. Mobilization of restricted rotation in the cervical spine.

Arrow. fixation by the thumb from behind,

ingly. "Functional" and "counterstrain" techniques achic'Yc

Fig. 11.35. Mobilization of CO·C1 retroflexion. release by moving the patient to a relief position in which lix
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\'c-
ment. gravity, and respiration-making many of these tech-
niqucs 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 u
of force just by springing those joints, The importance of min-
imum force lies in that the joint has to spring back into neu~
Fig. 11.36. Mobilization of CO·Cl an!ef!exion. tral after applying a springing force. and the intrinsic forces of
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 '1"\1'<U/'"\L. ...... HAI"" I tH 11 : HVLt VI"" MANWULAIIUN IN ;jI""INAL Kt.HAtHLlIAlIUI\l 21:;

j'lillb h.\:" an cXL"cptional position. Here. the barrier is engaged

in a "illldar way, but then a fast impulse or (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 re-
siSlallCL' ,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 tem-
poraL;>. ~, ":
It i... easily under"tood that most complications ascribed to
manipulation and related to thrust techniques and that re-
peated thrusts at short intervals produce permanent hypenno-
bility. 3. condition cvery experienccd clinichin \·iews with ap-
prchen"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
Fig. 11.39. Mobilization of rotation at the cervicothoracic junction. thrust until the slack has been properly taken iJut and the pa-
tient ha~ relaxed: therefore, \Ve should never thrust in a pain-
ful 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 ma-
nipulation arc caused by vertebral artery injury, the comb ina-

V
'-.,-,--I_r~--'c-~---=--_
CI';,I~ve
Fig. 11.40. Mobilization in slight kyphosis, with the lower vertebra
!====~~,~R~\=*\===
i.~lnch
fixed by the therapist's hand and thumb, Fig. 11.41. Active repetitive mobilization of the lumbar spine with
ILL.'lCk
the patient lying on a side,
~ngc of
.'\\Jch
:Ic"imd 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 con-
stantly 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 manip-
ulation is synonymous with thrust techniques. To this point.
our main criterion has been the barrier and release phcnomc-
non dcaling not only with joiiHs but also with most structures Fig. 11.42. Repetitive mobilization of the first and second ribs by
of the molOr systcm. In this respect. thrust manipulation of isometric rhythmic contraclion of the scalenus.

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j-
A B
Fig. 11.43. Mobilization of the acromioclavicular joint by shifting the clavicle against the acromion ventroctorsally (a) and cranio-
caudally (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 <I tcst to
sec whether the joint or mobile segment is prepared to accept
it, but ncvcr as a forced procedure to achieve the click. Our
aim is not a click, but rather relcase and nonnal function, ob-
tained by thc most appropriatc mcans.~~-52
The usual list of "contraindications" involving tumor,
acute inflammation, fracture, etc. is out of place becausc no
Fig. 11.44. Traction~mobilization of the acromioclavicular joint.
competent practitioner would knowingly usc manipulation in
such cases as those. No one is infallible. howevcr. and diag-
nostic errors are a possibility. particularly in the carll' stages
of disease. Even in such cascs, howcvcr. neuromuscular tech-
niques 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, im-
mediate 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 symp-
toms 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
Fig. 11.45. Mobilization of the fibular head against the tibia. nervc cntrapment is understandable, as the irritated nerve may

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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

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 re-
markably 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
\0
~ ,~
" arca is postisollletric traction. which has already been Je-
T('n$IOn on kq
scribl.'d. It is indicated for individuals with acute wry neck and
Fig. 11.46. Relationship between distraction force and joint sur- root syndrollles. and is specific in the treatment of e2/3 re-
face separation for a joint that cracked when a distraction force strict ion (SCI,": Fig. 1l.19).
was applied. (From Roston JB, Haines RW: Cracking in the For anatomic re:tsons. traction in the lumbar spine affect
metacarpo-phalangeal joints. J Anat 81:165.1947.)
joints only minimally. but it is specific in the treatment of disk
lesions. ~n fact. clinical improvement after traction is poten-
tially diagnostic of a disk lesion.

---=='~'

E,
E
S
;f;r~
I
c
o
"0

t
o
~

.:; J

._._' --:---:-~---::-,,---~
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
t

Anal 81:165,1947.)

be edematous and therefore profit from the extra freedom

given by temporary hypermobility. Its value is evidclH \vhcn
the carpal bones <lfC thrust into traction (Fig. 11.49) in a carpal
tunnel syndrome. and in the ccrvicothoracic outlet syndrome
(Fig. 11.50). It can be equally succcssful in root syndromcs.
by judicious usc of a technique by which the intervertebral
foramina arc widened and little or no rotation takes place, and
in simple traction tcchniques in the cervical and cervicotho-
racic area and in llexion techniques in the lumbar region (Fig.
11.51). Again. however. even if successful. a thrust should not
be repeated at short intcrvals: likcwisc, it should never be re-
peated if the lirst thrust did not succeed with little force.
Thrusts arc useful for areas with minimal pain and spasm, so
that only minimal resistance is met. Sometimcs thrusting is Fig. 11.48. Radiographs of the third metacarpophalangeal joint
the only possible tcchnique to usc in small children who do during the resting phase and distraction phase, before and after
not cooperate and where fast action is required. but only ex- manipulation. a, Pretreatment. nondistracted joint space; b, Pre·
perienced practitioners with faultless tcchniquc should vcn- treatment, distracted join! space; c, Post·treatment. nondistracted
ture into this arena. This caution applies particularly to the use joint space; d, Post-treatment, distracted joint space and gas
of traction manipulation in the upper cervical spine. arthrogram.

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 , . . . . . . . . ~,_ • • • " ' ...... , . . . . . •• , ...... , " ..... 1"\ r n/"\ ..... 11 I IVI'lc::n ;:) IVlf"\I'llUI-\L

I 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 .)_"' l-
I\s mentiolled prc\'iollsly. postisolll~tric tral'tioll in thc
lumbar region makes usc of respiratory synkinc:-;is: the..: tha~l~
a 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 in- .,~

halatioll.
As with other mtltlipulativc techniques. tr<lction must he
adapted to the patient in such a way as to be painless and. if
possible, to give immediate relid. If the patient experiences
b pain we mu:\t changc the techniquc or desiSl altogether.
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. THEORETIC CONSIDEIlATIO:-:S
All manipulative tcchniqucs dcal with mechanical probkl1l:'.
The barrier phenomenon. with all its rcllcx implic.ltion:-;. i:,
The following techniques are mO~l useful. In rhythmic :llso it mechanical problem. yet its nature is not surlicit:'lllly
traction prone (Fig. 11.52). the patient holds the end of the understood. However important muscle spasm and TrP may
table while the operalOr pulls rhythmically with his or her be. they cannot explain rcstriclion in such joints as the sacroil-
hands around the patient's ankles (which should not be iac and others. let alone barriers in connectivc tissue SInK·
squeezed!), after first making sure that the patient is relaxed. tures. One fact pertaining to joint and spinal mWlipulation that
The operator must then establish the correct rhylhm to local- is well established. however. is that manipulation restores nlO· .. _~

i
ize the effect in the low back. If the rhythm is mo slow, the tion and that its object is revcrsible movement restriction. The:
patiem's whole body will move up and down on the table. By implication of this statement is thaI the imponance of the rel-
quickening the rhythm, the therapist will find out when only ative position of bones or vcnebrac should not be overrated.
the leg and pelvis move while the rest of the back remains This has practical relevance, because asymmetry, particularly
still. the low back being like a nodal point in a sianding wave. in the pelvis, may appcar considerable. bUI asymmelry with·
Rhythmic traction prone can also be carried out by pulling out dysfunction does not require manipulation.
only one leg. which also produces a slight side·bending effect Recent experience and research have shed some light on
at the same time. this question. First, it has becn shown that typical pelvic db-
If the prone position is poorly tolerated because of forced tortion with clear asymmetry of the anterior and posterior
lordosis. traction is carried out in kyphosis with the patient iliac spines is not regularly related 10 sacroiliac dysfunction
supine. The therapist stands at the side of the table (which and C<:ln. as a rule. be treated. successfully by manipulation of
must be lowered) and place5 his or her foot on the table. the struclUrcs outside the pelvis. m05t frequently those of the
thigh and knee should be horizontal. The thcrapislthcn places craniocervical junction. Second. lindings show that th~ nt:u-

, ... ~
\ .. }

Fig. 11.50. Traction high-velocity thrust on the cervicothoracic junction.

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.)

-
 CHAe I eH 11 : HULe UF MANIPULATION IN SPINAL REHABILITATION 217
~~

i
.,, dysfunction is pain with sitting or standing, especially when

I "J
<
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-

Ii !'is.h~nt gravitational torques are being bome by ligamcnts. or

if excessive nuscular contraction is required to maiutain bal-
ance. this principle is being violatcd.":'>(,
For the slatic function of thc ~runk and the spinal column,
I
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 hang-
the position (tilt, inclination) of the base plays a decisive role,
but assessment by purely clinical means is impossible. The
ing down over the edge of thi table. exact position of the promontorium, of L5 and even of L4,
ti can only be revealed radiographically under standard condi-
I tions-standing. The ideal method is radiographic examina-

I~
tion of the entire spine. If this study is not available, a plumb
line can show the position of the external occipital protuber-
ance in the anteroposterior view and of the outcr meatus acus-
ticus in the side vicw. The position of the feet must be held
q constant; in the antcroposteriof view, they should be symmet-
ric to a line of the noor corresponding to the center of the x-
~
"

ray screen. In the side view. thc feet should be placed on the

I same line at the site of the outer ankle (Fig. 11.55).

The mechanism of balance differs in the coronal and the
.
I ",'\
sagittal planes. This difference is readily understood if the ef-
J Fig. 11.52. Rhythmic traction prone of the lumbar spine. fect of (1 heelpad is considered. An artificial difference of
more than I cm in leg lenglh is felt imi'iicdi<:atcly {~iid re-
I sented) in the coronal plane, whereas raising. (or lowering) of
'~ lfal position in the spinal column is not absolutcly consHmt;
!
aftef maximum side bending of the ccrvical spinc or rotation.

II 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.
M
If. for example. ventral and dorsal flexion is restricted, we arc
, r
I j
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"
j
i '~
(see Fig. 11.30 to 11.33), ..IS long as mobility is fully restored.

DISTURBANCE OF BODY STATICS

I Gutmann and Vcle sUllllllcd lip the import:'lI1ce of st<ltic func-

tion: "The dominating principle of the spinal column is body

I ,)
statics. All other functions arc subordinated to the require-
mcnts of the upright posture on two legs. Loss of mobility and

I
m
painful impingement of nervc roots is preferred to sacrifice of
the erect rlasturc."5.54_\~
Static fUllction of the spinal column is a specific charac-
k teristic of the bipedal hUlll;:\n racc. Its importance increases in Fig. 11.53. Rhythmic
l' our technic.1I civilization in which static loads mc prepondcr- lraction supine of thl

I mll (sitting .1Ild standing). The clinical manifestation of static lumbar region.

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~
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~
 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 in which casc nur intcnded correction may make thing5
the coronal plane. the line of gravity passes between the tW(1 even worse. This cirCulllsta11l.:c. too. c,m only bc rc\'cakd
hip joints (stable equilibrium). and one can crfectively correct radiogr.lphically (Fig. 11.57). This failure ofren occurs if the
pelvic obliquity by lifting one fool. pelvic obliquity is compensatory. as is the case in idiopathic
The physiologic reaction to pelvic obliquity-obliquity of scoliosis.
the sacrum (!)-is scoliosis to'the lower side. rotation to the The criteria of improvement after sUltic correction are
side of the scoliosis. and pelvic shift lO the higher side. The as follows: the lhoracolumbar junction returns to stand di-
summit of the scoliotic curve is in the midlumb.u region. and reclly above the lumbosacml junction: scoliotic curvature de- C)
the thoracolumbar junction should be above the lumbosacral crcases: and the pelvis and h~ad (plumb Iinc) return to mid-
junction. 5 line (Fig. 11.58).
\Vith the most frequent type of abnornlality. Ihe thora- The same static disturbanc~'can be caused by obliquity at
columbar junction does nol stand above the lumbosacral junc- the base of the spinal column. thus erell/illg pdvic obliquity.
tion but i~ deviated to one side. more frequently to the side of hut normalizing spinal statics (Fig. 11.59). In this case. obliq-
scoliosis. Rotation depends on the degree of lordosis. If the \Jity is caused by asynH11ctry inside the pelvis. This obliquity.
lumbar spine shows 110 lordosis or even kyphosis. there may unlike that caused hy leg length inequality. pcr~isl!' when lhe
be no rotation or cvcn rot::ltion to the side of inclini.uion (not subject is sc.::.ltcd •.lIld should h~ corret:tcd by a board under the
scoliosis):'" ischial tuberosity on the 100.. . er side or obliquity.
The most important point. howc\·cr. is that obliquity must If correction is (0 involve a hcclpad. it is essential to con-
concern the base of the spinal column. not the pelvis as such. sider whether the spinal column can react clinically to m~­
Unfortunately, neither difference in leg length nor pelvic chanical com.:t:tion. Such a response is not possible in th~
obliquity necessarily correlate with obliquity of the sacrum or acute stage of lumbago or a root syndrome with obvious all-
L5 or even L4. Therefore, we may easily create an oblique talgesic posture. un.rol1l1ll<ltcly. the Silllle is true in the event
b::L"ie of the spinal column by correcting pelvic obliquity of movement restriction. c.::spccially in a key region. A good
and/or leg length inequality. In other words. we correct the example is pelvic distOl1ion rdated to a restriction (blockag~)
morphologic appearance of the legs and pelvis. but seriously Ott the <,;raniocervical junction tFig. 11.60). It is therefore rec-
disturb static function or balance of the spinal column (Fig. omJ1lended to examine a pmicnt for segmenli.ll dysfunction
11.56). Because lhis most relevant obliquity CimnO( be seen or and to treill this problem tina. beforc radiographic re-exi.lll.li-
palpated. radiographs arc essential for correct ~ssessmen(. nation with a vicw to static correction.
Radiographic evaluation is equally es~cntial for the as- If static correction is likely to be useful. m.: first lest thl..'
sessment of spinal statics at [he base of the spinal colul11n as patient's reaction to raising the fOOL with the aid of a board
for lhe <Issessmenl of corrcclion. Unfortunately. the spinal less than I cm high. If the patient finds it pleas ani or is indif-
..J
,
column decs not nlways "accept" our cOITcclion (heel pad). ferent to it. it is probable that the mcasure will be well tokr-
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----------------------------_.... ,"
,
CHAPTER 11 : ROLE OF MANIPULATION IN SPINAL REHABILITATION 219

A B

c 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 ex-
amination, 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.)

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 .•• _ . , . , """'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.

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,..
Fig. 11.58. Pelvic and sacral obliquity owing to a short leg. Fig. 11.59. Sacral obliquity without pelvic obliqui::. a. Betore cor-
a, Before correction; b, After correction. rection: b, Afler correction.

A 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
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, 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 ad-
usu<J.ily <.tIl: Ilhm,; lIullh;l\lll:-O lhan those recognized by the pa-
tient bccnuse of pain. NOI only <Ire these changes frequently
vised to try to get used to it if possible. i.c., to wear a heel pad nUlllerous. but also they form patterns or chain reactions thaI
only temporarily, so long as it does not calise discomfort or arc the expression of dysfunction. conccl'lling not one. hut
i, pain.
Once the patient has adapted. it is belief 10 raise the heel
111:1n)' structures. forming characteristic patlerns. Only whell
we understand thcse p.lth:rns. are wc <lhk to gel morc th;lll
1
4 of the shoe on onc side or 100vcr it on the other side; if. how- temporary results by our trealmcnt.
!
1 ever, the difference is more than I CIll. il is best to recommend Having m"lde the di"~JlOsis. we have UlallY methods Ilr

I
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-
treatmCI\l from which to choose. In most of the s<.lft tissues.
methods of physical medicine C'lIl bc applied. from lllassage
sitioned above the perfectly circular femoral heads. and b:.i1- to the v..lriolls forms of electrotherapy. to applications of heat
ance is maintained largely by muscular action, which should or cold. to lhe magnel as well as the laser. In fact. t~chnil.:al

I
be kept at a minimum. Spinal curvature is largely a result of progrcss is const;mlly providing us with new mcthods, It is.
sacrum inclination: if this is considerable. lordosis will be however. neither the scope nor the purpose of this pllblil:atio!l
considerablc. Under normal conditions, the thoracolumbar to discuss thc merils or disad\'alllages of these altcrn<ltiv~s or
junction is somcwhat behind thc lumbosacral junction. so that of needle. and local anesthesia.
I T12 lies 4 em behind L5 on average.~K If the thoracolumbar Manipulative techniques have olle great advantage OWl'
~ junction is in front of the lumbosacr<ll junction. a forward- other methods: rccdb'1Ck resulting from palp.uil,ln. which
)

I
drawn position resuJ(s. because of acute disk protrusion or pbces the operator constantly in i.\ situation of therapy and di·
muscular incoordination (see Hg. II. I 3). This forward-drawn agnosis. It is in this case that the barricr phenomcnon is par-
)
position is <1150 importalll in the cervical spine and goes hand licul:uly useful. givcn its greater precision borne (lut hy the
in hand with increased activity of the m. erector spinae repre- close correlation of the palhologic barrier. incrcas~d h.:nsioll. )
,~ senting an increased load for the spinal column (Fig. 11.61). and pain. Similarly. relief of pain is associated with the pal-

I
Hence, static imbalance (overloading) in the sagittal plane is pable sensation of release so we kilO\\' when a p,lint'ul sInH..· · ()
the result of muscular imbalance and must be treated as such. lure stops being painful. \vhich is why the focus of this dis-
not by mech.mical corrcction, cussion is on those techniques based on th~ barrier
In both [he front~ll and the sagittal planes, howc\'cr. spinal phenomenon. In this connection. it call be said thai where,ls
I curvature is an expression of stalic function. If the spinal col- most methods of "complementary (ahernativc)" medicine
1 umn is in good balance. i.e .. if only a minimum force is re~ treat mainly dysfunction, manipulative techniques pr(wide the

I quired to assure sUltie function. then spinal curvature fullills

its task. The s:mlC is true for scoliosis (if not excessive):'5 for
lordosis or kyphosis. In the author's opinion. no other physi-
ologic criterion is applicable for the assessment of spinal cur~
rational clinical diagnosis.

CLINICAL IMI'LiCATIONS

I "
vmure.
One morc importam as.pect warrants mention. The less
The importance of the diagnostic side of manipulati\·c tech-
niqucs has been stressed. It is the clinical implications that il-

j
curvature. the greater mobility. i.e.. the less stability. On the lustrate this point. The Illost frequent symptom of our patients
other hand. the nlQrc cun-ature. the less mobility and greater is rain. which is. in itself. a diagnos.tic problcm for most prac-
stability. lirioners. \Vc havc consistently shown that with our methods.

I
we arc able to dctect well-defined changes in almost all slrllc-
tures of the molor systcm and beyond: in skin. the \"·<.~nnective
MANIPULATIYE THERWY AND
tissues, muscles. fasciac. and joints in both tht:' ~xlrt:l1litics
ALTERNATIVE ~IETHODS
and the spinal column.

It
From a method of treming mainly articular dysfunction. mOl· Consider headache in a patient with "ncgati,'c.7''' Ilt:llI'O,
nipulative therapy has developed into a method thm is used to logic. orthopedic, otorhinolaryngologic. stomatologic. or
tr~at dysfunction of any structure and tissue in the motor sys- rheumatologic lindings. We may llnd tension in th~ mastica-
tem. and it is possible that ~Oll1~ ,·isceri.ll dysfunc'tion mny bc tory and submandiblllllr muscles. with deviation of the hyoid:
influenced by manipulatiq~ techniques as well. The prerequi. a scalp that docs nOl freely move on lhe skull in som~ places
site for all this applicmion. is the (lrr o!po{pario/l. Palpation is (and in some direction): hyperalgesic skin zones in Ihe cervi~
however. first and foremo.1:,( a di~lgll()stic procedure. and so cal region: TrP in most of lhe neck muscles al1d in the cervi-
manual functional diagnosis has become the most important cothoracic <Ire.!: movement restriction in the t~IllPOro­
dinical contribution of manipulation, enabling us to make m'llldibuhlr joint: dysfunction of joints in the cen'ical spine

I
pcnincnt diagnosis of all tissllcs and structures in the motor and the cervicothor<lcic rcgion. including the acromi~,clavicll­
:o;y:-;lcm. lar and the sternoclavicular joints: and p;'linful paiosteal
Prcciscly because of lhcs~ diagnostic possibilities, wc points wilh restricted mobility of slIbperiosteal tisslt", in SOl\H,~
have' learned thai importalll tissue changes lie far from the site direction. We may observe a forward-drawn positi~ln 01" the
\vhcre the pmiclH feels pain. nnd th.lt. in f::let. slI<.:h changes he<ld owing to increased tension in the <lbdolllinal lllllsdes

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CHAPTER 11 ROLE OF MANIPULATION IN SPINAL REHABILITATION

Fig. 11.61. Forward-dra'.... ,: posture with thoracolumbar junction ir' front of the
A lumbosacral (a) and with s:raighlening of a cervical curve (b).

with hypcrtollus of the glutei. and fauh~ motor patterns O\ving -I. Circc;,;; ::11 PE: Vcrkr/un~'::\hgkidl. NUll and Unnul/. l:~ :'\,'lIl1l;ll1n HD
and \\ liT HI) (cd~): Tb~"ro.:li~,'h,' F(ln~chrillc and ;'•. tkli~dH.: 1::rf;J1I~
to muscular imbalance. faulty rcspintion.•md/or cxogcnic
run f :.:;. dcr Jll:tlllldkn \kdi/in. BilL K(\llk(lrdi:1 (;::;:,11 Drud, \Il1d
rcasons. e.g .. al the \\orkpbl,,:c. This ,\C(Olll1! of the possible Vcrl;t:;~. l'J7'), pp .1~.,<q 1
findings is certainly not (Olllp!e(C. but what is true for 5. I.C\\I~ i-~: RIl1~I'llo1o~i~~h~' Krik'l'i,'ll "t;tli~~ltcr S(nllt:,:,';~ ,kl' Wirhc1suk
headache is as true for . . houldcr pain. leI\\" hac\..; pain, elc. in re- !ll;1l\'~~'::(: !lied, 19iC, pp :(j-.'.~,

gard 10 "negative lindings.'· The clinical impliGllion of func- ('. I.()~';t'__ liB: Tnlhoo].; of I.rlg;m B:hi,' ~klh(ld" St. L,';ii,. Lnpn F~l.
,I
tional pathology-nol a question of -.in1;lc method but of a
J9.'i()
7. Sdm:::Lr W. lhor;l].; J. D-.i,r'll-; Y. <..'1 :11: ~Lmlldk \lc',I:/IIl, Thcr:tpi,'.
different clinical approach in which dy,>functioll is as real as Slun;:,~L Thil'nh:, 19f\(). PI! '1-1.-;
structural pathologic changl' ,Ind therefore must be adequately X. Hur;';::~, A: Di(: hll1kll'l!1,kranklh:itcn dc' Ik\\ '::::;IIl:':~;lp[l:'r:lll'"
diagnoscd, i\-1anipulati\'c !t:('hniquc.. have thu:, opened the Funl:', :l,krnakh(:il(:11 d\:, B'~WC~\I11:':S:lJ1P:ll':ll\:' 1:7. !,)~~,
way to what i~ no\\' \\iddy ('ailed "m;oskektal" or "muscu- 'J Tr,j',:::; JG, Silllllll~ IXi: \l:.oLN'i;d P:lin :Hld Dy,hlt1,':,,\Il: Tile Tli~:':"'l
I'oln: \!:lllll;ll. \'1,1 2. Bal1:rI1'II'C, William, & Wilkill'. :,h)2
loskeletal" medicine. dcallllg with the l11(1st frcqucilt alTcc-
10. ll;d,!::::,,:llIl, s: I'rc~i(krH:,ti :tlldr,,~~, North All1Cli,',~:' :-\I'ioc SOl'il'l;'
tion, of the motor sy'-.tclll and cvcryda;. ailmcllls, hlil'J,~ '01 till' p;\(h(ll()~il,d mode'! (I pl'cdit:l bad. l'~:;" Spinc 15:71:-;,
I99 f l
REFERENCES 11. il'lal!;>~:y J: Till' oI110t:~n~il(; dl'\dl1plllCIil of IlCI'\'I' lc'r~l\il1:l1ion~ in the.'
I. Ciro':l:llm;J1l PE: PrirKipk .. pl' \bnual M"i..h~:lh':. BaltlllHlrl:. WilJial1l~ & inlcr', ';:1\:hral di~c of Ill,:fl, .·\Cl:l ..\11;11 (B'I'.l:!) ~X:9(,. 1,}~,)
\\'r1kin~, 1%9. pp XS-'.;3. 12, B(j;;l!'~!.:--:, Tyoall W. WiI"m AS: Th,'ncrve ~urJ1ly o!' l1h' hlll\l:\Il1ul11b;n
, L.ewil K: ~boiJ1ubl:\~ llh:I~\P;' in Rd;:,~i1ilalil\1l I't' the J.oco!1lo11'1 illl,T<~;~hr;ll di~b. J l\n::\ I ~2:Jq. 19KI.
S:' q,;m. 2nd Ed. O\lord. Butl,'r\\ nnh·' ktnc'l11alln, 1'l') 1. pp I-~-l. 7lJ-~K~. lJ. L':\',i~, K: Chaill l'c:tclion, iil di~lllrbnl flillUioll 01' lb<' I1h'lpt' ~y~ll.'rll..1
,\lilc!l,;l1 1'1.. !\lor;m I'S. Pru/I" NA: .-\~; r:\aIU,lli,11l and Tn:a(f1\cll\ M,\I;c;~: .\led ":27, 19X7

,\1.,1)\1:11 PI' O~lc"i':' :ih.' \Iu·",k I::t-:;::- Pln,',"\~ t,·, V:1I1<:: I':ul. I-Ilk r! \1(" 1,Illli"c' BUrIl' ~::-.:rn"ri:d k,'(ur,' 1\:rn'jlli"11 :':~,'u:,:h palp:lli\'11
,\ltlChdi. ~1t'r:lIl. :md I'nJII,' ,-\, ... 1'J7".·- ;-l,''',,-lJ J i\r; (),\I"llp;,:11 '\"'0(; :~'I 1,'-\

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 ••• _ ,-"" 'V'''\:.rl .:> .v "lUJ-'oL -,

15. Chaitow L: Palpatol)' Lite;;icy. Lo:~:!nl\. "!"!~nN'!~'i. !(H.)!. :lK Kiln 1fl.1: Prnpl'iuI:cph'r_ .llId sumati.: IlysIIllH:,itlll. J Am OSICtlp;lIh ASSH,:
16. Greenman PE: Shichtwcisc Palpation. Manud!.: MeL! 2~:46. 198-1. 7-l:6JS. 1975.
17. Travclt JG, Simons 00: Myofaseial 1';,il1 ;mll Dysfllllt'lil1n: The Trigger "IJ. 11,c lIlus\'ul:tr anll ;tMl":llbr (;Klllr in 1\10\,'11\":111 n.·str'i':lillll, 1 ~Ialll101l
Point M:lI\Uill. Vol I. Baltinl0n:. William>: &. Wilkins. IlJS3. ~kd 1:8". 19S5.
18. Bourdillon IF. Day EA: Spin;"!) f'.hnipul:ttioll. 41h Ed. L~lIld(ll1. ..tn. G:lym;lIls. I:: ni..: IkJ~'Il11llll! lk'r AICllll~T~1l fr die Mohilis;llinn der
HeinelUann. 19S7. PI" 38...40. Wirh...· 1suk. i\·l;ultldk \kd 18:96. I')XU.
19. Lcwit K: Pelvic dysfunction. In P:IlcrSt111 JK. Burn L: Ib~'k Pilin. 1\1l .t!. JOll<:S L11: Slraill .1Il.! C"lllillcrstniin. l\'l·w.uk. OIL Till' t\~';I\klllY III
IntcnlOltion;11 Review. Dordrecht. Kluwet. 1990. I'll 271-2:\4. O"tctlp:llhy.I'JX1.
20. Keating lC. ncr~lJ):llln TF. Jacohs GE. l'l al: Illh:r,,:x;IlUilll.'r rdiahilil)" uf ":2_ Gr~'Cllll\;1l1 PE: Prill~·lpk .. "f "'·t;mu;11 ;\k.h,·lIl,·. Iblli"ltlfl:. Wdh;lllI\ .'\:.
eil~hr evalu:tlj\'C dimensions tlf lumh:lr \C::ll1cnlal ahnOl'ln;llil\". Wilkins. IIJX<J. pp 101·_·1115.
M71llipulativc Ph)'siulllK'r 13:463. 191}U. - . 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
21. Boline PD. Kealing Jc. Brist J: Il\lerex;lllliner reliahilily of palp:tlUr)' '\11.11 SI:HtS. 11)47.
evalu;ltion (If the lumhar spine. Am J Chiropr.lI.: MCll 1:5. [9S1\. ":-1. Mi..:rau D. Cas.>:idy JD. Wmn:n V: ~'laniJllll;llioll ;lIIt111lllbiliz:llitlll tlfth..:
22. IXOocr Kr=. H:trll\on R. Tutlle CD. el al: Reliability stlldy of dctc.:til\l\ uf third met:u':;lfl'0-llhal'an:;e;11 jdill1. A 111I:lllIil:lli..·..: r;uJio~r;lJlhk f;tltg..: III
sOll1<llic d)'sfullction in the cervical spine. J ~1:111ipul'11in: physior -nl..:r 1II0lil11l Sllldy. J M;IIlU;11 ~ktI3:1~5. I'JXS.
8:9. 1985. 45. Dvorak 1. Or..:lli F: Wi,' !:!L'lhrlih ist ,IiI.' I\Llllil'ubtioll lkr I-LllswirhL'I\IIL" ~
13. Camlich<lcl lP: Inler- and intr<lexnmincr reliahility Ill' palp:ltiun for Malludlc ~...ted 2U:..:-I. It)S~.
sacroiliac joint dysfunction. 1 Manipulalh'c Physiol TIlI.:r 10: 154. j9S7. -16. Grnssinrd A: Les a~'cilknls l1CUf(II'l~j(llle~ d,'\ 1I1ilnipliialitlllS I..'..:n·kak·....

i 24. Hcrl.og W. R~ad U. Comway PJW: Rcll<lbililY of mOlion p'llpation pro-

L:cdurc~ [0 uctcct s:lc()iliac joint fixations. J ~'I;l1Iirulali\'e Ph)"silll Th.:r
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
-

I 1::2:86. 1989.
25. z;'ldnll:lll Z. Tr"in:l AD. Keating JC: Intaa:lIninl;r ~Iiahility :lOli cun·
currcn\ \'alidit), of Ihc iostrurnen\s for the IllC:lsuremCIJ! Ill' cer\'k:tl
·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

1i ranges of motion. 1 Manipulative Physiol Ther 12:205. !<Jgl).

26. Huncke r=: Hcrdgeschehen im LichlC der Bcilaflslhesic. Schnh..:nrdill.: fr
GanzhciISlllcdi1.in. SIUllgart. Hippokr.ltes. 1950.
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.
---"J

i 27. Dosch P: Lchrhuch det Seuralthcrdpie n:l("h HUlick..:. Viln. Il;Iu~. I<J(H. 5'" Fu\sgf\."\:11 J: EdiloriaL Cnmplic:lti\lll~ in m;ullI:.1 lII....dicill..·. J M;IllIl:.1
~
§.
2S. W;lrd R: Personal communication. 1990. Med (diJ. 1991.
29. Grecnm<ln PE: Principles of Manual Medicine. Bal1illwr.:. Williallh & 51. Dvorak J: In'lppwpri~l"" illdkaliolls ;lIId \·olllrailltlit·;llillll.>: of l11illlU:!1
1 Wilkins. 1990. pp 106-11::2. themp)'.l M;IIIU:.1 Med ('I:H5. 1991.
~ 30. Lcwi! K: Verspannungen der B:luch unrJ Gessllluskulalur mil 52. Patijn J: Complic:lIion.. 111 m:U1l1almedicim:: A re,·i..:w tlf Ih.: lih:ratur...•. J
)
~ Auswirkung :tuf die Krpcrst<llik. t>,·1ilnudlc Med 311:75. 1992. M,lIlllOll Mel.! 6:89. lYlJl.
31. Sih"er~lolp..: L: A pathological erCClOr spin::..: rdlex-:l new sign tlf Ill":'
I ch:mical pelvis dysfunction. 1 Manual ~·kd 4:::2K. 19N9.
53. KirOl.ll J: Persistence orynkin..:tk pallefll\ .. I" til..: .:cr,·i\-"I spill...•.
Neuwr,ldiolll£.Y 18: 167. 1971).

i~
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
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 ... · ...
---.J
Inlcmalioll;ll Review. Dordrceht. Kluwer. 199U. \Cn\chaftlihen Grundl:.gcn. Hciddhc~.:. I'hy\iloi:llishc "·kdi/ill. I'JiO.
I'"i!
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.
pp lU9-J27.
55. Gutmann G. Velc F: D;l\ :llIfredl1c Slchl!. Wcsh.klll~ ...hcr V"'I'Ia<:L·.

I 34. Stiles EG: Muskclenergiclcchnik (MET,. Thcr.'llo:Ulische Grund\I;':": ulld

praklische Anwendung. In r=risch H (cdr M:lIluellc Mediz.in HeUle.
FllN.:hungstlo:ridllc tk_ L1f1dl:s Ntlrdrh..:in· \\·...."'If:lhl:l1l Nil ~7l)(,. Fadl·
gruppc Medi7.in. 1978.

I Berlin. Springcr. 1985. pp [50-156.

35. 1'r::I\'(.·.I1 JG. Simons 00: ~l)'ofasci<l1 (>ain and OysfullCliun: The Trig.gcr
56. R;:L~h Pl. Burke RK: Kincsioltlgy and l\pr1it:d !\l1al\l111Y. I'hiJ:tddphi:1.
Lea & F~big~r. 1971.

II 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<lX (:ia. jej plXhl;lla ;1 potl.leilic fgr,lvil)" in-
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.'\.
i duCl..'<.! relaxation. its principles anti pr.ltliec app!icatiouJ. Praktick lka
68:147.1988.
.,
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 IL. ;::,plnallnerapeutlcs tsasea on t<.esponses
to Loading
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 predicated The Issue 01 when and how cntelld thct<lle the dr:
approach. protocols. or system. Ou~ purpose is to explicate rcction and type of rorcc applied 10 the spine is critical to the
the underlying philosophic and practical perspectives of the understanding of the McKenzie approal.:h.
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
im- (0'

part c1inicnl competency regarding the skills necessary to usc The criteria according to which any inquiry is conducted for
the McKenzie protocols in practice. Such competency re- the purpose of resolving a problem profoundly affect how the
quires study of "The Lumbar Spine"] and "TIle Cervical and solution is conceived. In Olher words. the am:wcr:, you get de-
Thoracic Spinc"2 by McKenzie, as well as the formal instruc- pend on the questions you ask. The McKenzie <lpproach pred-
lion til.., applies the clinical rC<lsoning found within these icates spinal asscssment and therapeulics on asking questions
texts to assessment and thcr.lpy of patients on a day-to-day aboUl the mechanical and symptomatic responses to loading
basis. The material presentcd here can only hope to supple- the spine.
mcnt such study and instruction. P..tticnt., preselll with a variety of mechanical and/or
symptomatic: spinal l.:ompli.lints. and their rcspons~s to move-
ments and positionings of the spine arc v'lriablc. Sitting may
APPROACH TO CLINICAL REASONING
exacerbme spine-related complaints in some individuals.
In the following attempt to expand an understanding of the whereas others find relief while seated. St.ulding.. walking. or
McKenzie system, new terminology is introduced. Hopefully reclining may similarly cvoke disp<lrate responses ill the same
what such terminology distinguishes will stimulate estab- or different individual. It is noted. tlll:rcforc. lh;lI patients h.wc
lished and future students of the McKenzie approach 10 fur- different stories to tell about how movement and positioning
ther appreciate its imrinsic principles. affecl (heir spine-rdated complaillls.
Concerns rcg,lrding specific spinc-rcbtcd complaints.
which are cssenti;dly mechanical and SYl11ptolll~lIil' responses
Relation of the McKenzie Approach to rvhmipulation
to movement and pusitioning. motivate paticllts tu seek pro-
~md Rehabilitation
fessional cmc. The details of how spine-rcl~llcd mcchanics
Both Jllillliplll~ltion and rehabilitation usc movement .IS ther- and symptoms me affected by movement and positioning.
apy_ In milllipulation. movement is used as therapy when the however. 'Ire seldom of specific concern to the clinician for
clinician moves the patient's spinal joint structufCS to end purposes of assessment or therapeutics.
range. The rehabilitation tradition also uses movement as St..mdard mnge of Illotion examinations and ol1hopcdic
therapy. but with a preference for "activity as therapy:' i.c.. tcsts do not adcquiltely explore how the particular patient's
patients performing.the movemcnts themselves. spinal mechanics and symptoms arc affected by specific
As with manipulation, the McKenzie approach uses spinal mOVClllCllls and/or positionings. Perhaps the greatest limita-
movements to end range. As with the rehabilitation traditioll. tion of thcse examinations and tests is the supposition'that
thc preference is for palient self-generated movements. The each test movement need be performed only once to fathom
significant difference belween Ihe McKenzie approach and how the p<.llicnt·s complaints respond. The cffcclS of repeti-
that of tradilional manipulative lherapy, however. is not thm tive movements. or positions mainl'lincd for prolonged peri-
of rejecting manipul.ltion in favor of patient-generated move- ods of time. arc not explored. evcn though sud\ loading
ments, althmlgh the latter is always preferred. Manipulation is strategies might better approximate what ()~(:llrs in the "rcal
aL:tually an option according to McKenzie protocols. when world."
patient-generated movemcnts prove only partially successful. The mcdwllic:al or symptomatic response to a movement
The most significant difference between the McKenzie performed once might be r'ldiGllly different fnJl\1 wh'lt would
•lpproilCh ;ll1d other melhods of treating the sp::1e is the crile- uccur if th'lt muvemcnt werc perfurmed lin: l)r ten times.
225
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 thcn.:by rC\'~alil\g an entirely dirr~n;1\l dini\:al picture. of the patholugy l1lodcl."'lllese :.I priori constructs. based on
Similarly, the mechanic.1I or symplom'lIit: rl'spon:-c.: iO aSSUlll· hypothesized pathO;JmHomy. have gencrated trcatments that
ing a particular positiol1 fllf a fe\,\, lllUllh':lIls miglll he r;luicall)' may br.: t'llIgr.:lltiallO lhe patient's ne~ds and obscurc the clin-
different from what would O\.."'.:ur ;Ifl~r assliming Ih;1t idl:lllical ical pcn.:eplioll of phcnomena :\pecilic to the individual pa-
position for it fe\\'" minutes. ti~llt's si\ll:tlioll.
Just as l1lc,:hanical and sympll.llllalic r(;spOl1SC~ aTC rardy FtJr t.:xampk. if all spine-rcblcd complaints afe perceived.
consi(krcd n:~:lrdillg their l\'bli\lll"hip III n:pL'liti\"e,: tllO\'C- a priori, tn hl' th~ result of inflammation. this preconception
menls :.md/or sustained pll~ilillllillf. Iillk inquiry i~ dircCh:t..I hI' limits the clinil'i'lll·s ahilil)' til appreciate the po:\sibilily of
how mcchanil..";11 ;\lId :-ymptolllalK rc"pollsCS rel;I!\,: /0 ('((cli mcchanical slratcgies for palielH C'lre. It conceptually pro-
other; i.e .. ho\\' [hey n:spLllld ill (;mdclII to lllO\,Cllll:111 ;mt.! po~ nltltcs tre<!tl11r.:1lI . . tralcgir.:s of rest anti anli-in!lalllmatory mcd-
sitioning. iGltioll. whidl may not be eflic<lcious if, indeed. mcchanics

I
The possihility of 111l:(,.'hanical and symphull;uic responses .md not t:hcmistry is the relev'lIlt component ill thal patient's
serving as Illcaningful criteria 011 whidl to prcdic'lt~ treatmCIlI case.
is precluded if cognition of such is wanting. Unfortunately,
j many spinal examinations "ln~ all 100 often only cursory for-
malities, serving as preludc~ In prcdetcrminctl trcatnlc'l1I
Patho.1I1atomy :md the McKenzie Approach

I
plans, indepcndent of sped lic a""C"'''lllent linding...
The McKcnzic appmach recognizes pallerns of mechanical
and symptomatic phenomena th.1t arc labeled "syndromes."
Although the McKenzie <Ippro"lch names :-;yndromes accord- -~
Treatment \Vithout Spcdlk Criteria
ing to certain p"lIhoanatomic suppositions. these syndromc~
~ Treatment for spine-related cOlllpl::lims is often routinely .lIld refer primarily to phcl\ol1lcnologic patterns that can be dis-
!
:f ceremoniously applied in the exact ~alllt: llWl1I1t:r for each pa· cerned apart from any particul..lr pathoan<Homic interpreta-
tient. even though distinglJishing mechanical und sympto· tion. The assertion th:.u the syndrome patterns detailed in the
miltie prcsemations <Ire potentially discerniblc belwecil indi· McKenzie approach accurJtcly describe the phenomena re-
viduals. More often th'lIl not. the niteri" that motiv:.llC the lated to spinal loading illde/Jt..'lllh'lll of the pathoanatomic in-
p<'lticill to seck care an: Ilot il1limutdv connccted with the cri- terpretation or,h~ day applies, as well. to those interpret~}[ions
teria used by the c1inici'lIl to asses.. the patient. 10 determine forwarded as pan of the ~kKcnzic <lppronch,
approprialc case management. or 10 monitor the effectiveness By lirsl describing presenting empiric phenomcna before
of C<'Irc, Identical care applied to all patients with common making pathoanatomic interpretations. we hope to afford the
spinal compl<.lints is often the result of criteria th<.lt roUlindy reader a fresh perspective without putting the "pathoana[omic
conceive of a universal problem underlying all panicul,lr cart before the empiric horse." The ahertl<ltivc method of nrst
complaints. presenting the p~\lhOal1:'llol1\ic conclusions of the McKenzie
~lpproach runs [he risk of diminishing an appreciation for the

A Priori Versus A Posteriori Approaches clinical uti lily of the approach. the basis of which is thera-
peutic imer.vcntion ~lI1d management made possible by careful
Preconceived. (I priori notions about common spinal disor· observations of spine·rclated responses 10 movements and iiO-
ders can bli~d clinicians to meaningful and individlJating phe- sitionings, and not by the ability 10 ascribe meanings to th('$c
nomena. A priori knowledge argues "from what is hdon:" responses via dogmatic diagnostic conclusions based on
(I.e., from causes 10 effects) and attempts to bc indepcndcnt of pathoanatoillic models.
particular expericnce. On the othcr hand. (f {losterior; knowl-
edge argucs "from wh.1t is aftcr" (i.e.. from effects to causes) Objective Signs Alone Arc Not Adequate Criteria
and uses empiric knowledge derived from experience.
Implicit in the McKenzie appro,Jcll is an ..I poslcriori. em· Some clinicians maintain the a priori notion that conc~ntra[­
piric study or phenomt:na rdOlled 10 spinal loadinc. ,lftcr iog on lllcchaniGl1 or other objectivc signs alone (and [ht.~r~­
which pathoanatomic cxplan:nions arc proposed. A -Glfl.:rul fore ignoring symptoms) is a more sci~l1tific approach. be-
description of clinically presenting phcnolllcna is possible in~ calise signs are more amenable to measurement. Mechanical
dependent of the pathO<ln,llOmic intcrpr~(ation of tile day. and .or other objccli\"c signs. however. such "lS range of tll('1,iOll
this description should remain <l<.:cur.He if th"t interpretation measun:lllents or spinal imaging. do not ::Idcquately ~K\'·l,'1l1nt
changes tomorrow. \Vith thb i.lppro"lCh. a priori judgments .Irt: for the phenomcna of spine-relatcd complaiTlls.
less likely to prejudice [he perception or the clinically pre. \Vh..1t might a[ first seem to be indistinguishable obj~~tive
senting phenomena. It is acknowled!.?ed tlwt one C<ln onlv al- me,lsurCl11ents between two patients. may. on closer in::~c­
tempI this goal. as no one can trul; he free of all pn::con. tioll. prove to be p.m of different ~linical pictures when
ccived notions, judged in the broader cOlllext within which they occur. The
identical mechanical sign may be associated with different
PUlling Pathmumtomic Criteria in Their' Place symptoms, or cven different other mechanienl signs, from pa·
lient to patient. In nddition. thc OfJfUlI'l'lIlly salllc mechanical
Predicaling treatment on a priori COl\struct:-> rooted in the sign may respond differently to identical movement and/or
pathology model h"s led to wh<.Jt h'l:-> h~~l\ t:allcd the "r:lilure
www.bodywork.su pusitioning stimuli rrom p"llicn! to ""tien!.

..-- ---------------------------
 OrtilUdox \"«.:rsu:'\ Alh:rni.ltin~ i-ic~lilil C:.tft: Signs Illcl'hanic!l and SYlllPIOJ1l~llic responscs to the !'timuli of
loading (applying forces lO) the spinc. This rccognition is
In onhodox medicil1\.'. the rm:us on signs and the a priori as-
dcrin:d from historical information relal~d by thc paticnt
sumptions of a patho:lIlatomic lllod(:1 is the n.:sult of. or leads
as wcll as clinical limlings that comparc mechanical .l1ld
to. an inability or unwillingness ,10 r;,uion<tlly apprcci;l1c Spill\,>
symptomatic rcspunscs hd'orc. during. <llld after (I' singu-
related symptomatology. Thi~ same i.lpproach taken ~y Ihe so-
l~,r l11\l\-("lllc:lItS. (2) rcpcliti\'e llHl\'l,.·ll1Cnts. and (31 sustaincd
called ":i1tcmmivcs" to onhodox medicine entails the lise of
positiuning:..
·'ahcrn;.nin:'· signs. which also avoids the recognition of
symptoms . IS meaningful. In this regard. no alternative is n::-
C01l1mon Connccling Critcria
ally being offered.
Alternative approaches. often described ;Is "holistic:' fre- Spine-relatcd complaims ;'\llli thc means for their resolution
quently m<lkc the a priori claim to "treat callses not symp- become intimatcly conncl:tcd at c<lch slagc of the McKcn;o.ic
toms:' This predilection often Icads the paticOl and practi- approach because of lhc l'OI1l11101l cOllllecting criteria. which
tioner to a/lL'rl/ati\'(! signs so removed from tile phenomena ;.11 is the mechanical and symptomatic response to loading strate-
hand that both common signs and symptoms related [Q the pa- gies. These criteria. on which the 'Ipproach is predicated. pro-

I .r",
-~- )
tient's complaints arc ignored. The signs sought may be so re-
moved from the patient's complnint5 that they better resemble
signs of "divination" (omens. portents. etc.' than <lny serious.
vide a rdtiollal (hread conncc1'1ng:
• Compl<lints

t
I·
rational diagnostic endeavor. C01ll1l10n. mundane signs and
symptoms are ignored in the search for the miraculQus.
Assessment
Therapeutic prescription
Monitoring the course of therapy

I The <lhernaiivc health care complaim that symptoms Prophylaxis

,
,
themselves cannot be treated is appreciated as a valid objec-
tion to the pharmacologic suppression of symptoms via i.lllal-
gcsics as a mcans of therapy. This concern. however. do.:s not
justify the total rejection of appraising symptoms as relevant
SPINAL LOADING
Spinal loading refcrs to the administration of a force lo the
! phenomenn.
spine. No matter what position the spine is in. at least the

I
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 un-
Subjective Symptoms As Potentially Valid Criteria derstood that the 1I111001i/ed spine refers to the reclined posi-
Symploms are an impon3nt key to the puzzle of spinal com- tion. it can also be viewed as a differel/r kind of loading.
plaints. Signs and symptoms are important diagnostic compo- Unloading thc spine. as il is cOlllmonly understood. may di-

I nents in most health care specialties. Unfol1unately. when the minish external axial forces to a motor segmcnt while in~
specialty concerns common spinal complaints. symptoms arc creasing internal forces as a result of the inhibition of fluid.
o usually denigrated to the status of epiphenomena. principally These distinctions may havc some impon;.mcc considering
the con\'entioni~1 <l priori notion that any wllo(ld~·f1g action is
because of the confusion that has resulted from the inability
of bcnefit to the spine. This is not necessarily true. For exam-
I to appreciate rationally the symptomatic responses to spinal
ple. for a signillc'lIlt number of pnticnts. low back and leg

I
IO<lding stimuli.
Because health care disciplines have been unable lo make p;lin is worse in the morning.. and others respond poorly to
sense of spine-related symptoms. these symptoms hilVC been traction.

I relegaled to the realm of nonsense. This lack of appreciation

nol only denies patiems a certain dignity and respect (the ab-
Loading can be viewed as a mechanical stimulu~ to which
mechanical and symptomatic rcsponses occur. Loading may

I sence of a concerncd audience regarding their symptomatic be considered the independent variable. with the result-
story). bUl it also denies health care practitioners the clinical ing mcchanical and symptomatic responses the dependent
utility of that story. v;lriables.

I Subjective Symptoms Alone Are Not Adequate Criteria LOADING TACTICS

I
As with mechanical signs. symptoms taken by themselves do l.oading tactics refer to individu<llioading stimuli. procedures
not account adequately for the clinical presentation of spine· or methods that ,Ire components contributing to an overall
(J rclaled complnints. Both the symptomatic (llId the mechanical loading strategy. They include the following:

,
N
responses 1O spinal loading must be considered to best appre-
ciate common spinal disorders.
Dynamic loading
Static loading

I,
Lmlding intensity
Responses of Mechanical Signs nnd Subjective Symptoms - Loading frequency
10 LO~lding As Criteria - Loading :lInplitudc (o\'crprcsslIn.:. mobilization. maniplll<Jlion)
Loading within ;1 ~pccilic JIlovcmenl plane direction
Thc ML:Kt;J1zic .approach i\ <l system ()f assessment :lnd thcm- Loading within a specific range of a movement plane
{I' peUlits based on thc recognition of patterns concerning thc Loading at a ~pcd(jc.:: point of a movement plane
~
I~ www.bodywork.su
;; $,,-,
l-':::...----~----------------------------------------------
,'il
f
 Lll;l\lifl!; p\)sturc thoughl to bring spinal joint structures beyond voluntary end
Loadinl! SOlJn:~ \S\l\lrI;C \ll" h)r~c) r;lIlge. to\\''lrd physiologic end r;.Ingc. M'lIliplilatie:~ is (hought
- l)alicnt·~(,llaal('t1lacli ...:, to bring spinal joint structurcs beyond physiologic end range.
- P,lIicnt ;I:'C of :Ippliancc or Ill;u.:hill~ just shon of anatomic end rangc,
- Clinicia!l.!.!l~ll('rall.'d t:lI.:tirs
For th~ McKcnzie approach. the mcchanical and symp-
_ Clinician ~Sl' uf tool, 'lppli:llICC. or lll;lChtlll'
tomatic responses 10 overpressure .md/or mobilization arc
carefully lloted ill order 10 predict wh:.n the mechanical and
l)ymll1lic I,oading sympwm;Jti, responses would be to m:.lnipulation. In other
This term rl.'rt:rs In ;1 sySh.:m of I1.H\:CS IHl th~ spinc ;f! I1/(lT;OI/, words. tltt', responses to 10~l(.ling at physiologk enu rallge
or 111ulcr~\)illg II/OI·('IIU'/Il. under spL"cilk l"lluLiitions. scrve ;IS a criteri;:l 011 which to predicate loading toward
anatomic end range. Only thcmpcutieally beneficial r~·
Static Lnadinl! SPOI1SCS noted with the former permit perfoffilancc or the
lallcr. Complete rccovery by IllC;lIlS of the former obvi-
Static loading refers to a syst~1ll or forcc.s ·0[\ the Spill~ at r~st. ates thc latter. Manipulation is appropriate when loading of
or during positioJ/ing. ullder speLilic conditions. St:.Hit.= load- lesser intensity evidences bencficial responses that are not
ing or th(' .,pint.: ill a specilic rmsitioll for a prolonged pcriod complcte.
or til1lt.: may h~ referred lO as ,'iIf.wui/f('d !'m;r;rl/l;"g.
Loading \Vithin a Specific Movement Plane Direction
Loading Intensity '1
.r
Movement planes arc derived from dimensions in space.
Intcnsity is ddincd as tensioll. activity. or energy. Curiously. Movement planes contain two opposite potential direction" in
the woro intensity i:-: derived. in pan. from the Latin vcrb. lCU- which loading can occur. referred to as I/I(}\'cmem I'lmu'
dere. to strctch. Illle/Isity rekrs to the frequency al1~lIor the l!irc(·ticm.'i.
amplitude accomp'lllyillg loading. To incrca~c thc intensity of
lo'lding. thc frequency and/or thc amplitude can be increased. SAGITTAL MOVEMENT PLANE j

in this plane. also called the anterior-postcrior movement

LOADING FREOUENCY
plane. movement occurs about the coronal axis. The opposite
Loading frequency refers to the number of loadings pcI' unit movement plane directions arc referred to as nexion an::! ::;-~
time (cycles). In dynamic loading. 10'lding frequency refers (0 tension.
the number of movements performed per unit time. In static Special featurcs regarding this movemcnt planc an: noted
loading. loading frequency refers to sustained positioning per for lhe cervical spine. Protrusion of the hC<ld in the :-.agiual
unit time. plane involves extension ot the u 'r cerVical s IIlC .lIlil n~x­
ion of the lower cervical s inc. Retraction of the head in the
s<.lgiual plane involves Ocxion of the tipper cervic<ll spine and
LOADING AMPLITUDE (OVERPRESSURE. MOBILIZATION.
extension of the lower cervical ~pinsJIllese movement::. may
MANIPULATION)
be referred to as trall,~/athm througli the sagittal plane.
Loading amplitude refers to the :.unOllllt of force applied dur-
ing c;,\ch cycle. For the purpose of thl': McKenzie appro'leh. TRANSVERSE MOVEMENT PLANE
loading <.lInplillldt.: usually refers tn the amOUlll of force ap-
.J
Movcment occurs about thc longitudinal axis. The oppo:,ite
plied to promote movement of the.: spine toward a morc COII/·
movcment plane directions within this pl<lIlC arc rcfcm:d to as
plete end range position. This movement is accomplishe.:d by
rotation right and rotation left.
the application of overpressure or In:'lllipulation.
Overpressure applied during dynamic loading permits
CORONAL MOVEMENT PLANE
further mOVCntcm into cnd range with cvery cycle. Ovcrpres. 1
-?
sure applied during statk loading. :1( end range pcrmits posi~ III Ihis pi<Jlle, also called the frontal or lateral n)(,w~ll\el1t
tioning even further into that end range. It may bc accom- plilllC. movemcnt occurs .Ibout the :-:agittal axis. The l1ppo:-.itc
plished strategically by the patient's <m'n means or with the movcment plane directions used by the McKenzie appfll<lch
usc of a device or .111 appliance. It 111<11' ;,liso be <.K'Complished within the coronal movement plane arc different for lh~ t:cr- ,.J
by the application of a force by the clinician. using a "hands vical and lumbar spinc. ror the cervicnl spine. right lateral
on" wchniquc. with or without. alollc or in combin'Hion wilh Ilexion and left lateral flexion arc noted. For the lumbar ~pinc.
a device or appliancc. Whcn the clinician's hands perform the right and left side-gliding arc noted.
overpressure in ;1 cyclic ,fashion. this practice is called mob;- Side-glid;lIK refers to a superior anatomic pal1 l1W\'illg
lizatioll, The chiropractic concept of "taking the sl;lck out" through (he coronal plane in the opposite direction rdatiyc to
corrc~ponds to moving a joint to end range. Th~ cyclic per- an inferior un atomic part. It also refers to the lrunk lllo\'ing in
formancc of this movement is mobilization, the relative opposite direction. through the coronal plane.
The greatest I(lading amplitude i~ applied by means above lhe pelvis. This movement ITl~~Y ~~ referred to a~ trall.\'·
of spinal l1Jatlipnllllioll. Ovcrprt.::'surc :lIIU mobilization arc lo{;oll through the coronal plane.
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 .. _ ....... ,~ ..... v .......,,;) VI"\.:lC:V VI" H.t:~I""'UN::;e::; IV LUADING 229

P\I.. itilllling within this llH1VCl1lCllI planc results inlhe clin- PATIENT USE OF APPLIANCE OR MACHINE
k'"l I'rc"'I..'nt"lioll of Ill...• ··..t1Halgic Ii:,!." This <llllalgil.." defor-
V,lriOUS devices lhal affccl spinal loading and do not require
llIit~. CI\ll:'liIUiing ~lll anile hunb'lf ...co!iosis. is a fC"'UIt of
tht:" assistance of the clinician or presence in the clinical set-
Iran .. l;llioll through tht' ('oronal plant'. The :lntalgic li:-;.t is rc-
ting :.Ire 'Ivailable to p.ltiel1ts. These appliances range from
fl'rr...·d hi :I" ;J letkntl shU/. and is nam....d ;tcI,:ording 11\ lh~ di-
maUrc;ss and dl.lir lypes to br<tccs. traction d~\'iccs. and cxcr-
r...·clil'll I righl lll" kfll by which the supcrior an;l\omi( p;1I1 is
c.::i",t:' ~quipmcnL
pll"iliPlh:d rclatin: till' inferior anatomic P:II·1.
ClINICIAN·GENERATED TACTICS
Luading Within .1 Spl'l'ilic Range of:.l rVlo\'cl11cnt Plane
Force introduced by lhe clinician may be combined with.
Whl'll dynamic IO;lding {1l:<:urS.il Illay involve movemcnt to
or aran from. pmicnl ..gcncratcd forces. Clinician~il1troduced
end ral1~c or only W wilhin mid-range of a movcment plane. r(lfL";..• ... r;mgc from mobilization to manipulation. Mobilization
Dlirill~ dyn:lmit: loading. e;l<:h poim in the mlWClllclH plane
Ita:o; becn characterized as forces that do not bring joint struc-
has a "dirct.:tional ('(lIllP(lllClll" defined by the int\}lidcd 1110VC-
lUrt~ beyond physiologic end range. whereas manipulation
.----;.. IllCIlI pl<llle direclioll.
has b~cn characterized as bringing joint structures beyond
physiologic end range. but short of anatomic cnd range.
Luading at a Specific Puinl of a l'-'lo\'cment Phmc

Sll~ledJ~.01~~lillg.-(,,(;,\(iG-loading-) may- be at mid-r.mgc or CLINICIAN USE OF TOOL, APPLIANCE. OR MACHINE

end r;lngc;. Susl~lincd po~itioning in mid·rangc may have a di- This category includes certain appliances or machines un-
rccti(ln~J!compollcnt n:I;ltive to :I previously assullled sus- available to patients because of expense. mechanics involved.
laillc;o positioning. S{~lli( loading al end range is usually re- or thc need of a c1inician's expertise. Examples include so-
ferred to ;;IS h~l\'ing lh~ 1I1()\'Clllcnl plane direction of which. phisticated traction units. "drop tables" that enhance manipu-
that end range is the culmination. I,Hive procedures. treatment tables permitting various spinal
positionings. and continuous passive motion units designed
Loading Poslure for the spine (Fig. 12.1). Surgical interv~mion is certainly a
ITlcc!mnical illlcrvention lhat reprcsents a loading tactic.
Thi~ term refer:>: to thc oricnt~l1ioll of the body (~landing. sit-
ting. t.:tc.).
I'REFERRED LOADING STRATEGY
Consider lhe ccrvic,ll spine lo.u.lcd in the movement plane
dircction of eXlension. The patient J11~IY be stmlding. sitting Str<Hegy refers 10 a plan dc\·ised to auain :1 goal. Loading
erccl. siuing slouched. lying prone. or lying supinc with the strategy refers to the choice or rejection of panicular loading
head and neck off the end of a lr~<IlIl1Cm lable-all examples lactics and lhe order in which those chosen loading tactics arc
of different W;lyS to position lhe body (loading postures) employed. A pnferred loadillg strategy is fr~l11cd by deciding
while extcnding the cen'ical spine. which:
Loading taclics 10 avuid
LO~lding Source (Source of Force) Loading taclics In purslle Sill111It'IllCOllsly
Loadmg tactll.:~ ma\' bt: gCllclatcd or modified by patients Loading tactics III pun;uc st:ttu~llli<llly
- Immcdi<.lIC ~CqUCllCC
themselves. appliances or machincs. as well as by lhe clini-
- Delayed sequl'ncc: introdllctitm of prcviously avoided loading
cian's intervcntion. Certain npplianccs or machines ~lrc rC~ld­
t;sctic
ily used by patients themselvcs. whereas other dcviccs (be-
cause of expense. mechanics. or expertise required) may bc
used only in a clinical setting.

PATIENT·GENERATED TACTICS

MovcmClHs or position:-;. may be accomplished by patients

themselves. Patients may perform movements activcly by re-
cruiling muscular struclures that specifically move or main-
tain 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 re-

I-t
~ t.;..}
cnliling the intrinsic neck musculature. Similarly. passive cx-
tension of the low back may be accomplished by performing
;1 "press-up" from the prone position with the pelvis remain-
[
t ing on lhe cxercise surf'K:c. lhus recruiling only elbow cxtcn~ Fig. 12.1. McKenzie Repex (Repeated End range Passive

t% SOfS and not lhe extcnsors of Ihe b;lCk. Exercise) unit.

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l
-lJ !:>'

~
::;;--'..:.~-;-----.,--------------------------------------------------
LvV n "" , ,n.' ~ I , _ •• _ ••••••• _ •• -

Tactics to Avoid Fig. 12.2. Right lateral

shift as a resull of clinician
Specific loading tactics dt:t:m~d therapeutically detrimemal overpressure during right
arc to be avoided as comaitucnts of the preferred loading side-gliding.
strategy. The practitioner Illuq lake into ;lccount the effccts of
avoiding specilic IO;'lding taclics ;'IS much as he or she consid-
ers 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 simultane-
ous performance of loading tactics: for example. it may con-
currently load the cervical spine dynamically. in the move-
ment plane direction of extension. while sitting. with
ovcrpres~lIrc. and a CCI1<1in frequcncy of rcpetition.

Tactics to Pursue Sequentially

.--~

Loading tactics applied one afler the mher. , 7

Response Value
IMMEDIATE SEOUENCE
Mechanical and symptomatic responses may be considered
This term refers to loading tactics applied immediately.
the S:'lIllC. better. or worse after:J particular loading strategy is
onc after the other. c.g., loading the cervical spine in the
pursued. Considering before and after possiblities. responses
movement plane direction of left lateral flexion. immediately
may be:
followed by loading in the movement plane direction of
extension. • Nonnal before and remain nomlal afterwards
• Nonnal before and remain abnormal aftcrw<lrds
• Abnonnal befoTC and remains abnormal aftcrwurds with
DELAYED SEOUENCE
• Equal magnitude
This term is used to describe the application of loading tactics • Greater magnitude
separated by a significant length of time. h usually refers to • Lesser magnitude
the timely re-introduction of previously avoided loading tac- • Abnonnal before and remains normal afterwards
tics. Loading tactics once considered ther••pcut;cally detri-
mental. may. after the appropriate delay. prove to be of sig- Response Temporal Faclors
nificant therapeutic benefic For example. on Day l. it is 11lCSC factors include frequency (~r camp/aims. timc required
detemlined lhat right side-gliding (Fig. 12.2) is the most (hcr~ to dicit a respm,...e. ::md n..·.tpmJs(· persi.wem.:£' a}[cr loading
apeutically beneficial movement plane dircction for the IUI11- ce.t.'latioll.
bar spine. and loading in all other movement plane directions
is considered detrimental. On Day 2. it is detennined that the FREOUENCY OF COMPLAINTS (RESPONSES)
previously avoided loading tactic of extension is now ther:.!- )
peutically beneficial. and in fact. necessary for fUrlher resolu- The frequency with which mcchanical or sympwl11;,uic rc-
tion of complaints. On Day 5. it is determined lhat the previ- sponses to loading occur during a specified time: paiod milY
ously avoided loading tactic of flexion is of benefit for the be charnctcrizcd as OIlC of the following:
patient so that full function may be recovered. Tot;'11 absence of the response (no complaints) ,--J
Intermittent frequency of the response (intermitt~llt COIll-
PROPERTIES COMMON TO MECHANICAL AND pl:.linls)
SYMPTOMATIC RESPONSES TO LOADING Constant frequency of the response (constant complaints).
Although mechanical \~ersus symptomatic responses to load- A plltien( may have no symptoms. experience symplOllls in-
ing have unique features or perspectives, they have certain termittcntly. or experience symptoms constantly during a
common response properties or parameters. described here <IS spccillcd period of time. Similarly. a patient may hayc no re-
response value. response temporal factors. poim of response strictcd r.mges of motion. experience a restricted i.mgc of mo-
elicitation. movemellt plane-specific respOfl.'ies. and m(~cl/{lIli­ tion intermittently. or experience :1 restricted r<lnge motion or
(:ally impeded end range. constantly during <l specified period of time.
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 CHAPTER 12 : SPINAL THERAPEUTICS BASED ON RESPONSES TO LOADING 231

TIME REOUIRED TO ELICIT A RESPONSE Responses do not persist afler loading ccss;ltion
RC~POllSCS persis! for a short period 01: time aftcr loading cess3tion
Thi~ p;lraHh~lcr n..·f.:r.' 1(1 th~ lHlmh.:r or duwtion of dyn:llllic Of
Rl:sponscs remain aner loading cessation
st;ui,: IO;lding q'<.:k:-- required 10 elicit ;1 mechanical or s)'mp-
101ll:ltk fl.'SPOllSC as. wdl as the tlday. if ;lIly. for the r,:"ponsc Consider <l patient who has 10\1,.' back symptoms that. at
W OL\:ur aria lo;ulil1:; ((,;lSCS. the end r~ll1g.c of flexioll, radiatc to the calf. If the radiation reM
Till' I/lIl/Ihcl" (lOom/illg cycles refer.:. 10 the frequency of a soh'e~ imlllediately, every time the patit.:l1t returns to lhe neu-
mt)\"I,.'llll,'1ll ~lr susl;lincd positinl1ill~ pl'f unit time: Ihc:,c may tral st,ll1ding position, this individual experiences a sympto-
hl' rd:ttin.:ly few (11' m:lll)'. IJllmlifJll r..:krs to the amount of. m:uic n:spollse that docs not persist.
timl' a -.u'[;tlncll pll,,,jliulIlng is held. All illIIJ/cdi(l((' I'('SI'0Il,H' If calf symptoms remain for a cl'uplc of minutcs afrcr re-
to d~ n;llnit.: loading or :'\waainctl positioning m:t:urs Oil the ini- Hlming. from flexion. to Ihe neutral posture, this person has
tialion (If the loading t:ll.:tic. A tlcla.wd rcsprJ11sc occurs some a response that persisted for a short period of time without
lilllt.' ;,1'11..'1" loading l:cast."s. remaining.
The [;luge or pl.ls.,ibilili~s arc: A response that persists is evident if dynamic flexion
No rt:"'p\III~l.: dicil..:d. r...·~;lrulcss tlf Ihe numher anUltll' uuralitll1 of
causes calf symptoms that rcmain for days after flexion load-
loadin~ l,:ydc.. . - ~ ing ceases.
RC"'I'0n~ ...• didh.:d tlll Illiti;llioll uf h};JdillJ,; eycle (illlllledi;lIC rc- Mechanically. consider a patient with 50 c/c flexion loss.
."plll\'-':' Dynamic extensions result in a 25% flexion loss. Dynamic
() Re~p"n~t: didtcd after relalively fl'W and/or slu.lfI duration of flexion results in a 75% flexion loss. After resting for a mo-
loadill~ cycles mcnt, however, after either dynamic H1Ctic. the 50% flexion
Rc"pnn.. t: eliciled :tlkr rdalivdy l1l:lIlY and/or long duration of loss returns regardless of the movement plane direction pur-
lO:I\..lill~ cycles sucd. These scenarios are examples of mechanical responses
Re ...ponw dicItcd aria l.:cSsatioll of l(ladin~ cycle (dcl:l)"ed rc- thar did not persist after loading cessation.
slwn"c)
If the patient has 0% flexion loss for 30 minutes as a
COI1~idcr (h~
following scenarios. result of performing to extensions, after which 50% flex-
Rc"pollses elicited 011 initiation of the hlading cycle Om- iOIl loss returns, this individual offers an example of are·
ll1edi~ltc response). for eX~llnplc. would be the patient who. spollse that persists for a short period of time after loading
during the performance of one dYlwmic extension or on initi- cessation.
ating ~tatic extension. expericnces symptoms or dc\'iation A response that persisls is evident if dynamic extensions
from the intended movement pl.me direction. Another pa· result in 0% flexion loss and rcmains so.
tient's rc"pol1se could be the relief of symptoms .lntl <Ibcrrant
movement.
f{c"pollses dicited after "rcl~lli\'ely few" or "short dura· Point of Response Elicitation
tion" of loading cycles. for ex~uilple. would be the patients for Mechanical :mdlor symptomatic rcsponscs may occur as a re-
whom 10 spinal extensions or .) l·ninUl\:s of static loading sult of loading at end range or between the two end ranges
result in thc onsct or resolution mechanical and symptomatic (mid*r,lIlgc) of a particular movement pl<llle.
rcspon . . c....
Rc\pollses dicill.:d aflcr '"relatively man>,' or "long dur'l-
tion" of loading cycles. for eX~lI11ple. would be the patients for i\:lovcment Plane·Specific Responses
whom 50 dynamic ~pin;11 extensions or sustained extension
end·r;lI1gc positioning for 30 minutcs is required to experi- Loading within ;\ particul~lr movcment plane dircction may
cnce the onset or resolution mechanical and symptomatic have mechanic<ll and/or symptomatic responses that are
rcspon ...cs. movement plane (or even movement plane direction) .'ipecijic:
Responses e1iciled .tfter cessation of lhe loading cycle spinal loading in onc movement plane direction may affect a
(delayed response) are. by definition. responses that oc· response in the same or another movemenl plane, The possi-
cur after the responsible dynamic or static loading stimuli bilities include onc or morc of the following:
ceases, Medicolegal bsues arise concerning the meaning No responses within the same or any olhl:r tlHlVCI1lCill
and the credibility of delaycd responses, proportional to the plane
delay. Responses in lhe sJme lllO....ClllCIl1 plane direction a~ loading
occurcd
Responses in the movemcnt pl;tne direction opposite 10 the load-
RESPONSE PERSISTENCE AFTER LOADING CESSATION ing direction
Rc.o;ponscs in iI movcmenl plane differcnt from Ihe lo:uling lUm'l'-
Mechanical and symptomatic responses may demonsrrate a ment plane
v;lrying dcgrce of persistence after cessation of the loading
slrategy responsible for generating the responses. The possi- Responses in the s<Une movement plane din.::clion in
hilities arc as follows: which loading occurs arc tina and foremost in the minds

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b
 REHA~ILlIATlON OF THE SPINE: A PRACTITIONER'S MANUAL
""'"
I.
of most clinicians. The patielll wh<? extends the spine and PROI'ERTIES UNIQUE TO MECHANICAL
experiences a limited. symptomatic end range exhibits a RESI'ONSES TO LOADING
mechanical and symptomatic rcspom:c in the movement Mech:tnical responses or objective signs constitutc c1inic;11
plane direction of extension. Repeated extensions cause cvidence (signs) pcrcepliblc to the e:<ntnining clinici~n. Th~
further extension loss and symptoms. If no other move- signs include observed ;lngul~tion. list. fixed deformities.
ments afC affected. these responses arc occurring in the rangc of motion phenom~na. and mcchanically impcdetl end
same movement plane direction in which loading raoge. TIle last tcrm rdcr~ (0 mechanical interference witlllhc
occurred. progress vI' lIlotion tv lh.lnnal. full end fange. The signs need
Consider (wo cases in which responses occur in the move·
not be associated with symplOI11s.
menl plane direction opposite (0 the IO<lding direction. Two
patients have flexion limited by 50%. One palient. after per-
forming dynamic extensions, can achieve full flexion. The Normal End Range and Curve Reversal
other, after pcrfomling dynamic extensions. is unable to per- Curve rcvcrsal rcfers to the ability to movc the spine from the
form any ncxion at all. These eascs arc examples of loading extreme of one movement plane direction to that of the oppo-
in onc movement plane direction that affects mechanical and site movement plane direction. Curve revcrsal includes· both
symptomatic responses in the opposite direction of the Same the ability to revcrse the "normal" anatomic curves in the
movement plane. sagittal plane and the ability to introduce curves in the oppo-
Responses in a movement plane different from the load- site directions of the coronal movement plane.
ing movement are noted in the following example. A patient Flexion in the sagi·:tal plane 1"('l'ff.'ieS the cervical lordosis.
with nexion limitcd by 50% due to symptoms c,m achiC"vc full increases the thoracic kyphosis. and reverses the lul1lb:~r lor-
flexion after performing dynamic right side-gliding. but is in dosis. Extension in the sagittal plane increases thc cervical
too much pain to perform any flexion after left side- lordosis. rel'i?r.w.'s the thoracic kyphosis. and increases the
gliding. In this case. loading within onc movement plane lumbar lordosis.
(coronal) affects the mechanical and symptomatic responses I-,tcral flexion or side gliding in the coronal plane pro-
in an entirely different movement plane (saggital). In fact. motcs a convexity in Ihe direction opposite that of the move-
loading in the OPPOSilC dircction of the coronal movement
plane (side gliding) had opposite effects on mechan-
mcnt pcrfomled. TI1C "nannal" ncutml spine has no curves in "'>.
,.
the coronal plane. These curves ilrc introduced or created
ical and symptomatic responses in the saggit:tl movement when movement in this plane is performed. Under normal
plane. circumstances. full range of motion from onc extreme of
the coronal movcmenl plane to the other is, accompanied
Mechanically Impeded End Range: by the ability to rel'er.H: curves th~lt were introduced by
The Mcchanical-SJ'Olptomalic Interface· movemenl and arc 1101 present in a neutral. resling. anatomic
position.
"Mechanically impeded end range" is a signilicam phI>
nomenon that call be perceived by both the clinician and
OBSTRUCTION TO CURVE REVERSAL
the patient. That it is recognized from both perspec-
tives makes mechanically impeded cnd rdnge an "interface:' An obstrm;l;oll 10 oint' rtl\'crsClI i.s a significant mechanically
in a sense. bctween "objcctive:' clinically assessed me- impeded end range lhal prc\'cllls spinal Illotion frolll pro-
chanical and "subjectively" perceived symptomatic phe- grcssing past the neutral position il1to the opposite movcmcnt
nomena. plane direction. Loss of the ability to reverse spinal curves re-
Consider patients who have restricted range of motion. sult.s in such clinical conditions as torticollis. acute scoliosis.
but no significant discomfort; i.e.. symptoms do not inter- and fixed kyphotic or lordotic deformities.
fere with the progression of movcmcnt. Thesc patients repon
that further movcmcnt is not possible. Not only is this lim-
MECHANICALLY IMPEDED END RANGE
itation observed clinically. but also. if the clinician attcmpts
to move the spinal area passively. an early cnd range is Althoul.!h loss of run~c of motion may resull from factors
detccted by the clinici<ln. It may be stmed thnt further m()~ othcr tl~all ll1ech;lllicali y impeded end mngc. only lhis factor
tion is "mechanically impeded:' This abnormal early end is considered in this di~cussion.
range resulting in mechanically impeded 1ll0VClllcill is rc· The degree 10 which curve reversal and normal end range
ferred to as a "Ulcc!wl/icalty iUl/Jcd,,(/ end rangc. .. with loss lllay be accomplished mfc:lulllicafly, when compared before
of global motion of which both thc clinician and thc patient and after loading. is listed in the order of diminishing succcss:
are aware.
Reversible cur"..: achic\"ing full. mechanically unimpeded end
Mechanically impeded end range docs nOI refer 10 motion range
palpation of vertcbral scgmcnts wherein the clinician oftcn Rever.-iblc cur\-..: Wilh mcch:ll1ically impetlcd end ran~\.·
detects restrictions or rixations unknown to the palicill. .lIld in Ohslrucliul\ {(l ~llr\'c IC\'crsal wilh nleCh;Hlically imp\.'dcd end
fact. full global range of motion may be present. range
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 ;:, ~A:;,cU UN RESPONSES TO LOADING
._ • _ 111L;nl"'lf'""t:U II
233

~ A revcrsibh: curve achieving full end rnngc would indicate meaning they arc equally positioned on opposite sides of the
I that 110 mcchanically impeded end rnngc is presenl. A me- spine. Unilateral symptoms affect one side of the spine only.

,~,
ch.mic;,llIy imr>l:dcd end mngc may be present. but curve re- The further from the spine symptoms arc experienced. the
vers,lI is pcnnittt:d nonetheless. i.e.. the progression of move- more peripheral arc the symptoms, \Vhen the topography of
~
ment is mcchanically impeded after curve reversal is symptoms ch:lIlgcs in response to loading. they may become
1 accomplished. more central or peripheral, referred to a~ the cclltrali:.m;oll J"l'-
! "f If the progr~ssion of movement is mechanically impeded sponse or the per;p!taoliwr;oll rcslumsc. respectively.
,~, before curve re"ersal is accomplished. the result is a substan-
~ ti •.! loss of movement and an eXlremely early mechanically CENTRALIZATION RESPONSE
~Ii
impeded end range. referred to ns a deformity. antalgia.list, or
, -, shift. In this symptomatic response to loading. lllore peripheral
" symptoms diminish or resolve and more ccntml symptoms re-

I
main. ;:Ippcar. and/or increase in severity.
.\
, ivtoycmcnt Quality
.'''''., Moyement quality refers to the ability to remain within PERIPHERALIZATION RESPONSE
"'-,}
the course of Iltt:: intended motion plane direction. It is tlS-
This symptomatic r':sponsc to loading. wherehy more periph-
,I' ' ) scsscd as:
.~ .~ eral symptoms incrcnse or appear. mayor Ill'l)' not be associ-

II
No t.lc\·j"tioll frum movement plane direction atcd with chiJngcs in central symptom::ltology.
OJ
~.. .-" Devialion from the intendcd movemcnt plane direction
Judgment of Fear
_.~

, Value of i\Jlechanical Responses

Fear of symptoms of discomfort. or fear that they might
p It is generally considered beneficial to effect mechanical re- worsen if experienced. is also an important li'ubjeclive phe-
sponses to pcnnil curve reversal with a full range of morion. nomenon because it may affect an individual's willingness to
i s') as well as the ability to accomplish. without devialion. the in- pursue a specific loading str"tegy. \Vhen possible. it is impor-
tendcd movement plane direction. t:'lIlt to dislinguish berween nn individual's willingness and the

1
:i
()
')
PROPERTIES UNIQUE TO SYMPTOMATIC
RESPONSES TO LOADING
individu<ll's ability to perform spinal motion,

Subjective Perception of Meclmnicall.y Impeded

i The symptomatic responses related to spinal disorders
End R:mge
commonly considered amenable to mcchi.1I1ical care arc Patients often report lhe inability to perform a spin:.il motion
.,... .,.~ pain. paresthe~ias. and' similar symptoms of discomfort. p.ISI :'1 certain point because of a sensc of being "blocked."
<y

,
Other symplOmatic (subjective) phenomena. however. arc They may report thaI. "Something is in there." "It feds like
.'''." equally impor1anl. Symptomatic (subjective) phenomena there is :.I rock or ball in there:' "A wedge is in there:' or the
.....) refer to: like. This subjective perception pn:n:nls further movement.
~.J
Often. il is the perccplioll of a mech:'1I1ically impeded end
Symptoms of discomfort
range. wilhOlU any symptoms of disl:omfoI1. that is rcported
~ - {opography of symptol11atic responses (ccnlr<lli~ali(1I1 or ~riph­
, by the patienl as the reason for r"ilure of further mo\·cment.

II , ...$
<c. craliz.'llion,
• Judgmcllt of fc,lr The patient's subjective pcrcepliol1 rc~cmblcs what is felt at
Subjectivc perception of mechanically imp'Cdcd end range the end rangc of norlllaL unrestricted spinal range of motion.
<
.J'
- with or withoul symptoms of discomfort at cnd rangc At other times, symptoms of disc(,lml\m occur at lhe sallle
time the subjectivc perception of thc "carly" mechanically
impeded end rang..:: occurs.
Symptoms of Discomfort
These symptoms include pain. numbness. p,ucsthcsias. burn- Value or Subjective Phenomena Responses
ing. and the like. They may be experienced during motion
or .It Ihe end range of morion, Not only do the symptoms of It is tltcmpeutic:'lily bencficial to diminish the subjcclh'c per-
discomfort havc different qualities. but also their location ception of mCc!l<lnil',llIy impeded end range. because the typ·

· may change in response to spinal loading. The location or ical result is impn.)\'cd mechanics. II is also therapeulically
. -~ I topography of symptoms is a key feature of the McKclli·.ic bcnclicial to diminish a palient's fear because fear prevents
.j
approach. the resumption of ;\t..·tivitics of daily Ih'ing,

I
<) It is not alw,lys Iherapeutically belldlcial 10 ;:\Void symp-
toms of discomfort. however. The Me Kenzie approach puts
Topography of Symptomatic Responses
into perspective which symptoms ,Ire therapeutically benefi~·
, t}
Symptoms may be cenrral, which means they arc experienced cial and which arc thcr<lpeutic,l1ly dctrimental (0 pursue. It is

I~ about thc midline of (he spine. Symptoms may be symmetric. hcndicial to c1idt the centralizatioll response. even though

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L·
-,- _
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~~ '-.j

,I,
 r •• , • ~ • • . • __ .

the severity of central symptolllS may incrl,?asL::. This mcrease; impurtant. Till'; \\L1~ Ihl.: diuician educates thc P;l\i~lll t1r;lll1~H'"
is usually followed by improved mechanics .md Ihe ultimate ically affcl:IS thai p..Hknl·sjudgment as LO whcther ur nOI fear
reduction of central symptoms. is appropriate. Laslly. regarding mcchanically il1lpeded end ... ".
Peripheralization responses ::trc therapeutically detri~ r'lllge. patiL::l1ts oftcn p-:rceivc Ihis carly i,,:lId rangc ;IS "normal"
mental if they remain after cessation of the responsible IO<ld~ hecause th~ir subjt.:L'livc perccption (lr tll1.: ill1pclkd t.:11l1 range
iog action. (0 special circumsl.l11ces, periphcralization tl1<1t may he idcllIicli {(l how "noflll;lF \.·lId range feeb. The dini-
does not persist after end range loading CC..ISCS is considL::rcLi d:m's assessment of lllct.:h'lllk;dly illlpeded r;lIl::c a" ;1 Illl·· ..... ,

beneficial. ("hallical sign play~ all import anI ft_lt.' in l!losc l':l~t.' ... ill whk'!l
! The McKcnzie appro:lch dcmonstrales it is therapeutic'llly p:l1iel11s do not realize any motion has heen 10SI at .111. ,
;
I, beneficial to pursuc cL::rtain symptoms and 10 avoid certain
symptoms. This principle becomes clearer subsequcntly when
i\ ~IECHANICALLY IMI'EDEIl END RANGE
I the syndrome patterns themselves arc discussed.
~
The lerm f1!e('/ulI/inllly im/)l'dnl n/rl IW1,t:C refers 10 an "Ih-
I Putting symptoms into <l perspective patients and clini-
nonnally early end range that interfcres with the progress (If
I
1
cians can understand, rather than fear lmd avoid, provides a
handle by which activity may comrol symptoms. The more
common practice is actively avoiding all symptoms, which
motion and mayor may not hc act.:lllnpanicd hy ~ymplollls.
Patients m"l)' perceive the samc proprioceptivc I.:UCS (10 11:111
I Illotion) m lhe mcchanically impedcd end range :1:-. they do :Ii
~
results in symptoms controlling activity.
normal and full end range.
I The c1inici:tn and the patielll bOlh. in their own ways. may
i LOSS OF RANGE OF MOTiON perceive lllcchanic:llly impeded end range. Thc patient sllh-
!
jcctively perceivc:, <I mechanically impeded cnd range pn:-

II Loss of range of motion plays a considcmblc role in Ihe cV<lI~

uation of impairment and disi.lbility. It is curious. lhcrcfmc.
that the mechanical and symptomatic responscs ass{)ci~
venting fllnher movcmcnl. whilc Ihe clinician may deduce it:'
ex.istence by obscn·ing the manner in whit.:h motion is illl~
peded, or may "feci" it by passively moving thc patient's
rued with range of motion loss do not ordinarily merit much

I attention.
Ostensibly, range of motion loss is an objectively mea-
spine until the mechanically impeded cnd range is dClect~d.

I
sured, mrchanical entity. Symptoms that the patient cxpcri~ Increasing Loading Intensit), to Differentiate Restricted
coces with range of motion loss arc recorded. if at all. withoul from Obstructcd End RangL'S
discriminating as to whether they occur during motion or <:It
If loading of sufficient intensity (cycles or ovcrprcssurd is
the end range of motion. As stated previously. range of mo-

I
not applied, the mechanically impeded end range may be un-
tion loss may not be associated with any significant symp-
accompanied by symptoms. Ov<:rprcssur~ is imponalll ill
toms. The patient's only subjective experience may be that of
order to load joint structur~s funher :\t lhe mechanically im- )
perceiving the abnonnally carly end range. \\o'hich may be per-
peded end range. thereby "overslating" typical end range rt.'-
ceived in the same manner as the "normal" proprioceplive cue
~ to halt movement.
sponses that occur there. The mechanical and symplOmali<.- rt.'- ,)
~ sponses to loading mechanically impeded end ranges with ;1
Range of motion studies usually have the patient perform
greater intensity differentiate mechanically impeded end
only a single motion in each movement plane direction. The
ranges into two types_ res/ric/ed end range ~nd ObslrllCll'd
effe<:ts of repetiLive movemenl or sustained positioning on
end ran.f!.('.
range of motion loss in lhe same or in a differenl movcment
plane direction. are rarely a~!\csscd.
RESTRICTED END RANGE

This mech~lI1ically impeded end range behave:-. as if lh~

"ReasonsH for Loss
progress of Illotion is limited. restrained. or "held back," It i:,
Loss of r~Ulge of motion d()e~ not result soldy from mechan . . slow to develop or resolve, wilh no mechanical or SYI11Plll~
ical factors that can be observed clinically or ~olcly from matic responses during motion. Any mechanical respol1:'t.'
subjective factors thm can onl)' be reported by the patient. (e.g.. dcviation from the intended movemcnt planc direclitm-'
Understanding range of motion loss requires integrating both occurs at the restricted end range only. If no symptoms arc rt.·-
of these perspectives. In slllllmarJ\ wnge of Illotion loss nlU)' ported at the restricted end (;.lnge. incrc'lsing the inlensily I I I
be attributed to symptom:- of discomfort. judgment of fear. loading at the restricted end range will elicit mechanical and
and mechanically impeded end range, which were described symptolllatic responses in a characteristic fashion. Celltral tlr
previously. This underlines the imponance of appreciating the periphcr<ll symploms ;:lre experienced immedialely .Illd only at
patient's symptomatic experience in order to .H.:count full)' for the restricted end range. and they do not persisllong after IO;ld~
mechanical disorders of the spine. ing ilt the restricted end rangc ccases. The centralizalion ft.'-
The clinician, howevcr. continues to 1'1..1)' a ke)' role. The sponsc never occurs. The pcriphcra1i:t.ation response, whcn il
clinical decision regarding the value of symptoms based on tiDes occur. tloes nO! persist. Overpressure simply exagger..u\.':,
their topography. ,md not just on their intensity_ is critically the symptomatic response at end range. whereas increasing {ll~
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 CHAPTER 12 : SPINAL THERAPEUTICS BASED ON RESPONSES TO LOADING 235
i
i frequenc)' of restricted cnd range loading docs nol change the Assume that with rcpctitin: dynamic loading to the ob-
1 characteristic rc~ponsc. During the initial examination. no structcd end range. every cycle of mOVClllelH results in a
~ change in how mechanics or symptoms respond to dyn<ll1li~ or lesser dcgree of mechanic~i1ly impeded end range. i.e .. per-
~
s(;l{ic loading at the restricted end range is appreciable. mining morc and Illore extension range of Illotion with each

I,
:
'~
?
OBSTRUCTED END RANGE

This mechanically impeded end range behaves as if an "ob-

stacle" or "blockage" is interfering with the progress of mo-
cycle of 1ll0WmcnL If discomfort was associmcd with loading:
at the obstruct~d end range. the Giscomfon would occur fur-
lher and funha into the range of motiol\ with cat:h cyl.'1t.· as
the stepwise pattern of improvement occurs,
Rcg:mjin& ~lalic 10<lding. assume again thaI the spine is
tioll. h ma)' oc quick to develop or resolve. Mcchunical :'ll1d mechanic'llly im~dcd in extension. Loading is pcrformc:d in

I
~
symptomatic responses may occur at any point of the in-
volved movement plane direction. 3$ well 35 at the obstructed
end range. Mechanical andlor symptomatic responses may
a static manner at the obstructed end range. The patient then
assume." a neutral posture and agnin performs sustained ex-
tension at the obstructed end range that is now encountered
1 develop immediately or aflcr a delay in response to a particu-
lar loading strategy. If no symptoms occur at the obstructed
after a greater range of motion. With each cycle. any di~co11l­
i end range. increasing the intensity of the loading will elicit
fort at the obstructed end range would occur further and fur-
ther into the range of motion as the obstructed end r;'\Ilgc
mcch:.mical and symptomatic responses in a characteristic moves along, again in a stepwise paHem,
1 fashion.
The centralization response or the pcriphenllization re-
On occasion. obstructcd end rangcs resolve rapidly
and, almost spontaneously without any special effort
sponse may be noted durin!! motion or at an obstructed end needed. In other cases. an increase of loading intensity (cy-
t r;.lnge. Elicitation of, or changes in. mechanical andlor symp·
tomatie responses to loading may persist after cessation of
cles or overpressure) may be necessary. after which [he
obstructed end range rapidly "gives way." The stepwise

I loading. Overpressure or increased frequency of loading at

the obstructed end range may radically change the mechani·
pattern just described may nO[ occur if the obstructed end
range "retreats" so rapidly that it appears to "melt away:'

i cal and/or symptomatic responses during motion or :It the ob-

structed end range. Overpressure at the obstructed end mngc
miJY result in Ihe centralizi.ltion response. the pcriphemliz;.I-
If loading at an obstructed end range causes its rapid retreat,
accompallied by a symptomatic market: the phenomenon may
be construed mistakenly to represent symptoms during me·

I tion 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 apprecia-
chanically unimpeded motion. It should be recalled in these
cases. howc\'er. that initial examination revealed a mechani-
cally impeded end range before aggressive loading t;:lctics

I i
C)
ble change in how mechanics or symptoms respond (Q dy-
namic or static loading at the obstructed end range is usually
notcd.
Differcntiating Obstructed End Rangc Symptoms from
Symptoms During Alotion. Mechanically impeded end
were pur~ued.

McKENZIE ASSESSMENT OF MECHANICAL AND

SYMPTOMATIC RESPONSES TO LOADING
ranges have been described as exhibiting two differcnt re- The McKcnzi~ npproach is that of assessing the responses.

I
sponse-s. one lypical of;) restricted end range. lhe other of an rc.lctioIlS. or effects of spinal loading. During Ihe inilial
ob!<>tructcd end range. LO<lding at the restricted end rangc encounter \,"ith the patient. this ~lssessment is performed
shows no significant change during [he initial examination, by evaluating Ihe history. posture. and quality of mo\'ement
and may show no significant changes for quite some time. of the patient. and by using dynamic and static testing pro-

I
Loading .It an obstrucled end range. on the other hand. ilia)' cedures.
demonslrate rapid changes concerning mechanical and symp-
tomatic responses.
Ordinarily, differentiating symptoms during motion from History
B symptoms at an obstrucled end range is not diftlcult. \Vhen an In addition to the usual history taken regarding neck and back
'§
obstructed end range resolves rapidly. however. symptoms
~ compl;'lilllS. the McK~nzie assessment makes particul;;lr in-
occurring at a mcch;.Il1ically impeded end range may be mis-
i takcnly construed as symptoms occurring during motion.
quiries regarding the following:
• Arc ")'UlplOm" consl~uu or intcrmiucnl?
I
ti
Confusion in this regard may muddle the proper choice of
therapeutic measures.
Assumc a C,ISC in which a mechanically impeded end
What is the t{Jp0gfaphy of symptoms?
Arc symptom" bcucr (lr worse with :Illy of the following?
- Bending

!
r;,ulge interferes with the progression of movement to full ex- - Silling
tension. Dynamic loading to the mechanically impeded cnd - Rising from ~iuing.
range of extension resolves the mechanically impeded end - SI;;lI1ding
ntngc within a minute or Iwo-a typical response of all ob- - Walking

I
stnlCleu <':l1d range. - Lyin,e

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- 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 pos-
tures are noted. This inform<'ltion rcvci.lls how the spine is ha-
bitually 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 conccn- Fig. 12.4. Cervical flexion.
trates on mcchanics (qu.unity and quality of movement). llot
on symptoms. At Ihis poiIll. the examiner .llso docs nol con-
centrate 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. 12.5. Cervical retraction.

II Modifications from typical range or motion studic:, in-

clude 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.

~
}1 CERVICAL SPINE STUDIES
,\!
.~ Protrusion (Fig. 12.3)

i Fig. 12.3. Cervical protrusion.

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Flexion (Fig. 12.4)

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(,

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 ___ . • ~.~ "<.-n rc::Vllv,:, OM':'C.U Ut~ Kt:.tit-'UN::)l::S TO LOADING 237

repetition ()( lILt: S;lllll: 1Il0VClllCnl. Till.: etfcl.:ts of

;;:-: ..,;- :",:, ,:1..:1'
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.., load-
ing or "lHaillcd positioning (sttltiL~ loading) hCltL'r dCll1\lll-
slrale:- 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.

Fig. 12.6. Cervical extension.

) Retraction (Fig. 12.5)

ExtelJsion (Fig. 12.6)
Side·bending ri~lll
Sidt:-bcndin£ len
Rutation right
Rotation left

Fig, 12.7. Lumbar flexion.

LUMBAR SPINE STUDIES

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\'i-

cal 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. there-
fore. 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 sympto-
l1l:Jtic responses to dynamic and/or static loading, especially
concerning the most pcripheral symptomatic compl<lints.
The mcch;'lllical and symptomatic responses that occur as
a result or one or two l11o\,cmCIHS may change signiIIG::Hly Fig. 12.8. Lumbar extension.

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 " .... ''"' .... , ..... 'f''\''VI~ VI " , ' - ..... ' ,,~ ......... r n ......... llllvl'lc:n~ lVI ..... I'IU ..... L

Fig. 1:l.g. Left lateral loading ill tht: 1ll0\'~1l1~1\I plan~ direction of concern ceases.
shift as a result 01 side- The usual progression of dynamic tcsts for the cervical .111<.1
gliding left. lumhar spine follows:

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 Dynamic loading in silgittal movement plane directions is

typically explored first. unless the patiem has signific<lnt ant·
algia in a coronal movement plane direction, in which case.
Fig. 12.10. Retraction lying.

:~ the coronal movement plane is explored first. If the patient :lp-

pears amenable (0 therapeutic spinal loading str.ltcgics in the

I
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

I
the lumbar spine.
Should loading in the coronal plane not provide s.llisfac-
tory answers. the transverse movement plane is explored. For
Fig. 12.11. Retraction lying with clinician overpressure.
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 dy-
namic testing, the sagittal plane is explored first. Olhcr movc-
mem planes and static tests arc secondary con~idcr.ltions to ,
,J
sagittal dynamic testing.

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
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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 I,.~xtcn$ioll wilh

left I,ltcral ~hift

STATIC TESTS

Static loading is often used as an of/cillary test 10 cOllllnn dy~

Fig. 12.13. Clinician traction-retraction-extension lying. 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)' be used in comhination with dynamic

Fig. 12.14. Retracted side-bending right sitting . and/or st'-ltic \(';sling. permitting further I,,;nd r.II1gl,,; PI-l:-'ilioning.
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 REHABILITATION Of' I Ht::: ::iI-'INt::: A. I-'KALi 1IIIUI~C.M ,;:)
240 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.
1
I -,
The lvld\.col.ic <.Ippnl:lch rc(.'ognizcs behavior paHcrns as t
syndromes ;uncnahk to tllcch;mi(.'<11 lO;'ldillg strategies. ,\ '-',
£

.-~

':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 gcncr~ltcd or c1inici"lll gen-

craled(Figs.12.21 Lo 12.231.
,)
Spine.Related Responses Versus Behaviors
A response may be deli ned <lS the reaction elicited by a ~till1·
ulus. In the McKenzie approach. the stimulus is mechanical ()
(spinal loading), and the response is the mcclwnical or symp-
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 demon-
strate 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<t1 IO:lding strategies.
Regarding terminology used to dcsl:fihe mechanical ;.md
symptomatic responses to spinal loading. behavior is often
used interchangeably with responSl'. Behavior. however. is
considered a broad tcrlll used to connote all the lllcch;'lIlic;l1
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and symptomatic responses to a pilrticular loading stl':lh.:gy. Fig. 12.19. Sitting slouched.
 -'"'' ...... , . , . ~'ll'l""'L. Int:.HAPt:UTlCS BASED ON RESPONSES TO LOADING
241

resrxlHd In the mechanical inllucnce or 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 COI1-
dititlllS. 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 load-
ing Slmtcgics in a specific m'lllncr. '

Clinical Rc~..soning and Utility

Tile syndrome pallcrns do not encompass all spin,11 C(}I11-
pl.dnts :llld conditions.lnll rather dclinc spin:d condilions IIl.1t Fig. 12.23. Extension in lying with clinician overpressure.
5i
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>(>~"'~/,ill'~'i>J~~~"''i~~~:.;~,~~¢>~'MMkI""-,,,"'<=J~''Wi''"\'>:f''''''~JWi>'''''''!.';\W'';;'''·~:'',WJ,'>'i"'"'J'>'''''''·~·'iJ'''ij·~~\'l'<~~1,,*,,\~,'''.'~M"",\\:U4,\'«","".,·".,!-\,~<>,·"t""'">"",'"""",\,.I.,, "~'I,\
".,,;"~_.•:.. 1:=,e<~'\>"""':

Table 12.1 Summary 01 the Three Syndrome Palterns

Rosponse
• Responses at Responses at Movemont
Mechanical or Frequency or Point of Rale 01 Persistence affer Rate or Responses Mechanically Mec!'lanieally Plane Preferred Aoasons lor
Symptomatic Complaints Response Response loading Syndromo During unimpoded Impeded End Specific Loading Potient
Aesponses (Responses) Elicitation Elicilalion CCssolion Rosolution Molion End Range Rango Rosponses Strategios Falluro

Postural Symplomatic only InlormlUenl Suslninod ond Ocl3yod onsel None Weeks No", Sympl~tic Nono ollisl Movement pl3flC AVol(j symptoms Igr,l/oflCo, In-
rango oller SVSllllllOC dJ/celion tlQvo, solf-
olld fnnQO po. spocllie conscious
Si!ionillg

Dy!>!unclion $ymplomatic and Ifllorm,tlcnl RCSlriele<! cnd 'mmcdjlllO O. re- Nono Mon!l,s Non" Nonc McchnnleiJl and Movemenl pl3nc Pvrsuo symploms Avoiding SyrTlp-
m"ehllnic,1! rango sl~ted end symplomatie dircctiOo spt!· toms
/3ngo eirlC

Oerangomcnl SymplQrnilliC nnd tnlcrmitltmt or Dvriog motiol'\. Imm~3toor Olien persisls Days Yo. Mcdlflfl!eltl and MecMnical and ton<f<O!J In ono Pursvo ccnlrllfizo· Avoiding symp-
mceh3nical Coo!>t3n! obslructed or (foI3YOcl. dvr- symptomatic symplom:t\iC movement lion. avoid po- roms of ccn-
unobslrueted ing motiOn. 01 plano dirC!Clion riptloraTiz:tlion trlllizalion
end rllngo obSli'\Jcte<lor may affect un-
ullOb$l:ucled othcr
cnd rango

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P,ltho;lna(UlIli<: S~'IHlnlll1C NOl11cllcbturc P.S. RATE OF SYNDROME RESOLUTION

Till.' syndnlllll' p;llll'rns ar~ idl'IHilkd by l'l.'(ognizillg group- The charnCltristic responses of the Postural Syndrome may
ings or Gltl.'goril'~ \If lll~l.:hanical ,\ltd symptom,nil.: r~spons~s take weeks 1(1 ch.\nge with propcr therapy. This period of time
10 loading. 111\1 lh~ p;lthO,Ill;IWlIlic hasis ror Ih~lH. NOHI.'- may be rcquir~d before it is possible to sustain positioning at
tlJl..'kss. the sYllJnlm~s Il;Iv~ bl.'~11 lI:tllll:d al.·l.:ordillg 10 the hy- the L'llipahl~ end range <lbsent a symptomatic response.
poti1l.'si/.~t.I p:lllh1;Ul'ltmni..: ba:,i", fpr their hdl:l\"iors. While Changes in tht: cnd-r.lnge sYlnptomatic respollse. ch<lracteris-
IhL'sC hypothL'sc, aI'\,.' lhe McKl.'ll/,ic s)'sll.:ln's "ilL'sl gut:s:-::' it Ik of this ...yndromc, cannot be accomplished during the ini-
j", imp0rlalll (0 rl'memher t\V(1 ",,\lient points regarding the tial evaluation.
Il;Ithoall;llomil· lith.':-, for these syndromcs. Thc lirst is lh'1I lhe
I
'yndromc:-: arl.' gnHlp~d ;u.:nm.ling 10 responses and I/O( P.S. RESPONSES DURING MOTION
p;uho;lI1aloI1lY. If resc.m;h provcs the rvkKcllzie palhonna-
I Curve rc\'cr~1 and the abilily to achieve mechanically unim-
$ wmic hypotheses aroncolls. the ohserved grouping or rt:-
peded end range without de"i<ltion from the intended move-
spollses will remain as empiric f'lel. Thc. l<;cc:ond point is lhat
ment pl'lllc direction arc fully preserved. No symptoms occur
the p.lthoanatol11ic.: litles of the syndromes help the clinician

I
during motion. The centralization or peripheralization re-
remcmber the conligllntliol1 of complaints so named. It also
sponses are never noted during motion.
.~ ... helps hoth thc clinician ,111d the p..uient to remember the rules
' .. ~
~urrounding trcaimcll( of the ~yndrol11es.
P.S. RESPO"lSES AT MECHANICALLY UNIMPEDED
~ Bcc:allsc tht: ulility of the syslem rests in its ability to 01'- END RANGES
I, g~nizc. dassify. and predict associated mechanical <Ind symp-
,, tommie responses to loading strategies, il may be granted that There is no deviation from the intcnded moveme.nt plane di-

i
I
~
Ii
..
the pathoamuomic c:oncillsions arc as If conclusions.
The pathoanalomic titles for lhe syndromes are tJ1C pos-
wral. dysfunction. and derangement syndromes. These syn-
dromc p;Hterns .HC summarized in Table 12.1.
rections. The symptomatic responses occur only after sus-
tained loading at lhc culpable mechanically unimpeded end
range. Ovcr~pressure docs not change symptoms significantly.
Symptoms are central, bilateral, or unilateral. depending on

I -, Postural Syndrome
the nature of the sustained end range positioning. The cen-
tralization or pcripherali7.3tion responses are never noted.

I
) Responses that do occur do not persist ancr loading ceascs.
P.S. MECHANICAL AND SYMPTOMATIC RESPONSES
P.S. RESPONSES AT MECHANICALLY IMPEDED END RANGES
Symptomatic responses characterize this syndrome. No me-
chanical response.. :Ire noted. Mechanically impedcd end ranges do not exist in the Postural

II
Syndrome.
C) P.S. FREQUENCY OF RESPONSES (COMPLAINTS)
P.S. MOVEMENT PLANE-SPECIFIC RESPONSES
The frequency of responses is ilHcrmittcnL
Loading in the symptQIll<ltic m\,Jvemcnt plane direction does
P.S. POINT OF RESPONSE ELICITATION not result in mechanical or symptomatic responses within the
~
opposite or \~ ithin 'other movement plane directions. Loading
RCSPOllSt;S an; elicited .It :I Illechanic<llly unimpeded end
in the oppo~itt: direction of the symptomatic movement plane
I, <") rmlge. llsllally in onc movcmcnt plane direction only.

P.S. RATE OF RESPONSE ELICITATION

direction, or in :Inother movement plane. does not direc!ly of
fecI the mechanical or symptomatic responses of the sympto-

I
l1l<ltic movement plane direction.
, This syndrome exhibits delayed onset of symptoms in re- Avoiding loading at thc symptomatic end range is Ihera-
",,",_-7
sponse 10 sustained slatic loading at end range. Sustaincd po- peutic in and of itself. Loading in <111 other movement plane
sitioning at end mnge l1Iust be assumed for a relatively long directions is equally therapeutic, inasmuch as they all :I\'oid
period of lime (c.g., 20 minutes) before symptoms arc thc symptomatic end range, although they have no direct ther-

I
elicited. The delayed onset of symptoms in response to sus~ apeutic bencflL
tained slatic loading may 110t be evidenl during the initial CX~
U aminatiol1 becausc of fOlilure to provide adequate static load· P.S. PREFERRED LOADING STRATEGY
ing time for the delayed onset response to occur.
., In the Postural Syndrome, avoiding the symptomatic end
range is of paramount importance. Pursuing symptoms at the

I
P.S. RESPONSE PERSISTENCE AFTER LOADING CESSATION
culpable cnd range is detrimental. Whcn the symptomatic cnd
Symptomatic responses elicited aftcr sustained static loading range is avoided over a period of time. symptoms at end range
at end range resolve once that loading taclic is terminated. are morc difficult to elicit, and cventually the PoslUral
\~)
• This bclmvior is typical of the Postural Syndrome and con- Syndrome re~olvcs. Whcn static loading at the symplomatic
~
tributes 10 the intermittent nature of complaints. end range is frequently pursued, it rC!T~!uatcs the syndrome
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and may diminish the delay regarding elicitation of symp· thorax nnd pel\'is in opposite directions wi!!lin !h': ce~~!l~~1
toms. Constant vigilance regarding. avoidance of the symp· movcment plnnc.
lomatic end range is rcquired to resolvc (his condition. which
gencrally is accomplishcd ovcr <I period of several weeks. P.S. SUMMARY INCORPORATING HYPOTHESIZED
PATHOANATOMY
P.S. REASONS FOR FAILURE OF PATIENT STRATEGIES
When noncontr.lctilc. lignmclHous. capsular. etc. slrlll.:tures
\Vhen paticnts do not sliccessfully resolve Ihis syndromc on are held at sustained end r<lnge for long periods of lime.
their OWI1, it is bCGmsc Illey :.Ire not avoiding thc symptomatic symplol1ls develop in what is ,I II/edlllllicaffy /llIilllpl'(/ed nor·
end range for long cnough periods of time. Postural correction mal Spinal joim structure subjected to abnormal stresses.
is required. and the paticnt mUSl be \'igilant to ..\Void the pm;· Release of the abnormal stress on these structures is ~lCC()Il1·
tural habit that holds the spinal joint al the "offending" end panied by immediate symptom:uic relief. As this abnormal
range. Pntients may feel too awkward or be too concerned stress or static loading at end r.mge occurs with greater frc~
about their appearance if this requires them to maintain <Ill up~ quency and/or duration. discomfort is easier to elicit. The
right. ncutnl1. sitting poslllrc. The p;uient may expericnce <I condition develops slowly. and the pain is intermittent be-
sense of fatigue in the corrected sitting position. or may ex· cause it is experienccd only when spinal joint structures arc
pcriencc new discomfort when performing proper sitting pos· held at sustained end range for a prolonged period.
turc. The Postural Syndrome is a mechanical problcm for Examination reveals no loss of motion or deviation of
"which pain or antiinflammatory medication is inapproprinlc movement, i.c.. no abnom1al mechanical responses. In "lddi-
and incffective. It has a specific mechanical correclion-to tion, no symploms ocqn during movcment or at end fi.ll1ge on
(lI'oid the symptomatic end range. exnmination. To provoke symptoms. the joint must be held at .,
, Jl
end range for a prolonged period. Therefore. the traditional
P.S. HYPOTHESIZED PATHOANATOMY examinmion of patients with "pure" Postur<ll Syndromes r~·
veals no objective or subjective findings.
\Vhen joints are held at end range. whether they arc extremity Neverthcless, these patienls may report having had symp·
joints or spinal joints. noncontractile structures such as liga- toms in multiple areas of the spine. which occur because of
ments and joint capsules arc stressed. An example is the bent holding multiple areas at end range. These patients .Irc nm
finger illustration. If the index finger is hypcrextcndcd. dis· hysterical. nor are they hypennobile. The best therapeutic i.\\"-
comfort is experienced almost immediatel~·. !f :: ::; hdd just enue is one of avoiding symptoms (sustained end range) for
short of the point of immediate discomfort, discomfort would a period of time long enough for the offended tissue to ex-
be experienced within 20 minutes. No pathologic condition tinguish the symptomatic response 10 suslained cnd·range
need exist for this abnormal stress to cause discomfort in <l loading.
nom1al joint. These principles applied to the spine arc pro~
posed as the origin of Postural Syndrome symptoms. which
Dysfunction S)'ndromc
occur when spinal joints arc held at end range for a prolonged
period of time. Dy.S. MECHANICAL AND SYMPTOMATIC RESPONSES
u
Symptomatic and mechanical responses characterize (hi:- )
P.S. RELATED TERMINOLOGY
syndrome.
The particular PoslUral Syndrome is named according 10 the
movement plnne" direction of which the offending sustained Oy.S. FREQUENCY OF RESPONSES (COMPLAINTS)
position represents the end range. The particular Postural
)
Responses arc intermittent.
Syndrome. therefore. is named in referencc to the particu-
lar end range at which stntic loading occurs. Somc exam-
Dy.S. POINT OF RESPONSE EliCITATION
ples arc: sustained extension. sustained flexion. suswincd
right lateral shift. and/or a combination of movement plane Responses are elicited al a mcchanically impeded end raT1g~
directions. of the restrh:lt'd elld range varicty.
Susrailled extension of the lumbosacral spine may bc
experienced during poor standing posture. especinlly in Dy.S. RATE OF RESPONSE EliCITATION
pregnant patients or lhose with a "beer belly:' In nddilion.
The Dysrunction Syndrome exhibits an immcdi:'llc elicitation
sustained extension of the upper cervical spine is experi-
of symptOimuic and mechanical responses at the resrrict('d
enced commonly with the poor sitting posture of head
emf rallge when sufficient loading ovcrpressure is prescnt.
"protraction.
Sustained fJe:(ioll of the lower cervical. thoracic. and lum.
u
Dy.S. RESPONSE PERSISTENCE AFTER LOADING CESSATION
bosac-ral spine commonly occurs with poor. slouched sitting
postures. Mechanical and symptomatic responses elicited immediately
A sll.'ilained lateral sllift may bc seen when all weight when loading at the restricted end range rcsolve once that
re~ts on one leg in a standing position. thereby shifting the loading lactic is (crmimued. This behavior is typical of lhe
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CHAPTER 12 : SPINAL THERAPEUTICS BASED ON RESPONSES TO LOADING 245

Dysfulll:lion Syndrome and contribUlcs to the intcnlliucnl na- nnd pcrhnps pennits the mechanically limited end range to be-
(un.:. or ('otllp1:linls. comc marc restricted in the future_ Daily frequent and repeti-
tive motion to the symptomatic end range is required to rc-
Dy.S. RATE OF SYNDROME RESOLUTION solve this condition, which generully occurs slowly over 6 to
20 weeks.
The charact~ristic responses of the Dysfunction Syndrome
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 Dy.S. REASONS FOR FAILURE OF PATIENT STRATEGIES

the syndrome ('annol be m:complishcd during the initial l\tticl1ls may avoid th..: r~:-.triL:lt;J t:IlU ntllgt= UCt.:"IU:-,t:= ur lh~
evaluation. discomfort involved as well as the proprioceptive clle of
reaching the limits of motion. In so doing. they avoid "thera-
Dy.S. RESPONSES AT MECHANICALLY IMPEDED END RANGES peutically beneficial" restricted end-range discomfort and
Restricted end range usuall), occurs in only one movement perpetuate the Dysfunction Syndrome.
plane direction. If it occurs in morc than one movement plane Pain or anti-inflammatory medication cannot correct the
direction, n:sponscs ;It the individu<ll restricted end range mechanical problem underlying lhis syndromc. which re-
have no clTcct on each other. Mechanical and symptomatic re- quirc.1:; restricted end-range loading for its resolution.
sponses occur immediately at the restricted end range only.
These responses do ilot persist after loading at the restricted Dy.S. HYPOTHESIZED PATHOANATOMY
end range ceases. Any deviation from the intendcd movcment As a result of chronic postural habits tha! avoid bringing
plane dircction occurs at the restricted end range only. spin:ll joint~ to certain end ranges. or as the result of tissue
Restrictcd end range may be accompanied by the subjective damage leading to scar fonnation. adaptive shortening or dys-
perception of mechanically impeded end range. If discomfort fllllctioll of tissue may occur. A loss of elasticity occurs caus-
i.\' /lot pre.fem at the rcstricted end range, overpressure creates ing restriction of spinal movement. If a perfectly nonnal
i(, but this discomfort resolves when loading at the restricted elbow is cast in a flexed position for I month. the ability to
end range ccases. If discornfon is presem at the restricted end extend it is restricted when the cast is removed, nn example of
r.mge. overpressure increases it. but again. this increased dis- the dysfunction behaviors just de~cribed.
comfort resohes when overprcssure at the restricted cnd Scar tissue. which shC'rtens over lime. may fornl at the site
range ccases. The centralization response does not occur. If of disk derangement or spinal surg~ry. After significant de-
the periphcraliz<1tion response occurs. it is experienced only rangement or surgicnl intervention. an at/herem nerve roof
during motions containing a component that achieves the re- may develop. exhibiting the typical mechanical and sympto-
stricted end range of the Oexion movement plane direction. matic responses of the dysfunction syndrome. The ndherent
Typical of the dysfunction pattcrn, symptoms thm pcripheral- nerve root condition may involve the peripheraliziltion of
ize do not persist aftcr cessation of loading at the restricted symptoms to an extremity without an associated "centraliza-
end r.mge of flexion. tion response:' This pcripheraliz.uion response occurs at the
restricted end r(l1I~(' of the flexion mo\'ement plane direction
Dy.S. MOVEMENT PLANE-SPECIFIC RESPONSES only. Olher special conditions must accompany this end-
Loading in thc symptomatic movement plane direction docs range flexion to elicit adherent n~f\'C root responses; e.g.,
not result in mcch.mical or symptomatic responses within thc extended knee for the lumbar spint:' and btend flexion of the
opposite movement plane direction' or other movement cervical spine combined with $houldt:'r ;:lbtluction. The pe·
planes. Conversely. loading in the opposite direction of the ripheraliz<1tion response noted with the adherent nerve root
symptomatic movement plane direction. or in another move~ docs not remain after the precipitaling loading actions ccase.
ment plane. has 110 effect on the mechanical or symptomatic Trc<ltment is ri:lshioned according to the preferred IO<ld-
responses in the symptomatic movement plane direction. ing Slratcgy for dysfunction: i.e.. t:yoking the discomfort <It
Frcquent Sialic or dynamic loading at or to the restricted end range. which. in this casco ill\'('\I\'l~s periphcralization of
end r.inge helps resolve the syndrome over time. Swtic or dy- symptoms.
namic loading in the opposite direction of the same move-
ment plane, or in another movcment plane. selVes no thcra- Dy.S. RELATED TERMINOLOGY
peutic benefit. The only therapeutic action is thal of pursuing
The particular Dysfunction Syndromc is named according to
the symptomatic premature end rnnge. All other movements
the movcment plane direction limilt:'d by r('stricted ('11(/ range.
or positionings arc equally ineffective regarding resolution of
EX:lInples include the following:
the syndrome.
Extension dysfunclion
Dy.S. PREFERRED LOADING STRATEGY Flexion dysfunction Undudcs "adh~'r~nt nerve rooC')
Righi rot,llioll dysrUnr.:ll011
In the DysfLlnction Syndrome. pursuing lhe symptomatic re- Len rowliu!l t.Iysrulli,:li~m
stricted end range is of paramollnt importance. Avoiding the Right hl(Cral ncxion dysfunction
symptomatic restricted end-range pcrpcLUatcs the syndrome Lcft latent I lh:xion t.Iy:,fUtlClioll
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I • Right side·gliding dysfunction pcd':-l'.:Il'!l<! r...n~~.·!..:~. tlwi,,~' lllidr~ll1ge motiol1. or during mid-
• Left side-gliding dysfunction range statil" loading.
Typically, rotation and lateralnCXiOll dysfunctions upply to
Dc.S. LOADING TIME REOUIRED TO ELICIT A RESPONSE
the cervical spine. whcr..:as the side-gliding dysfunctions
apply [0 the lumbosacml spine. The Dcri.l1t~~ll1-.:nt S)'lldrol11~ nlay exhibit illlillediatc clicit:l-
Because of the predominance of flexion in the industrial tion or dclay-.:d onsct of SYlllPI{)l\l:lliL' <lnd I1lcchanical rc-
lifestyle, extension dysfunctions develop cOlllmonly in the spons('s al the obstrw.;h:d cnd rallgt:. ;11 111l.'L'h:lllically ul\im-
lower cervical spine and lumbosacral SpillC by middle age. peded end rang.es. during IlltltiOIl. ~lr with midrangt.' :-t~llic
Bec.lUse of poor sitling posture, protr<lclion of the head oc- IOi.lding.
curs, which involves extension of the upper cervical spine.
Flexion dysfunction of the upper cervical spine commonly De.S. RESPONSE PERSISTENCE AFTER LOADING CESSATION
occurs as a result.
Responses or bdlaviors dicited as <t rcsult of loading <1t ~111 ob-
Dy.S. SUMMARY stfucted end r'll1ge. at ~I ll1cl:h.ttlic~1I1y unimpeded end r.mgc.
during midrange mOlion, or with midrange st.ltic loading may
The cause of the syndrome is shortened. nonclnslic structures remain ~lftcr the IOiHJing tactic responsible is terminatcd. This
that restrict spinal movemcnt. Rcsolution involves stretching persislcllcc i~ lypic.::.11 or the f)('mllgt'lIlt'lIl Symlmll1t' whidl i~
these structures. The loss of range of motion or deviation the only syndrome with constant S)'IllPll.llllS. especially those
from the imcndcd movement plane direction results from in· or pcriphcraliz;.Ition.
clasticity. Avoiding symptom:·: only perpctuates the syndromc
and may. in fact. slO\\lly enable it to develop funher by Dc.S. RATE OF SYNDROME RESOLUTION
approximating the ends of structures that arc then pcnnincd
to shorten further. Frequent and repetitive elicitation of The char;'lctcriMic responses of thc Derangement Syndrome
discomfort is required to improve quality of movement may changc rapidly and ntdically during the time provided
Periphcralizalion to the extfemity occurs only when the for the initial cvaluation. Resolution of this syndn.}mc may he
healing process subsequent to disk injury or surgery results in possible within a matter of da)'s.
the tethering of neurologic structures. which limits and is
challengcJ by the movement plane direction of flexion. De.S. RESPONSES DURING MOTION
Therefore. adherent nerve root is a subcategory of flexion The obstructcd end range may be significant enough to pre-
dysfunction. vent curve fcvcrsal. An obstructed end range exists in :11 least
For didactic purposes. this syndrome has been described onc movement plane direction.•md ma)' exist in multiple
as displaying syrnptomatic fesponses at a restricted end range movcment plane directions. Deviation from the intended
that cease once loading at that end r;;mge ceases. For all in· movement plane direction or symptollls during motion 11\:1)'
tents and purposes. this description is truc. To differentiate be nOled. The centralization or pcriphcraliztltioll responses
this syndrome from the Derangement Syndrome, 11Owever. may be noted during motion.
one must be cognizant of the possibility of a symptomatic re·
sponse that will not cease should overstretching occur. Such De.S. RESPONSES AT MECHANICALLY UNIMPEDED
symptom~llology is considered evidence of an inflammatory END RANGES
response to overstretching and damaging tissue. The potential
inflammatory response to overstretching shortened tissuc Deviation from an intended rnOVCJ1lell{ plane direction 'lIld/or
must be kept ill mind to differentialc this contingency from symptoms may occur. Overpressure may change mCl..·hanic;,I!
and/or symptomatic behavior. Thc ('entn.i1iz~ltion rc:,pollse
the constant symptomatic response attributable to mech'lI1ical
factors of the Derangcment Syndrome. docs not occur: the peripheralization re~ponsc may OCC\lr.

Derangemenl Syndrome De.s. RESPONSES AT MECHANICALLY IMPEDED END RANGES

De.S. MECHANICAL AND SYMPTOMATIC RESPONSES Obstructcd end ranges may occur ill ;1 single or in Illul-
liple movemcnt planc directions. If an obstruClcd end range
Symptomatic and mechanical responses characterize thc Dc· occurs in more than one movel1lCJ1[ planc direction. re-
rangement Syndrome. sponses at the individual obstructed end range may affect
etlch other. Mechanical and symplOl11Jlic responses may be
De.S. FREQUENCY OF RESPONSES (COMPLAINTS) elicited immediately or exhibit delayed onset as ~l result
Responses may be inlefmittcnt or constant. of loading at lhe obstructed end ran~~. Deviation from the
intended movement plane dircction may occur at the ob-
structed end range as well as at thL' unimpeded cnd range.
De.S. POINT OF RESPONSE ELICITATION
Lo'1ding at the obstructed end range may bc accompanied by
Responses are elicited at mechanically impeded cnd r~ngc(s) the subjrttivc perception of a mechanically impeded end
of the obstructed end range variety. al mechanically unim. range.
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 CHAPTER 12 : SPINAL THERAPEUTICS BASED ON RESPONSES TO LOADING 247
.. ~

If discomfon is nor preselll nt the obstructed end range. The preferred loading strategy revolves "round rcducin2.
(lvcrpressur~ may create it. and this discomfort may then ex· Inc key obstruction. This effon may be ..ccompanied b\' th~
hibi( it cemf<llizJtion or periphcmli7.alion response. If discom- rapid resolution of symptoms. or by the temporary incr~ased
fort is pn.!s(·",. overpressure may increase or decrease it. as symptomalology of the centralization response. after which
wcll as prc::cipita(c a centralization or pcriphemliz:.Itiol1 rc· symptoms resolve.
SpOIlSC. The centralization or pcripherali7..a tion responsl:s may Phenomena related to the resolution of derangemcnts
occur ~ll obstruCh::u end r.11lgcs. Centralizati(lll occurs only in exhibit varying degrees of complexity. The simplest GISe
mOVl.::mcnt ph\l1c directions (during motion or at end r;jnge) involves only onc obstrucled end ran~c in the saginal
'lhal comain the ""key" obstructed cnd range. plane. which is lhe key obstructed end rang~. The c~ntral­
i7.ation response may be noted at the obstructed end range.
De,S, MOVEMENT PLANE-SPECIFIC RESPONSES The peripheralization response is elicited typically by
means of loading within the opposite movement plane di-
Loading in a symptomatic or asymptomatic movement plane
rection. Peripheralization by means of loading in the movc-
direction may change mechanical and/or symptomatic re·
ment plane direction opposite to that of the obstructed end
sponses of the opposite movement plane direction or of <In-
i,
range may be elicited immediately or by deluyed onsct: i.e..
iI ()
olhcr movcmcnt plane dircclion, Thc,c changc, may bc thcr-
mechanically unimpeded nexion may pcripheralize. whereas
< apeutically beneficial or dClrimcnwl.
extension to the obstructed end r.mge centralizes. The less

I, d
<
In Ihe Derangement Syndrome, (he therapeutically bene·
ficial IO<lding action to pursue involves loading at the "key"
obstructed end range. In other words. iftherc is more than one
common. but opposite simple sagittal pattern. may also be
found.
~ ) More complex situations entailing multiple obstructed
obstructed cnd range. loading at onc" obstructeu end range

Ii
end ranges, of which only one is the key. may mandate an ini-
may be therapeutically beneficial, whereas loading at another
1 tial preferred loading stra[egy within a coronal or transverse
may be therapeutically detrimental or neutral. If there is only
movement plane. Consider a case involving an obstructed end
onc obstructed end range. that is the "key." Avoiding thera-
"l range in one sagiual movement plane direclion. a.~ well as an
peutically detrimental obstructed end ranges. moycment
I plane directions. or other loading tactics is of paramount im-
obstructed end mnge in one coronal movement plane direc-
~ ) tion. In such cases, it is possible that loading in both the unim-
% portance in resolving this syndrome.
peded and obstructed sagiual movement plane directions elic
S
p

'~
In general. the celltralizarioll response is nnlf'd ~\, n r(',ult
its the periphcralization response. Loading in the coronal or
" of loading morions toward or static loading at the "key" ob·
1;
transverse movemCIH plane is at first required to elicit the cen-
structed end range. Symptoms generally do not occur during
"
t' tr;jlization rcsponse. Subsequently. loading in the sagittal
motion within the movement plane direction that leads to the
~ "key" obstructed end range. especially after the first few cy-
plane becomcs necessary for further resolution or the syn-
I c .. ~.-J cles of dynamic loading arc <lccomplished. As discussed pre-
drome.
~ It is possible in cases involving muhiple obstructed move-
,~• (J viously. a rapidly retreating obstructed end range may mimic
symptoms during motion. when in fact symptoms arc occur-
menl plane directions. for loading at a single (key) obslrucled
•
• , ring at it rapidly resolving obstructed end range.
end range to resolve all obstructions. without requiring the sc-

I,
J quentiul end range loading just dcscribed.
The pcripherali;:.atioll response is noted as i.l rcsuh of
loading motions toward or at end ranges that do not cOllwin
,) De,S, REASONS FOR FAILURE OF PATIENT STRATEGIES
thc kcy obstructed. end range. These end ranges may be mc-
challicnlly unimpeded or may contain obstructions th.1t arc The ccntralizJlion response that occurs m the key ob:,tmcted
,\.J
I
"< -:~)
not reduced as a result of loading and. in fact. may becomc
worsc.
end range may entail a significant increase or creation of cen-
tr.ll symptoms. which patients understandably avoid. Because
~ the ccntralization responsc is associated with an increase of
k
cJ De,S, PREFERRED LOADING STRATEGY marc central spinal symptoms, patients may choose the thera-
:":,j peutically detrimClHal strategy of pursuing loading tactics that
',~
Pursuing and avoiding certain loading tactics. as well as lhe
',) diminish spinal discomfort, even though 'lesser paiphcral
\" ordcr in which lhey arc accomplished. is critical in the care of
f{ symptomatic complaints and significant mechanical disorders
, this syndrome.
Ii arc perpetuatcd.
~ In gcncral. symptomatic responses arc pursued if char'lc-
i terized by the centraliz.;uion response and avoided if ch'lrac-
De-S, HYPOTHESIZED PATHOANATOMY
(j
i
]
lcrized by the peripheralization response. The "key" ob-
structed end range is the one that exhibits the centrali7.<ltion The model for this syndrome is the derangement of imradiscal
J J response when pursued. Avoided arc obstructed end mnges. material or substance. whether it is solid (nuclear. annular).

iu mechanically unimpeded end ranges. or loading within move-

ment plane directions that evidence the pcriphcraliz<ltion
liquid (watcr. electrolytes, etc.), or gm;eous (e.g.. nitrogen).
The bchavior of symptoms and mechanics changes according
i , response. Avoidance of loading tactics that elicit the peripher- to migmtion and/or accumulation of intnldiscal substance or
I ',] aJi7.ation rcsponse is nor suitieicnt. as loading at the key ob- materinl in the anlerior. posterior. or lateral aspects of the in-

i \.Ji
strucled end range may still nor be accomplished.
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tervenebr'll disk space.

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Imagine a simple cas~ iii whid: :nli:idisc..: Iiia:.:ri;i: ...:..:- ";:1:Jer;lllgclllcllI i:, thought 10 h:l\'e occurred. SWlcd another '.,
ranged in a posterior direction. callsing ohstrucled end r.mgc way, it i~ descriptivc of hdta,·iors noted as ~,. (krangellh.'m
to extension. Flexion would remain ullobstructed but would of imradisL'al 1l1:11erial occurrcd ill the dCSL'rih~d anatomic
further promote this posterior derangement, eliciting pcriph- directioll"

I
z
I
j
eraliz<ltion during. or at the end range of. the dcmngcmclIl·
promoting flexion movement pl.me direction. The c:t'JI{mli:/I-
fioll respoll.\"l! would :.IcComp.ul), extension wilh oycrprcssurc.
as the derangement bcco:l1l::S rcdlH.:cd. The n:vcrsc case could
be imagined as well.
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
Consider a more complex situation ill whid. illlradisl.:..ll migrati(lll ()(" intlatlisc;'11 m"h:ri,,1 (lL'currcd. An accuiliulati(m
malcrial migrated in a posterolateral direction; flexion may in thc anterior companmcnt of lhe disk makes llexion I11C-.
further this migration. An obstnlcted end range could exist not <.:hani<.:ally difli<.:uh to perform. In cxtn:me cases. lord(l~i;'o is
only for extension. bUl also for sidc~glidillg as well. If the Iilt~ fixcd <.Illd irn:\'crsibk. Extension pronHHes the migrati{lll 01"
eral component is significant. extension may only serve 10 lllateri;.i1 to the ;uHaior ('olllpartlllelll. Extensioll Illay bl' ac-
squeeze this material more to the side. In Ihis case, both the companied by pcriphcraliz<ltiUIl or symptoms during IIH)tion
mechanically unimpeded flexion C1nd the ·obstructed extension or
or at end range as a result deranging material aIlH.:rillr:llIy.
could elicit the peripherali7..C1tion response. Loading in the Any limitation of cxtcl\:"ion woulL! he dill: 10 imolcr'l1ll:1.' of
I coronal (sidc~gliding) or the transvc~c movement plane di~ symptoms but not to mc(:hanic:illy impcdl.'d end !";lngl.'.

Ii
rcction (rolation) may be needed to reducc the key lateral ob~ Pcripheralizatioll generally docs not occur below the kllcl.: he-
struction and elicit the ccntrtlliz;.nion responsc. After this step, causc the nerve radicab arc nol idTectcd hy di~tortiol1 of the
Ihc previously aVOided extcnsion component becomes lhe key antcrior aspect of the annulus. Flexion is ohstnH.:ted and ac-
obstruction, and loading in extension may be needcd to fur- comp;'lI1ied by symptollls ..It obslrllctcd end range:. Flexit..'" to
thcr promote the centralization response. The laleral compo- obstructcd end rangc with overpressufe is ac<':olllpanicd hy thl..'
nent has been reduced sufficiently, and the task is then to n,> centralization response <.:orresponding 10 a redistributi()ll or

I
duce the posterior component. intradiscal marerial to a more cClltralloe:;.ltioll. ft.:sultillg in illl-
When disk material has migrated, both posteriorly and lat- proved biomechanics as wcll.
erally. obstructed end ranges exist in the respective sagittal Posferior (/erange/l1etlf describes behaviors (IS ~rposh:rior
and coronal movement plane directions. If loading in Ihe migration of intradiscal material occurred. An acculllul:nion
movement plane direction of extension reduces both of the in the postcrior compartment of the disk f11<.1kes eXh:n~inl1
obstructed end ranges, the lateral component is not consid- mechanically difficult to pcrform. In cxtreme cases, kypl\()~is
ered relevant. If loading in the ~oronal movement pl<.lnc di- is fix~d and irreversiblc. Flexion promotes the l1ligr:lli~'n ()f
rection is required first. the Imeral component of disk migra- malcrials to thc posrcrior comp<lrtmcnt, Flexion may be
tion is considered relevll'" to a loading str<.ltegy involving a ,Iccompanied by pcriphcraliz;.nion of symptoms during mo-
nonsagiual movement plane. tion or at end range as a result of deranging material pos-
tcriorally. Any limitation of flexion would be Jue 10 jllh,kr-
ance of sympwllls bUI not to mechanically impetkJ t:l1d
RELATED TERMINOLOGY
rangc. The pcripheraliz;'lIioll could extcnd belt)\.... IItt: knt'c.
Postuml Syndrome terminology is predic..1lcd on the position- because the ncr\"c radicals or spinal cord I1wy be afft.'l'!cd
ing that precipitates symptoms. Dysfunction Syndromc tcnni- by distortion of the po~terior ;.\:-;pecl of the annulus. E.\h.:n-
nology is predicatcd on the movement of the person that pre- sion is obstrucled ,mel accompanied by ~YJllptolllS ;1I l,b~
cipitates symptoms. Derangcment Syndrome terminology structed end range. Extension to ohstrll('tcd end rang~ \\-jlh
refers, in pan, to the lInatomic dircction of intradiscal de- overpressure is accompanied by the ccntraliz.uioll ph\.'llllm-
rangement. In contrast 10 the Postural and Dysfunction Syn- ena, during which intradiscal material rcdistriblltc~ w a
dromes. 1\\"0 classification systems arc used to organize De- more central location, resulting in improved bioll1c<.:h:lIlic~
r;.mgemcm Syndrome phenomena. as well.
Similar to the Postl"lral and Dysfunction Syndromes, L(/feral derallgeme/lt may occur alolle or in combill:Hil)(l"
the first method dcscribes dewngcmcnts based strictly on with anterior or posterior dcrangement: most frequently. il \'l.'-
the behavior of mechanics and symptoms in response to curs in combination with the latter, Unilatcral sYlllptOll\~. L':'· "j
loading tacrics, and namcs these bchavior patterns by p;'ltho- peei<tlly if they pcripher'llize, ;'Ire assumcd to have ;1 1:II..:'f:l1
anatomic inferences--derat,gemetll belwvicw tlomcnclalttre, component. If dynamic and/or static loading in the sa~itlal
The second mcthod refers to the presenting symptolll lO- plane centralizes symptoms, it is not considered a "rek\":lnt"
pography ;.md deformities. in 'Iddition to the dcr;'lIlgcl11ent Imeml componcnt. i.e.. the "key" obstructed end f;l1I~L' is
behaviors-derclllgemcnf bellavior-fOpCJK ral'hy·deforllli fy in the sagittal plane. If the uniiater,,1 techniques of :,iJt.'-
(87D) tlomenclature. gliding or rotation arc required to centralize symptolll:'. it is
Derangement Behavior Nomenclature, This tcrminology considcred a relc\'<.llll lateral component. i.e.. the Imer;,ll'olll-
is descriptivc of the anatomic direction in which the intradis- ponent is thc "key" obstructed end range. With a rclcv:l1l1 Ia{-
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 CHAPTER 12 : SPINAL THERAPEUTICS BASED ON RESPONSES TO LOADING 249

cral component. it is thought that an accumulation of in· i)~r:lll':;Cllh.:1l1 Thr~e:

tradisc;:IJmalcrial to one side or the other of the coron.l1 plane UnilLlll'ral or asymmclric SYlllPlOlIIS ahOlll thc :,pinc
is sufl1cicllt lO require a unilateral loading lcchniquc. Whcn Wilh ur \\ ithuut shoulder/arm tlr bllthld,~thi:;h ~Ylllptlllll ..
N(I deformity
there is a "relevant" lateral componem. movCIllCll[ in the
sagitlal plane not only may f<lil to elicit the ('cntralization phc. J)~ral\gcllll't1tFilm:

,,
nomen a, blll also may aClu.111y elicit tile paiphcl'aliwrioll n> Unil:lll'r:11 ur aSYlll1l1elrk ~YlllplOlllS ahoullhl.: spint:o
, sponse if further lateml mi£r:llion of intrtldiscal material n> Wilh Ilr \\ilh.mt shoullkr/anll \If bll!hll.:bllhi:;h ~yl1lplllllh
I suits. After rotation or side-gliding is performed to reduce till' With tkft1rlliity (If turtil,,·\llli .. ,Ir lumhar "'l'lllill~i~

II j
lateral component in these cases. the situation may require
sagitlal plane techniques to reduce the cClllr;i1 anterior or pos-
terior derangement.
()crangclll~nl fivc:
Unilah.:ral or asymmctric ~YlJlptnms "hml1 lhe spinc
Wilh ur without shuuldcr/ann ur hUll ods/thigh S),lllph1l11";
I An accumulation of disk malerial in the lateral compan- With symptom..; cxtcnding bl.:low the dhnw or knec
:~ ment resists side-gliding to that side becausc of the obstructed No deformity
~
n end range. In extreme cases. a list or lateral shift is ilxed
Denlngerncllt Six:
I" 1 ;:lnd irreversible. Side-gliding in the movemcnt p!;:iIle dirt~c­
Unil;ltcr;:tl or asymmetric ~ymptOlns ahout the spine
~
! -'-,
.7
lion of lhe patient's lateral shift has (he potential of pro-
moting the further migration of intradiscal material. aCCOIll-
With or witlluut :-;houklcr/arm (If bUlhl(,:ksllhigh symphllll";

I ',-,,-
',..J
p~\I1icd by pcriphcraliz..1tion of symptoms during motion or
..It end range as a result of derangi~g material more latcrally.
With symptoms cxtending ot:lnw [hc dbow or knce
With dcfonnity of acule kyphusis. IUr1icullis. or lumhar si,.'i1!i(lsis

I
.)'j
~
Any limitation of movement in the direction of the lateral
shift relates to intolerance of symptoms and not to a mechan-
ically impeded end range. Pcripheralizatioll may occur be-
Derangement Seven:
Symmetric or asymmetric symptoms about the spinc
With or without Shollldc.:r/arm or bUHocksllhigh SYl1lptC01~
! Deformity or
accentuated lordosis m,ly or may !lot be pre5Cl1l

Ii
low the knec because lhe nerve radicals are easily affectcd
"; by latcml distortions of the annulus when a posterior com- The "couplet" system of symptom topography. without and
" .,F ponent is prescnl as well. Side-gliding in the movcment with deformity. does not extend to the anterior dcrang-:ll1cllts.
planc direction opposite 10 the latcral shift is obstructed An anterior derange1l1elll with central symptoms. unil:ucml
)
I and <u.:companicd by symptoms ;It the obslfllclcd end symptoms. without deformity or with deformity. is classilicd
range. Side-gliding to the obstructed end range with over- as a derangement sevcn. The BTD nomenclature is reduced to

1 pressure is accompanied by the centralization response corn:-

sponding to a redistribution of intradiscal material to a more
behavior nomenclature only for anterior dcrangel11~lH~. which
arc assigncd the number 7.

I ... ~
ccntwl location, resulting in improycd biomechanics as well.
Derungemellt Be/zavior-Topograplry-Deformity (BTD) PARTIAL PATIERNS OF DERANGEMENT

I
-•..Y Nomenclature. This tenninology uses a numeric system,
labeling various derangcmcnt presentations from I through 7. One distinguishing feature of the Derangement Syndrome is
) the exhibition of parli;ll patterns. Because of Ihc l'omplex me-
Thc first subclassification of the dcrangcments is accord-
ing 10 their /,e!/{f\'iOl; as described previollsly. Derangemcnls chanical and symptomatic responses associ"tco wilb the
, I through 6 arc posterior derangements. Derangement 7 is an Dcrangement Syndrome. the absclH.:c of some of the typical
''~Ii anterior derangement dcrangcmclH responses docs not diminish Ihc ability w rec-
Dcrangcl1lcnl~ I through 6 .Irc arranged in couplets. with ognize thi!ol syndrome. Examples of partial beh'l\'ior pallcrns
lhe odd nUl1lbcr~ describing symptom topography. and the of demngcmcnt arc as follo\\'s:
,)
subsequent even-numbercd derangemcnts dcscribing (he Periphcr.slization rcsponse persisls without Ihe ability 10 dicit a
,) S'II11C symptom topography i.lccompanying a fixed dcfonn- centralization response
ity (alll<.llgia or deviation) of the spine. prevcnting curve Periphcr<llizution response pcrsisls after sustained end rall~": hl:ld-
{:..-~
reversal. Therefore. the derangement number indicates its iug only: no pcripher;llizalion elicited during mo.... ement
<';"";c
l behavior, symptom topography, and presence or lack of Centralizati(ln response pcr~i.~ts without thc ability 10 di . : il a pc-
',& dcformily. ripheralization response
~ This derangcmclll nOlllcndaturc is dcfined as follows: Pcriphcrulii'.ation resp\lH~e resol\'cs witlluut any l.'kar p;lll~rn of
£ '-.)
ccntmliziltinn rcsponse

I
DerLlllgl.:l11cm One: No pcriphcrJlir....ltioll. ccntraliwtion. or uther synlptolll .,:hanges:
, Central or ~Yf11metric sympwllls ablHlt the spin(: howe\'cr. mechanical rcsponscs occur
oJ No mcch;lnical resp~HlscS occur: howcver. symplumatil.' rl'spollses
R~ln':l)' shuulder/:mn or butl()eksllhi~h symptoms
,
--:\,_/i No dcfurmit)· dn occur

:~
d Derangement Two: SUMMARY

I .("".

J
C~l1tral or s)'1l11l11.:!ric symptoms alwut the spine
With or without shoulderhlrm or hUl10ckslthigh symptoms
With defurmily of kyphosh
The goal in the Dcrangcmclll Syndrome is 10 reduct:' the dc~
r;U1gcmcnl of illtradiscal material by having it migralt: back

I ~5~ "'",],
t.)

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;:.... n:::ntcr of the di~k Sp'ICC. Ohslructcd end r;U1gc in pcripherali/.~ltioll rcspun:'~ with i.I Dysfunction Syndrome
purely ilntL'rior or poslcrior dcr:lllgcl1ll'J\ls occurs in one l<lrcly pcrsists .Iftcr ce.:ssation of the loading action th.1t prc-
movemem plane direction. Obstnlcled I.'nd range GIll CXiSI in c.:ipit'lll.':' it. and Ihis loading actioll typically has n componcnt
more lhan one mow_mcnt plilllC dircl.:tion \\ ilh eilhcr rdc\·;Int of Ikxion In end rang.e.:. In thc Dcrangcment Syndrome, pe-
.--"~
or nonrek\·anl hueral C(lmpllncnts. If nlhtrU<.:tioll 10 mo\\> riphcr;.di/.alion may occur a\ any point of a movement plane
Illelll in tilL' cornnal pl:tll~ is dilllill<lll'd by loading in Ihe Ihal promolcs the dcrall~e.:IllCllt. and pe.:riphcral compl;lints
sagittal pbnt:. the lillcr:t1 h,:onlnal) t.:nmp"rll.'llt is not \,.'oll..;id- typiL"ally persist ;Ifter heing dicih:d. The.: pe.:riphcmlizatioll re· ,
-~

ered relc\·ant. SptHlSC of de.:rangclllelll is typil:ally associah:d with cClltraliza-

l1Hcnnilt~n( sylllj111111l:Jlic n;sj11111sC~ \\ ilh .1 Dcr.lI1gcl11clH lilHI rC~I}{)I\ses. Tilc pcriphcrOllization ..esi~l)nsc of dysfullctiOil
Syndromc lllay involv\,.· rq>ctitivc rcduction and der.lIlgclllcnl is IH1t.
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·
APPROPRIATENESS OF MANIPULATION ()
cui dispbcclllcnt of disk material llO! reduced by the llSU;.iJ lvlanfpul;.Hioll. within the.: McKenzie <Jpproach, is considered
movcments and positi()nill~s or the paticl1I. Prcscriptive load~ inappropriatc in l1lovcme.:nt planc dire.:etions that do not pos-
ing (a prd('rr~d IO<lding ~lr<lteg)') at the key obstructcd cuo sess Illcchanici.llly impeded end ranges. Therefore. manipula-
range is ofh:n slIcccs:-.ful in reducing Derangement Syn- tion is in'lpproprialc for the Postur~ll Syndrome. Only postural
dromes in these latter cases. correction is warrantcd.
Rcgarding the Dysfunction Syndrome, manipulation l11ay
Relationships Uctwccn Syndromes bc contraindicated at first. becausc of lhe danger of over-
stretching shortened tissue. Symptomatic responses to load-
In a sense. the prefcrrcd loading stratcgy for the Derangellll:nt ing persist only when shortcned tissue is strctched too fast or
Syndrome combines those of the Postural and Dysfullction 100 far. causing tissue injury that results in chemical. non me-
syndromes. inasmuch as ce.:nain discomfon!- must be avoided chanica I inflammatory pain. During i.l manipulative thrust on
and certain discomforts must bc pursued. Typically.•1 IIlcch~ a patient with a Dysfunction Syndrome, the operator may feci
nically unimpeded end range is avoided while a Illcchunically as if he or she has "bounced off' as a result of the resistance
impeded end range is pursued. Therefore. the sh;'lrp distinc· offered by shonened structures. In the Dysfunction Syn-
tioll made between the syndromes may be, instead. diffuse drome. manipulation is appropriate only after the adaptive
lines of demarcation; certain propcnics of onc mil)' mcrg~ shortening has been reduced signiflcantly. Manipulation is in·
into the other. appropriate as ~l main fonn of therapy in this syndromc be·
C<luse of the need to stretch this tissue repetitively during the
MIXED SYNDROMES course of the day over many wecks. This effon. is best ac-
In the previous dcscriptions of syndromcs. each is presented complished by patients themselvcs.
as if it exists "by itsclf.·· In clinical prilctice, multiple syn- The Der:lIlgcment Syndrome bcst represetHs the chiro-
dromes may coexist. .Ind all thrce may be seen in one p,ltiellL practic concC\)t of the manipulmablc Icsion or subluxation.
Movement of the inlradiscal substance rcsults in asymmetric -)
relationships of joint Wrf'ICCS. The supposition that the disk is
SIMILAR SYMPTOMS, DIFFERENT RESPONSES
n:sponsible for this disrcl'ltionship WilS nOlcd by Gonstcild,.l
The importancc of invcstigating me.:chanical and symptomatic ahhough thc critcriiJ on which he predicated mallipulation
responses to loading tactics cannot be overemphasized. wcrc mdiographic findings and not the mechanical and symp-
Information concerning a single mcch'lIlical or symptomatic tomatic re.:sponses to loading thc spine. The mechanical and
rcsponsc to a single loading tactic is not the nccessary and symptomatic responses to end-range 10ilding mobilizations
suffieiclH condition by which to diagnose a syndrome. (taking the slack out) performed by the patient or the clinician
Symptoms associated wilh siHing. may be aHributablc to a predict what the responses will be to manipulation ;'lccording
postural syndrome of sustained nexion. a Ocxion dysfunction to similar loading strategies. A lack of response or a detri-
syndrome. the promotion or a posterior derangcment, or the mcntal response to patiellt~gcnef<lted or c1inici311 mobiliza·
reduction of an anterior derangemcilt. Symptoms associuted tiOllS argucs against performing the manipulation, which
with standing may be associated wilh a sustained extension would rcprcscnlthc same loading stratcgy, albeit wilh greater
postural syndrome. an extension dysfunction, the promotion force. Radiographic evaluation or thc palpation of "sticky
of an anterior derangement. or the reduction or a posterior de- joints" docs not afford the clinician this samc information.
rangement. A thorough investigation of mechanical and The McKenzie approach recommends .manipulation only
symptomatic responses to IO~lding helps to dirrerGntiatc aftcr sclf·generated movcments have been explored fully and
among these possiblc caus<ltivc factors. cvidence partial therapcutic responses. Loading intensity is
The periphemfizalioll respo11.,\" may OCClir during the then incrc<lscd by IllC<lns of clinician overpressure.: (taking thc
Dysfunction Syndrome or during the Derangemcnt SYI1~ slack OUI) and frequency of loading (repetitions) to "test the
dromc. It docs not occur during thc Postural Syndrome. Thc watcrs" us to the potenlial benefit or detriment of manipula-

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 CHAPTER 12: SPINAL THERAPEUTICS BASED ON RESPONSES TO LOADING 251

live thrusts. h is impol1am to note th:.u the 1lI0\l:IIICIll plall\.: FlIIlI.:iiulI.::d rcslOralioll.~ work cOllditiollill~.s and work
direction of the manipulation cOlllcmplalcd is tktcnnincd by h"lfdening" pf(\~ral11s usc (his striCI dclinition of rdlf.lhilir~lion.
mcchnical and symptomatic rCSpOll$CS (0 loading. incJudil1!;!. The <Ipproach ,tresses the physical and psy,.:hologic advan-
patient-generated movements. patient rcp0r1~ concerning ccn- tages of rehat--!liwtioll dclinl.'d as acti\·ity.
lraliziJtion. and bOlh patient and clinician ohsa\,;l1iolls 1.'011· The phy:-i.:;:l advantages of these programs il1\'olyc rcac·
ccrning mechanic;\1 observations. tivating thl.' ]i1Ji, idual who may hay\.' heCOlllL' fcarful PI"
Lastly. n;~3njillg the relationship In chirnpral'lic. Ih..· 1Il0Vt,;IIlt,;11I .:mJ I.:llllSCqut,;lltiy dccondition..:d. ilt The p,,~ dlO-
McKelvie <'lpproach docs not claim lO be the llfst or unly ;11" logic ad\'anl':~:=;: i:.- to n..'''crSl' or prc\"I,.'11I .:Ihnonn:'11 iUne..... ht,;-
pro<lch (0 include the movement plane dinxtion of extension havior. ll hdpl:lf the paticlll idl.'llIify with :.-ocicl:l1 and wOfker

I (,I
~

j
'/"
as a thcmpcutic possibility. Rcinart'\ referred 10 extension ex-
ercise technique, therapy, and theory at (C.1SI as c<lrly as I96::!:.
roles rather than the role of a patient 'IS .';1 p;'ls:d,·\.' receptacle
of carc."I~
The distinguishing feature of the McKenzie approach is not FUllctional restoration, \\"ork conditioning. and work hard-
the advocacy of extension in selected cases, but the fact that ening program, ufC used on chronic c;.lses. Oftcn patlclH:, arc
treatment is predicated on medmnical and symptomatic re- referred to surh programs af\l.'r passiyc lll~thllds. Ill~di('atioll.
sponses to loading. In m;.my cases, extension .is indicated: or no lhcrapy at ;,111 (thc tincwrc of till1l:) fall 10 resoh'c the
however, ill many C<lses. movements otherthall extension arc chronic condition, III th~sc i,.. in':lI111stall~cs. passive cart:' h:1S-
wh:.n is required. The McKenzie approach is equ.lted incor- not helped the individu:'ll. but Ill:'y hayc .:ICIU;llly ··cncour;lgcd
rectly with an exclusive predilection for extension. Thc ap- lllusculoskeleull morbidity.··"
proach makcs. no a priori, dogmatic conclusions about what Patients presenting (Q ·'rehabilitation" centers with acute
every spine needs, which is perhaps the greatest virtue of its conditions often recl.'ivc passive therapy initially.n Thb ther-
clinical reasoning. apy continues until the demands of an activity program le.g..
progressive weight rc~ist;'lIlce) can be tOlerated without harm.
APPROPRIATENESS OF PROGRESSIVE The disadvantage of such initial passi\"l~ carc is (hat it 1113y ul-
RESISTANCE EXERCISES limately serve a purpose contrary to that of the physical and
psychologic goals of rehabilitation. Passivc therapy. if ilHro-
The McKenzie approach permits a thorough exploration of
duced first. has (he potential of ··~poiling" the paiicnt·s
which movement plane directions may be pursued and which
chances of progressing to unassisted. actlvc functional Jl..'tivi-
must be avoided. based on the mechanical and symptomatic
lies as thcrapy.<~ and incrcases the possibility or thc dc\·clop-
responses to spinal loading. A progressive resistance exercise
ment of abnonnal illness behaviors.l~ Sl,ll1lC authors:~ state
program is often possible much sooner than would otherwise
lhat much lo\\' back disability is iatrogenic and results fr0111
be permitted because the clinician possesses a clear under-
the medical prescription of rest fm simple bnck;'lche that is
standing of how a patients' spine reacts to moyement and po-
based on the misCOIll".'l.'ptioll lhat inl1;'ll11l11ation or olhcr p.:1tho-
silioning at the outset of such a program.
logic change pl:lys It ~igniticant role as a caus.ative faCll)r.
A rehabilitation approach in the a("utc phase can prlwidc
THE McKENZIE APPROACH AND DEMA:\DS
the physiC'll <lnd psychologic benefits of functional rcsh.)ration
OF REHABILITATION
and work conditioning/hardening programs that arc ll,t'd to
The McKenzie approach distinguishes itself among other re- treat chronic disort\('rs. It can, thereby. prcvclll the Ilccd to rc·
habilitation methods as being useful to patients with either solvc chronic conditions by not Icttin~ tl1(:m t.lc\'clop in the
acute or chronic spine-related complaints. As such, it is often first place. The McKcnzic appro,Jeh salislics these require-
an appropriate first step before considering passive therapy or ments. It proyides self-lrealment f.lcti,·ity techniques tokrablc
other aClivity therapies. When explored first. it often proves during the acute phase rhf.lt enl<lil th(' physicf.l1 and p:,ycho-
passive Ihcrapy is gratuitous and safely guides the course of logic bcnefit~ of more expensive and kngthicr rehabilit.uioll
subsequent activity therapies. such as strengthening roulines. pmgrams. It may c\'cn prevent the need fOf such sub~~quent
"Rehabilitation:' (0 some, equates to therapy in general, rehabilitation programs, as il employ~ 1110lny of the sal1l~ phys-
aflY kind of therapy. Used in this,manner. the term loses its in- ical and psychologic principles.
tended meaning and is even applied to passive methods. such If functional restoration or work ('onditioning/Ilan.kning
as hOi packs and ultrasound. Rehabilitation is not any means programs arc ncctkt.l subsequently. the initial liSt.' l)f the
to flllK'tional ends, but signifies fll11CfiOllCl1 means to rUrlC- Mi..'Kcllzie protocols is likely to cnh:u\i..'c the po:,sibililics
tion'll ends. of their success, bl'c.:IUSC lhese pn,lgr;ulls arc a COIKCPW-
The key concepts defining rchabilit;.ttion relate (0 cswb- ally consistent continuum from tha: initial acule carl' ac·
lishing an individual's skill (0 be able to "maintain :1 maxi- tivily therapy. Through its physical effcct. the rvkKcllZic
lllUIll level of independent functioning such as self C;'lrc ;.mu approach addresses Ihe mechanical na!un: or lhe p'l,icnt's
emploYlllent'·" In rehabilitation, the actions of the patient arc disorder. Through its tcaching of mech;'lIllcal prilH..'irk':, of
of p;'lr~11110unt impol1ancc. Guidance is provided by the prac- sclf·trcatmcnt. it is l.·onsistcnl with the prinCiples llf n:ha-
titionl.'r. but the burden of treatment involves what the pmient bilitation tl1<lt prc\'l'nt the develupmcnt of abnormal illncss
do(·.... ,md nOI what is done 10 thc p;'llicnl. behavior.

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 I Nt: ~t'INt::
, ..... ' 'r\V''-' '''I 'UI,. ur- A PRACTITIONER'S MANUAL
1'"
The paticlH lcarn~ that therapculic movement and posi- "[f there is the sliglllcst chance tllat ;:1 p~l\iCllt be CdllC:ltcd
C:iIl
l'
:I
tioning may be accompaniL'd by incn:a:,cd pain wilh improvcd in ;:1 mclhud of IrCatmcnt lhat ellahks him to reduce his own
:1 ,-"
funclion .•1Ild thaI ccnain p.lins ;lfC 1101 to hc avoided. pain and disahili!)' llsill~ his own underst:lIu..ling and resources.
I
COllgruclll with the ~trictL'st rehahilit;ltiOli prillciplL's i.' the hI.' should n:r.:eivc that education. Evcry palient is cntitled 10
"halld~ off' first approach. If rcsuh~ ;trc limiled. lh\.' ;Ipplil'a- !hb illfuflnation. and ,,:"l.'I"y th..:r::lpist ~h(llll(J he ohliged lo pro·
tion nf passive approachc!'l is :.tl\\'a)"!'l p\lssihle. hut Iht' l'OI\1ml \ ill..: it:""
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' HEFEHENCE.."i
trcalment p(,ssihk duril1~ the itl.;utc ph;tsc. Pt'flllillillg contin- I, ~kKell/.ie RA. ·1111.' lumbar spille: r..k..:halli\:;ll Diagnosis and Ther;lflY.
uous. rclativdy passi,'c spinal motioll to hI.": slrategic.:ally pCI'· WaiLlIl:le. New '1...::11;md. Spinal Publkalions. 1981.
~kKcn/.1c RA: 1111: Cen'iI;al ;Illd 'nlOmdc Spinc: Mech:lIlic;l1 Diagnosis
formed by the paliclH. Tht:sc llHIVL'IllCl1tS cnh'lllcc tilt: organi. 1

:1ll~1 Tller-IPY. W:libu;lc. New Zcal:lIld. Spin:ll Publkaliolls. 1990.

zation of "ncw" tissue along lht: lines of stress. with th~
.'. 11:IIdl:lll>l1l S: North AlIleril'all Spine $oeiel)': Failure ~\f the palhology
formation of Ikxiblc scar tisslle, Ii T<lsks arc ilHroduced OJ} a m\~ld III pn:dicl back p;lin. Spinc 15:718. 1990.
dcmand-graded basis. -l. Hcrbst RW: GCUlsle;lL! chiropral:llc scicncc and :m. r.,·11. Horch. WI. Sci·
If McKcl1:t.ic activit)' thcrilpy is dispensed uunng the ,Icute thi l'uhlic;lliullS. J9XO.
phase. fear of p'lin and the signs 01" pain avoidance or illness :i. 1l:lrrak R. Di:lIl1ollll R. Fiboll R. 1.'1 011: M;lIlipulalivc m:lIl;lgelllelll hUH-
h:lr disc bulge. Chiw Tedl 1:87. 1989.
beha\'iors arc nut cllcouraged. 11l and the protrilctcd treallnent
6. Dculsch P. Sawcr H: Guidc 10 Rchahilil:uiull. New York. ~·t:ltthew
illlcrvcmion for piltients \Vilh chronic disorders is i.l\:oided. lIcncler.'<: Co., pp :W-'O. Suppl & Rc" 1989.
Ttwt it is of potential benelit during the ,Icute phase should 7. Mayer T. Gmchc1 R: Funclion:11 ReslOr:llion for Spin:11 Disorders: The
not subtracl from considering McKenzie protocols as the log. SP()rts tvk'tlidnc Approach 10 Low B:lck Pain. Phil:ldclphia. Lea &
iClll first step for lhc treatment of chronic conditions. for the h:higer. 1988-
X. hcr:lhagcn S: Work h:mlcning or work conditionillg.-whal's ill a n;II11C.
samc reasons just givcn. Jr strength training is not needed for
Il1du~1 Rehahil Q He:!l:7. 1989.
trcmment of a chronic condition. the McKen:t.ic protocol rep· 9.....·lalhe:-un LN. Kelllp OJ: Work h:udcninl;: (kcupalion:lliher.,py in in·
resents a relatively quick and inexpensive alternative. du~trial rchahitilalion. Am J Occur TIler 39:314.1985.

The McKenzie protocol is an exccllent intervention 10 In. Troup J: 111e perccplion of musculoskdelal pain [lIld incapacil)' for work:
prevent physic:.ll and psychologic complications of injuric!'l. It Prcvcnlicll1 :ll1d early lre:lllllel\l. PhysiOlherapy 74:435. 1988.
II. !'jtowsky J: Abnonnal illness behaviour. Psychialr Med 5:85. 1987.
includes individuals laking an :Jctivc, responsible role in re·
12. 5..:11 J: Inter\'ertebr:tl disk heOlialioll in nonopcr::ltive tre;ltmClll. In
habilitation appropriate to their level of functioning. illl· Phy~ic;11 Medicine and Rehabilil:ll;on: St.. lc llf lhe An Revie\\"s.
provemenl in physical functioning rather than simply cOllcen· Philaddphi:I. Hanley & Dcllfus. 1990. p 185.
lrating on symptomatic relief. safet)' practices. maintaining 13. Mi\(:hclt RI. Carmen GM: Inlellsi'.e active c~ercisc pmgi,llll. Spin,,;
the worker role through minimal time iIWi.IY from the work 15:51-l.1990.
I-I. Dcrcherry VJ. Tullis WH: Dehl)'ed recovery in the palient with a work
place. activity control of symptoms as opposed to s)'mplO·
(Ollll'ICns;Ihlc injury. J O~'cup Mcd 25:829. 191D.
matic control or activity. and an attemplto avoid usc or anal· I:; . Ww..k kll G: A new clinical lIlodel for the lreallllelll Ill' !OW·h:1Ck pain.
gesics or passive treatment methods. Spine J2:(.32. 1987.
As st;:ltcd elsewhere: 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.
"By rcllucing the usc of llll..'rapist's t~c1llliqtle in the initiul ,tag\,;:- 17. E\,:.lns I): 111c he:lling process 'It cellular level. Physiolher:lpy 66:~.
of trC~ltlllellt ~uu..ll1la:o;imi1.illg paticllI tcchllilillC. the p:lticnl will I\}SO.
recognize that his recovery is largely the result of his own 1.:1'. IX. McKerll,ie RA: The Ccr\"ic31 and Thoracic Spine: Mechanic:\1 Diagno·
..i\ and Therilpy. W:lik:lOae. New Zealand. Spinal Publications. 1990.
to a"sume rc~ponsibilit), for acti,·c par-
forts. r:'cw patients filii
p Ifn.
ticipation in their treatmen!. pruvi(Jing the inslructioll :1Il(J cdu- 19. MeKe",~ic !{A: ·nlc CerVical amI l11OT:lcic Spine: Mechanic:II Diagllosis
cation process is firmly and vig(,rou~ly pursued."ls :Incl Ther:lpy. Waikanac. !'\cw Zealand. Spin~ll Publkatioll.~. 1990. p 113.

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; 10 Manual Resistance Techniques and Self-
Ii Stretches for Improving Flexibility/Mobility
I CRAIG LIE BENSON

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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·
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

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dun:s (\IEP/ of the oSIt:opathy. These techniques illYO!VC
manual re"ist;lllcc of a paticnt's isometric or isotonic museu·
FI.EXIBILITYTII,\I"I1\(;
lar efron. This resisted elTon is typic"lly followed by a slrclch Two a:-.pects to MRT arc their ilbility to relax an o\'eractive

I of a light or tense mllscle. The MRT arc primarily used to

rcl<lx o\"cr<Jclivc IlHlsdcs or ll) stretch shone ned Illuscles and
their associated fascia. Many different methods have been de-
veloped depending 011 the clinical goal. To achieve these pos-
itive clinical dICciS. tvlRT t'.lke advantage of two physiologic
muscle lincreased neuromuscular lens ion or "spasm") and
their ability to enhance stretch of a shortened muscle or its as-
sm.: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 at-

II
phenomena: postcontraclion inhibilion and reciprocal inhibi- tcmpting any aggressive stretching maneuver. Often a "re-
tion (RI), The MRT arc in":lluable workhorses in the re!l;Jbil· lease phenomena" Ol..:curs so that a length change occurs llU-
ilatian of the motor system, tom;'ltically after merely relaxing excessive neuromuscular
These techniques ilre also used to facilitate or train an in- tension (~ce Chapter II). In such Cases. treatment serves as a
hibited or weak musl:lc. Because the doctor or therapist pro· di;I~Hl0qic lest. differentiating neuromuscular (contractile)
vides the resistance. precise patient positioning and move- from nmnecti\'c tissue (noncontractile) probkms. Even if
ment cnn be controlled to;'1 degree not possible with machines noncontractile p;lthologic changes have OCCUlTed. it is still

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or even free weights. Manu;'11 COIlt;'lcts also allow for proprio-
ceptive 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 strength-
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

I cning.
Publications about thc lISC of PNF to facilitate ncurologi-
cally 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
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 (reci-
prol:tJl inhibition). which sl;.ltes lhat when one mu:,dc is con-
tr<lctcd. it'" ;lIH;'lgonist is aUlomatically inhibited. For instance.

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d<:vclopment or various forms of PNF (i,e.. hold-relax. COI1-
tracl~rc1ax. elc.) that could be used for onhopcdic ;'IS well ;IS
neurologic problems. The osteopaths primarily used Illuscle
ir the quadriccps is cOnlructcd. the hamstrings ar(' inhibited.
tllUS allowing for easier stretching of the 1'1Itt.'r muscks. This
prol..:cdurc takes advantage of Sherrington's Law of reciprocal
energy procedures (MEP) to mobilize joints, They abo dc\'el- inhibition. The purpose of Rl is to allow an "lgoni:,{ (i.e.. bi-

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oped <l \'aricty of applications designed to stretch shortened CCPS) to achieve its ;.u.:tion (flexion) unimpeded by ib antago-
) muscular and connective tissucs and to strengthen weak nist (i.e .. triceps). Different cxplal1iJtions have ~'el1 proposed
muscles.• for how the effects of MRT arc ;u.:hicved. Whert:..ls only post-
Manual medicine practitioners in Europe werc nol far be- contr<tc.:tion inhibililll\ ami RI havc been validatt:'d. other sug-

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hind in incorporating these new methods. Gaym<lns and gcstt.:d mechanisms includc autogenic inhibition. Goigi tcn-
Lcwit~ wrQlC of success in applying these techniques for joint don org.1O stimuhnion. rccipwl.:;ll inncrv<Ilion. pr~syn<lptic
mobilization using specific eye movements and respiratory inhibition of la afrercnts. rescuing or the gamma system, <.\l1d

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{) synkinesis to cnhance the physiologic effecti\'cness of the postsynar1ic.; inhibitioll.
procedures (sec Chapter II). Later. Lcwit~ foclIscd Oil a gen- 11 hal., been demonstraled that the receptors r~sponsible for
tic muscle relaxation tcchniqut.:. termed post-isolllt.:tric relax- this inhibition arc intramuscular ,ll1d arc not in the skin or
253
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joints." Measurements of the Hoffman renex activity (reprc- stabilization. The HR technique involves isometric resistance
sCnlativc of the excitabilily of the motor neuron pool) show and is u.•.:d mostly for pain relief. Used for relaxing and
activity is inhibited ror up to 15 to 30 sCl.:onds after an agonist stretching tight musclcs and related soft tissues, CR incorp{)~
or antagonist contraction. \\'ht:I\~aS inhibition only lasts about rates isotonic resist:.mcc and l1lultiplanar (usually diagonal)
10 sec~nds during sratiL' slr:.:tclling. 7 This effcL:1 has been movemcnt. Both "lgonist and <llltagoni:'it muscles arc used to
found to be neurologically m~di;.ncd .md not a result of any cre:.He a neurophysiologic sUlllmation of RI and postcontrac-
mechanical dfl..'('·t.:< tion inhibition. •,
Mu!'clc fiber:' also han:: l.:LI"tain billlllt:chanical dmractcr- When ost~op:lthic physicians used these procedures. they
istics thai ..Iffecl their stilrn~ss_ SJ.:'.:lctal muscle f1bcrs arc applied them 10 lllobilil.e joinls. as well as to strenglhen and
known to adapl to imposed dcmands. For instance, during relax muscles. referring to them as muscle cnergy procedures
growth. muscle length incl"l.."lsCS as new sarcomeres arc added (MEP)."' Using a langu"lge familiar to chiropractors. they de-
~ (in serie.s) and inJividml1 libcrs illcrc.lsc their girth." Pro- scribed the area where Ihey fell movement was limited, or if
t
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longed iml\\obitizi:llion of a limb joim in"\11 extended or short-
c,;cd position resui(s in all increase or decrease in the number
resistance is perceived prematurely after moving a joint
through its full available range of motion or lengthening a
II of sarcomcres. respectively."·I" Whcn immobilized in a short-
cned posilion. musdc sliffness incrC\lSCS. 1O It has been ob-
muscle as far a.c; it will allow, as a "pathologic" barrier (sec
Fig. 11.3). The MEP were developed by o,teopalhs as aller-
fI served that an il1l::rcase in connective tissue occurs with natives to thrust manipulation procedures for restricted joilll

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iml1lobilizHtillll in ..I shortened positien. II mobility. In these cl.lscs. the usc of fairly gentle forces arc re-
Conncl.:tivt: tissuc proliferation is minimized if the immo- quired. 1lley were also used on muscles in a way similar to
bilized muscles arc placed in a lengthcned posilion or their PNF.
contruclile aCli\·ity is m.lintaincd with c1cctric<.11 stimula- In Eu·rope. milnual medicine physicians soon began expcr~
tion. IIl· 11 Thereforc. either p.lssive stretching or maintenance imcnling with Ihese methods. Gaymans and Lcwit~ wrote of-
of contractile activity in immobilized muscles can prevent success when using these techniques in an extremely gentle )
I muscle sh0l1cning and connective tissue proliferation. fashion. At first, they used the rhythmic stabilization appro~\ch
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I Shortencd muscles that have becn immobilized require
about 4 weeks of treatment to return to their pre-immobilil..a-
borrowed from PNF. Latcr. Lc\Vit~ focused on the HR ap-
proach. He found that by positioning an overactive muscle in

I tion 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 ec-
centric muscles contractions all reduce muscle stiffncss. I~"L\
a full stretch position and then resisting a gentle isometric con-
traclion. 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
.)

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also incorporated specific eye movements. asking the patient
:This plasticity of muscle fibers in response (0 passive or active to look in the direction of contraclion and then in the direction
movements is described ~IS thixotrophic behavior. This of stretch. For most muscles. breathing in facilitates contrac-
lhixotrophy relates [0 changes in viscosity and resislance 10 de- lion, ..md cxhaling aids relaxation in the overactive muscle.
formaliOlI of the intrinsic molccular make-up of muscle fihers Lcwit believed only the gentlest force was requircd.~
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Ii that result from shaking or slirring motions. Both intrafusal and Janda used HR with signilicantly greater forces for treat-
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extrafusal muscle fibers have thixotrophic propcnics. 14 ing true muscular and connectivc tissue shortening. Ii This

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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
adapt<ltion. tcnned postfacilitation strclch (PFS). is for chron-
ically shortened muscles. The patient performs a maximal
contraction with the tighl muscle from cl midrange position. "
On relaxalion. the dOClOr quickly stretchcs the muscle. taking
out all the slack.
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Icngth."14 He also statcd. "Strong iSOI11clric contractions and Today. work by Evjenth and Hamberg stands as the most
muscle slretching maneuvers arc likely to dissolve preexisting 'luthoritalive manual for these muscle stretching procedures. H\
actomyosin bonds and thereby rcdul.:c lhe inherent stiffness of They demonstrate the exact doctor and patient positions for
the cxtr.lfusal muscle fibers."l~ paforming HR for e~lch joint and muscle. Other ..wthms Iwvc

I DIFFERENT METHODS

Proprioceptive Ilcuromuscul<lr facilitation (PNF) is the 1110st

complex systcm of MRTJ(, In PNF. ncuromuscular reeduca-
also used MRT. including Holl.'·' describing the scientific

Table 13.1. Manual Resistance Techniques

Pcoprioceplive neuromuscular lacifilalion'C.

tion is thc goal. Manual COllWc:lJ, {Jatlellf prepo.\'itio1ling. I1WS- Hold-relax
Contract-relax
ch~ ceJlltrm:tioll against resislClIIce. irradiation. lind \'erhal Rhythmic stabilization

1 co"",uwds are all uscll ill concert to begi" the process of im-
I,roving 11/ovcmeflf. The inhibilOry techniques used mas1com-
11I0nly arc hold-relax (HR). l.:ontracH·clax (CR). and rhy[hmic
Muscle energy procedures,)
Postisometric ee!axation~'
PosUacilitation strelch 11

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:,lrCII,:hing for spon D S sll'L'IL'hingl; Callil'l:". llsing l1l11dilil't1 Table 13.4, Goals of Manual Resislance Techniques
rhYlhlllic ~[;,hilil.ati()ll: and LiL'bC'llSnll ..",': ll~illg ;\lo."livc lllU",-
Muscle inhibi tion· relaxalion/decontraction
eh: re1;\.\;11101\ lechniques. The various ~Hrf :11\' Sllllllll;lril.cd Muscle stretch
ill Tab": 1.,.1 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' ivl'lIlua! r~:-i~lancc h:chniq'!es havc bcen presented as al-
,J -, g{lrics.:· ;"ll1~de dysfullction i, typic;dly ;111rihul;,hlc tu cilha tern;'lli\,cs 10 thrust manCllvers. but in the context of this chap-

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neuromuscular or Clll1nCclin.~ li~SllC r.K(Ors. Dilfcrclll Iyp'-'s of
dysfulll:lioll include rclk.\ ~paslll. il1lCrneUHlll f;ll,:ilitati\lll
ter. they 'Ire :-C'(:11 primarily <IS a complcment to traditional chi-
mpraclic and m:mual mcdicine mcthods. III as much as
frolll j(Jint llysfuIlCli(lll. trigger pili Ills, cCllIr;,1 nel'\'\HIS systcm (}\'Cf(lctil'l' or .\/ItJr(('/lt'd II/ltsd('s are n!l(l/ed to a specific joint
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inl1ucllccs (i.e.. limbic ill\·o]vcmellt). or gradual uvcnl~"':~ dysjifllCf i01/. 1I1'1'Iyillg M RT may re.m! t ill iI/eli reet mob;!;:llIiOfl
'--1 , (Tahlc 13.2). For a full discussion of tlll.,:se diffcn':111 rilctor~. l?f' a joilll or at least make (11/ mljltSfmellt ",On: comforrable
i, see Chaph.:r .::, C//IClloflg-laslill:: for fhe plltienr. Thll.'i, their mai" a/,p!icar;(m
~, ) j\...1akill~ a precise asses~mcm of soft lissuc fUl\ctiol1<.l! i.'i ill dirc('f {/Hlilllellt of fire IIlf1sclIlar ('oll/Iument so as to 1.:11-
•, , palhology helps to guide thc trcatll1cllt dC'I~loIHnakil\!.! lranee the efficacy of jO;nf adjf!,ttmenfs. For both acute situa-

I,,
) process. In the c'lse ur mu~clc tightness <.Ir tension (T<able
13.3). specific IrcatmcllIS <Ire appropriale for each difTerent
type of dysfunction.
tions. which involve muscular guarding (neuromuscular ten-
sion or ··spasm"'), and chronic cases, which involve muscle
and fascinl shortening (connective tissue changes). MRT
,~, serve as invaluable c1inic.allools.
CLINICAL '\1'1'LiCATION These techniques may be used 10 rcl'lx tension in muscles
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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
before thrust manipulmion. If, however, we desire to stretch
shortened muscles or fascia. then chiropractic adjustments
1:
c-; should preccde any aggressive stretching. Following an ad~
doctor providC's appropriate resistance to specific movements
justmcnt. MRT can be used to reinforce neuromuscular re-
tlmt are being trained. Whcn pcrforming rvlRT, it is hcl pl"u I 10
education.
realize that although many different namcs Iw\'c been used for
The MRT require activc patient participation and arc
different techniques (PNF. i\,1EP, PIR, eIC.). there arc certain
therefore les~ llkely thun p<lssive methods to encourage pa-
common clements to successful MRT applk:Hioll, The MRT
tient dependency. They arc, howe vcr, more demanding: of the
- involve isometric. concentric. or eccentric COIltr:IctiOllS. They
patient. Methods involving RI or gentle PIR typically are
-~ arc used to relax muscles. stretch muscles or fascia, mobilizc
j' painless, and. with a little patient education, arc simple to per~
:~ joints, or fucilitatc mllscles. The clinical indic:ltlollS for these
form.
i§ methods arc summarized in Tuble 13.4
.Compared to decp tissue massage <lnd trigger point thcr~
, apy (myo(hcrapy or receptor tonus). MRT can be a faster and
:'§

*i less painful Wl.lY or

reducing increasl:d muscle tension or lrig~
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gcr points, except if thc patient has poor coordination or is
i ) Table 13.2. Classificalion of Tight or Tense Muscles
simply umtble to relax. Patients with diHiculty relaxing often

I .)
Neuromuscular
Reflex spasm
Connective tissue
Overuse muscle lightness
nCl:d moist heal. relaxation and breathing exercises, and some
type of gentlc, nonpainful massage (i.e.. effieuragc). The

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Interneuron
~) Trigger point combinalion of M RT and soft tissuc procedurcs can be used
Umbric with grci.lt effect For instance, if <.In area of tcnsion i:, found
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as Ihe tissuc~ arc being massaged. thc patient can be in-
slructctl to contracl with that tissue, This combination can

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Table 13.3. Specific Treatment for Differenl Types of Muscle

ortcn overcome even stubborn "knots,"'
For some patienls who cannot tolerate llcep soft tissue
m<.lnipulation (j.e.. Rolling or lransverse friction m;js~age),
I• l~_.J" Tensionmghlness

Type
MRT may be used to reducc the sensitivily of the area.
~ J Following MRT application. decp massage or ischemic com-
,j Rellex Cause (i.e .. remove appendix) pression techniques usually are tolerable to the palient. Any
l , Interneuron Joint manipulation massage or p,.~sivc therapy runs the risk of encouraging pa-
'''~ Trigger point PIR or ischemic compression'
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Limbic Yoga, meditation. counseling tient dependcncy. Their usc should ;'lhv;'lYS be combined with

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~ J Muscle lighlness PFS or eccentric MEP

'Abbrcviations: PIA, poslisomnttic rcla:o:alion; PFS, postlacifitalion strclch;

some form of paticllI education. exercise. and sclf~tn~allnent.
Positional release (i.e .• strain/countcrstnlin) or osteopathic

!-
MEP. muscle energy procedures. fUllction'lltechniqucs ;,m;: preferable to MRT when it j .. diffi-

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 cuI! to flnd an active movement that docs not provoke the
symplollls. Th~sc posilional rclC'lSC n~clhods (finding a .r~.:ain­
RULES FOR APPLICATION I .'"'1.

less muscle or joint posilion and holdlllg lhere) arc a pamless \Vhen using MRT. Ihe more specifically we can facililiJ(~ con-
and effcclivc means 10 n.::ducc irritability and incrcnsc motion traction in Ihe dcsirt:d muscle, the betler our results Will be.
in II pntient with soft tissuc p'lin. . . Table 13.5 summarizes some of the keys to 3chicving suc-
cessful facilit:ltion. For inst.lI1ce. how the patient is preposi-
,
The MRT and Spray .ll1d Stretch have sundar goals and
may be used interch:lllge,.lb.ly. ~~oth arc consi?cred alt.ema- tinned affects how easy or Iw,rd it is to actiV<lle the muscle.
tives 10 dry needling and IIlJccllon of anesthetic for relief of Our verbal command is also importune not only for what we
painful trigger poi:lls or rcriostC.11 auaciuncl~1 poil1l.sJ-I Spray sa\'. hut <llso Ihe inncction we usc. Triul and error wilh cach
and Stretch is p<lssivc and (hus 111<1)' be better IIllhe fust slagcs pa~icnt will reveal which commands activ:llC the desired
of lreatment when a pmicllt has poor motor control (inr.::oordi- movcment beuer. In gcneml. saying to a patient to push to thc
nation ,lIld difficulty relaxing). Patients who 'lre cold intoler- right or left is not as good as giving them an actual larget.
ant may require even more passive methods. such as heat. M.tnual contacts arc facilitative. so it is normal to place a con-
electrotherapy. oSlcopathic functional technique. joint mobi- wct on the muscle you wish to activate. Massage while the pa-
lization. or m<J,ssage. Spray and Stretch Can be used as an tienl is attcmpting to contract the muscle Illay help 10 mvakcn
altemative to PFS for lengthening shortened connective tis- a panicularly inhibited musclc. Irradiation is somctimcs use.d
sue. SOI1\t:limes Spray and Stretch and various MRT can bc to facilitate a muscle that is especially "dormant:' ThiS
combined. Trial af:d error often dctermines which npproach process involvcs using a synergistic muscle that is stronger to
h<lS a greater inhibitory effcct on the muscle. Bccause of Ihe pull its inhibited neighbor into action. .
negative environmenlal profile of fluoromethanes. PfR and Various ouidelincs help us to avoid irritating patients
o '" ..
intermittent cold and Sirelch have ocen proposed as altern a- whr.n !'trelching. \Ve must not put relaled Jomts In n position
tivesY of strain (Le.• ~Iose packed position) during stretching. For ·l
An alternative to PFS for musculofao;cinl shortening is os- example. when stretching the iliopsoas. allowing the lumbar
)
teopathic myofascial release method. which typically encom- spine to extend puts too much strain on the low back. \Vh~n
passes lifting the involved soft tissues and stretching it per- stretching in the spinal column. it is also irnporta~l to a~old
pendicular to its muscle fiber orientation. 1(, This melhod is uncoupled movements. For instance. in the cervical spme.
onen advant&lgeous because it avoids engaging the stretch re- proper coupling occurs when rotation and side bending o~cllr
flex. Postfacilitation strclch, myofascial release. and deep tis- in the same direction (srinous process toward the convcxily).
sue massage can often complement each other. In the lumbar spine. it is the opposite. unless the spine is
The use of hot packs. ultrasound. electrical muscle stimu- flexed: in the neutral or extended positions. normal lumbar
lation. and other passive lhcfmal or electrical methods is com- coupling takes place when rotation and side bending OCcur in
mon in musculoskelclal clinical care. Their usc is sometimes opposite directions (the spinous process moves IOwa:~ ~he
<Ippropriate in acute and subacute care. but is inappropriate in concavity). This infonnation is important when mobl!l7.1~g
rehabilitation beyond lhe phase of early soft tissue healing.. joints with MRT and when stretching muscles that reqUire
Maflual resislaflce lechniques hav.c Ihe adl'amagc Ilwl taking out slack in what would be an uncoupled manner for
while easily lolermed. like passive melhods. Ihey also involve the underlying spinal joints. .
Ihe paliem ill all aClll'f \I·lIY. ihus limilinf! paliem dependency. An example of an uncoupled joint position is the l:crvl~al
The thrust of modem management of chronic pain is aW::IY side bending awny and rotation toward an upper Ir<lpczl~s
from passive therapy (physical agents) and toward active pa- muscle being stretched. Because this positioning would stram
tient involvement in the rehabilitation processY~1I This focus the' cerVical'" spine. we slretch almost complctely over the
does not c1iminmc the role of passive thcrapies. bUl rather di- upper back and shoulder area and avoid any cOl~trac!ion or
r~cts patiel1ls tml,'&lrd functional restornlion in nctivities of strong stretching in the neck area. This situation Illustrates a
daily Jiving. The MRT &lrc ideal bridges between passivc and gcncnll rule in stretching-stretch over lhe largest. Ill.ost st;].~
active carc. ble. and le<lst painful joint.!'j Additionally. how we "Wind-up
To summarize. when wc lind an abnormal restriction of the upper trapezius will reduce the potential for neck str::lin.
motion in a certain dircction. we have encolJlllered a patho- \Ve first take out full ncxion and rotation. {hCll gentl}' side-.
logic barrier at that point of resistance. This barricr may rcsult bend the neck away from the muscle. and finally firml}' take
from joim blockagc. muscle shortening. or II combination of out slack in the upper back :'lIld shoulder regions. The pa-
the two. Manual resistance techniques arc one approach 10 tient's contraction would be only from the shoulder ill <l di-
eliminate this barricr and to restore normal r<lnge of motion
(ROM). They achieve this end by relaxing Ihe shortened mus- Table 13.5. Facililalion Techniques
cle and/or mobilizing lhe hypomobile joint. \Vhen true joint
blockage exists. a chiropmctic adjustmcnt is without peer .IS Preposilioning
Hand contacts
the treatment of choice. The MRT can stand all their own. but Tissue stimulation
they are bettcr as a complement to the adjustment and <l Verbal cues or commands
bridge to exercisc. Irradiation

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 l,;HA .... 1tH 13: MANUAL Ht:::SISTANCE ANl) ::it::LF-STRETCHES t-OH IMPROVING FLEXIBILITY/MOBILITY 257

Table 13.6. Safety Rules 3. Having "let go" and rela,.ed fully. the musclc is slowly, passively
lengthenLJ toward a new resting length as far as relaxation wilt
Stretch over largest. most stable, least painful joint allow.
PI<.lce joints in Mloose packed~ posilion
Avoid uncoupled spinal movemenls 4. Without b;lcking away from the new end point. perform two (0
Do nol streIch nerves. it iuitaled four 'ldditiOllal rcpclitions.
5. If rdu;atiun is nut achieved. tf)' the following:
• Be slIrc the palient hrcilthC5 ill during contraction phase :Iud ex-
~
hales during rcl;Jxation phase
~ Fur most (<<Illk and cXlrcmity Illll..dc..·.... the p3til.,nt o,;JulIlld look
j n:t:tioll or ~kv;ltiOI1. Ouring relaxation ;1l1t1 strctch, we take
in the direction of contraction and then in the direction of
i out the s1;l<:k o\'~r Ih~ larger, more stabk shoulder and avoid
stretch
~ ) taking out slack ill (he neck, ex.cept perhaps in ncxion.
• Lengthen the lime of eonlfaction up to 30 scconds
AnOlher ruk is to avoid stretching related SlrUCLUrcs, such
JI .IS a nerve root, if il is irritatcd. N Hopefully, every clinician
• Try a harder conI rae lion, although do not rcsist the contr.Iction
~ when the muscles arc in Iheir fully lengthened position
l kltlJ\vs not to streich the hamstrings if the sciu.tic nervc is irri- • St<lrting from a midrange position. usc isotonic resistance of
i
j
1 wtcd. Another simil:.tr arC;l is the femoral ncrve anti rectus
femoris. or the br;lchi;11 plexus, which C:.lll be stretched when
movemenl by the antagonist muscle towurd thl: reslrieted bar-
rier onc to three tillles
j 1 ;utcl1lpting to stretch the scalene or subscapularis muscle. 6. After nccornplishing the preceding sleps, instruct the patient to
~ pcrfonn active ROM exercise through the new range
< T"lb1c 13.6 summarizes these import:.lnt safety tips during
I , slretching.
I~ J How wc "wind-up·' the muscle, in other words the order
Success wilh Ihis method depends on precise posilioning
of lhe body part 10 isolale lhe lense muscular bundles in-
I, '"",
wilh which we lake out the slack in the different movement
,*?
" dircctions (rot;llioll, Ocxion/cxtcllsioll. side bending), dramat-
volved. Il is also essenliallo lake out all the slack in the mus-
cle and to stay at lhe end point of the available ROM through-
ically :.liters when the p;lticnt fccls most of the streteh.~o,l
i'"
-11
Playing with this v;'lri:.lblc allows for bcltcr isolu.tioll of the rel-
out the procedure. Indications for its use include increased
neuromuscular lcnsion (i.e., trigger points) and joint mobi-
~ evant tissue. Most people use too great of force when they liz:.ltion (gentle).
~ lirsl begin to usc MRT. According to Larricq, the forces used
";; A second valuable MRT, particularly for patients with my-
during MRT should be "as little:.ls possible for as long as nec- ofascia1 shortening (viscoehlstic stiffness), is postfacilitntion
.'"
cssary:'~'1 According to Lewit, the time of the contraction can stretch (PFS).11 Tl,i:'> ,','ldIl0u ilhl)lve~ the following steps:
be lengthened for up to 30 seconds if inhibition is h:.lrd to
achieve.~ Whether to adjust joints before or after MRT is a I. Place shortened muscle in a position approximately midway be-
-~ common question. If significant joint restriction is encoun- tween its fully approximated and stretched positions
2. Have the patienl contrJct isomelrically with m:.Lximum effort for
li tered during attempts to stretch, it is crucial to adjust the joint
7 to 10 scconds. and resist this movcment to create a nearly iso-
y, first. Otherwise, adjustment is easier and thereby requires less melric eOlltmction
$ force if we wait until :.lfter the contmctilc clements have been 3. When the patient has "let go," perform a quick stretch to the final
,~ relaxed. Different ways to improvc MRT results ;lre listed in end point (:lv()id bouncing) :U1d hold for up to 20 sl:conds
.~ Table 13.7. 4. Allow the p.llicnt to rc!;\x for 20 to 30 seconds

I
I ,)
)
SPECIFIC I'ROCEI)URES
Postisomctric relaxation (PIR) is one of the most useful MRT.
This method is Lewit's modification of the gentle. indirect
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

I,
li
-;.,.<-~
isometric MEP that osteopaths applied to joints. s It is also
similar to hold-(clax. The main indication for PIR is relax-
wannth, weakness, burning, or tingling in the :,tretched tissue
is normal. An appropriate series or such stretches \,.'Ould in-
clude six visits over a 2-wcck period.
it
~
,
'\-,~~
ation (decontraction) of a hypertonic (contractcd) muscle.
Posti~omctric relaxation is the preferred method if the patient [n PNF, two of the most famous MRT arc holti·re{ax (HRl
has difficulty relaxing or you simply want 10 use a "soflcr" ap- and contract-relax (CR). The former invol\"t~:' positioning the
I• u .proach until you gain the patient's trust. It is ideal for trigger
points, joint mobilization, and neuromuscular tension.
patient in the stretch position Jnd pushing ilHo the "barrier" of
resistance while u.sking the patient lo hold. Thi~ step encour-
I, -~
~.J Postisornctric relaxmion (PIR) involves the following
simple s(eps:~
ages an isometric contraction. After the rc~i~tcd contraction.
~ •
i oj
I. Passively Icnglhcn lense muscle 10 a point JUSt shon of pain or Table 13.7. Ways to Maximize Results of Manual
I ~
C)
where rcsist.lOee to movement (barrier) is feh. Avoid bouncing.
2. Have palient gently contract lhe ovcracti ....e muscle away from
Resistance Techniques

~
N
, '4
, barrier fur 5 to 10 seconds. 'ntis movement should he resisted
with equal cuulllerforce. creating an isometric cOlltr.lction. For
~Wind up" muscles 10 maximize isolalion
Slart gentle and add (orce only if necessary
Increase contraction lime up to 30 seconds
l, most muscles. the patient should breathe in while contracting the Adjust restricteQ joints first
:g muscle.
Jr
~
;;
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!..
.••._...•.... _-------
 ....,

Table 13.8. Matching Therapeutic Goals to Manual SELECTED ~IRT PI~(}C:~ntJI~ES

Resistance Techniques
Manual resistance techniqu~s can be used for a "ariet)' of pur-
Inhibit Stretch Stretch Mobilize poses. Thc)' Jorc ahcrnativcs to adjmamcnls or soft ,issue
Techniques' Muscle Musde Fascia Joint
work. The)' ,Ire powcrful facilitation and strengthening tech-
PIR + ... niques. They ar~ most famolls. howcvcr. for tht'ir <Ihility to
HR + +
+ + stretch Illuscks.
CR
PFS + +
Eccentric MEP + + •.. "",
PIR Procedures for Muscle Relaxation and Stretch
'PIA, postisomctric relaxation; HA. hokl·relax; CR. con\racHelax: PFS. post
facilitation stretch; MEP, muscle anergy procedures. The format for this scclion is designed for casy clinical 'lppJi.
cation. Rei:ldcrs arc encouraged tu rdcr to Chaplers 5. 6. I·t
stretch may be increased either actively (by the patient) or and IS for morc dct:.lil rcg;lrding spcdlit.: te~;(s. rclmcd
passively (by the doctor). When performed actively. the pa- strengthening exercises, or treatment protocols. The follow-
tient is activating the antagonist to move toward the restrictcd ing hendings are used for most ()!' the musdcs described:
barrier. This effort engages RI. which inhibits the tight mus-
Referred Pain: Location (If pain cmnpl:lilll
cle even more. When performed passlvcl)'~ the doctor must
Clinical Result of Shortened Musclc: Relal~d dinic.:allimtlngs
not overstretch the tight muscle to avoid activating the stretch
Activation or Perpetuation: \Vlmt activ:l1cs (l( pcrpctu,lICS trig-
reflex, which would only increase the tension in the muscle ger point
and defeat the purpose of the eOlire exercise. Obscr\'<Jtion: Postur..11 analysis
Con'r"ct-r~I;lx involves laking out the slack and then Triggcr Point: L(X,;;\tio!l
commanding the patient to "push against mc" or "push to- Pcriosteal Point: Localion
ward.... (an objcct or t<lrgcl)." This step encourages a con· E\'alualion for Q·icr".JctivHy: How muscle (lvcr:lCtivily w(luld
centric contraction because pushing implies movement be seCIl
(whereas holding implies staying stationary). Unlike PIR, you E\'aluation for Muscle Shortening: Test fur muscle tiglllllcss
allow a greater force and Jccornp'lIlying movement. At thc Joint D)'sfunction: Rehllcd joint dysfunctioJl
end of the contraction. Rima)' be used so it is the patient who Corrective Actions: Exercise <lnd educational :.lpproach
actively takes out the slack. Th!s combination is often called MRT Stretch:
Patient Position
contract·relcu alllagofli.w contraction (CRAC). This mcthod
Doctor Position
is preferable to HR if the patient is using a stronger muscle Patient's Activc Effon
that would be hard for you to resist isometrically. Stretch
An alternative to PFS for stretching connective tissues is Other MRT Stretches
the osteopathic eccelllric M£/~ which involvcs starting at a Self-Stretches
midrange position and having the patient push lightly ag.linst
your resislance (20% effort). Although they push lightly. you HAMSTRING (Fig. 13.1)
lengthen the muscle. The patient must continue to contract
lightly so that it is a lengthening or eccentric contraction. This Referred Paill
maneuver is excellent for lengthening noncontractile cle- Lower bunod: to upper c:lIf
ments.
Clillical Result oj Sltortelled Muscle
Table 13.8 summarizes the choice of MRT depending on
Recurrent pulled hamstring::-
the spccific treauncnt goal.
Self-stretching should be performed on a regular b'lsis to /\cti,'atioll or Perpelllatioll
prevent recurrence of viscoelastic stiffncss or elcv:ued neuro- Compensation for weak glutcus maxinms
muscular tension. Oncc or twit:C'l day. key tense or stiff mllS- Compression of posterior thigh from a chair that is ton high
c1es may be gently strctchcd. Simple guidclincs for self- Being in a shortened posilion from prolonged silting .J
stretching are as follows:
I. If possible. perform simple w;lrm-ups before stretching
Trigger Points
Midhdly
2. Gently take out allihe slack in the ill\'ol\'l:d muscle until you fcel
a gentle pulling
.J
3. Maintain good body posture so no str,lin is felt anywhere else in Periosteal Points
the body Ischi:J1 tuberosity
4. Hold the stretch position for 101020 sel.:ouus. t;lking OUI t'unhcr Fibular head (biceps femoris)
slack as relaxation is achieved
5. Brc;llh deeply and slowly to encourage relaxation E"alllati(JJJJor Ot·erar..'ti"ity
6. Repeat stretches at least twice per session :mtl one to two times Knee flexion during prone hip extension tes!
per d3)'
7. Aftcr stretching. actively contract the muscle and move it throut!h EI'allilI/iQil Jor Shortenillg
a full ROt\'1 a few times Y
Strai~ht leg rai~illg tcst (If less than ~O"
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 CHAPTER 13 , MANUAL RESISTANCE AND SELF· STRETCHES FOR IMPROVING FLEXIBILITY/MOBILITY 259

10illt !)ys!uflctioll Stretch

15·SI
• Flexion of hip while m~lintailling knee in extcnsioll
/:ihtll"l" hl,.';\d

C:"n'('din' Action COl1lmelll

I::ll·ililal..: {Ir "'lrl·Ilg,!..h;:J.L!J.~ ~hll":U~.!t!~~\illltiS
:\\oil! prnllllt,::..:d ~iHin~ Care should be t"ken whenever stretching the h:lIl1strin~... that
the sciatic nayc tcnsion tests (Lcsaguc's tcst or Str~i~ht Leg
:H NT .'·trctch R:lising lest) ar~Jlcgativc. Also. in lhe casc of lumb;.u- j\")int ir-
PI/tina /'(I.\·ir;/I/I ritability. :he opposite hip and knee Illay be Ilcxeli h) rl'dllt::~
Supill": strain on the lumbar spine.
llip Ikxcd ;1110 kllcc I.:xlcl1lkd 1l1l involvcd limh Other iURT Stretches. Additional hamstring PIR proce-
dures arc shown for the medial fibers (Fig. 13.2a. L lateral
fibers (Fig. 13.2b). and the one joint hamstring-the biceps
femoris (Fig. 13.3).
Slal1lling Oil ,id.. . of tr.. . aling limb
C.... pllal.ld hand proximal 10 patdlac maintaining. kncl.: in eXll.:n~iu[\
Self-Stretches. For hamstring self-strelches. the back
1';\lil.:lIl's h,.-g ,upportco 011 doctor"s shuulder or ill crook of dbuw mu<l be stable. The patiel1l should feel the stretch in the
posterior thigh. but no stnlin in the lower back (Fi~:-. 13.4
and 13.5). Oncc the final strctch position is 3.:-hic\'cd
during the standing self-strclches. (hc paticnt will fed a
Alh.:mpls to pu"h kg down IOWi.m.lli.lblc greater stretch if instruclcd to pcrfoml an 'antt:rlo( pelvic
Effort i~ rc!'>i~tcd by doctur 10 keep cOIllr.lctinll ;IS close (0 isomet-
tilt.
rit' a:- ptl:-~ihk

ADDUCTORS (F;gs. 13.6 and 13.7)

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
• Tihi;t1 tubcrdt: (pes ;1Il:;.... rinu~) (two j{lim ;Idductors)
Fig. 13.1. Hamstring PIA.

Fig. 13.2. Medial and lateral hamstring PIA.

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 .. ,_ .••.••,... ..... ', ,v,~,-n.;;) IVII-\I,/UI-\L ,,
EI'!ll!!~!f!.':: 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' (Ill\..' or 1\\'(1 joinl
mJductu(s., n:spccti\'c1y) until rCs.i~t;\IIl.:C is fdt
Opposite kn~1.: i:- bellI
,
J

[)oClOr Po.\-;tio"

Swnding with on~ leg hl:twcl:n P:JliCIII"s ahduc[l'u thigh and lhl'
table
Fig. 13.3. Biceps femoris PIA.

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.

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vM"~ I eH '" : MANUAL RESISTANCE AND SELF-STRETCHES FOR IMPROVING FLEXIBILITY/MOBILITY 261

, .-
.- _-/... ~ -.: ~rY~~ ,

Fig. 13.6. One and two joint adductor PIA.

Fig. 13.7. One and two joint adductor PIA.

Doctor Pos;lh", Self·Slrelelles

Self· stretches ilrc shown in Figure 13.8.
Standing behind patient
Abducts p:llicl1l's Ihigh. caudal hand hooking 11lldcr patient's kllc~'
ILIOPSOAS (Fig. 13.9)
Cephalad hand SI<lbilizcs pelvis
Referred Paill
"otie"':.. AClin' Effort Low back and s'lcroiliac joint. anteriur {high

Attempts 10 push thigh jilin adduction toward table Clinical He.mlt of t.111scle Shortelling
Effort is resisted by doctor's caudill arm ((l keep contraction a... Poor hip extension
c!(lSC 10 isometric as possihk Forward-druwn posture
Difficulty with posterior pelvic till
Slreleil
Activation ()r Perpetuation
• Doctor lhl'" lakc~ {lut sl;lck inln further abductiol1 Recenl irllCfvcrtchral di~k syndrmnc

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 ••• ~ ~ . . . . . . . . "'" • .-.1"\ ..... , I ' ,v",~n ~ I'II',...I'IVI-\L

~
.,. ,
'T,'.

,
• ''!,

Fig. 13.8. AdduClor self-slrelches.

SW,ly b,lck (pSO;\$ must act ,IS a checkrein) Correc/il'e Action

Prolonged sitting Avoid prolollg~d ~ilting
Compensation for weak abdominals Facilitate ;lIld :-l~ngthen abduminals
Sln:teh cn;Clnr ~rinac
Trigger Points
Anywhere in muscle belly MRT Stretch: Supine
Pmh'lIt POJir;oll
Evaluation for Overactivity
lmlbility to keep heels on floor during kncc bem sit-up Sllpine
Lumbar spine Ol.:iy be latemlly flexed away from psoas
Eva/ua/ioll for Shortelling Contr.llalcral hip and knee held in full flexion against chest
Modified Thomas test Involvcd hip frcdy extending off end or side of wble (prefer-lolc
Patient pulls opposite knee to chest with table height of al le,lst 40 inches)
Allow tested Icg to extend off table
Posltivc (cst if hip raises without knee extension (tigtll rcctus Doctor PO.'iirirm
femoris) or abduction (tight TFL)
Al ~;\lne ~idc of l:Jblc as invulved limb or al end of table
Joint Dysfunction One h'lml IwlJ, cnntral;\tcr:ll knee to chest. thereby stabili1.jn~
TIO·L1 pelvis
Oth~r h:llltl t:olll.:in:- proximal to knee or eXh:nded leg

Pari£'1ll \' Actin' [:.:flo'"

• Rai~cs involq::d thigh up towmd ceiling

Fig. 13.9. Iliopsoas PIA. Fig. 13.10. Rectus lemoris PIA.

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 ..... ' ,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 I Y 263

::: :hc attempt to tak..:: -.:!lthc

u;:~!nn ::~ay r;"~lr.;::-;: "b;:;,::';'i;j~ ,~f:"
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:..· il-
iopsoas (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<ls stretch. but it is a trcllll.'n~hlllS
sll.11n on the doctor without the usc of an elevation tabk. Ifall
elevation t;.\blc i!'ro used, Sti.lrt in elevation ~lIld hold the (hi~h up
while allowing the tablc to lower and silllll!l;Il1Ctlusly . . tr('t(!l
the muscle. A stretching belt may ;\Iso be used.
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 ~tlpin"tc fool against n,:. TENSOR FASCIA LATAE (TFL) (Fig. 13.14)
sistance orfcred by ther<lpist's leg
Efron is resisted isometrically by doctor
Referred Pain
L:IICf:11 :1~Pl;'ct C);. thigh III knee
.~·,,.~;r(·/, Clinical Rewll of SllOr/cncd i\1uscle
Knee extensor mechanism disorders
Once patient ha!> fully relaxed. doctor takes up sl;lck by extending
Sacroiliac problems
hip to its new cnd point while sl;tbilizing opposite side
QL myofasc:ial di"orucrs

Co/llmenl Actimthm Of Perpetuation

Repetitive' strain frum funning
Palients orten complain of discomfon in the fully llcxed hip LHeml pelvic ...hi!"1
(the onc not being stretched). which may bt: provoked by the Forcrunt inslability (ex.ccssive pronation)
passivc o\'crprcs~urc rcquired lO nallCn the low back. This sit· Pro!ongeu sittinf wilh hip too ncxcd
Cmnpells:llinn u, :1 wC;lk gllltcu~ l1Ieuius

Fig. 13.12. Iliopsoas self-stretches.

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L .._._ . --_._-_.._.
 \)
I.--~~
,i J
,''1:
, ,,'
Fig. 13.13. Rectus femoris self-stretches.
'~

I -'
I,
Trigger Palm MilT Streich !
Superior or mid porti(ln of muscle Pot;elll Po.\';r;OI1

Observation Side lying. invoh'cd ~i(.k up

Groove presellt in iliotibiJI b~ll1d NOlltrc;\tcu leg hem at knee ~lrlcJ hip
Ll1cral dc\'i'Hion of pafdlac Thigh addllctcd behind patient unlil rcsisl~IIU;C is felt

EvaluatiolZ for O~'eractil'il)'

Hip flexion during hip :.lbdUClio!l (gIU[Cll~ medius) test /)oc[or Po.\'ifhm

El'aluatioll for Shorteuing Sl~lndillg behind pali~nl

Ober's (cst Addll<:l~ patienl's Ihi~h with caudal hand a!:x)\'c kncc
Resistance to addllction of thigh Cephalad hand stahilize, pelvis

10illt Dysfunction
Sacroiliac joint Patient\" Acri\'" 1:.1Iorr
Patdlofclllor.ti joiut Attcmpl\ tn push Ih;~h ill\o ;lbduClioll 1tl\vard ceiling
Eff(.Jr1i~ n.:sistcd by d<.Klor's c;lmlal !l;l1ld to h:cJl COtltr;lL'tiol1 ;IS
Corrective Action '-';
c1(l~C In isollleiric a~ po.."iblc
"Short fool" cxcrcisc~
Foot orthotics
racilitatc and strengthen glutclIs medius Strctch
Doclor then takes out ~Iack into further adduction

Other MRT Stretches, The TFL C<tJl also be stretched

with the patient supine (Fig. 13.15). This stretch is felt in the
quadratus lumborum (QL) if the TFL is not light
Self-Stretches. A self-stretch for lhe TFL similm to the
lateral pelvic shift technique that is often used before cngag~
ing in McKenzie extension exercises.

PIRIFORMIS (F!g, 13-161

Referred Paitl
Posterior thigh. buttock. and sacroiliac joint

Clinical Effect of Shortelled Mllscle

Sacroiliilc disorders
Fig. 13,14. Tensor fascia latae PIR. Entrapmenl neuropathy fst::i;llic ncrve)
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 CHAPTER 13: MANUAL RESISTANCE AND SELF·STRETCHES FQR IMPROVING FLEXIBILITY/MOBILITY 265
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:\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,:: .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
Fig. 13.15. Tensor fascia [alae PIR. nllallllll

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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

j
., 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 possi-
ble in a \'aricty of positions (Fig. 13.1 R). Figure 13.19 shows
a strong posterior hip capsulc streIch that also addresses piri-
Fig. 13.16. Piriformis PIR. formis shortcning.
()
QUADRICEPS
) /\ctiJ'at;oll or Perpetuation
Short leg Thc quadriccp:-- is morc commonly weak than i( is tight.
Long drive with hip flexed OJnd 'lhductcd Ortell. n:clll . . fl.'llloris tighillC.. . S is mistaken for quadriceps
C(lll1pcn~ali(ln for we,lk ~lU1Cll'" medius

, ,..
tightlll'S\. \\'cak ljlladriccp.. . typically kad iO stoop rather than
ObserWllioJJ squat lifting lcchlliquc, which leads III lumbar O\·l.'fstrcss.
fouul lurnc(J (lUI in :.I'lIIdinJ; pusture Squats ;101i lunges arc the most fUllclional exercises for train-
) ing the quadriceps.
TrigKer Poim Postborlll:tric I'daxati()ll on the quadriceps is l.'asily per-
) ~'lus<:lc helly hlrnlcd while PH)ll\.' (Fig. 1.1.2(»). Tllis pro<.::cdurc is like the
l\.·-lllscul'lf guardillg elicited on light p'llpation over sciatic nOIl;'h
fcmoral nerve strc{l:h tcst ill that if the ilssol:iatcd nerVe is
h"wlhwfioll for Overaclil'ily compromi\cd. thiS strctch i:-- contraindil:iltcd. Self-stretch can
!-lip c:\lcrrwl rotation or pelvic rOlillion during hip abduction (~Iu· be aided by the tlSl,; of a belt looped around thl' fOOl (Fig.
teus mediu!'» tcst 13.21). Self-Pm. l:all l:asily be' ac<.:omplishcd with this
mcthod.
(J Evaluation for Shortening
Palien! !-upinc. flex hip less ll1an 60°, Apply compressive pressure
IhrUll!;h femur tu hip. and mJducl fully: fecI resiliency to internal GLUTEUS MAXIMUS
wlatiun of hip
Stretching Ihis prim,lry hip extensor is orten 110t neces-
') Joint Dy.~fll"cliall sary. except for those lndividuals in whom this muscle is very
L4-L5 am! sac.:roiliac joilH light. The PIR techniClllc is also a good way to facilitate
Carrective l\ctiOlI this muscle for (raining with posterior pelvic tills. bridg~s.
Correct !'ohnrt fOOl and other strengthening cxcn.:ises. Self·stretching is per·
,.....J\ rormed .il"t like (ht: Ir;ulition;a) Williams cxef(:i~l..·s (Figs.
Improvc chair
F;11:ililalc <llld :-lrell~lhel1 gltlh:US lllcdiu!'o I ~.22 ilml I ~.2:\ I.
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 nCnnl,.Jll-.' Inl IV''1 u r ,nc ,;,rll'lc. n r n .... v 1IIIUI'lCn,;, IYI ..... I'llVnl..

A B

c Fig. 13.17. Piriformis PIA.

Fig. 13.18. Piriformis self-slrelches.

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 CHAPTER 13: MANUAL RESISTANCE AND SELF,STRETCHES FOR IMPROVING FLEXIBILITY/MOBILITY 267

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Fig. 13.19. Posterior hip capsule and piriformis sell-stretch.

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Trigger Polms

I Bencath erector ~pin:le l1luscic \;llcr;lIIO tr:.lll$Vcn.c processes

Best to palpate with patient side Iyin~

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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 ,
EI'(l{U(ltioll for Shortcuing
St:rccllill~ le't: si\h: I~ in:; patient r.lil'l.'l' tfunk lip \\'itlt hand or fore-

I "j ann tllll.h:r .. hmlllk'r. P\lsitive result i:, ;lhsellCc of smooth COllvex-
il): of lumhar Spill\.' \\1w;1fl1 down side.

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joi"t lJy...ftmc:timt
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Fig. 13.20. Quadriceps PIR.
'1'111,1.1

Corrective Action

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HIP INTERNAL ROTATORS PRONE
11:);
("iIlTCl,;\ .. hon
Ctlrrct:t Illlkn:1 pd\ i.. when .. ittiu);
F;lciliw{c (If strl'n~!h\.'11 ghllells medi\l:'

I Postisol11ctric relaxation for rC~lric!cd hip external nH,uioll i... Te;ll.:b proper liflil\~ 1\'l,,'hlliqllC
\.) similar to the prone piriformis technique (Fig. 13.24). The MRT Strelell
pelvis must be firmly st<.tbili~cd during this procedure. Porie,,' 1'0,\';1;011
,*.', Side lying. lnvolwd side down
:v OUADRATUS LUMBORUM (OL) (Fig. 13.25) Pdvis {lH:kcd so 1\1['S\1 is slightly Hl!;\{l,:d hack ward
'~
Referred Pain 1lips and knccs 11..':\\.'\.190" wilh ankks \'wsscd
!! i.J
~ Lah:ral fibers-iliac cresl and laleral hip
't Medial fibers-sacroiliac joint. deep in buttock
~
> "'..I
;

• Clinical Result of ShorICllccl/Husc!e

I, ()
'if
Low back pain
Ill.:rpctuatioll or sacroiliac di..,ordcrs
Abnormal hip hiking during £;,tit
.~
~ Activatioll or Perpetuatioll
~ J Lifling \\'ilh tnmk Iwisled

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Su:"taincd OVCrlll;\d as in g;lrdcll;lI~ Of working in sl()(lped pusition
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Fig, 13.21. Quadriceps self-PIA.

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 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 Evaluation for O~'eractivity
Doctor gr~lsps patient"s ankles. raising them During hip cl<tcnsion. lumbar ereC!<lr spinae norm:llly follows glu-
Patienl's thighs rest on doctor's caudal thigh. tcus maxillllls and hamstring activit)' (conlralalcwl prccedes ipsi-
Cephalad hand rree 10 palpalc down side ercl.:lllr spinae muscles lalcr<ll)
for contraction 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 cllc()~lragcd \(I "let
go" or rdax

Stretch
Pelvis in lUckClI position J
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). Somc-
times, it is diftkult to isolate lhe muscle with PIR, and intcr-
miuent cold and stretch (formerly spray <lnd strctch) is <I usc-
fuloption.
Self-Stretches. A 'standing self-stretch is shown in Figure
13.260.

ERECTOR SPINAE (Fig. 13.27)

Referred Pain
Sacroiliac join!. diffuse area in low hack. hUllock www.bodywork.su
Fig, 13.25. Quadratus lumborum PIA.

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 CH,\PTER 13 : ',IANUAL RESISTANCE AND SELF· STRETCHES FOR IMPROVING FLEXIBILITY/MOBILITY 269

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streIch (e).
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Fig. 13.26. (Continued).
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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 <llso be in~trucled to look inl!ir~ctioll ofturningl
Fig. 13.27. Erector spinae PIR.

Streit·"
After contracting erector spinae, palic:nt askelllo rdax am.! hreath\..'
Fingenip to noor distancc not villid for IUlllbar flcxibility bccausc
out
of hip motion, hamstring tension. and rcl;ltivc lIiffercncc between
Whcn doctor feds Illusclc has "leI gu," he or stll.' tal\es 11tH slack
;Unl and torso length versus leg length
toward new barrier

joillt Dysfunction Otller A/RT Stretches. The ereclOr spinae may he

Segmcllt .It corrcsponlling Ievcl. c.~pcciilily L4~L5 and L5-S I !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
Correc/;w:, "rtim,
to avoid uncoupled movcmcnts. If stretching in flexion. be
Strengthen abdominals
sure to rotate and side bend to the same side. If stretching or
Facilitatc or strengthen gluteus maximu:"
Teach proper lifting tcchnique
mobilizing in a neutral or extended position. place the patknt
Strengthcn <luadriccps in rotation and siJc bending to opposite sides,
Lumb;.tr support for chair Self-Stretcltes, Self-stretchcs for the low b~lCk lll11sdt:'s
arc abundant (Fig. 13.30). A simple sclf-PIR technique is :llso
MRT Stretch an excellent way for <l patient to relax their lower back (Fig. .~

J
Pllliellf Posilioll 13.31). h is pragmatic 10 have the patients explore whkh
Side lying. inHllvcd side lip
strclchcs seem more neutral for lhem.
Down side arm back and behind paticlH
Upper torso rowtcd forward

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Fig. 13.28. Erector spinae PIA.

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 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..:

I Cephalad fllrcarnl pusllcd :;houldcr backward

(';nlll:tl It;IUd ;1Ilt! wrist pull pelvis rorward

l'aJ;t'lIl \- Aelin' qrurl

RUI;I(C~ lorsn t'urwOlrd whik Illoving p~h'is hackward

.~ ElTon i... rcsi~h..d hy 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<ld.

Clinical Result of Shortened Atuscle

. Fig. 13.29. Erector spinae PIA. "Short neck" or ccryicocranial h)'p~rext~nsjon
Cervical headaches
Dizziness of cervical origin
LUMBAR MULTIFIDI (Fig. 13.32) Cervical zyg,tpoph)':-cal joint disordcr~
M lIT Stretch ,\ctimtioll or Perpetllotioll
IJulielll j'lJ\ir;oll Susl,lincd neck (h:.:... i,·'ii '''':lik. rc.I\lill~ ;1111.1 writing
FOl"wurd-l1rawn or slunpcd pos!lln.'
Side l~ in:;
T(lr~\l nll,tled ha\:kw.\rd Trauma (i.e .. whipl;lsh)
1'..:1\+, n.lah:d f(1rw;lfjj Trigger Poillts
Occiput, suboccipilaltri;mglc to C.l-C5

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Fig. 13.30. Erector spinae sell-stretches.

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_------------_._-------_._--_.,,~-_._---
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Fig. 13.31. Erector spinae self-PIR.

SEMISPINALIS CAPITUS !Fig. 13.33)

MRT Stretch .,
Pmielff Pos;t;on f
• Supine

Doctor POSiTio/l
t
At hC<ld of table ~
f \
Patient's hcad lIl"y llc ...uppt1rlcd lly dtlCIUf'S cro!>scd 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
)
Fig. 13.32. Multifidi PIA.

Parieflt\' Actil'c E/fort

AnelllplS to gently pu:-;h head hack and hn'::'llhe in while dol'lOl' t\r·
fer:-- lllatching resistance
Afler S to 10 seconds. inil!rUl.'teo to "kt );tl"

Stretch )
Whcn doctor pcrccin:!> patient has fully rd:'lxeo. p:.ttiCIlI a...kctl hI
lake deep breath in and out
A!'> p<lticnt exhales :.md continues 10 rd;Jx. dOl.:!ur lakes up <;,lm.:k ill
muscle
New resting length should be achieved thai is ranher into forward
flexioll th:.m before streich
?; Thcse steps can be repeatcd two or lhree more times

Fig. 13.33. Semispinalis capitus PIA. LEFT SPLENIUS CAPITUS/CERVICUS (~'g. 13.34)

t I\1RT Stretch, Combine llcxion with rotation ami si<.k

I
~ Periosteal Poilll.'i
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·
~ • Transverse process of the atlas
nique (intermittent cold and stretch is an option).

I
,~

§
~
Joint DysfunctiOlI
CO-Clio midccrvical

Corrective Action
LEFT SEMISPINALIS CERVICUS (Fig. t 3.35)

lHRT Stretch. This maneuver is an ul1l;oupled movcment

il 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;, for the cervical spinc. Therefore, if joint pain is provoked.

il! and pcctur:'lb;,)

Facilitall.' ;.Int! strenglhcn glulCll\ ma;ximus anti deep lll.'ck
lessen the side bending componcnt. Very gentlc forces should
be used ill this technique (ilHcnniltcnt cold and stn:l(;h is an
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 GHAeTER 13: MANUAL RESISTANCE AND SELF·STRETCHES FOR IMPROVING FLEXIBILITYIMOBILITY 273

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Pur,,"' 1'1\1 hl';l\ ~ (If should"'l
ClllllPl..'lI:o.:LliHI\ 1\1 short !c~
SllI}uhkr "k\·;ali'Hl wilh rl..'spir"li'lil
Ellltllitlilal :o.lrl'_~"
"\\'ci~ht of th" wurld 011
"tCII'

shouldl'l<'
l,',· tIll"

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()!JS{'t'I'atiflll
Slr:ti;;IHl'llill~
nf I\\'d~·:o.hnllltkr lin;: ,,'\'lItOUI" i ,.( ;"1111\.'·· ;II'P'::::.: :."

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

Fig. 13.34. Splenius capiluslcervicus PIR (Iefl). Lllcr"Uy hcnd hl'ild .1\\-':1)' and rulal.: hl';lll 1\)\\;11"\1 ;o.id..: III hl'!l·'h'.l.
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
Fig. 13,36. Multifidi and rolators PIR (left).
be llsed in thi~ technique (intermittent (old and ~tn.:tch IS ;In
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\\\ Fig. 13.37. Upper lrapezius PIR,
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 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<LIC diaphrafnl:.llic hn:athing
F:Jciliwte and slren~lh;:n hnvcr lix;llnr, of sC~lpul;IC

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<tlkm's side
,)
Doclor Position
Stilmling al head of side of ifl\'olvcmcilt
l;lOlc (Ill

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Fig. 13.39. Levator scapulae PIA.
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Joilll Dysfunctional
Atlanto-occipital. any mhcr !l<\stcriur cer.... ical joint including lhc '1
;,..,J
cervicothoracic junction

Corrective Actions
,
\...J)<
Improve workstation ergonomics
Make sure elbows arc properly supported by ~mn rests
Correct desk. typewriter. or kcybo;lrd heighl
u
Shoulders relaxed
\ ".j"
Elbows bent at 90°
H'lllds rcla:'l:r;d with wrist ill "neutral posilion" on work surfilce Fig. 13.40. Levator scapulae PIR.
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Fig. 13.41. Levator s.:apulae self·
stretches.

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Crossed or 1I11lTtlS'Ctl arlll C(llllac( wilh Olll.: h'llld gCnll~ on P;t-
lknl\. 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.
LEVATOR SCAPULAE (Fig, 13,39)

Referred 1>ai"
Vertebral border
Nape lIeck or
or scapula

ClilliCll1 Effect of Shartt'"ed iHuscle

i
Pain 011 sallle ~ide ;lS palielll lllrn~ hcaJ
Torticollis

,I~~
Altered scapulllhllllleral rhYIIl1\l
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 ActiwlliOIl
dcvaling il hlward car Poslures in \Vlti..:!\ paticHI h;l:, ht,';td lumed li..'f ;';-~'Iullged pcri~ld..;.
Efron is n:sisll.'d hy doctor 10 kcr.:p corllraclioll as t,:llISC 10 i'<JrJlI,:l- e.g.. talking 10 somCllllC sillin~ h' the side
ric as possible Excessive Iclphnnc wnrk
Working over a desk for pn'!lll11!cl! periods lIt' ;;;,',k Ilexioll
o~ f' Siretclt
ObJen'atioll
'~ Aflcr cOlllracling upper Ir.lpaim for appruprialc period. patient is '11' l",.'...'k line <.lpp,,';lr:o
Wilh shortcnint:. I.:onlour ,!:" ;1 duuhle wan:

I
CIlCOUfilgcd t(l "leI £0" or rel;\x where musde inserts into sl..'apul;l
Once rcla:<;llion of muscle is fell. uoctOf m;l)' t:.lke lip shIck hy de-
prcssing shlluldcr ~l~ far as it will ~lIh1W Trigger /,(}i"rs
SOllle slm:k 1I1a)' ,l!so be taken (Jut by increasing neck flexion, SupcfOlllcdial horder of scapula
Push tr"lpczius lataally to palp;lll.' fulllclll=th l'f nlllsdc

I
hut no more in llllCllUplcd side bendin,g away and !'OlatiOll toward
musclc Periosteal /'oints
Later-II surface Ilr SpillllUS Pfll~'l'SS Ill' C2
Self-Stretches. Excclknt .sclr-strclchc~ ar~ shown in
Figure 1.1.~:-\. Sclf·PIR call c:lsil)' be incorporated into other Eva{UClrimr for Slwr1l'l/illg
! self-treatmcnt methods. LaWr<111y hend alld rolal\.." Ik\l'd lk'ad away (rl'::~ 1~'SICd sitk~

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:\pph ~emk prCSSI:r~ to ipsilah:ral :-I\\Julll\,·1' Otha MRT Strctclu:s. PostisolllCll'ic rclaxalioll may also
l'o:-i[j\,e,; lest b lack ill' r..·."ilic11cy wlll'Jl 1'1I~hitl~ 1111 :-hl1uhkr he u~~d with rcsistall':~ lltrough the palicnts elbow (Fig,
13.-W1.
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
(Fi~. 13.4101) and \\'il!l PIR (Fig, [lAth <lnd cl.
Correcth'c Actiolls
,I
Using hc'ldsd
Rearr:lIlging C(llllpllh:r ilhlJlilHf HI' r\,·:td't1~ llIall,.'ri:li .~o 1111 nccd [II SUBOCCIPITALS
turn head
Rcferretll'ain
Fadli[:lle of slrell~[I\\"ll Imn.:r lix:llilr~ 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 "Sh~n Ileck"-(;cr\'icncralli~llhYI>cn.::xlcllsion
,lllthe way ulllkr hack of lhi~h :lIld lIeek is rotaled away
Acti~'alioll
SUsl;lincd Ilcxinll
Doctor Position
r.. 1al;Jdjustcd cycglas:o. (rames
AI head of lahh:: Oil side llr involvcment RC<.Lding or writing ,fl·
Arm closest ttl p:lIicnt"s head SllpptlrlS hcad while lhe hand COll- Suslained extension
laclS p:llicnt\; supcmllledial horder of shoultler hl:lde
Outer .Ifln crosses in frOll! of olher arm ~{1 OpCll hand C<.Ill COlll,ll':1
Bil,:y,k riding
!-lou:.c painting
t)
p;
~ }-
nwstoid prm;ess Forward-drawn P()stllf~
~
We,ll.: dl,.'cp neck llc.'\of\
P;uient\ head lllaXim:llly Ilexed, laterally lIe.'\cd, alltl rulalcd to·
w:Jrd siuc opposite of involvl,.'Il\Clll
Trigger J1(Jinl.~·
-
Takc out ~ll slack in din':'lioll of slwult.ter (!I::prcssiun and minimizc j ",
Deep to lr..lpaitls and ...t.'nlispinalis CapiltlS
forces on hC:ld
~
Era/uatiun for Shortening -'<
?micnr:{ Actit'(' l~ff(}rl Supine patient drilws chin to chest
Positive finding if gilp of nn..: or l1ll,lrC linger's brc:ldth remains
Tries to gently ele"ale shoulder blade
Effon is rcsiqcd by doctor \n kcep (;ontf:lclion 'IS close w i"mllt.:t- )oi"t I>ysfrmctiotla/
ric as possible C!J-CI

Stretch Corrective tlctiolts

Improvc ft1rw~ml-drawn posture
Once palient has fully rclaxcd. dnCl(lr takcs out slack by im:rea:.- '\wmencss trJining of "~hon n~l'k" (i.e .. Alexander leehnique)
iog shoulder depression Book stand or writing w~dge

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Fig. 13,42, Sternocleidomastoid PIA.

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• CUlllPIll\:I m"IlIlo-r ;,; ~'ul",:d Ikl:lll Il..l..'h;~'

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~ ~ li ... ,Ilh ;111.1 Skqlin~ "II ;\\,. ;'dltlw.. :-ohllrll'n S('\1
nose) 1','..lur;1I ... 111'''0' ' ...·,.mpl·l\s:lti,lll hi !ll'rt k~1
Strengthcn \\~';l" ,kcp nc~'" Ik\.,\r... l·nc,IIT..'I'h',1 i""" ;.:~:.::-igIH
For,,";!rd h,',:,l r,'~IUn.:
MRT StrCfch \\'1';11, \kql Il,'~~, :1.' \01':-
Paricllr Posiriol/ 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 I'oint
Al head of lilhk
Anywhen.: illlll\l,~'k, partil.'ul;lrl~ hl'IIIW llla:-:lllid pnll:C:-:S
One hand bdlind neck. ilpplying tral.:lllll\ (~Iiglll)
Heel of nllH:r h;1I1d 011 forehead \\'ilh till~cr~ ptlillling IOwaI'd I,:hill Em(uariOll 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
Pn:-:ilivc 1...·'1 iI' ,:hill pH"''::-: dllrill~ inili;llir'lI or 11l\1\\:IIH.:nl
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· Joint 1JY.'ifullctioll
ric <IS possil:lk CO·CI ~lIld C~,C:

Sm!ldr Correcti\'e Actioll.\·

Pillow should be lUcked helwccn \IHlllltkr ;1I1d <:hin. NOT unJa
Once p:ltienl h:l" fully rcla.\cd. dOl'wr illcn:ascs {raclion I'uree will1 s!ltlllltk'r
haml supporting neck Correl'l head-hlr" :lrtl !'nslurc (... hnr!cns SCM)
Doetor lakes Oul .. 1;lCk wilh heel of hamJ till forehead illl(1 f(Jrward LlImh:lr pill{l\\ m::y help rc:-Iorc bOlh Itllllh.u· ;tnd cervical CUI" ..'~
nexioll Cum:;:1 Ilc;lr.. igbh:dness
Ifpatiellt resi\t .. forward flexion. :I,kcd In :u:ti\"dy Itlck chin in ;Illd Limil ovcrhcad '.\ llrk thai (l\"...:rl(I'ld .. chcckn:in fUllclion of SC\ 1
lhen relax: p:lliclll will havc in .;:-ffcCl t:lkcn oul ~Iack thems..:!\"c,' Rt1und-shoulth:r-.:d po,lUr.., (light pt:t.::t<lr:lli~ mu:-:dc:-:) cormihtll-:'; It"
and ~inHlllalleou ..ly lIsed RI hcat!·h1rw;lnl pi.,lufe
SIl"Cnglhcll \\C;l~, Ikcp 1l\'\'1, l\c\(ll''''

STERNOCLEIDOMASTOID (SCM) (Fig. 13.42) Slrclch "IH)n<':l1~'d ,uhtll.:l.:il'il;ll,

Referred Pain iHRT Relaxatiolt

Over eyc. frunt;.J! :m:u. 111aslOltl proct:::-:s
PlIli('Jlf Po.\"irioJl
Supine
Clinical Effect of Shortened Muscle Shuuldcrs al t::J;;c of lahk, ..u head i.. \UPPorl..·d \1111)' al basc \1!.' ,1.....
I-Icad:lChc (o\"cr eyes} ;.:illUl
Ei.tmche Head wlaled ;:\'.")' frolll ill\"lll\"cd \idc and ;lll(lWcd It I c\l,'nJ
Decre:l:-:ed ne;.:k r{llation ...Iightly (()ek'~ Ill'" Il,'''l po\iliOll'

Actimt;oll
/)OC(OI" Po,\";/irJlf
l'v1cdl;mic;lllI\ l.:rloiltl (execs"i\{: ilt::ck cxlcnsimll
P:liluin~ :1 cl,'iling :\1 h.:ad (If lahle
\V<llehill~ a lll<"\ ic frUlll lhe froll\ row Cephalad hand ih:llld ncah.·.. t III hc;ul.' n;ld\cs h':;Id
Bicycle I'idillg' Olhn haul! pl<ll·:':t..! on p:Il I..:nl·.. forehead

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 MCM/,\DILIIAIIUN Uf THE SPINE: A PRACTITIONER'S MANUAL

Correcti"e Adiolls
Retrain diaphragmati, :m~a(hing pattern
;\lh.'l1lPI~ In raj~l' h.. . ad ~Ii~htly. \\ llhllul ally rotatioll
Stress m:ln:tgellk'1I1
Effort is n:sisl .... d by dtl~'lllr hI h'~'p ~·(llllra<..·lillil <1:- cl(l~t.' to iSOlll.... l-

ric as IXl"sihk MilT Sfrelc"

PlIlk"t Po.\'ilioll
I~ £'!(I,\'(/ 1iOIl
Supinc, lIead Iak'rall)' helll In oppllsite sitle and slightly extcnJeJ
I)oc\flr tl11..'l'I,:I~ .dhl\\" Iwad \Hl'\h:lld a" 1':\1' :,~ i1 w;1l111l ;ts OWII i\ntcrillr liher~ lllllSI Ill: strl;'ldll'O with hcatl rot;lled t\lW;mJ in-
Gra\'it)' i~ .. nl~ f",,:\." rcquirl~d Il' lai-.l' up slal'k vol \'cd sidc
:\ lX'rkl'1 ,,~'lr·lll·;llllll"1l1 111~'llhld ;I' \\'l'11 Mcdi;L1 libeLS rl.'qllire 11(1 rot,lIion
('nlllr;,indi..:;l1l·d if ;,ny ~i~,,~ tlf \ I.'rt<."hr(lha~ilar il1~llfjk;t.'m:y noted Postcr;or liher:, n:quire h~ad is rlll:ttcll :1\\';1)'

Other 'MilT Strctchc:,\' ((ud Self-Stretches. If the cervical

Doclor Posiliol/
-"pille is irritahk. lh~ SCM Ill"y still be treated by preposi.
tinning in Ik'-"iOll. thus 'lvoitling provoc;,t1ive cxtcnsion posi- At hC:l(i of 1;lbk
tiolls (Figs. l.l,-t.l and 13.44). These strctches arc ideal in·of- Anterior libers isolated \vith olle hand on mcdial clavicular origin
1 ril~ or self-lfl.:allllclll methods, This ledmiquc is oflcn an and other hand ju:q ant..:rior to m;lstnid process
ex('dlcllt prL'thrusl rcl'lxation tcchniquc for .1 patient who Medi:1I fihers rcquir..: one h;md on midclavictll;u orig.in and other
"guards" c.xL'L':-."i\'t.~ly. hand on mastoid process
Posterior libcrs rC\luirc unc hand un later-,I c1:tvieul:tr orig.in and
SCALENES (FIG. 13.45) other twnd just pmilerior IlIl mastoid process

ReJern:d Pain Patielll Ellorl

Peetor"lis I1lU~(:It;,. upper afln, h;lIlJ. :lllli rhurnh(lid~
• Aucmpts 10 ~idc hend b;lck Inward midline
Clinical Effects of Shortened Alusete
Possible IIUlllbnc .... or t;ngling ill h:mds and/or fingers
Differentia! diilgn('sis
Stretc"
Ulnar di~tfiblltion of symptoms frulll the hrachial plexus or sub- Slack I;lken out into grcater 1;lleral l1exioll
cJ:lvian vein Anterior tiber Ienglhening \"ilh rotation tow;ml involved "idL'
Radial distribution fmm ll1Y(lra~cial rcfcrr;11 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
If the neck is hypersensitive or any vertcbrobasil;'lf symptOms
Tension ill nther fix:llors of shoulder girdle
are present. this technique is contraindicatcd. Joint manipula-
Trigger Paims tion may be nccessary before using this method to cllsur(' the
Anywhere within anterior. metlial. or posterior divisions of muscle join.s arc not compressing. especially with respect to the :'1.';1-
Palp;\Ie and treat ..calenc~ with c:lution hecause of proximity of ex- lcne anticus stretch (Fig. 13.4Sa).
tremely sensitive lICllfO ....;lscular li .....uc Gtl,er MRT Stretches. An alternative w,ly to <.lddrc,,~ ::l:a-

Joint Dy,\fullctioll lene dysfunction involves prcpositioning the patient's ned..: in

Flexion li,x;ttion... of cCl'"ical ~pine (antcri(lr cervical!!! d stretch position and then contacting the origin of thc I1lu:'l'!c ~
"
First rih blockage over the anterior chest. Resistance to inspiration can be :,ufli·

Fig. 13.44. Sternocleidomastoid PlR.

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 CHAPTER 13 : MANUAL RESISTANCE AND SELF·STRETCHES FOR IMPROW.~ =LEXIBllITYIMOBllITY 279

Fig. 13.45. S" ~oe PIA.

c
cienl to achieve posrcontraclion inhibitioll. SI:Kk call he taken AfIllS il1l1:r:l:" ~Ill:lk'd

out with the hand over the ante.:rior rcgitm (11' the chest or d~I\·· Sc.:apula ahd~_' :,-1 alld I'n'll':tc.:H:d
ide to lengthen the shortellcd musdc. '/i"iggt'l" IJ(li/If'
Self-Stretches. S~lf-lr(;atlllcnl is I.'a~y ami ';Ifc. cspl'\':i~lll~ I\II~ \\ 11...·1.,; ;. .,...·k l>.'ll~
if L'xlCllSion j:, minimized (Fig. 1:\.4(1). Fi~Ul\: 1:;.47 sll<l\\':- ;1
~idc-lying technique for pCrftllming self-PIR \\illl gra\"ily n:,:. l'erios((,lIl Foillis
;"iswncc. Rib Iwad :IL._· ';\;:nh

J:'m/ualio!l {f)r .r-iltortclJil1g

?ECTORAUS r·.AAJOR (Fig. 13.48)
Ann ;Ihdlll·;:.;:: }iJ' and ,"ll'fIl::!I:. rillall'd
Referred Pain S:tllh' Hill, \11 l~ll .\hdUt:li'l1l
Anterior part or chl:sL bn:'I~1. inn('f .11'111. '\Ill.! t'llr'':;lrI11
Joiu! /).n{uIH:timl
Clillicall:,Jfect oj" 5;/wr(('ued Muscle liPPlT nb...
P;lill similar lu angi11a
Bn;asl Ilypcr~cn~ili\'iIY Corn!",i\"(:. \ctim,...
Anterior humer,,1 pt1siliotl l,;an prolllOh: slwlIldcr impillgc1Il1.:!l1 11111'l\lVI..' r(lj",'.;~,d Wl'i~111·\'~arjJlg P(l~lllrl..'

syndrome F:lcililall: i!wj ,'rl:ll~llh.'ll l\lWl:r (Ixalors (If :'l'apulac

;\c/iJ,'atioll M RT Slretell
Rlllllld-shoukkrcJ. hl';ld·!",u"\\ ;ml PI):,Illl"l' I'o.\;li'_,i,
1'1/1it'lIl

ObSerntliml Stll'itll'
RIllilld SI'\I\Jldcr" ArIll ahdul',,; !i)' and ,'"ll'rn:lll> nll:tIL,d

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Fig. 13.46. Scalene self-stretch.

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Fig. 13.47. Scalene self-PIA.

Doctur Position C01lcem

At head of table on involved side If br~lchial plexus syrnplOrns arc encoun[ered PIR. may be
One hand COnl<lcts muscle belly (;,\bdomin:ll or sternal) or opposite pcrfonned without stretch.
clavicle
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 PECTORALIS MINOR (Fig. 13.49)
Effort is resisted by doclor to keep contraction .IS close 10 isomet- Clinical details arc similar to those for pectoralis major.
ric as possible
Application of PIR can CilUSC nerve entrapment related to tho-
racic outlet syndrome.
Stretch
Once paticnt has rclaxed fully. doctor may retract shoulder to new
MRT Slrelch
barrier
Patie", Positioll
Must firmly stabilize muscle belly over ribs while !,Iking ~!;' Sl;lCk • Supine

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 u' "" ' .... " , . ) . 'VI"'~UKL M~~r~ IANCt ANU :;;t:LF·STRETCHES FOA IMPROVING FLEXIBILITY/MOBILlTY
281

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Fig. 13.48. Pectoralis major PIA.

~ Ann abducted :':0" ;llId ~x!::rnally rotated

I~ ( ) H:tmllwnging hl\\'cr thall ,holildcr
Sfretch

Ouel.: palielH has rda,xed rul1)'. dt1;'°ltlr may lake sbd, tllli loward
i u f)oC/or P(J,'j;rirm lI~W harril:r ny pushing shouldl'r :lway from d<l\'iI,,·k

J• , %...,~
AI head (If '"hk' Oil in\"uh;:d ...ide Other J\tlllT Strctclw.\". ;\ mollified lc<:hniqlk' for prow;
~ Ccphal<.td hand I:olllac!'- gkllohtHllcral juint positioning is shown in Figlln.'. 1."50.
t Caudal hand gra!'ps ann
f1 SUPRASPINATUS
"11 Pariellt \' !\cril'(' .qrorl
~
() Referred l'a;1I
..\llclllp'" \0 rai:...: ,houkkr III l't.:iling (kccpill,g hand lower Ih,lll

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;-.Iululdcr
Efror! i'i resisted hy dUl:l{'; III keep i:oll(ractj{.n
l'l\: <IS pu\'~ihk
:l'i dt)~c 1(1 i"ornel-
Ikhoid rq;iun. I:Ilcral upper afln

Cliuical J(c.w/t of S/wrtf!"cd IHu.\"cle

Painful ~dxllll'li(\ll (p'lillfu] illl"j
;Illt! dhm•.:

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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<lchillg above shoulder

ROlator cuff c.Iisordcr$ (i.e .. impingemcnt ~)'llllrome) uften result
from tightness of eXlernal rotators (infraspinatus. teres minor. and
supmspinatus)

Activating Factors
O\'crhc:td work (i,e .. weight lining. throwing. swimming. \,,'[l.'.)
Puor :-c:lpu]o!lulTlcral rhythm Fig. 13.52. Subscapularis PIA.

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 CHAPTER 13 : MANUAL RESISTANCE AND SELF·STRETCHES FOR IMPROVING FLEXIBILITY/MOBILITY 283

1'1;ln: \Jlll' haml ;lgainsl llr~r arm illid g.rasp patient's wrist with COlleem
nlh..:r hanll
Although this method is simple to perform. care is nceded if
the shoulder joint is hypersensitive,
Other MRT Stre/cltes. An alternative method that rc-
Gl'lHly pu:-hc.; "rp~r ann out into :lhlluctlOU duces sirain on the ~houlder joint is accomplished with the
Effort is rc~i"h:d i:-ullll'tril"ally aml brought into ful: internal rotation and adduction across
.1':llil'lll .;hotlld follt,w normal orcatbing pror.::cdun:
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
• As paliclH rda\l's. dlll.:lo( takes up slack in adduction attachment rather than the shoulder attachment of the infra-
spinatus.
INFRASPINATUS (Fig. 13.51)
SUBSCAPULARIS (Fig. 13.52)
Uefirred Paill
:\lltcriol' ddtnid-shuuldcr. dowl1 ann to hand Referred Pain
Posterior deltoid and posterior ann
Clillical J:.ffect,li of Shortened Mm'cle
Paill whcll sleeping Oil either side Clinical Effects of Shortened Muscle
Diflkulty rc..chillg llChind back to unhook br.l Difficulty reaching back as in throwing
Diflicuhy rcaching b~ICk pocket for wallet Involved in "frozen shoulder"
Rotator cuff disorders (i.e .. instability syndrome) often result from Promotes subacromial impingo:ment m~d rotator cuff syndromes
liglullCSS of external rotators (infraspinatus. teres minor. and
supra:-.pinatus) Activa/ion
Shouldcr ovcruse syndromc
Activatioll Lack of variety of motion in shoulder area
NcglCl'lcd shoull.kr overose svndrome Forward·drawn posture. especially tight pectornls
:\ltcrcd..scapulohumcral rhythm Trigger Points
Vcntral scapula
Trigger Poiuts
Infruspinatus. fossa (especiilily supcromedial) Joint Dysfunction
Glenohumeral joint
Correcth'e Actious
Sleep with involvcd side up .md pillow under involvcd mill
Correcti.'e Actions
Improve scapulohunleral rhydlnl
When lying on involved side. place pillow between ann and chcst
10 maintJin abduction
MilT Slrelch When lying on uninvolvcd side. place pillow in from to prevent
Patient Positioll excessi .... e abduction
Supine Improve scapulohulllcral rhythm
Involved shouklcr supported by table Slrctch peclor<llis major

MRTStrelch
Docror J>osilioJl Patient PQJiliofl

Ahduct .Irlll ;Ino flex dbm...· to 90" Supine

Allow furearm 10 fall into <IS much internal rotation (forcarm to- • Involved shoulder supported by table
Wilrd Ihigh) as gr'lvity will force il
EnSlife shoulder docs not bc£in to lift off table DOClor Posilion

Facing patient nn same side as involved shoulder

PatieJ/t:\, Aui\'{, Elfor! Abduct arm and nc~ elbow to 90 D

Allow forearm 10 f;all into as much external rot<llion (forearm 10-

With {JIIC himo <1Il afln abov.,; c1bO\v and other hand on dorsal as-
ward head) as gmvity will force it
peci of forearm, gently pushes forearm up or backward toward CX~ Ensure shoulder does not begin to lift off table
tcm,L! rotation
Effort isomctric,llIy resisled (.again ensuring shoulder docs not rise
orf t.. hle) I'atielll:'i Active Effort
With one hand on ,Inn above elbow and olher hnnd on \"Cnlntl ns-
pecl of forearm, gently pushcs their forearm up or forw3rd loward
Stretch
inlemal rotation
When paticllt has fully relaxed. lake up slack IOward ncw barrier Effort is isometrically resisted (shoulder should not ri~c sjgnifi~
in inwfIlal rotation cami)' uff table)

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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 When pat1cm has fully n:l.n.~',1. take IIJl sku.:k 1\lw;lnl IlI.:W harrier
in externul rotation in ill\kk dllrsilkxioH

Self-Stretchl's. Sdf-slr.. ·. Il'l,ing tile gilstrocncmius is hest

Concern performed with thc s{andil\~ w;tli lean and it:- lllodilll:;ltiollS
This technique is contraindicated if :mlcrior instability is pr~­ (Fi!.!.. U5-t). It is csscnti;l! lhat the knl~l~ is eXlcnded ;tlld the
senL It also will provoke extreme pain if 2 "frozen shoulder" hed docs 1101 ri~c up.
is the problem. In either casco the functional range for PIR
may be limited 10 less than 90° of shoulder abduction. SOLEUS (Fig. 13.55)

Referred Pain
GASTROCNEMIUS (F;g. 13.53)
Heel. posterior calf
Referred Pai" Clinical Result of Shortcned l\1uscle
Calf. posterior knee. and instep
foorwilrd weight-bearing. pt1slUre
Clillical Result of Shortell cd Muscle DIfficulty squuning
Forw;lrd wcighl·bcnring posture
Acli~'ation
Achilles tendinitis
High hcels
Acli~'alioll Exccssi'iC running
Scat height too high
High heels Trigger Points
Superior and inferior musdc belly
Too much driving (pushing on ;leedefinor)

Trigger POilllS Evaluation for Shortening

Prone with knee bent 9W. dor~il1ex. ;tI1k\c: ~h()uIJ have 20" d(lrsi~
Medial and lateml border of muscle
flexion
Evaluatioll for Shortening
Supine dorsiflex ankle without allowing knce to bend. Should have MRT StreIch
I0° d()r~iflexioll. Patient Positioll

MRT Stretch • Prone

Patiell1 Positifm
Doctor Positio1l
• Supine with legs extcnded
Standing at side of table, places patient's leg in 90" knee tlc:-.:ion
Doctor Position Passively dorsiflexcs patient's foot by pUlling up on hed while
pushing down on metatarsals
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~ Resisted Effort
y
,
Resisted clfort
Attempts 10 plantarflcx fOOl {not toc:-)
Effort is isometrically rc~i~tcd .f
,
Patient imcmpts 10 plantmflcx fool (mu toc!')
Effort is isolllelric~lIy resisled Stretch '....j
"
.:1<
Whcn patient has fully relaxed, t~lke up slack toward lIew barrier
,)
in ankle dorsiflexion

Self-Stretch. Self-stretch is accomplished ,IS for the gas- , '>

:'
,;"<

trocnemius. except that knee flexion is allowed (Fig. 13.56).

, 0"
Postisometric Relaxation Joint t\.1obilization Procedures ~
..;.$
""
HIP JOINT (Fig. 13.57)
~ .~-~

Patiellt Positiou tf ,"

Supine
~ ,J
Involved leg flcxed at knee and dr.aped over scaled l!\letnr's
shoulder f
d
Doctor Positioll ,
Fig. 13.53. Gastrocnemius PIA. Se;l!cd ;11 s;mlt: sidc or l:.1nk ;IS involvcd hip. (;lcing p;tli...·111 -..v)
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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 LUMBAR SPINE (EXTENSION MOBILIZATION) (F;g. 13.58)
Cont<.lct m;'dl.: over p<.lticnt's alUcrio( hip with both hand!> and pull:-:
Patieltt Positioll
A to P to takl.: out ,Ill available shick in posterior glide
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
Doctor Positiolt
Facing IUw;m.l patient
Patient and doctor shmlld reel contraclion occurring in anterior hip
P]:Jccs lingers ovcr spinous pr~lccssC!'> (one hanJ over thc other)
region
Patient's knees in conlact with duclOr's anterior lhigh
Stretch Doctor lllust take om <III sbd in lumbar CXICIlSi{ll1 t'l). pushing with
Once paticnt has fully rcl<t~cd, doctor takes up SI;lCk by incrcasin~ lhigh intu paliern·... knecs while "lahilizing vertebral segment
posterior glid..., hi I1S new end point ahuve juilll lixaliun with hand ...·(\III.let

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 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<lIIllCIlI Ill' Ih.: hlln!l:lf spine

in1\\ c.'\l!.:nSitHl l';lll he ;I1.'colllplishl'd hy performing the 1 "\

,
:\kKl'IlZic prout.' l'll dhow:-:. proUt.' press-up. and sl:llH.I-
illf I.'xh:nsioll \.'\\"'n.:iscs (Fig. 1.1591. If (ill'S": l'xcn:bcs an::
!,
i
, ,,
1l1h:tllllfllrtahk. lh\,.' hal..-k 1.:.'\I\.:nsioll . . lrl...·\l.:h till 11l1' I..'xt,;rcisl:
!
1 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.
!
i
)
, THORACIC SPINE EXTENSION MOBILIZATION (F;g. 13.60)
t ,
! P<l:'lisoll\etric rda\:llioll l';11\ he lIsl..'d 10 improVl' eXIl.:lIsillll
11l\)bility in lhe I!Hlracil' spille, Thl' seated patient \Hl:-:hl's with
?

their dhmvs dO\\'Il\\"ard against the practitioller's n,.:sist;lllce.

:vll.lbilizing [he thnracil' Spillt,; iHlo l''\(l'llsioll is thel1 ;lCC0111-
plishe.: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. (-""),
f

RIB MOBILIZATION )
Fig. 13.55. Soleus PIR. 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
~ )

.~
.<

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 i, ,)
Kyphosis or patient's spine should result ., !
~
,
Stretch , -"
Once patient has rull)' relaxed. doctor extends patient's spine by ~
pressing hands anterior 10 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
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 CHAPTER 13 : MANUAL RESISTANCE AND SELF-STRETCHES FOR IMPROVING FLEXIBILITY/MOBILITY 287

,
.~

~
< .,
,,t
I
)

IIi
'1
~
g
•
j
')
I "f

I,
,
"
.~
J
~
~
~
~
I)
•
I
I
,n
)

~ Fig. 13.59. Lumbar spine extension automobilization.

g
! ,...",\

I .J
ex.tcnsion by raising the ipsilatcral elbow. Thc patient is in· RHYTHMIC STABILIZATION OF SHOULDER JOINT

I
J~ structed to push his or her elbow downwnrd. Aflcr resistancc A wcll-known PNF technique for the shoulder inyolvcs re-
is applied to this movemcnt and the p<Uient relaxes, the joint sisting contractions by the intcrnal and external rotators in
may be mobilized (Fig. 13.62). various degrees of abduction (Figures 13.65 and 13.66).
:1
,~ Facilitation Techniques
LOWER FIXATORS OF THE SCAPULAE (LOWER & MIDDLE

I
J TRAPEZIUS) (F;g. '3.63)

,) Patiellt Positioll
Supine
,"
I,~{ ""'.7 Doctor Position
Standing to side of patient
'fi Grasps paticl1l"s arm with both hands iHH.l pull~ ~hollJdcr blmlc into
protraclion1<lbduclioll

1'....J,
~ \, /
Resisted Effort
Palicnt pulls should h;\ck towOJrd tJblc ;llld in toward spine. avoilJ-

I ing hiking shoulder 1(lw;lrd Iheir C;lr or usc of triceps (elbow is

secn to bend)
I 11
• Effort is isometrically resisted by doctor

{( Other Facilitatioll Techniques. The PNF DE2 pattern

.~
, shown in Figure 13.64 is .lIlother excellent way to facilitate
the lowcr fixiltors of Ihe scapulae. Fig. 13.60. Thoracic spine extension PIA mobilization.
)
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~
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 n.C."Mt:llLIIAI 'UN UF THE SPINE: A PRACTITIONER'S MANUAL

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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

R;lise~ ,lflllSinto CX(Cn.. iOll with
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.
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
Fig. 13.62. Upper rib PIR mobilization. the (laticllt can avoid shoulder shrugging (upper trapezius ac-
tivation) 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 me-
dial 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 infcf{~mcdi:tl hon!cr uf sC,lpUIa\'"

l'atiell/~'i Acti~'e '".oJ/arl

Fig. 13.63. Lower fixators of the scapulae facilitation (contracl· Pulls shnulder hbdc h<.lck Inward spine while :I\'t1iding .. ny tcn-
relax), dt:l\cy to shrug shoulul.:f\

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CHAPTER 13: MANUAL RESISTANCE AND SELF·STRETCHES FOR IMPROVING FLEXIBILlTY'MOBILlTY 289

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)

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 .. _ , ."', ''-'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
Rapid mobilization into abduction \vhilc ;lpplyillg "goading" stitll-
Fig. 13.68, Middle trapezius facilitation exercise (elbows bent). ulation to tendinous insertion
Each mobilization should incrementally incn:ase range into hip
Effort should be isometric,llly n,:si~(cu ny dt}('l<lf ;\1 inferomcdial abduction (may be performed in f.ISI. ratchet)' manner four It) eigllt
border of sc;qmlm: (or po,tcrior SIHlllluI,"rl I!mes)
Palient may iSlllllctri<:~lIy huld ;lddlJl,:ted ;Hld l1qm:ssed rb;lCk ,lIlli After Illobiliz:ltioll, leg placed inlo abduction. internal rotatiol1.
down) posilion uf sc... pul~e tlnd perform: . and slight extension: paticnI Iwlds leg. up as doctor suddenly let ...
';1;"
Shoulder ~ldduc(ioll!~bJuCli(lll leg drop
• Shoulder Ih:.\ion/e.\lt.,t1 .. inn Muscle should he !-ccn 10 i.(uic.:kiy contract so leg ducs nut dwp
"

,
}

.'>
Fig. 13.69. Middle trapezius contract-relax facilitation.

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_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _----A_
 "V '; !PH,) r-Lt:All;11111 Y i....1VOILII Y
·_----=-'-

,•,~
,
~
'~".

,,
"
Fig. 13.70. Lower and middle trapeZll~s contract-relax facilitation.

Fig. 13.71. Gluteus medius lacilitation.

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-
CONCLUSIOS 7. Guissard N. Duchalc;llI J. Ihinaut K: Mu.~clc strctching .1IId motoncuron
excitability. Eur J Appl Ph)'si\ll 58:47. 1988.
The MRT arc invaluable lools when sofl tissue lesIons are S. SehieppJti M. Crcntl.1 P: From activity 10 rest: Gating of excil:nor)· 'Ill,
considered primary or significant in the patient's functional togenctic affcrences from the relaxing muscle in m:ln. Exp Brolin Res
56:448. 1984.
pathology. If chiropractic ~\dju~illt1ents are unsuccessful in re-
9. Willi:tms PE. Goldspink G: Longitudinal growth or striatcd lllusck Ii·
laxin" contracted musculature. MRT should be applied. High brcs. J Cell Sci 9:751. 1971.
velocity adjustments arc still the most potent tool available. 10. Tarbal')' Je. Tarhary C. T:lrdicu C. Cl 'II: Physiologic;11 :md structural
especially when;] joint lesion is primary. In patients with sig- changes in ca(s soleus lll\lsck due ttl illllllobili7.atiou;lt diffcrellt lengths
nificant guarding. however. MRT relax the pJlient and inhibil hy plastcr cam. J Physiol P"ris 224:2:\ I. 1972.
muscle tension. thereby making the adjustment easier to per- II. Williams PE. Catanese T. Luce)' EG. ct al: 11lc illlportam:c or strctch and
contrnctile activity in thc prevention of conneclive tissue acculllUlalioll in
form and longer lasting.
muscle. J All.1t 158:109. 1988.
Generally. tense muscles should be relaxed <:.nd shortened 12. lakei M. Robson LG: lllixotrophie changes in human musclc stiffnl::ss
rnyofascial tissue stretched before weak muscles are exer- and thc errecL~ of fatigue. Q J Exp Physiol 73:487. 1988.
cised. Therefore, MRT should be used allhe beginning of any 13. Habarth KE. Hagglund JV. Nordin M. e~ al: Thixotrophic behaviour of
rehabilitation program before initiating a strengthening pro- human finger flcxor muscles wilh accompanying changes in spindle :md
rcflex responses to stretch. J Physiol (Land) 368:323. 1985.
gram. 14. Hagbarth KE: Evaluation of and melhods to ch.mge muscle lone. SC;ll1d
M~lIlual resistance techniques are simple and allow a J R,habil M,d Suppl 30: 19. 199~.
patient to learn self-treatment. Their usc enhances the doctor· 15. HUllon. RS: Neuromuscularb3.<;is of stretching excrcises. In COllli P (cd):
patient relationship, encouraging the patient to become morc Strength and Powcr in Spon: The Encyclopcdi;L of Sports l\-1cdicillC
tlclively involvcd in their own health carc. Well-prepared pa- Scries. London. Blackwell Scientific. 1992..
16. Voss DE, IOnia MK. Myers BJ: Propriocepti\'e Neuromuscular
tients arc be ncr ablc to manage minor aggravations of their
Facilitation. Pattems and Tcchniques. 3rd Ed. Philadelphia. Harper &
symptoms on their own. Self-treatment docs not replace chi- Row. 1985.
ropractic or manual medicine treatmcnt, but it is increasingly 17. Janda V: Seminar notes. LosAngcles Collegc ofChiropraclic. May 1988.
valuable in an era of diminishing third~party reimbursement. 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
ACKNOWLEDGEMENTS
Prcss, 1976.
20. Cailliet R: Shoulder Pain. 2nd Ed. Philadelphia. EA. Da\·is. 198 I.
I thank Joanne Larricq. Jerry Hyman. Vladimir Janda. and
21. Liebcnson CL: Acti~'e muscle relaxalion techniqucs. Part I: B'1Sic princi·
Karel Lewit for their suggestions and contributions to th;:~
pIes and mcthods. J Manipuhllivc Physio! Ther 12:446, 1989.
chapter. 22. Liebenson CL: Activc musclc relax:nion techniques. Part II: Clinical ap-
plication. J Manipulative Physiol Thcr 13:2, 1989.
REFERENCES 23. Janda V: Musclc spasm-a proposed procedure for differcntial diagno--
1. Kabot H: Studies on neuromuscular dysfunction. XIII: New concepts sis. J Manual Med 6: 136. 1991.
and leehniques of neuromuscular reeducation for p-,ralysis. Pcnnanente 24. Lewil K. Simons 00: Myofascial pain: Relief by post-isomctric relax·
Found Med Bull 8:121, 1950. :lIion. Arch Phys Med Reh:lbil 65:452, 1984.
2. Le,'ine MG. Kabat H. Knott M. et 01.1: Relaxation of spa.<;ticity by physi- 25. Travel! J, Simons 0: Myofa...cial Pain and Dysfunction: Th..: Trigger
ological techniques. Arch Phys Med Rehabil 35:214. 1954. Point Manual. Vol. 2. Baltimore. Williams & Wilkins. 1992.
J. Mitchell Jr F. Moran PS. Prouo NA: .m Evaluation of Osteop;Hhic 26. Grcenm:;1.n PE: PrincipleS of Manual Medicinc. Baltimorc. WilJiall1.~ &
Musclc Energy Procedurcs. Valley Park. Prouo. 1979. Wilkins. 1991.
4. GaY'mms E Lewit K: MobiliZ<ltion techniqucs using prc..<;sure (pull) and 27. Spilzcr WOo LeBJance It. Dupuis M. el :II: Seienlific arrro;u;h to the :IS-
-~
m\l~cu1ar facilitation and inhibition. In Lewis K. Gutmann G (Eds): sessment and management of acti,·ity·rcl:llcd spinal disorders: A mono-
Funclional Pathology of lhc Motor .Systcm. Rchabilitacia Supplemcn- gr:lph for clinicians. Report of the Quebee Task Forcc Oil Spin:,l
tum. 10-11. Bratislava. Obzor, 1975. flP 47-52. DiSQrders. Spinc 12 (SuppI7):SI. 1987.
5. Lewit K: Postisomelnc relaxalion in combination with other methods of 28. Bigos S. Bowyer O. Bmen G. t:t al: Acute Low Uad: Problems ill Adults.
muscular facilitation and inhibilion. Manucllc Med 2:101. 1986. Clinical Practicc Guidclinc. Rockvillc, U.S. Departmcnt of Hcalth and
6. Robinson KL. McComas AJ, Belanger AY: Control of soleus motoneu· Human Scn·ic!::s. Puhlic HC'llth Servicc. Agl::ncy for Health Cme Policy
ron excitability during musclc streIch in man. J Ncural Neurosurg and Research. Dccembc:r 1994.
Psychiatl')' 45:699. 1982. 29. Lmricq J: Lecture. Los Angeles Collegc of Chiropr-,lctic, April 1994.

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. ----.----. J.
 14 Spinal Stabilization Exercise Program
JERRY HYMAN and CRAIG lIEBENSON
,,

Repetitive strain is the 1110S( <:ommon fl"aSOn pcopic dC\"l:lnp elicit proper responses from the patient. Maintaining proper
pain. Improving load handling ability is instrumental in pre- lurnbopclvic stability requires limiting and controlling exces~
venting chronic or rccurrCll! pain. Ironically, by redirecting sivr;: or undesired lumbopelvic movelllcnt strategies: e.g., per-
the patient's (ocus from chronic pain 10 functional integrity. forming a lunge with too much anterior pelvic tilt and resul-
the pain is more likely to "go aw'ly:· The result of controlJing tant lumbar hypcrlordosis.
.~ loads in .1 more biomcchanically effective manner is less tis- Patient education about the importance of good function
1 () sue strain 'll1d. therefore. fewer pi.linful.cpisotlcs. StabilizOltion for preventing pain recurrencc.s is esscnti;'Jlto motivate the pa-
"ii,
exercises twin a patient to coruml posturally destabilizing tient to work on creating a healthier back. Explaining that fit-
I ) forces. These exercises may start by requiring isometric pos· ter backs have fewer symptoms is helpful. Therefore, it is
I tural slabili7.alion of a key area. such as lh~ lumbopelvic june· wise for patients to remediate function r..Hher than just to seek
)
I,, )
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
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
I~ ,, exercises are Ihf?rapew;c in that they teilch the patient how to a commitment from them is one of our most crucial functions.
l maintilin postural control in activities of daily living. By fo-
{
~ cusing primarily on reducing lumbar overstress during func·
l STAIlILIZATION I'ROGRAM AND OVERALL
!, tional exercises. the quadriceps. glutci.lls. ~lIld abdominals arc
trained without increasing back or hip pain. With this pro-
PATIENT CARE
':; gram, it is possible to achieve strength and endurance gains The stabilization program starts by identifying the training or
'/

\i because the back is not stressed. thus the individual can train "functional range" in which movement can be performed in a
.~
muscles to the point of exhaustion. Postexercise muscle sore- biomechanically correct and painless manner. Staying within
;'~ () ness without symptom eX41cerb.uion is one of the essential this range may initially require performing isometric stabi-
stepping stones to returning to full p'lrticipation in the <lctivj· lization exercises by co-contracting (he gluteal and abdominal
i
,~ } tics of daily living.
Physical training addresses key functional deficits of
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
1 ,, strength. mobility. or motor control (endurance. coordination. both ("dead bug"), they find thai holding the pelvic tilt
~ J
balance). Functional stabilization (FS) exercises begin with "burns" the abdominals. Kinesthetic awareness. coordination.
t \ identification of a functional range. especially of lumbopelvic strength. and endurance are all trained in the process. A sim-
I 'J >' movcment. This is the range of movcment that is both safe
and appropri:ltc for the task at Imnd. Pathoanatomic diagnosis
ple trunk curl is another example of an exercise that requires
proper lumbopelvic control. During a trunk curl. the patient
I1
,
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.'1
{ , is of secondary imponance in these paticnts. Assessment of
functional deficits or palhology (specific joint or muscular
dysfunction and abnonnal movement patterns) and identifica-
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 stabi-
tion of a safe training range (neutral spine position and func- lizing demands. The stabilization routine can begin in non-
f;
tional range) are of primary importance in successful physical weight~bearing positions and thus achieves intense training
1'c-;]
training of the patient with back pain. .effects. such as postexercise muscle soreness in failed back
"','
Functional stabilization achieves muscular reconditioning surgery. postsurgical. subacute. and chronic pain patients
g without aggravating presenting symptoms by focusing on without causing harm.
{;

I \.~?
, control of the lumbopelvic junction (maintaining'l functiOlwl
range) while exercising the "weak link" with the lIeceSS.lry in-
The main go;)1 of this program is reconditioning key
spinal stabilizers through building ~treng(h and endurance
~ tensity to achieve a training effcct. Neuromuscular control. while insisting on proper neuromuscular control and coordi-
I~
) mobility. pain-free range. endurance. and willingness afe all nation. The program also is of value as a mobilization ap-
~ assessed during this process. Basic exercises such a.~ pelvic proach that gently shows the path to movement exploration
f
~ f) tilts. bridges. trunk curls. lunges. and othcrs are included. II is and re·education. In (his case. the de~ircd end result is less a
I~ .,J
, necessary for the pr:lclitioncr to experience their own abilities conditioning effcci (postexercise sorencss) and more increa~­
iug patient confidence. muscle relaxation. circulation. and
through active ICilrning during such a training rcgimen 10
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 nc;nf\DII.. II""IIUN VI- I He ::;PtNE: A PRACTITIONER'S MANUAL
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joint movement. In addition, while pcrfomling stabilization "functional rangc" for the particular task at hand. Idt'1l'ij)'ilfg I
exercises, struclUral limitations ~lrc clearly identificd (Le.., in-
ability to pcrfonn a posterior ~iil during a bridge as an indica-
Ihe tmilling rauge is impOrlll1ll for petiorm;".': therapcutic ex·
ercise ill (lily part oflhe body. \Vilh resfJccllO spillal prohlems.
i
tor of tight anterior hip struclUres) that may require remcdiu- IWIi'cI'er, Ihe lttmboprll'ic Illolion i... of grealc.<;{ \·allu'. The
tion thr;ugh stretching tedmiqucs. beaut)' of this exercise approach is that the patient !c..lfIlS lhat
This exercise progression is oncn facilitated by the <tddi- it is possible to exercise without p;tin. As a rcsuh the p<.nicnt
tion of manipulative Iherapy to improve joint or muscle func- gains confidcncc that some control over symptoms Gill be
tion. Sometimes an exercise th;lt is painful al first becomes achieved with the usc of spccilic sclf·trcatmcilt procedures.
painless after an ~ldjustmcnt or muscle inhibition technique.
RULE FOR TRAINING THE "FAILEO"BACK
The combination of passive and active care is ideally suited to
Find the painfree range of mOl ion or functional mnge
enhance the effects of either alone. Adjustments should last
longer and pain recurrcnces diminish in frequency as a patient Identifying the training range involves uncovering pos-
begins to gain greater lumbopelvic camral and thus improved tural, movement, and weight-bearing sensitivitics. 7 individu-
1
spinal stability. als with postural sensitivities usually must sit or stand a spc-
This exercise program was first formulated for patients cific way (Q "void pain. For instance, an individual with a
wilh low back pain by Vollowitz and Mo,gan, and is called flexion bias is nOI able (0 stand for prolonged periods because
functional stabilization or spinal stabilization.l.2 It has been of an inability to tolerate lumbar extension. They must prepo-
adapted [0< usc by orthopedists and has ,educed the need [0< sition their spine in some flexion, c.g.. using a fOOl stool.
surgery.~.4lts integration with other rehabilitation methods in a Patients with mOVfment sensitivities may have pain dur~
chiropractic setting has been discus~ed previously.s In a study ing certain activities. An individual who experiences pain
of various treatments for chronic low back pain following un~ when bending forward to tie shoes or put on pants may have
successful L5 laminectomy, stabilization exercises along with an eXlcnsion bias. The functional range of such a patient may
McKenzie-type exercises were the most effective. 6 These low- not include flexion of the lumbar spine. A weight-bearing sen-
technologic exercises were found to be superior when com· sitivity or gravity intolerance may be revealed by a history of
pared with passive methods, joint mobilization, and high- pain Ihat OCCUfS during sitting or standing and is relievcd
technologic exercise experimental groups_ Alltreatmenls werc when resting. Compression usually aggravatcs these symp-
administered three times per week for 8 weeks, Specifically. in- tOrrlS, as does coughing, sneezing, or any strong muscular
creased function as measured by lumbar range of motion (mod· con·tractions. This situation is common in patients with acute
ified-modified Schober fo< flexion and extension), spinal mus- disk syndromes, who may have no functional range when up·
cle st,ength du,ing lifting (Cybex Liftask), and self-report of right, but can train effectively whcn recumbent. Another op-
disability (the Oswestry Low Back Pain Disability Question- tion for the weight-bearing sensitive patient is water cxer·
naire) showed greater improvement with the active approaches ciscs. Exercise performed in water should not mimic
than with passive methods. Flnally. the mean intcrval for pain land-based exercises because mO[Qr progwmming may be in-
')
relief was highest in the low-technologic exercise group (91.4 appropriately altered by the combined effects of water contact ,
weeks)compa<ed t,52.8 weeks forthe high-technologic gmup on the skin and reduced weight bcaring.
and less.than 10 weeks for Ihe othe, gmups. Finding the training range is somewhat like a provocative .
J
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}
examination used in the McKenzie system (sec Chapter 12).
The goal is 1O detennine what movements and positions rc-
FUNCTIONAL OR TRAINING RANGE
Iieve, aggravate, or ha\'c no effect on symptoms. Those move· ,
}:
Many chronic pain, subacute, postsurgical. or failed back melHs and positions in which symptoms arc relieved or arc
surgery patients arc fearful that exercise will incrcase their unchanged can be used as pari of a training program.
pain. Some simple concepts can be applied that enable nearly Activity within (he training. range is best tolerated by the )
anyone to begin to stabilize their spine. Training an area re- paticnt when attempting repetitive and prolonged exercise ,~

quires first that the range of motion (ROM) for the particular training. The pain-free range is nol always one and the same J
movement is defined. The goal is to find a range in which the with the most stable or biomechanically·. correct movernenl. ,."'\'
patient can exercise without eliciting symptoms other th<ln For cxample, ~l posterior pelvic tilt during (runk flexion is bio- ',...ft
physiologic SOreness (postexercise soreness). This range m•.lY mechanically efficient. because ~10 anterior tilt C,IO overstrain
be narrow, leading initially to only isometric exercise (i.e., a the lumbar spine and encourages substitution of the hip ncxor
I J
pelvic tilt). Some patients demonstrate a nexion or extension muscles (i.e., iliopsoas) for the abdominal muscles (see
I . ~

"bias" that must be respected. Some patients may not tolerate Chapters 6 and 18). Many patients, however. report more pilin 1
sagittal motions. but arc fine with rotary or side-bending ac- with this positioning than with the anferior tilt of the pelvis. , j"
tive movements. Wilen the painfree range or "bias" 'W.f bee" In cases in which the less stable or biomechanically inefti·
delermined 10 be biomechanicllily safe or .wable. if ... 1wuld be cicnt movement is more pain·rree, the joints and related soft
llsed in progressive exercise Iherap)~ This range milY changc tissucs should be analyzed for dysfunction, with ..1 focus on
depending on the position the patient assumes or the move- poor mobility or flexibility because of adnpti\'c shortening or
ment being tested. This tf'lining mnge has been labeled the poor soft tissue extcnsibility.
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 vnt\r' I t:t1 14 : ::>t'INAL ~ IABILIZATION EXERCISE PROGRAM 295

BI.',::Il1"1.." of the indiYit.luality of ~;\I..'h p~llicnl's fUllctional tiOtI.\". alallg WillI olher additional (1u/{.:ome measures (i.e., lim-
ranJ;t'.lhIW llHH.:h antcrior nr posterior !ll'h'jc tilt is. feasible will ;Ied range of /1/0(ioll. areas of lel/{I(~mess). should be per-
vary (~lr 1..'\-1..'1)'0111..'. hnding the p:linlcs.s range. '1long with as- IOl'lI/ctJ. This poslcheck is a crucial step in increasing patient
Sl..'ssill:: (til" s!l(}I1111tlS(,:k" .llld capsular rt.':'triClions and diagnos.- conlidencc abolit the positive benefits of exercise. It can allay
ing slru..:lur;d patho)ol!Y Ii. t •.• spondylolisthesis) will !c.ld tOlh::· fe;lr and .IIlXicly ahout p;'lin and convert Ihe patient from a p;'lin-
IL'rtllillill~ [he functional or training ran,gl' for each palit'll!. <lvoidcr In a pain Ill,mager. Also. showing the paticnt thallhcy
Th\.' hl'id~c c.\cl\:is,l' provides :'lllothcr example of whell :11· C;1ll1ll0W casier :ll1d with less pain aftcr the exercises have bccn
h.:rl'd IIh:..-h;lI1ics hct.·;llIsc of poor mobility or Ocxibility can n:- performed enhances pmicllt compliance and motivation.
,
,
,,
1 suit in thl." cxcn:isc being leSs. painful when pcrfomlcd incor- Evaluation or the prospective slabilizalion rchabilit<.ltion
r..:t.:II~ Ih~1Il wh..:n il i~ pcrform":d com:clly. Biomechanically. p;'ltient is summarized in Table 14.1.
1 ') the bridgL'i~ most ~table and efficient when a sufficient poste-
~ rior lill i~ used. thus r~ducing lumbar stress :ll1d increasing STABILIZATION CONCEI'TS
t ., glutcal ;lCti\'ity. If. howcver.)he patient has tight hip flexors,
~ .' TI1C imponant conccpts that pcrtain to this therapeutic exer-
j shorh::ning of tile hip joint cap~ulc. andlor tightness of (he
cise philosophy arc defined as follows.
§ lo\\'cr lumbar cr~ctor spinae musclcs. little if any posterior
t' pdviL' till will be wlemted by the patient. This case is one in FunctiOlml or training range: P;linfrcc ;lTld stublc joint runge '1f lllO-
"
! whit'h muscle relaxation "ltd/or ~tretching and joint mobiliza- tion (USU:lUy wilh respect to hllnbopclvic motion) and appropri-
ate for the task nt hand
I ;~J
tion allJJm aujuslillciH would be required before the bridge
L'ould he used as a stabilization cxercise. Passive prepositioning: Using body position and/or suppons to pas-
sively place joints within the functiOilal range (i.e .• lumbar roll to
J preposition lumbar spine in extension during sining)
! I'ROGRESSIVE S1;\BILIZATION Active prcpositioning: Patient actively pUiS his or her lumbopclvie
I ) EXERCISE TRAINli'\G joint into (he functional runge nnd holds it isometrically during

I! Exercise therapy should be simple and painless to promoie

patient confidence. lnilial rcactinuion c.xcrciscs arc dcsi£ncd
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~

I~
)
spccilically for a paliclll cmcrging from an acule episode or
for it p~Hicnt with chronic pain \\"ith fear of movement ("kine-
siophobia") and symptom magnificalion (0 allow them 10
tion into the functional nmgc during c~crcisc (grJ.dually chang-
ing a pelvic tilt from squalling to standing)
F:lcililation: Process of :l<;tiv3ting ("waking up") <t Illu~I..'iC iil<ti is

I exercise \",,'ithout cxacerbating their symptolTls. The pmienr

shol/ld leam 10 explore b(lsic IWII!Jope!I'ic IIw\'cmenrs. slu.:h
inhibited
Labile surfaces: Support surfaces that arc unstable. such as styro·

I
) foam rolls. bahmce or wobble boards. and "gymnastic" balls
liS IIIl' pc!I'ic lill. lIlUl perform g('",le .wrelches a"d ligltl ca,.-
Functional tasks: Tasks which one would pcrfann during the nor·
diomscular ('xen.:i.'\(:. Weight be~tring or gravity strcss can be
mal course of daily work. recreational. or spans activity.
(} minimized by focusing on supint:. prone. and siHing positions
Perfamling these lasks with stabililY i.\nd coordimltion is the final
during exercise. The stress may be greater during upright ac- goal of thcmpcutic exercise.
,j1
~ tivilics of d'lily living.
, Initial c~erciscs whereil1the patient c~plores movement;:ll The purpose of stabili7..<ltion c:ltcrciscs is to train proper
I • the lumbosacral junclion ill a variety of postures demonstratcs coordin;;nion during posture. movement, and exercises of pro-
gressing levels of difficulty. The stabilization program teachcs
l the patient's neuromuscular control (or kinesthetic aware-
ness). These exercises also fcn;:ll any structural limitation. an individual to: identify correct posture, find their training

I• J~
Such a Iimiwtion may be prcs~nl as a result of viscoelastic
stitTTlt::ss. elevated ncurol11UScul.lr tonc. bony abnonnality. or
struclural palhology.
r.mge. maintain postural comrol while perfonning intensive
excrcises. and nlHomatizc coordinated, stable movements and
postures during activitics of daily living (Table 1~.2).
~ U When acute pain is <lc<:omp;'lnicd by inflammation. (he pa- When training a palient with back pain. improving stabil-

I
tient will have p;'lin with most or all movclllcnts. "Rclalive ity involves more th~n just "dding resistance and repetitions.
) Table 14.3 lists important v'lriables to consider as patients
rcst" and physical agents arc Il~cessilry for this "chemical"
progress through a routine.
u pain. As innamlllmion sl,Ibsides. symptoms will begin to be-
have "mechanically:' meaning certain movcments will pro- In the office setting. stabilization c:ltcrcises can be used
~ voke .symptolll~ whereas other movements will relieve symp- like olher conditioning programs by increasing repetitions
•i,
~
toms. As symptoms become mechanical. active exercise is
indicated.
.lOd resistancc according to standardized protocols (i.e.. goal
of 3 sets/IS rcps). According to Morgan, it is customarily no-
I
~:;
i
The staning point for the exercise is determincd by appro-
priate histOi"y and cxamination. The answers one receives arc
Table 14.1. IdentifyIng the TrainIng Range
determined by the questions onc asks. Movcments and posi-
• ) tions that provoke symptoms an: best avoidcd. and those that History of static, dynamic and weight·bearing intolerance
* .,
relieve symptoms should be indudcd in an exercise regimen. Identification of the movements thai provoke ar relieve symptoms
Identification of the positions that provoke or relieve symptoms

1i "\.}
PO.\"I.traillirlg check.\" of /m;,,·/,ro,·okillJ.: IIIm'ell/eHlS or poxi-

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Table 14.2. Trunk Stabilization Routine Staoilil-alion cxcn;isc:-. 'IIC uftcn pi.linful if extcnsibility is
poor. \Vhcn this situalion is identified. it must bc addressed be-
1. Identify and explore training ~r function~l range. .
2. Train lumbopelvic control dunng dynamic exerCise uSing
fore the p::ltiCIH (.111 successfully pcrform stabilization cxer·
• Passive prepositioning cise~i. For in.';;(allcc. difficulty in activating the g.luIC:J1 muscles
• Active prepositioning is oftcn rcl::ltcd to "lower crossed syndromc" with light anterior
• Other facilitation methods . . .
3. Automatize coordinated posture and movement In dally skills hip struclures. Any attcmpt at hip extension exercises typically ,
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).
Gravitt load Often during therapeutic exercise training. a muscle is
Movement complexity hard to activate. The Illuscle Illay not be weak from loss of in-
Balance requirement nervation. or disuse atrophy, bUI Ill"'y only be inhibited. Rene:\.
Repetitions
Resistance inhibition from related joints and reciprocal inhibition from
antagonist .muscles arc both potential therapeutic targets that
should be addressed (sec Chapters 2 and 18):Such relics ther-
apy can facilitate a "donnant" muscle. Oth~r lllet~lOcis to wake
vantageous to perform stabilization exercises to a point of ex- up 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 func- optimum 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 to-
be 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 pa-
tigue 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 exhaust- These 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 sland-
functional 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 facil-
spine. itate the transition from nonweight bearing to \veight bearing.
Achieving post-exercise muscle soreness requires a cer- Individuals 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 ef- or problems can be avoidcd by determining mutually accept-
fect in just a handful of lumbopelvic musclcs (e.g.. abdomi- able 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 applica- progress. 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 man- 1
Therapeutic intervention with stabilization exercises requires ner. After identifying and exploring their functional range.
a clinical problem-solving approach. Typical problems efl~
cmmtered n.·hen progressing patients through a stabilization
they may begin by performing isometric floor stabilization
exercises in the recumbent (nonwcight bearing) position with
I
~
routiue are ,mor flexibility, muscle i"I,ibition, weight-bearing traction assistance (see Figure 14.56). The patient may
imolerallce. or low motivation. Addressing these situations as progress with or without traclion assist;,mcc to other mo.re dc-
one encounters [hem is essential. mallJing positions, sut:h as quadruped. se.ned. or standlng. if
',
..

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 I.;HAe I loti 14 : ~elNAL STABILIZATION EXERCISE PROGRAM 297

Table 14.4. Lunge Test as a Functional Screen infonn third pal1y payers of the patient's st<ltus. if titis type IS
quanlifiablc. it is an id~al oulcomcs assessment tool. Another
• Trunk drills forward during lunge: tight hip flexors. weak gluteal
muscles type of functional testing seeks to identify functional dclkits
• Increased hyperlordosis during lunge: tight erector spinae, weak that arc cnlTccwblc with specific prescribed illlcrvclllions. For
, , abdomina Is
• Front leg's heelliHs aU floor: tighl soleus
the purpose of spinal siabilil.ation training. such pn:scripti"c
• Excessive knee shaking: weak qual'is, poor balance fUl\ctiollaltcSliug would assess the patient's ability to perform
• Front knee in Iront of foot: too short of a stride or torso moves too anterior ami posterior pelvic tilts in a variety of positions
far for.vard
(hook lying. quadruped, sCilted. standing). lunges. squats.
trunk curls. sit backs, single leg balances. and bridges. Other
I tests could be singled out, but.1 few sin1plc tesui, such .IS those
,
~
I
Ihe p;,lticnt has difficulty mainlaining their function'.l1 range
through activc prepositioning. Ihey may usc passivc prcposi-
listed, can provide infonnation about coordination. slrength.
and flexibility. Table 14.4 shows how the lunge can be used .IS
~
I j lioning. For instance, supine hook lying with a cushion under a screening tesl.

I )
the knees kceps the spine in a posterior pelvic tilt and allows
easier stabiliz31ion training with either trunk (sit· up) or ex-
STABILIZATION EXERCISE TRACKS
I ..;
,
tremity movements (respecting any flexion orextcnsion bias).
The exact progressions chosen depend on Ihe patient's rc· Stabilil.ation training as described in Ihis chapter deals with it
~
~'
;'
sponse to training and the individual work or activity de-
mands to which they must return safely.
progressive program of exercises designed to reverse the ef-
fects of deconditioning or to maximize performance potcmial.
I Training c::tn also pr~gress by increasing the move- Exercises are' organized into various "tracks," each one e1ml-
;I
I ), ment complexity. For instance, movements may begin in car-
dinal planes (sagillal or coronal) and advance lO include tor-
lenging the patient's ability to stabilize their spine in a differ-
ent way. Within each track. the exercises arc ordered so that
~ , sional. coupled, and functional movements. Once a paticnt they progress from simple to more complex movements. Each
I I
has learned to explore lumbopclvic motion and to identify
their asymptomatic and stable functional range. they can per-
track is in effect a progress chart of a patient's spinal stability.
The patient who C.1n successfully perform only the first few
I )
form various exercises while isometrically holding their exercises in a specific track is more dccondilioned than the
j spine within this range. Adding extremity movcmcnts to b;'lsie patient who can execute all the exercises in that track. It is
~ trunk exercises further challenges Ihc palit.:lJl·~ lurnbopclvic best to find the exercise within each track where "breakdown"
;I \
" control. occurs, and then "peel back" to the one in which control is re-
j
',; The goal of FS exercises is 10 perfonn skilled funclional gained, Finding the palient's limit and peeling back is the art
,~ movements with the spine stabilized as the p::ttient moves of spinal stabilization.
from one position to another. Examples include moving from Progressing through a stabilization program docs not

I
:I sitting to standing, standing to knceling, and quadruped to mean maslcring one track before moving on the next. \Vhcn
standing. At limes, the functional range may change during .1 difficulty or weakness is encountered in one track. switching
¥ movernc'1l. A classic example of a transitional siabilization to another is often a catalyst to progress. Progress can be
exercise is performing a lift from a squat position l() st<lnding monitored by using a checklist (Appendix 14, I).
~ ,) with overhead rcaching. In the squat position, an anterior One key clement to stabiliz.llion exercises is the emphasis
~
! .~)
pelvic tilt is held. and in the standing. overhead reaching po- on maintaining the spine in a functional range during training.
'~ sition, a relative posterior tilt is maintained, This change is ne- often incolTeclly termed Ihe "neutral spine rosilion:' Most
}i
N cessitated by the tendency of the lumbar spine to hypcrlordo- abdominal and gluteal exercises require a posterior pelvic tilt.
Xj sis when rcaching overhead. Just how much flexion c,leh patient needs should be deter-
~ ,) Another type of progression involves increasing the bal- mined individually. Most individu.lls do not have a "neutral

I
ance requirement during exercise. Progressing from noor to spine posture" but ff.uher lmve a functional range. Each pa-
,
J
gymnastic ball or balance board cxercises heighlens the bal- tient, with the help of their clinician. must learn how 10 con-
ance demands. This increase allows for a training effect th,lt trol exccss motion to avoid exc~eding Ihe boundaries of their
simuhaneously improves strength, coordination. and balance. functional range. Some p,uierns indeed hi.iVe a "bins" toward
,..J more eXlcnsion or flcxion of the lumbar spine. ;:Igain cmpha-
The freedom of movement provided by a labile surface allows
~ i ~' subcortical training of renexes that helps the patient to au- sizing the need for individualized training. Similarly. ccrti..lin
I ._,1'
tomatize bcttcr spinal stability. Improved rcflcx. automatic universal biornechanical principles dictate that when sitting,
~ control of lumbopelvic motion during activities of daily liv- standing, or lifting, the spine shnuld be upright (lordotic).
ti
:,'
ing is the final goal of spinal siabilization training. When the How much lordosis will v<lry. Some people tend to be
lJ patient has automatized this behavior, they can be considered "slumpers," whereas others arc more "swayback," Each

I• 11
j
re-educated.
Two types of functional lesling are described. One Iypc
provides baselinc infonnation that shows overall progress.
group of individuals needs to develop reflex. automatic con-
lrol of their lumbopclvic junction a lillie differently 10 avoid
excessive loading. 111is fine tuning is what FS excrcises arc
~ J " ntis fonu of ic:tiiug can be used to motivate the patient and to all about. Training may sl;,trt with illL:reasillg awareness
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lIuuugII facilitation lllcthuu,..,. i;ll.::ll pr(1gr~ss to l'xl1allslill~ ~x­ Ofril'l..' scssiol1s ShtHdd OCcLlr no more; than three to four
crciscs and daily hypcr\'igihuu:e (for ahmll 6 \\·cck:,). put it times pl.'f week. At IIr'1. {he patient is simply trying 10 led a
will ultimately fail lInlc~s norlllal 1Il0\ clll~lH p;Hlcrns arlO uot '"hum" ill the '"bi{' Illu:,eks whik feeling no stfain in lhe;
reprogrammed so ,that the illdivitlu;l! "C;lll:!lcs l!lcllbdn:s spinal ;11'1..';1:'. EXel\:isl' inlensity is inl.;"rcascd until pos(cxercise
doing it right.·· SO..l..'llI..·........ is ;\chicn:d \\ ithout s)'mpllllU eX:Kcrbatiou. A few
The following spc~ifk exercise.. . ;11\.' Jcsi~lled as dirf~I\:l\1 _'C~Si()ll' lIlay he rl.'qllirl..'d 10 lind Ihl..' training range and
avenues to travd wilh a patient. I-:;Idl palicllt will pnll..·L·cd al achiL""c this rcsull. OIll"I.· this lask i., ilCl':lllllplished. the pro·
i\ different rate. Sessiolls lIl;ly vary fH111I I () minutes HI mOl\''' gr;IlH qllit:kly ~:l1hL'r" Ilh)llll..'niUm. :\, Illllg ;IS ;Ul cxcn.:isc
than I hour depending Illi the ll....eJs (If thl.: patil.:1I1. and Ilol r..::tUSI..'", poslexl..'n:ise Il1thL"k sorcllcss. il ,11OUld nO{ bc repented
those or the pr.lCtitiona. In gCllcr;l1. each regimen carries the daily. WilhoUllhc il1h:lbily of lraining re4uircd to achiL:\'c this
pOlcntinl for patient frustratioll bc(au_,>c a gn.::ll de;1I or coor- dfcc!. the 1110tor 1.;"0111rol lh;r..:essary to achievc spin:.tl swbility
dination is required by thc patiem. Ckar g()als must be laid in Jaily lifc is 1l00likcly 10 result. Once a patient is discharged
out and the prilclitioncr must be p,,{icll( and cmp:uhctic. ;\ from the prog.ram, intensity and rrcqucnl.·y may be decreased
6-wcek course of Slabilizatioll session", is often atk::qLlille to to a IlWimCllallce It;ycl.
begin the process of ··reprogr:.l11uning·· hetter neurolllllS(lIlar
control ilnd spinal stability. 1. Floor Slilhllii'.ation Excrdscs
A. LUMBOPELVIC FUNCTIONAL RANGE EXPLORATION

Lumbopdvic range of lllUlioll i~ ~xplorcd by performing pos-

terior and ant~rior pel\'ie tilts.
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) ""
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Fig. 14.1. Anlerior <al and poslerior (b) pelvic till (hook lying). Fig, 14.2. Posterior pelvic tilt (supine).
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 <;HAPTER 14 : SPINAL STABILIZATION EXERCISE PROGRAM 299

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) Fig. 14.6. Posterior (a) and anterior (b) pelvic lilt (kneeling with
buttocks on heels) .

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• Scated (Fig. 14.31
B • Standing (Fig. 14.4)
.) Quadruped (Fig. 14.5)
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Kneeling with bUt\UCKs \111 hccb (Fig. 14.6)
li• () Kneeling with thighs vcrti("011 (Fig. 14.7)
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•~ u Silting on 110m with feCi \s(llc~) logether (Fig. 14.8J
Prone
i Difticulty performing pelvic lilt~ often is <.I result of poor
t L)
! neuromuscular control. Appropriate verbal commands. r~\{:ilip
if: >, tative cues, passive prepositioning, and <lpproprkncly dirL"l.'tcd
rcsist<lnce arc all helpful aids in achieving the ability 1(1 pcr·
,;
.
form these basic movements.
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~ Adjustment or l11obili1..a tion to the lumbar spine in I.'ithcr
¥ ,J Fig. 14.5. POSlerior (3), anterior (b), and parti3.1 (c) pelvic till ncxion or cxtcn\ion is often helpful. as is relaxation (If ('1\"('[.
m (quadruped). active erector spirwc ll1Llscies.
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B. "DEAD BUG" TRACK (ABDOMINALS)

For each exercise in this track, ensure that the pa-

tiellt maintain:-: the posterior pclvic tilt not only at
lh~ heginning or
the movcmcnt, but also to the end of the cx-
en.:isL'.

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
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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" ~

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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 alternat-
A ing 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

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 train-
ing 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

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
Fig. 14.7. Posterior (a) and anterior (b) pelvic tilt (kneeling with 3. Pcrfonn bridge. then "march"· with only one foot on the floor
thighs vertical). (shift weight before marching) (Fig. 14.13)

A 8
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Fig. 14.8. Posterior (a) and anterior (b) pelvic tilt (sitting with soles together).

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 CHAPTER 14: SPINAL STABILIZATION EXERCISE PROGRAM
301

Fig. 14.9. Posterior pelvic tilt with opposite arm and leg raised.

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. per-
form one-leg bridges or "dips" (Fig. 14.14)
5. Holding bridge with straight leg. lower and raise leg

A training effect is possible with application of exercises

Fig. 14.12. Bridge. 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 exer-
cise involves use oflhe gluteal medius, and its difficulty may
be associated with piriformis or thigh adductor tighlness/
ovcractivity. Additionally, lumbar segments may have de-
creased 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
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Diniculty ort~n arises because of decreased spinal and hip

~xl~nsihilily. :\
lighl psoas (hip flexor) muscle or hip capsule
may be il1\'oh·ed. Decreascd lumbi.lr spine mobility in exten-
sion (lixed kyphosis) is also a faclor.

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
A Add cxterrw] rcsistanc~ with doctor pushes <Fig. 14.17)
With 0111.' :lflll r:lised. perform trunk rot;\tion (Fig. 14.18n)
Support arlll on balance board. pcrfonn trunk rotation
(Fig. 14.181» ()
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Fig. 14.16. Quadruped progression. Fig. 14.17. Quadruped with extern~1 resislance.
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Fig. 14.18. Quadruped with trunk rotation (a) and on balance board (b). I
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Fig. 14.19. Kneeling hip extension.

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!-~ lhe prone track is not mastered. Also. gluteus medius weak- tightness in the erector spinae or n,~ClUs femoris. Erector
" J ness/inhibition on the supPol1lcg side may be present bCl:l.\uSC spinae shol1cning or decreased lumbar flexion mol ion is also
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of adductor, piriformis tensor fascia 1,.11<.1, or quadratus lUll1bo~
rum hyperactivity/tightness.
a factor.

G. ABDOMINALS
n F, KNEELING TRACK (QUADRICEPS, GLUTEUS MAXIMUSj
-~ Crunch with pa:-sivc pn:positiolling (hips ;llld knees positiol1t"u ;11
iJ{! J 1a. Siuin£ on heels. trunk and hips Ocxed. poslerior pelvic tilt. 90" llcxioll a" Oil :1 chair)
r;lisc torso by extending hip... (abdominals and gluteus max· Crunch wilh ;lclive pr~positi()nin£ (Fig. 1~.22)
!• ,.,1 imus) (Fig. 14.19) • Trunk curl (willi knc...·s h~nt ;md partiully ..::\tcndcd) (Figs. I.L~J
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lb. Silting on heels. trunk upright, posterior pelvic tilt. r.:lise IUrsn and 14.24)
.~ , by extending hips (Fig. 14.20 a illld b) Posterior pel vic' tilt
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2. Sallie position as shown in Figure 14.20B with arms raised Keep chin tucked. raise head then uppcr back until should..:r
t"li ',,-J
(Fig. 14.20e)
3. Wilh weights (Fig. 14.21)
bhtdcs arc off Ooor
Feel shnululIlll lift up
~ 4. Hold rOtiscd pnsilic... while Ilcxing ;llld extending ;lrlllS (Pig.
~ ) 14.21C)

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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

Difficulty is often encountered when the erector spinae or

hip flexors arc overactive/light. Lumbar spine joint dysfunc-
Fig. 14.23. Trunk curl with knees bent. tion may also be prescnt.
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 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' (1'1"1111\ knl'l' lJ{)"
Ik",iol\)
Slight pllsleri(lf pL'lvic lilt lllay (ll' lll'e,kd Ill';ll' ,'<llllpkti'lll Ill"

descelll
Stride should he long cnough S() kn<.'e is jUq (J\"I.:r (,1,'\
Lungc forward until back knee touches !loo!" (Fig, 1-1.27B)
Add hand weighb. lIledicinc ball. (\r wl'ighl bar
Adt! resistance fmm behind with pulley or exercise tubing
hooked Ollto patient's belt
Backward lunge
Sideways lunge

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, shoul-

der shrug), and slllall jerky- transitional movcmcnts.

I. SQUATS
B With feci shoulder width apart, actively preposition in pal1ial an-
terior 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!

Difficulty can be encountered if adductors arc shortcned.

Fig. 14.26. Lower abdominal hlp thrust. I-feels will lift lip if soleus is tight.

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 2. Styrofoam, ;"ledicine Ball. Stick. Exercise 'nlhil1~ Note: Tllesl' lI\O\,CIllCIHs ;m: Ill\lrl' difficult (lll circular-tuhular (O,llIl
Stahilization Exercises Altcrn:lh:ly lifl onc fOOl sli1;llIly \ll'l" l100r (f:i~, 1-l.~9hl
Prngrcss tn lJO" hip I1cxitlll
A. ON STYROFOAM Rep-:;ll ,lh(l\'C with anll:' o\'Crhl',1l1 (Fig. J.L29d
Pcrfllrlll posterior pC!\'ic lilt with hands on l1uOf (I/~ l'irch;) (Ii:l'l Repeal ah\I\'\.· with hoth hands ahovc chesl Wi,g. 1~.:!9dl .-1;,

closcr together is h;mkr) (Fig. 1-l.::!9a) On drdc wcd,ge. hands (11\ t,-hl'sl. onc knec tn l.:ht'~l

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.
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Fig. 14.28. Squat. A. Correct. B. Incorrect.

A B

Fig. 14.29. Styroloam progression. o

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Ii Fig. 14,30. Isometric abdominal "crunch" position with resistance. .

l
~ Be careful that the head docs not shift forward (+ Z) or lhM the
J chin pokes OUI causing ecrvicocranial hyperextcnsion
i Scated, posterior tilt. and roll down ball part way until abdOlui-

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) nals 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)

I~ Hold bridge and fk~ onc leg with knee bent (Fig. 14.37)
Keep postcrior till and prcvcnt oppositc hip from f<llling and/or
hiking

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Hold bridge and flcx onc leg with knce eXlcnded (Fig. 14.38)
Bridge up and down with one leg on floor

I C. ABDQMINALS

I
) Middle of back on ball. trunk curls
Fig. 14.31. Isometric abdominal "crunch" position wilh medicine Stall low on b'lll (passively prcpositioned in flexion) :Illd
ball. progress higher on ball until exercising ill extended position

I
(Figs. 14.39 nnd 14.40)
Middle of back 011 ball. perform partial trunk curl. l·'llCh bnll
thrown by doctl1r (Fig. 14.41)
A. SEATED
u Perform anteriDr and po~\crior pelvic tilt on ball (Fig, 14.32)
Progress to harder positions on ball
Middle of b<.lck Oil ball. pcrfoml partiallrUllk curl. ptlll (miley or
Active prepOsiliol1, in nculr:ll position, perform single leg raise exercise lubing in rotary directioll (elbow:" should :"lay extended.

II (Fig. 14.33;1)
Sillgle leg raise and rull back (maintain slight lumbar lordosl:-J
(Fig. 14..11h)
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

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B. BRIDGE (QUADRICEPS. GLUTEALS) D. HAMSTRINGS

With legs extended ,100 feet on b.l!1. bridge up .Illd roll lK11I to-
I, Sealed, perform posterior pelvic lilt and roli down b.llllO bridge
(Fig. 14.34)
Return to sitting position with pusterior or antcrior tilt (small
ward bUllocks by Hcxing knees, then roll ball away (Fig.. 14.43)
With hips and knees .It 90/90 nc~i(ln. pCrfUnll bridges (Fig.
1 steps do nUl stup) 14.44)
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Fig. 14.32. Sealed anterior and posterior pelvic lill.

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B
Fig. 14.33. Single leg raise and roll back.

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 CHAPTER 14 : SPINAL STABILIZATION EXERCISE PROGRAM 309

A B

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 par- If this exercise is Jinicult to perform. retrcat to till;.' kncel-
tial bridge). ing (rack exercise :,hown in Figun: 1...J..19.

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 MCMROlLiIAllUN Ut- THE SPINE: A PRACTITIONER'S fl.o1ANUAL
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c Fig. 14.36. Posterior pelvic lilt and bridge up.

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Fig. 14.38. Hold bridge and flex straight leg.

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Fig. 14.39. Trunk cur! lower on ball (easierl.
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 CHAPTER 14 : SPINAL STABILIZATION EXERCISE PROGRAM 311

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Fig. 14.42. All fours front roll.

B
Fig. 14.40. Trunk curl higher on ball (harder).

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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 ncu-

trod pusitiun. r<lise ;Ill'" lo\'..·cr upp~r :lnd lower body alternately
(sec-saw) (Fig. I-lASl.1 am! h)
Raise nne leg ttl perform the scis:"or Wi,g. 1-1.4Rc)

Difficulty c:m be cncoul1(crl.'d if erector spina(' or hip flex-

c
ors arc light Fig. 14.43. BridQp. and roll ball in and Oul.

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 A
A

B B
Fig. 14.44. 90190 bddge. Fig. 14.45. One leg bridge with roll.

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Fig. 14.46. One leg bridge 90/90. !
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c Fig. 14.47. Supr;:man progression.

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 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)

B
Fig. 14.49. Squat.

t. OTHER BALL EXERCISES

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. • B; ~k,(rt:tL"1l (111 h,dl (Fi:~, 1·1.:'·1)
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Fig. 14.50. One leg squat.

B
Fig. 14.52. Lumbar extension.

Fig. 14.51. Knees on ball circumduction.

B
Fig, 14.53. Dorsal extenSion.
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 CHAPTER 14: SPINAL STABILIZATION EXERCISE PROGRAM 315

A B

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 t(l ;lhdplllcn 'l;.;ainst 1\'sisl,IlKT; Fig. 1,,+.)(1) Fig. 14.56. Pelvic tilt and pull downs with traction.

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I C. RECUMBENT BICYCLE

Supine 011 floor or lay h:l..:k 011 large hall whik riding stational;;

I bicycle (r:ig. 14.57)

REFERENCES

1,
l
l. Mon.::1Il D: C(lIlC':l't~ in fIllKH''lI;11 tr:lining ;ll1d Jl<hIUr:11 l'lahili7~lliol\ fur
the I;Jw.h:Il'j.;.injurl'll. Tllp . \l·tH..: C;m,: Traul\1a R..:hahil 2:8, 19HH.
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·

I~ br:t1l1i~c wilh r:llliculop;llhy. Spin..: 1... :-01. 1~)H9.

4. S:I;J1 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. A
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
I. TII.:r :m:27(1. 11)<)4.
~ 7. Vollowil/. E: Furniture prcscriptinn for the cOllscr..:ui\'c l1l:IIl;lgclIlcnt of

i
low·had p:Lill. T(I[l/\cUlc Clr..: Traullla Reh:lhil 1: IS, 1988.

ACKNOWLEDGMENTS

I We arc grateful for the example and guidance of Dennis

I Morgan and JO.IIlIlC Llrricq in the completion of this ch:lptcr.

I \\: APPENDIX 14.1 Exercise Checklist:

I, I. FLOOR STAllILiZATION EXERCISES

a. Lumbopeh'ic functional range exploration
__ Hook lying
-Flg. 1<1.57. Recumbent bicycle.
B

_ _ Supine legs extended

Ii
e. Quadruped Track (gluteal maximus, medius)
Scaled Raise I arm
_ _ Sl:mding _ _ Raise I leg
_ _Quadruped _ _ Raise opposite ann and leg
~ _ _ ~neeling with buttocks on heels _ _ Wrist and ankle weights
i
! _ _ Kneeling with thighs verticul External resistance
i _ _ Sitting on floor with fcct (solcs) togcther _ _ 1 arm raised perform trunk rotation

I~ b. "Dead hug" Track (abdomina Is)

_ _ Raise I arm at a lime overhc<ld
_ _ Balance board perform trunk rotation
f. Kneeling Track (quadriceps, glute.al maxim us)
_ _ Raise both arms ()verhc.ld

I
_ _ Silting on heels mise torso
_ _ "March" _ _ Silting on heels. trunk upright raise torso
_ _ Bring I knee to chest al a time _ _ Sitting on heels. trunk upright raise torso wI r.liscd arms
_ _ Bring I knee to chest at a time while raising opp_ arm

I
__WI weights
_ _ Alternating kicks _ _ Flexing and extending arllls
_ _ Dead bug g, Abdominals

I,
_ _ Ankle and wrist weights _ _Crunch
c. Bridge Truck (glutcals and quadriceps) Trunk curl
_ _ Bridge Sit b.lck
_ _ Bridge wI heel lifts _ _ Hip lhrust

I _ _ Bridge wI "march"
__ I leg bridge
_ _ Obliques
h. Lunge (quadriceps)
_ _ Bridge and lower and raise leg _ _ Lunge
-~ d. Prone Tmck (gluleus maximus) __ WI weight

II
_ _ Single ..Irm raise wI pillo\v __ WI pulley or exercise tubing
__ Arm/opp. leg raise wI pillow Backward lunge
_ _ W/nut pillow _ _ Sideways lunge

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_ _ Squal ~_~\'liddh: ~lf " ..,di. Ull balllnlllk curls
\VI l'Ilr\\.lhi r.\.·II,1 ~_Trul\k cml and c;Hch ball thrown by dncUlr
_ _ l'rugA'SS hI harl.ll,,'r positions on b~ll
2. STYIWFOA'I. '1EIHCINE 11,\1.1., STICK. EXERCISE
_ _ Trull" l·url/pulky or exercise tubing in Wl.. tliol)
TUIIIN!; ST,\BILIZATlO;-; EXERCISES
All !"tlur" fnllli rnll
a. 011 st)THr(l~1ll
d. H:lIlls{rin~s
_" "Pnsll.'ri'll" 1'.:1\ i~· tilt
FI,,'l'1 1111 hall hridt:1,,' w/mll in
I 1\111.'1.' 111 ,11~'''1
t)O/IJO hIIUgl''''
___ I I\l1l.'l' III dl~'~1 w/arllls t1\'l.'l"h~·ad
~_ Roll 11:111 w/ singk kg

,.. ,
\\\..Jg~
,,
~ __ On t.:irl"k !lamb 'III

h. Ismuctric ..\ hdominllts (w/doctor or thcnlJlisl1

l,:hl·"! I I\lIl.'l' III dll'''l
90/90 \\1 "mg.!l' kg
c, SUI)cnnan
i \ _ _ Crunl,:h plhitiun with f~lalll Ill·\\\l'l.'lI klll.'....s ~hli."h.r pu"hcs ur
. __.SllpCrlll..1Il
I! pulls
I\lcdll:1Il1.' n.lll nl.'t\~I.'Cll 11.:1.'1/ UU(!ur 111nl\\S h,dl
- WI ann . . wing
__
f. Sec-saw
) _ _ B"11I het\\I.'\.·n fl.'l.'t ano gym hall nn ahdulIh:ll/JIl\.·\or pulls.

Ii "'"'":!. , h"1I
MI.'I..h<.·tlIl.' tJ,llI held hct\\cl.'lI fl.'l't/"tlcb
Sec-s:!w
({'lise I kg scissor
g, Squats
~ 3. GYMNASTIC BAI.L EXERCISES Wall slide
;1
d Isometric St,lhiliz::ltiol1 WI <:omcthtng in h:.lmt<:
I, ) .1. SC::lted WI I loot on nOOl
i~ "~
_ _ Anterior
__Single kg raisl.'
~nJ
pnstcriur p\.'I\'ic till h. Knec on Imll front roll
Front roll
~ _ _ Single leg raise and roll back i. Other b:lll exercises
, )
1 b, Bridge (quadriceps. ~Iute::llsl B'lck extension
___ Uppcr back cxtension
~nd

I
SC'-llcd rolll.km n h.lll 10 bndge
~) Stretch
__ Return to sitting position
__ Y~ sit up and ··nmn:h'·
4. PULLEYS A;-;n IIICYCLE
") _ _ Bridge up/down
Trunk twists
$. __ Bridge and flex! leg wI knee bent
.?;I __ Gravity-assisted pull downs
11 __ Progress 10 only upper b~lck and he.\d ()II ball
I{CCltlllh(,,'llt bicycle

I,
_ _ Bridge ,lOd flcx I Icg wI knee extl.'llded
) _ _ Bridgc up ;lnd down wI I leg on noor
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VLADIMIR JANDA and MARIE VAVROVA'

Tht:rapelllic~lpproaches have (hanged along with our in¥ the foot joints and incoordinated muscle function of the lower
creasing kllO\\'h:dgc and underslanding of physiology. In the leg ..' Apart from fundamental experimental work, such as that
original approach to therapy, we viewed the motor system as by Wykc~ and Skoglund,~ it was Freeman and co-workers
an effector only. and did not C:lltlsidcr its rok with the alTcr- (1964, 1965, 1967) who, in Ihe clinical selling, systematically
en! system as one functional unit. The conclusion was drawn considered some aspects of joint traumatology and the im-
[hat motor performIll1cc is a result of isolated and separate. al- portance of impaired afference in the genesis of an unstable
though coorJinatcd. activation of individual muscles. The ankle joint,(}·R Freeman and colleagues also introduced, in
focus of these techniques was activation of individual mus- non-neurologic cases, a detailed evaluation of coordination.
cles or llluscle groups in the hope that the new motor pattern and stressed the importance of muscle inhibition as an inte-
would develop automatically. Examples of such thinking arc gral part of the clinical picture. Since the publication of this
exercises prescribed according to muscle testing or the pro- initial report by Freeman and Wyke, interest in tillS problem
gressive resistance exercise program. has increased. One of the most extensive works on this topic
The next qCP in thc evolution of therapcutic approaches is by Hervcou and Messcan.')
accepted Ihat a movement cannot be accomplished without In 1970. we started to work out our program for clinical
coordination of the afferent pathways and centers. Along with use, based to some extent on the published reports just men-
this knowledge came the realization that the motor system tioned. To avoid problems in terminology and/or confusion
and the afferent system were closely linked, with terms such as PNF, we named our technique "sensory
motor stimulation" with the hope of stressi!~g th~ !.!!"'),ity be-
tween the afferent and efferent system without implicating
VARIETY OF THERAPEUTIC APPROACHES any specific structure or function.
Kabat developed and introduced into practice the concept of
activation of afferent patlmtays as an approach to movement
BASIC CONCEPTS OF MOTOR LEARNING
re-education. ' In therapy, this concept is the basis of the
Proprioceptive Neuromuscular Facilit':ltion (PNF) technique. The principle of sensory motor stimulation is based on the
This approach. as well as others such as those developed by concept of two stages of motor learning.l\l The first stage is
Temple Fay. the Bobaths, Vojta, and Brunnstrom, systemati- characterized as an attempt to achieve new movement perfor-
cally stresses muscle coordination and the importance of pro- mance and to work Ollt the basic motor program. The brain
prioceptive information. At present, it is understood that the cortex (predominantly the frontal and parietal lobes) arc
afferent system not only has an informative role. but also par~ strongly involved in this process. This type of motor regula-
ticipates substantially in motor programming and motor sys- tion has some advantages as well as disadvantages. It enables
tem regulation. Therefore. proprioceptive stimulation is the individual to achieve new skills, although it is rather slow
stressed more and more. as it passes several synapses, and it is tiring given [he neces-
The term proprioception was used for the first time in sary conscious participation of the cortex. Therefore. the
1907 by Sherrington to describe the sense of position. pos- brain tries to minimize the pathways and to simplify the reg-
ture. and movement.) This term has since been defined in a ulatory circuits. This mechanism has been named as the sec-
broader way. and today. although not quite correctly. it is used onel stage of motor learning. It enables a reduction of cortical
to describe the function of the entire afferent system. participation, and thus is less tiring and much faster. If such a
It is now underslOod that to split the function and/or dys- motor program has become fixed once. however. it is diffi-
function of the rnyo-ostco-al1icular system from central regu- cult. if not impossible. to change it. Therefore. in motor re-
latory nervous mechanisms is wrong. Both parts function as education, the goal is to achieve a quality of movement pat-
one inseparable functional unit and cannot be separated. terns that is as close to normal as possible.
Thus. any lesion or impaired function of any pall of the pe- To prevent injury. and microinjury in particular. fast re-
ripheral motor system leads to adaptive mechanisms in the flex muscle contraction is needed to protect lhe joints. The
ccntral nervous system and vice versa. second stage of molOr learning enables such a faster response.
Kurtz was probably thc 11rstto notice, from a clinical which may, in fact, play a decisi\"(:: role in prt:vcntion.
point of viev.... the relatiollship betwcen the lesion (injury) of Bullock-Saxton and colkagucs" reportcd it is po:,siblc to
319
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 ". _ . • • • _ ........ ~ ..... ,... rn/"\\.,.l II lVNt:H"ti MANUAL

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
,
1
lhose Ilwue of plasti.. . matcriaL h~causc woou.stimul<.ltes Ihe
receptors to a gre:ller extcnL For the s<lmc re"soI1S. IOYS Illade ".",

or wooumon..' readily slilllU!:lIC propriocepliotl ill children.

The an;r.,~e dimcllsi:lIIs (lenglh X width X height) Illr
the rockcr board arc .15 elll X 15 elll X 15 em. II> The radills
Fig. 15.1. Rocker board. of the wobble board is 35 1.:111 on :m..:ragc <llld the height is
15 cm. Exercises 011 thc rocker hoard arc easier than on the
wobble board. ;'lnd therefore it is <Id\"is'lble 10 sian wilh its lise
(Figs. 15.1 and 15.2).
accelerate muscle contmction approximately twofold with in- The size of balance shoes (Fig. IS.3) depends 011 the size
creased propriol:cptivc flow and balance excrciscs. in scnsory of the foot. Sand'lls Illust have ;,1 linll. innexiblc ~olc that is
motor stimulation. an attempt is made to facilitate the propri- modeled and 'HIS metatarsal support: these fe:Hurcs help 10
oceptive system and those circlIils and pathw<.lys thai play an configure lhe small fool. There should be just one str;'lp O\"(.·r
important role in regulation of equilibrium and posture. the forefoot and the heel should rem~lin free. again to help III
From the point of vicw of affercncc. reccptors in Ihe sole :'Ictiv;ttc the intrir.l:-;ic muscles of the foot. The hemispheres arc
of the 1'001. 7 from the neck l~lllSclcs.'~ and in (he sacroiliac of solid mhbcr. 5 10 7 em in diallleler. and arc placed in the
arcal.l have the Ill<lin proprioceptive influcnce. center of gravity.
Receptors from the sole can be f<lcilitmed in different The twister enables ~\l.:tivati()n of the trunk .1Ilt! huth.ll..·k " f
ways. e.g.. by stimulation of the skin receptors or. more mllscles. Exercising before <t mirror helps to visu:Jlii'.e any
effectively. by active contraction of the intrinsic muscles of aSYlllmetry in muscle strength and/or asymilletrically p~r·
the foot by forming the so-called "short or slllall fOOL" formed cxercise. Wc prefer to usc a flat twister that is 40 l'(l\
Clinical experience has revealed that isolated activation of the in diameter.
imrinsic muscles wirhout activation of Ihe long loe flexors is The Fillcr. likc the {\\listcr.. is strictly speaking not a de\"jcc
most effective. Therefore, it is diffieu"illo agree wilh Ihara and for proprioceptive training. 'Ilthough it helps to improve co-
Nakayama. who recommended the "fOOl fist"· (0 :Jetivatc pro- ordination. Scveral devices with similar function arc currcntly
prioeeptors. I~ av'lilablc. We usc onc developed by Fitter Intcrn<ltional from
The deep neck muscles contain m,my more proprioceptors Canada (Fig. 15.4).
th'lIl 'Ire found in other striated mllscles.l~ Abwhams has A minitrampoline (Fig. 15.5) is an excellent device f\lr
shown Ihat these muscles should be considered for maintain· stimulating the proprioceptors of the entire body. Unfollu·
ing posturc and equilibrium rather than for producing dy- nately. the material lIsed for most trampolines is not suffi·
namic movc'ncnl. It should be menlioned that deep tonic neck ciently resilient. The stimulalory effect is thus redul·cl,.L
reflexes arc thc result of muscle activation and do not involve Springs that arc 15 to 18 e111 in lenglh provide a suilllbly un·
the neck join!.",.•IS was described originally. stable base: springs of less than 7 em do not provide cllou~h
In c1inic:d practice, the sacral region is now recognized as proprioceptive stimulation. i')
an important area in the control of posture and equilibriulll. Other devices include b:dancc b.dls th.u "<lfy in size fl\llll
This observation was conrinncd by I-linoki and UshioY At 60 to 120 cm in diameter. They 'tfe efficient for kincsthcti ....
present. however. it is not possiblc 10 differentiate whether it stimulation and balance training. Rolls frolll polyester ;Ire
is the sacrum itself and its position or the sacroiliac joints that widely used in the United States and help to activ.ltc the trunk ,'.J.
'-.~

pl<lY the decisive role. muscles ill general. Because these rolls <lrc used mos!ly whil-.'
A special role has been recognized for the cerebellum and the patient is supine. they do not overstn.:ss lhe spine ;\nd
the whole spinovestibulocercbcllm regulatory circuit

SENSORY MOTOR DEVICES AND AIDS

The sensory motor approach is not a rigid program or sys- "'?;.,),

tem. It can be used in all cases .md can be tailored to each ,.
i
p:Jtienl. V;lriolis b<llancc exercises ;'Ire used. Any equipmcnt j.i---~
!~,J
required is simple and inexpensive. The principlcs arc not
new and wen.~ introduccd by Bobath and Bob.lth for motor I, "

re-education of childrcn with cerebral pals)'. 1.\ The npplicatioll i\)

of this approach to patients with chronic back pain patients.
however. was intruJt.i..:~d only recently.
IiV'.'''.
Fig. 15.2. Wobble board. I
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Fig. 15.3. Balance shoes.

Fig. 15.4. The Fitter.

Fig. 15.5. Minitrampoline.

lhcrcforc can be used by individuals with ~Ul "cute low back thus help in prcventing falls. This tcchniquc C~1Ilt10[ be rt:L'-
, p~\in syndrome. olluncndcd. however. for patients with ..tCll{e pain syndromes.
J

INDICATIONS FOR USE METHODOLOGY

Sensory motor stimulation is bendlcial when used as a part In this chapler. we describe only th~ main Illl;thodologic prill·
of any exercise program in that it helps to 'improve muscle ciples. A detailed dcst:riptioll is 'I\'ailablc clscwll(·("c. l ·;
coordination and motor programming or regulation and in~ One of the most important ~ldvalltagcs or this progr<llll is
crc..\ses the speed of activation of a muscle. Used originally lO that it helps to improve not only muscle imbalalll.'(' blu. ill par-
ithprove the unstable ankle after an injury. sensory molor
:,timulation C"Ul be of value to individuals with it variety of
Table 15.1. Indications for Sensory Motor Stimulation
conditions (Table 15.1). Chronic back pain syndromes reprc-
:,cnt onc of the most important indications. Better cOlllrol of • Unstable knee
the (runk. improved activation of the gluteal muscles...md • Sprained or unstable ankle
• ldiopalhic scoliosis
thus better stability of the pelvis arc achieved. There is a • Faulty posture
broad indic:ltioll for its application for sensory defects of neu- • Postural defects in general
rologic origin. Carefully (to avoid injury). the method can • Chronic back or neck p<lin
• Prevention or treatment 01 ataxia
help to compensate proprioceptivc loss in aged subjecls <lnd

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 · ._ ...•_._..... ",,-..:>r ,".c::. ,.... t'tiJ-\\., 1111UNt:.H·:::; MANUAL

ticular, the most important motor 'lctivili~s, such 'IS sWllding. The tam "smail (shtl!"u 1'001" lhg. 1:'./lJ Is II:-L:'d II' ~Il'­
i.e., posture and gait. Then.:forc, the most important cxadst:s snit'll.: Iht: slml1ening and n:lrrowing llf Iht: fll{l( whik till' 11ll'S
art~ those performed in lhe upright position. ;Ire rda\l.'d :IS llHH.. . ll a~ possible. The :-1\1:111 rllllt hdps [\\ in-
Respecting the appro;lch of motor leanting :.JlHJ motor rq::- (fC;lSt,; aff..:rent input. mainly from thl' ~ok. h impHl\'l':- lht.'
uhltion, <iny dysfullction in the periphery should be nor11lal- pnsillon Ill' lltt.: hody sl.'gmt:llts and till.' ~[:lbility of tilL:' hlld~ ill
ized Hrst. bcc.ltlo.;e allY p.\tlmlngic or ul1wamcd proprinct:pli\"c lilt.: upright positio1l. and hl'lps ttl illlprmc til... rcquirl·t! spril1~'
information from lhc paiphery results in fllllt,;lion;!l ad;lpta- ing mOWiHl'll( Ill' till' fOOl during walkill~.
ti\'c processes or the cntire t.:entr..llncrvous systcm. Thcrdort.'.
attention is lirst paid to thc skin, joinls. and their adjal't:nt
SlruclUrcs, followcd by IlHlsdes and thcir fasci.1. Thc lrig~er
IKlint..;. either .Icti\,c or btent, should he trc;llcd.•Illd ll1u~(1c
imbalancc, which is ;tlways present to ."ollle degree. is im-
proved by .1 rc.\son:lhk slrcldling prugr'IIH.
To illCrc:Jsc proprioceptive Ilow, special .ltlcntiol\ is paid
w fonning the small (short) foot, lhe Int.:king mechanism of
th~ knee. stabilization of the pelvis, and the position of the
hend and shouldcr girdles.
The excn:isc progr:lI11 in the upright position follows :-L'\'-
cr.ll rules:
I. Currcctlun lJI,;~ill~ ill di"l<ti ;lIca:- alld gradually t:olllitltlCS prl)\'
illlally. tVfoddin,g. tlf the foot (l'el'l) mlllC.. lirsl. rolJow.. . J by
l'orreCIIUIl ot' Ihe position of the knec. thl'll lhl' pelvis. :llld lln:llly
lhe hC;It! ~lIld shlluldcr~.
~ 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 <Illel those that
f~lt.'llS more on b.i1ancc and lllusl'ie coordination in general. Fig. 15.6. The short foOl.

Fig. 15.7. Passive modeling of the short loot.

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 ...... m ... r"" I t:.t1 ,~ : :st:N::iUHY MOTOR STIMULATION 323
(
! When the patient achieves suffkient skill. similar exer-
cises on the rocker board and later on the wobble board arc
"dded. Thc dcmands can be increased by <tdditional varia-
tions. such as maintaining the balance in one leg stance Of in
a scmi~(luat with a slight external rotation in the hip joint:-.
This position is rcconnnemkrJ especially for patients with all
unstable knee joint. Almost speciflc;'llIy. the .Ictiv:ltioll th~ or
vaslus medialis is incrc<lsed.
Another step is the performance of lunges (Fig. 15.9). first
on the linn noor. then on the rocker. and finally Oil thc.: woh-
ble board. Fast lunges accelerate reaction and control and arc
Ihus effeclive for preventing knee injuries and. in panicular.
falls resulting from incoordination.
The program continues with jumps (Fig. 15.10). ag~lin on
both legs on a firm noor. Progressions include performing on
onc leg. on labile boards, and/or on the trampoline.
Pushes toward the pelvis. trunk. shoulder girdles in dif-
ferent directions. combined with perpendicular pushes toward
lhe labile boards (Fig. 15.11). significantly increase the pro-
prioceptive flow to the central nervous system. which facili-
tates the spinovestibulocercbellar circuits. This activalion
brings sometimes quite surprising and fast therapeutic effects.
This technique has been introduced into therapeutic practice
only recently. Its application for diagnostic purposes wns de-
scribed by the French neurologist Foix in 1903 and has since
been used clinically in the diagnosis of cerebellar lesions. l~
Fig. 15.8. Short feet and half slep !orward stance. Balance shoes (Fig. 15.12) are exceptionalIy useful. and
most patienls like them more than most other exercises.
Balance shoes increase thc dcmands on the entire postural
Initially, the formation of the small fOOl is difficult to mechanism and automatically. without a conscious effort.
perform in erect posture. Therefore, it is advisable to sian help to correct posturc. Because this exercise docs not require
the fonnation while silting. usually in three steps: (I) sitting. special control and can be used throughout Ihe day. it is usu-
with passive modeling by the therapist: (2) scmiactivc (pas- ally easy to milintain the patient's motivation to cooperate, In
sive modeling by the therapist in combination with active general. the improved posture becomes evident \vithin <.I few
palient effort): and (3) aClive self-formation (Fig. 15.7). weeks of training. Better <.:oordination and increased speed of
Proprioceptive stimulation can be increased by additional muscle contraction can be noticed within I week of (raining.
prC5surc applied toward lhe knee ~md thus via the shin to the attributable to improved activation of the gluteal Illu:,dc~. \I In
fool. all unpublished study. we demonstrated that the abdominal
In standing. Oll~ tf'lining exercise begins with the small recti. if hypotonic or inhibited. were better _Icti\,atcd after
feet parallcl and slig.htly apart. Then. the body sways slowly lIsing the shoes for I week. This improvement could be rc-
forward and back. the heels remain fixed toward the floor. and lated to both thc speed of muscle contraction as well .IS the
(he lower extrcmiti~s and the tfunk arc in alignment. The total amount of elcctromyographic activity during. a ,,:url up.
range of motion must be controlled to prevent falls. The ther· When using balance shoes. sevcral important aspects
::lpist controls the ~ways by touching the chest from thc front must be considercd:
and the buttocks from the back.
In another v'lri:uion the knees arc bellllO 20 to 30°. The • The small feet mus! be. maintained if po!isihlc. Jurill~ Ih..: whole
gait cycle.
hips nrc slightly abducted so that the knees arc slightly apart.
• The subject should Ir)' to control the posture. in particular the po·
Both positions and ,idditional swaying movemClHs help to in·
sition of the pelvis. shoulder g.irdles. ~1I1l1 hem!.
crease the body awareness and the feeling of a well-b~llanccd
• The sleps should be short but quick.
and controlled posture. • The reel should he held p:lr~1I1el.
The next steps arc body control in a IIalf SIC!, lonvard L~lter<ll ;lnd verliC_11 shirt or the pd .... i:- :-hnuld he a"'oidt'd.
slaTlce. the corrected stance on both legs. and in one
leg stance. To iu(:reasc proprioccptive flow. slow pushes G_lil should be trained in place lirst. jf necessary with
and then even strokes in different directions tow;.m! the some support lO avoid inslilhility and falls. At the beginning
pelvis. shouldcrs. and hoth areas arc added by the therapist of the training program, it is advisable 10 control th~ gail in
(Fig. 15.8) balance shoes hcfore: :I mirror. According to our dini(iI\ cx~

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Fig. 15.10. (continued)

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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 min-
utes). several times p;:r day.
The [\I'iSla help :0 impw\"c the 'Ktiv<ltioll or the tnlnk
and buttock l1lu:-oclc In addition. till.:" twi;-;tin~ 11100'cmcnt;-;
:-opccifkally ..lCtiv.lle·th-: deep intrill'>il: .. 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<lUy
increase proprioception. but il impro\'c\ coordin"ltion amI all·
lOmatizcs trunk .md ptlvic cOlllrol.
The "';lI('rT~1 functions in a similar way as the twister. al-
though the cstinli.ltiQn of body asymrnetrit:s is kss rccogni/-
able. It also cl1lphasjz~.. the ghlleus medius lHusdc and its Ial-
eral stabilizing functions (Fig. 15.13,.
The usc of rollers lIl/(/ bllltll/c(' halls in Ill\..' treatment 01'
back pain h;'IS gained popularity. although (h~y wcre used fl'r
decades III the treatment or children with cerebral palsy. Olh.'
adv:'llllagc in using balis is th:tl they arc safl2'. minimize lill'
danger or an injury almost to nil. .Uld help to ill"tivatc propri-
oception. balance, and equilibriulll control. Till' il1l"rediblc \';1-
riety of possible exercises. \..'spcciaJly with rc~ard to the pl'-
lential positit1llS, h~lps 10 l':,wbli<;h impn1\"cd kinestheti . . .
Fig. 15,11. Therapist pushes. aW'lrcness. :,pin:l! ~t,~bility. :1I1d l1ew 1ll0VCIlll'1lI palterns.
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Fig. 15.13. Training tile gluteus medius on the Fitter. Fig. 15,14. Walkin9 on a rninilrampoline.

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Tht.: IJlillitr:;/II/mlill(' i:-. :t paninllarly lJ~~ful devil.:c. REFERENCES
I
.' ~-

Jogging or jUIH;,ing :u.:ti\";llCS proprioceptors 1110(1.' dTcclivcly 1. Kah:u II: C..:mr;,1 m..:..::hanisl1ls fur r..:co\"cry (If lU:urunlu""'ul:tr rlln~'tl"ll
l!l;lll il simil:lI' ~·.\~rci.'ic pcrt'Ol"lnl'U on ;J lil"ll1 none In addi· Scicncc J 12:2.'.1950.
{ion, it prole<.:t, lhe joints l1CGlU.. . C il rlllH:lioll~ ;I" a shock ;Ib· Shcrril1~lol1 CS: On r<.'..:ipr,x:aJ il111<.'r\':rliol1 of alll;lgo11i:-<li..· l1lu~ck,. Pr' ...·
R Su..:: L'llllJ iBlt'1l7lJB:J:n. 11)07.
sorhcr. Excrl'j,;.:-, on"l trampolilh..' do lUll nccu lO k performed
Kun7. ..\l): Chwm..: "prail1<.'d ;mkk.Am J Surg ,U:I~S, )I).W.
in ;lll upright position only. Ex~n.:iscs pcrform~J while sit- ..l. Wyk..: B)): The neurology of joinl:-. Ann R Coli Surg Ell~1 -l I:25. 1')('-_
ling. afC particularly dTcctive in strengthening the abdom- ". Skogbnd S: AIl:llOlI\ic.,l and phys;o!ogi"'al sludil's ot' klll'<.' jllinl iUlla';\·
inal llHlsclcs.•:ilL! fOllr point kneeling is n.Tolllllh.:ndcu for cI- liol1 in Ihl' GIl. :\.:Ia Physiol SC:lIld ~6 (SUpp! I 2..l'J: I. 195(1.
ucrly women '.'.-ith kyphosis rd'llcd to ostcnpt,rosis (Figs. (1. h..::el1l:111 MAR, Dean MRE. Hanh:llll IWF: 11\\: l'liol,,!,:y :llld rr," <'1\.
tion (If fun..::t!l.n:s! in,whility of tit..: f(lol. J Bllll\.' JI1;1lI SUfF Inri ..l-.t'-~.
15.1..J.;lIld 15.:"1,
1%:".
Fr..::..::m;lII MAJ{. Wykc no: Articular ..::nutril1llti"u, to limh llltlH'k r...· ·
lle,..::s. J I'hysiol 'Londl 171 :201'. IWH.
CONCLUSIO:\ ,"i. Frcl.'lIlall MAR. Wykc no: Ani"::lliar r<.'tIc"l.'.S al Ill..:: anklc joint.:\n d,-'~'­

tWlllyl'grOlphic "tudy of nunnal ;llld ahnorm:lt inlluell"'-":::- of :lIlkk .I,'tnt

The sensory motor stilllul;ltioll approadl rcprc~t:nl' all essen- rm·dl'LI1\lrl.'''::Cr[(lr~ upun rcllc:o.: Ol":li,,!ty in kg lllu~dl.'s. Br J Surg :"J:'h)tl.
tial p;lrl of till: IhcmpclItic progr.un fur p~lIicnt;" with chronic 1967.
back pain .1~ "ell as for indi,'idtlals with pO~!llral lkkcl.S. 9, l-!<.'n·cllL! C. \h;"C,11l L: Tcdllliquc tk rcedw.:atioJl l.'t d crJlII.:alilll1 pr,'!~ri.
()((plive. Pari". .\laloin. 1976.
such as idiop~lthic scoliosis or faully poslUre. and for <.Ill situ-
Ill, GUYh>n AC: B;:~lC Ncurm:dcn..::c.l'hil:l\Jclphi:l. WB S~Ul.Jcrs. 1%-,
ations in which Jde!.:ls in affercncc .Ife presumed. Such a II, Bu\lu..::k-Sa~\lln JE. Janda V, Bullock "II: Rdkx :u;ti"i1lillll uf ::hlll,';lt
progr;ll11 C:I1l ~d"o be llsed effccii,'c1y to imprn"c the ability of llIUSI,.·h:,,, in \,;lIking. Spinc 18:71).1, J91"J~.
the "hc;lhhy" motor system 10 rc\polld Illore quickly. Givcn i:. Ahrahalll' VC: Th.: physilliogy of nCl;k Ulus...-ks. ·nl<.'ir ruh: ill h~·.l,1
that the speed or muscle l:ontraction is one of the most illl- 1111\\'l'111.:nt and m;:inICn;l1\l;":: of pmlurc. Can J Physilll Jlh;lnnanll 55:.~.'~,
port:llll lllean" to protect the joints. it seems propriol:cptive 1977.
I). Hillllki M. L'"hlll:-':: Lumhllsacral propriu..::cpliw rd1c:o.:c" ill hl'd~ ...·.Iui·
facilililtion can cOl1lribUle substantially to the prevention of lihriulll. Acla Ololaryngol 33()~SupplJ: 197. 1975.
recurrences or acule pain. The sensory motor \tilllulation I·t Ih:lr.l H, Nak:l~:illla A: Dynamic join! CUllIWllr:lilling fur kn..::<.' li::.llll;.·lll
progr<l11l is not a fixed or rigid program: rJihcr. it must be iniurics, Am J Sports t-.kd t4:309. Infl.
adapted to the individual problems of the indi,'idual patient. 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~.
The need to I..timulatc proprioceptors is even greater thall a
16. Umhll1 AK: Trullk musck activity induced hy 1lH">.'1: size" uf wI.ht>k ,ro.ll·
fe'.. . decades ilgO: our lifestyle ha... d1<lllgcd slJb~lantially .Illtl anl,'d hO:lrd,. J Onhop Spurts Phy.. Thcr R:70. \98(1.
is assol:iatcd ,':itll a gcneral decrease in scnsory (propril1t:cp- 17, J:llld:l V. V;l"W\:t .\·1: SellS""")' MOlor Slimul:llil'll: i\ Vidcll.l'r<.'s..::l11...·,: t-~
tive) stimulation. JE B\I!hx:k-S;I.\I~)fl. Brishanc, AU\lr:.dia. Body C\lIIlrol Syslems. 1')':'_\

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 16 Postural Disorders of the Body Axis
PIERRE-MARIE GAGEY and RENE GENTAZ

POWEll OF THE POSTUIlOLOGIST Input into the Fine Postural System

\Vhen posturologists undertook the study of postural control. EXTEROCEPTIVE INPUT
they did not suspect how much power would fall into their
To remain upright and slCady in their surroundings. people
hands. I Slowly. year af[er year, they discovered their ability to
usc all tbe information about lheir position provided by their
manipulate muscle tone by manipulating the input into the
st:l1sory org.ans in relation Wilh the surroundings. including the
postural system. Preceding generations of neurologists had
dectromagnctic ficld,~·IfHI" the gravitalional ficld,20-2! and the
conducted studies of muscle lOne and th<ll ended in failure. In
) pressure Hcld underfoot. ~.\A~'Thrcc outwardly directed sensors.
I 1948. Thomas and de Ajuriagucrra wrote. "Lc tonus varie ~t
or cXlcroceptors-vision. vcstibular apparatus. and barore-
toul moment. il est continucllemcnt en jeu ... Toutcs Ics ex-
I citalions pCriphcriqucs. de quclque nature qu' cllcs soienl.
ceptors from plantar soles-provide information; we do not
know of any others apart from these three captors (Fig. 16.1).
i sont capables de provoqucr des reactions toniques" (The tone

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varies at every tum. it is continuously at work. Any peripheral
excitation of whatever kind can bring aboUl tonic reactions).:
At present. posturologists arc fInding that they do know how
PROPRIOCEPTIVE INPUTS

The cye moyco;, about in the socket. while the vestibular ap-
to manipulate tone. and this knowledge empowers them. This paratus is enclosed in <I bOlly mas.s. The system cannot inte-
I power is indeed extraordinary in its novelty. but not always in grate positional information from these two sensors unless it
I
! its reliability; posturologists arc reminded from time to time
that they do not yet know everything ahout manipulating
knows their relative pm,itiollS. which are given by the oculo-
motor system. :'-.'0 Thus arises the idea of another kind of sen-
muscle tonc. The basis of this new knowledge is worth ex- sor, inwardly directcd. a proprioceptor. which has no direct
plaining. relation to the surroundings but is nevertheless indispensable
to a steady posture within them. Likewise. the feet can move
BASIS OF POSTUIlOLOGY by many degrees in relation to the head. but postural infor-
matioll from the feet and the head cannot be used together un-
Ever since BelP askcd how a pcrson maintains an upright or
less the system knows the relative positions of the head and
inclined posture when facing into the wind. physiologists
{he soles. This type of information is assessed by propriocep-
have asked the same difficuh question. Over many years. the
tion of the whole body axis:II - 36
contributions of various types of sensory input (0 the control
of upright posture were discovered one by one: vision~ and
Cenlntl Integration
signals from the legs and feet,~ the vestibular apparatus.~
-' paraspinal muscles,to and oculomotor system.' Not until the NECESSARY BUT PRECARIOUS INTEGRATION
concept of (he system appeared w....s it possible to understand
, ,) hawaII these different senses work together to control pos-
Retinal. otolithic. ,lOd plantar exteroceptivc information,
combined with proprioceptive infonnation from the 12 oculo-

-
, ture. Researchers could not observe and record the subtle phe-
nomenon of upright posture!l.~1S adequately until (he resources
motor muscles. all the paras pinal muscles. and the muscles of
the legs and feet. unite to give the relative positions of skele-
of clectronics l6 and computers were availablc to allow them
tal elements from the occiput-atlas to Lisfranc's joint. This
to make recordings that do not modify the phenomenon and
combination generates il considerable amount of information
can be interpreted by signal analysis.
) that the system must integrate, in real time. if the posture is
Today. after many years of study, Bell's question can be
not to waver. Therefore. problems with the control of ortho-
answered in terms of a simple and consistent model of the
) static posture do not necessarily indicate that a sensor has
mechanisms participating in the control of orthostatic posture:
failed. Rather. it may involve faulty integration,:" which may
the model of the fine postural systcm. The term 5)'slem is used
OCf.ur for many reasons.
here in accordance with control system theory. i.e.. we do not
need a detailed underst<lnding of thc nervous centers and
DISORDERS OF INTEGRATION OF VISUAL INPUT
pathways participating in Ihis control in order to study Ihe
\
I
input and the output of this black box and to analyze its trans- Faulty integration of visuJI input is easier to analyze than thilt
fer functioll. relating to other types of input. bcc.llIsc it is easy to record a
329
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 HI=HAt1ILIIAIIUN OF THE ~PINE: A PRACTITIONER'S MANUAL

stcildine~s of stance with and withoUI the help of vision. and

to reckon the cOlltribution of the vi:-:llal input using the
j so-called "Romberg's quoticnt:'-I Postural sway is oneil mea·
sured on a stalokincsigram. a record of the successive posi-
tions of the subject':; centeror 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 sim-
ple [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 Fig. 16.2. Histogram of the distribution of Romberg's quotient in
strabislllu's."1 and low back pain.~11 182 patients with vestibular neuritis. The gaussian curve shows
the theoretic normal distribution of Romberg's quotient in a normal
Deficicncies of integration of visu;.d input arc so frcquent
popUlation. logarithmic scale. 253, mean for normal subjects;
in clinical pmctkc that \'isual input despite its powerful ef-
152, mean for patients with vestibular neuritis; CL 95% confidence
fect (usually postun!l steadincss is 150% bctlcr whcn thc eycs
limits; p < 0.001. Student's Hest.
arc open~l J. seems <llso to be cnsily disrupted. Its integration
is thought to depend on the nonn;'ll funclioning of the other
sensors. By itself, the signal of retinal slip is ambiguous; it
may be related to movcment of the body. or the surroundings. Output of the Fine Postural System: Muscle TOIle
OJ" of the eyes. Its postural significance.: must .be dctcmlined
Few would argue that maintaining an upright position IS
by comparison with signals from other sensors: oculomotor
achieved by mcans other than muscle-postural tonc. At lhe
inplH (is it lhe rcsuh of mOVC1l1elll of lhe eyes"!) or vestibular
beginning of the last cenlury. Bell noted that it is only by the
or plantar input. in the lalter case combined with propriocep-
lise of muscles that thc limbs stiffen and the body is firmly
tive input concerning the body axis (is it the result of body
balanced and kept upright.) \Vhat is new is the knowlcdge that
movement?). One mighl predict that integrntion of visual
postural tone is controlled by a postural system. Th~rcJore, hy
input is poor when olher input in[o the fine posturdl system is
manipulating the input into the postulJ,l system. one can ma-
malfullctioning. and that situation is precisely what is ob-
nipulate postural tone almost at will.
served clinically.
Observations Relaling to the Fine Postural System
The most striking fea[urt~ of the control of onhostatic posture
is its fineness; every normal person keeps his or her gmvita-
tional axis inside a cyl:nder less than J em! in cross sec-
tion:u """"" We know that the fine stretching of the neuromus-
cular 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 lhe-
oretic 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 be-
tween the neurophysiologic comrol of fine movcments and
the control of wider movemcnts. Theoretically. in posturol-
\I\~ ogy. 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 <l\"oid confusing behaviors controlled by
differcnt neurophysiologic mechanisms; such confusioll leads
to difficulty in interpreting data ..t7 It is to prevent such confu-
sion that the sct of mcchanism~ controlling orthost;.ttic posture
Fig. 16.1. The postural man. is called the fine postural system.
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 CHAPTER 16 : POSTURAL DISORDERS OF THE BODY AXIS 331

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The Postural Patient
; \ subject The person \vhose spine hurts for a postural reason is said
- r-\! i\
to have a functional disorder. Radiographic and laboratory
- : '\e l~sls !l:\ve diminatcd rheumatic disc;.\sc. orthopedic illness.

I
i -·1! \: :md ohviotls nucleus pulposus herniation. but pain continues
I ; \

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for unknown rc;\sons. Onen. [he patient feels bener after man-
lIal therapy. hut lhe pain keeps coming b'lck. Such recur-
I I i \-l
I ' , !\I rences likdy h;I\'(: a cause that the manual therapy has not ad·

31 225
i! Ill-I 5 056
dressed. In fact. Olle can obscrve in these patients abnonnal
asymmetry of postural tonc. Is this the mysterious cause of
the rccurrences'~'}
Fig. 16.3. Hislogram of the distribution of statokinesigram arEas
in 182 patients with vestibular neuritis (eyes closed). The gauss-
Identifying Postural Tonic Asymmctr:y
ian curve shows the lheoretic normal dislribution 01 the parameler
of statokinesigram area in a normal population (eyes closed). PHYSIOLOGIC ASYMMETRY
Logarithmic scale. CL. 95% confider1ce limits; 225. mean for nor-
mal SUbjects: 282. mean for patients with vestibular neuritis. A human being docs not have the perfect symmetry of a
(From Gagey PM. Toupel M: Onhostalic postural control in Greek statue: rather. the statistical norm is postural asymme-
vestibular neuritis. A stabilometric analysis. Ann Otol Rhinal try. Not only have we seen asymmetry of orthostatic posture
La<yngoI100:971,1991.) 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
/1\ asymmetry is characterized by laws. The practitioner must not
o 10 subjects ;

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conclude that every type of postural asymmctry is abnom1al.
,
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,
/ . PATHOLOGIC ASYMMETRY

To distinguish pathologic from physiologic asymmetry. the

gains of neck reflcxes are measurcd during a stepping test. -
,I 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
91 210 493 1691 4024 820J
; several technical points must be considered. Testing condi-
Fig. 16,4. Histogram of the distribution of stalokinesigram areas tions should includc no sound or light source that could indi-
for 800 unstable patients (eyes open). The gaussian curve (Iefl.
catc a direction. The Ihighs should be raised neither 100 far
heavy line) shows the theorelic distribution 01 this parameter in a
nor too little at each step (about 45 0 :s right). The pace should
normal population. The fine curves have been superimposed
be neither too slow nor .too fast (1.4 Hz is goOd).H \Vhen
merely to emphasize the bimodal aspect of the distribution.
Logarilhmic scale. 91. mean lor normal subjects: 210. upper 95% putting on the blindfold. the eyes should be in the "primary
confidence limit. position" (looking straight ahcad).~~ The head should be nei-
ther rolated nor tilted,~~ and the anns should bc stretched for-
Limit"i of Posturology ward. horizontal and parallel.~l.~l
Although this simple test, with the head in a neutral posi-
To consider thc centml ncrvous system as a "black box" is
tion, provides useful information. we prefer a more rigorous
certainly an 4Ivowal of weakncss. Until ncuroanatomy can ex·
test that makes usc of the postural neck reflex.
plain where and how the multimod'll information ttwt helps
~~ Measuring the Gain of Neck Reflexes. \Vhen a nomml
people stand upright is integrated. however. we have no .I!(
subject keeps his or her head turned to the right. the tone of
other choicc. We cannot prctcnd to know enough abollt the
) the extensor muscles of thc right leg increases. and vice versa
,~

nervous centers and pathways controlling posture to be able for the left sidc.~,~7 When a nannal subject pcrfomts (he
to propose a neuroanatomic model useful in clinical practice.
:m
Fukud<l-Untcrberger stepping test with the head turned to lhe
:}i The scientific way forward is 10 establish what linb we can
right. he or she rotates farther leftward than if the test is per-
"

I
obscrve between tlte input of the fine postural system .and its
fonned with the head facing forward (Fig, 16.5). Thc differ-

I
output.
ence between thcse two angles of rotation is a measure of lhe
i gain of the right neck rcnex. The sante applics. mutatis mu-
I POSTUIlAL DISOIlDEIlS OF THE SPINE
landis. if the head is turned lefl.~~
,
§
~ II The subject that panicularly interests the therapist is how pos-
turology can help the p~rson for whom standing upright is dif-
ficult or painful.
The test must be carried out methodically to avoid confu-
sion. The results arc tabulaled, following clearly defined con-
ventions. Angles of rot~ltion are denoted r·+" if rightward

I_1
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 HtHAtllLlTATION OF THE SPINE: A PRACTITIONER'S MANUAL

HO.,,", to Manipulate Input into lhe Fine Postural System

2
~~".
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;.
, I Three types of input arc accessible tu the clinician: spinal.
Fig. 16.5. Fukuda-Unterberger's slepping lest with head rotation. oculomotor, and plantar.
When the subject performs the lest with the head rotaled to the
right rather than straight ahead. he or she rotates farther leftward SPINAL INPUT
and vice versa.
Manual therapy of the spine is well known. and for the pa~
tients considered in this chapter, it is assumed that clinical
and "-" if leftward; + 10° means the patient had turned 10° success is only temporary. That assumption does not always
to the right al the end of the lest and - 30° means the patient apply to other postural patients. such as those labeled unsta-
turned 30° to the left), Calculating the absolute value of the ble and the squinter. The practitioner should consider the pos-
gain of the neck renex requires paying attention to the signs: sibility of acting on the fine postural system through this sen-
+ 10Q and - 30° make 40° of difference. not 20°! It is impor~ sory roule.
tant to adopt new conventions for the gain of the neck rcf1cx~
for inst<lllcc. a gain in the "normal" (predicted) direction as OCULOMOTOR INPUT
just dc'scribed is denoted "+," otherwise "-." Oculomotor (and possibly viSUitl) input can be manipulated
An example of how [0 calculate the predominance of neck
by putting a weak prism. of I to 4 prism diopters. in front of
reflexes is provided in Table 16.1. The following explanation the patient's eyc.~~ An optical prism de .... iates light rays toward
relates 10 this sample. its base. For pedagogic purposes. think of a weak prism put in
HL. +50~: Head lUmed left: the patient rotated 50° rightward from of a normal eye as moving t'le eyeball by e.liciting the
HA. -10»: Head straight; {he patient rotated 10° leftward fusion re·flex opposing diplopia_ This movement stretches var-
HR. + 20~: Head turned right: the patient rotated 20° rightward ious oculomotor muscles in accordance with the various posi-
LG. +60": Absolute value of the gain of the left neck reflcJC. is 60°. tions of the base of the prism. (In fact. this cannot be the true
noted with a "+" because it is in the nonnal direction explanation of the action of such prisms because they act even
RG, - 30~; Absolute value of the gain of the right neck reflex is 30°. in the absence of binocular vision.)
noted "-," because it is not in [he nonnal direction Conventiolls of Notatioll, Imagine an optical prism. base
Left predominance 90°: The best gain is the gain of the left neck rc- down in front of a subject's eye and with one of its dioptric
·flex because it is in the nonnal direclion; the difference between
faces perpendicular to the subjcct's visual axis. If the prism is
the t\\'o gains is 90°. (If both gains arc in the nonnal direction. the
rotated around this axis. its base describes successive tangents
larger is considered best. If neither gain is· in the nomlaI direction.
the smaller is considered bcst.) on a trigonometric circle centered on the subject's visual axis.
By convention. degrees on this circle are counted counter-
This mel hod allows testing of the muscle. tone as it varies clockwise from the observer's viewpoint. Regarding the sub-
in accordance wilh a postural tonic reflex. Although it is ac- ject's left eye. 0° is tOward the subject's temple. 90° at the
)
cepted that .1 predominance of more than 50° is surely patho- zenith. and 180° toward the nose. where<.ls for the subjccl's
logic. the risk of error in <.lccepting this limit is not yet known. right eye. 0° is toward the nose. 90° at the zenith. and so on. J
(Fig. 16.6). -,
,y
Strabismologists consider that each of the six oculomotor
Table 16.1. How to Calculate the Predominance of
Neck Reflexes muscles has a main direction of action (ar 0°. 55°. 125°. 180:".
235<>. or 3050).~9 Because a prism deviates light rays toward
HL HA HR RG Predominance its base, the main oculomotor muscle it forces to work is the
+50" -10" +20~ _30" Left 90" one with the main direclion of action thm is opposite the base
HL, +50·: Head turned lelt: the palient rotated 50· rightward. HA, -10·: of the prism (sec Fig. 16.6). Table 16.2 illuslrates 'he correla-
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
tions between prism positioning and activation of oculomotor
the left neck re!lex is 60·. noted wilh a + sign, because it is in the normal di- muscles. The formula RLR 3 refers to a prism of 3 diopters.
rection. AG. - 30·: Tho absolute value oltha gain ollhe right neck reflex ;s in front of the right eye. base tangent at OQ, activating the right
30', noted -. because it is not in the normal dircclion_
lateral rectus.
Lell predominance 90': The best gain is the gain of the left neck reflex be- lAw oftlJe Semicircular Calla/s. Even when considering
cause 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 only the main direction of action of each oculomotor muscle.
neither gain is in the norma! direction, the smaller is considered best).
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 lCHAt>IER 16: POSTURAL DISORDERS OFTHE BODY AXIS 333

55' 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
0' 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
Fig. 16.6. Main directions of action 01 the oculomotor muscles Infratubcrous. under lhe calcancallubcrosity
and positions of prism bases.
For spots. side-to-side positioning is also specified:
Medial infracapital and lateral infracapital. under the heads of.
Table 16.2. Relations Between the Positions of the Base respectively. the first and second and the fourth and finh
of Prism and Oculomotor Muscles metalarsals
Stlelched Muscle
• Anlcrornedial and anterolatcral, behind the he:Jds of tht: corre-
sponding metatarsals: and so forth (1l1ediomcdial. rncdiol:U-
Base 01 Prism At Right Eye loti Eye
eral: posteromedial. postcrol;]teral; and medial and latcr.ll in-
0' RLR LMR fratubcrous)
55' RIR LOS
125" ROS L1R Any CO!1struct:C!1 must be positioned in accordance with
180" RMR LLR the podographic footprint. with due attention to dysmor-
235' ROI LSR
305" RSR LOI phisms of the fect. The footprint can be achieved by using a
LA: lalctal r{!Clus; MR: medial rectus; IR: in/crior ractus; SA: superior reclus;
light layer of ink under the foot and then having the subject
SO: superior obliquus: 10: inferior obUquus. place that foot onto white paper.
Fool Paiu. The effectiveness of these exteroceptive stim-
Six oculomotor muscles increase the gain of the left neck rc~ ulntions mny be limited by any pain in the foot of which the
flex. and the other six increase that of the right neck reflex. It patient r:nay not even be aware. ~herefore. we recommend
is bcucr to decide in advance which oculomotor muscles may both questioning the patient and pressing with the thumb on
bring about better balance of the muscle tone than to proceed various regions of the soles to discover any painful area that
solely by trial and error. The law of the semicircutar canals the patient had not not;ced. In such cases. antalgic elements
can help in the decision. should be provided in addition to the element for postural
According to the law of the semicircular canals (Table stimulation.
16.3). deviation of light rays away from the main direction of Proprioceptive Disorders of the Legs alld Feet. \Vhcn
aC'ion of an oculomotor muscle acts on the tone of the c;ltten- free movement of the joints of the legs and feet is impaired to
sor muscles of the legs in the same way as deviation of the en- 'he extent that proprioception is affected greatly. plantar pos-
dolymph stimulating the cupula of the semicircular canal gov- tural stimulntions are less effective. Such disorders must be,
erning the rencx activity of this oculomotor musclc.«)...(,4 If you corrected before stimulatory wedges arc used.
know on which side you wish to increase the gain of the neck
reflc;lt. six oculomotor muscles can be eliminated' immediately Identifying the Right Input
by referring to law summarized in Table 16.3. 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

Table 16.3. Law of the Semicircular Canals
soles. The mcchanorcceplors of thc sales are accurate to
within I g.. and the wedges used to stimulate them must Increases the gain of the neck rellex
be correspondingly thin (about 1 mOl in thickness). Thick Righi Left
wedges do not alter postural-tone. ~
>- RMR RLR
Microwedges act on plantar baroreceptors. They may also ~ ~
RSR RIO
"0
stimulate deeper proprioceptive sensors. such as capsular or ~ Z RIR RSO
~

ligamentous Pacini's and Ruffini's corpuscles. Golgi tendon E a:'"

0
organs, and neuromuscular spindles. Microwedges placed 1ii ~
LLR LMR
>-
under cenain regions of the sole modify the sensory input into
the fine postural system.
"
0
0
~

'"
~
-'
L10
LSO
LSR
L1R
Because the technology of conventional orthopedic shoes
! does not correspond to that for postural stimulation. we pro~
LA: lateral rectus; MR: medial reclUS; IA: inlerior rectus; SA: superior recluS:

I
SO: superior obliquus: 10: inferior obliquus.

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 REHABILITATION OF THE SPINE: A PRACTITIONER'S MANUAL

I
.1
will cffcC'tively alter the patient's postural tone, and the prac- edge of the soks wilhout touching them. and the mcdial edge
"I titioner must look for it Then, the quickest and most adapt- of your thenar eminenccs pressing 011 the anterior edge or the
able clinical test is the rotators test. 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
ROTATORS TEST
and leaning slightly back. so that you arc pulling gClltly 011 thL'
OUf tcam has lIsed this clinic'.li tcst of tht.: tone of the hip ro- patient's Icgs. With the subjc,.:1 relaxed with feet slightly
tator muscles since the work of Conslantincsco and Autct."~ ;!rart. pl'rftmll llvc or six succcssivc medial rotations of both
This lest has the great advantage that the patient is lying down feet at once to tcst the p;\ssivc rCSiSl<lllCC of the external thigh
and does not gCllircd. and that the effectiveness of each Illa· rolators to these movements. Nine out of lCIl timcs. the exh::r-
~ nipulation is known within seconds. Seen for the first time, it nal rotators of the right thigh offer the stronger resistance. \Ve

I looks like a conjuring trick, so before explaining how to do it,

we explain the underlying ideas.
say they arc hypertonic relativc to the symmetric muscles.
This tcst is not as easy to carry out as it may seem. Your

Ig
f,
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
pronation movements to rotate Ihe feCI should be supple. n:::-
laxed, and fairly fast-at a frequency of abolJt 2 Hz. which is
the resonant frequency of the hip joint in such axial rotation
movements (Walsh EG. personal communication). Thus. this

i 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
rapid test mainly investigates the viscous componcllt of mc-
chanical propcnics and the primary spindle endings: it elimi-
nates the effects of muscle thixotropy. (\Ve recolllmend prac-

I ,
Ii
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
ticing with volunteers: after nbout 100 exercises. you will
start doing it casily.)
Preparing to Perform the Test. The amplitude of Ionic
responses to manipulations of the postural system varies
among subjects. Therefore, it is important to take some time
at first to become acquainted with lhe amplitude of each pa-
tient's own reactions, to feel how the rotators respond when

I is panicularly great when we manipulate tone to test it. for

what is observed then is not "tone." but ruther certain tonic re-
actions to ccnain changes imposed by the clinician. In the un-
the head. eyes. or arms are turned.
Usually. the tone drops in the rotators on the side to which

I
lhe head is turned (or increases in the other side-the test fun-
avoidilble "action-reaction" pair. [he reaction will have epi· damentally is a comparison). The same holds true when
stemologic value only insofar as [he action is known. \Ve the eyes are turned. but for unknown reasons the eyes must 3
must know what we are doing before we can understand what be closed. Medial rotation of the aml (as when the right ,
I

we arc observing. hand is placed on the left shoulder) brings about a decrease
I I
Sherrington led the way in the rigorous study of muscle
tone by quantifying the lone of a muscle by its resistance to
of the lonc of the ipsilateral rOlators. and lateral rotation of
lhe arm (as when the lefl hand is placed under lhe neck)
I~ passive stretching in tcnus of the physical quanti tics Icngth. bring~ about a decrease of the tone of the contrahucral

,. time, and force applied. It is reasonable to continue strctching

muscles to tcst their resistance to stretching. and thus their
rOlators.
Once the practitioner can accur;.1tcly detect the patient's

I "tone:' but each maneuver must be defined in physical tcons.

Regarding stretching movement. the amplitude. speed. accel-
eration. time elapsed since the prcvious movement. and ap-
plied force must be specificd. Each parametcr matters: ampli·
responses. the next step is [0 climinate any interference rc-
lated to malocclusion.

I
,
tude for the properties of elasticity and for secondary spindle
endings: speed for the properties of viscosity: speed and ac-
celeration for primary spindle endings: nnd time elapsed be· ()

I
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 posturolo-
gist 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
I facing straight up, eyes in the primary position, jaw relaxed

I
(lhe teeth should not touch). Sland at the end of lhe lable, fac-
ing the patient's feet, and take the heels in your palms. with
'¥ your hypothenar eminences and linlc fingers resting www.bodywork.su
at the Fig. 16.7. Rotators lest.

I~-----,---------------------------------
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 """... , oK 16 : POSTURAL DISORDERS OF THE BODY AXIS 335
;
-,
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MANDIBULAR INTERFERENCE adapt to the new visual surrou!\ding::: by IUming his or her
eyes to look around in all directions.) If one or two muscles
Why or how m;,mdibular disorders can change lhe rules of lhe
bring about tonic reactions, this information is noted for a
galllt:: of postural lone is unknown. This still mysterious phe-
possible prescription. If none of them produces ~\ response.
nomenon must be borne in mind from the outset when exam-
we recommend testing the other six Illuscks anyway before
ining any postur..11 patient. for experience has taught us tll;]t it
going on to the next stcp~ the practitioner need not be a slave
;s a wash: of time to put prisms in front of the eyes or mi-
of the law of the canals.
nowctlgcs under the feel of a palicnl whose pos(ur..Il lone is
altcn.:d hy a mandibular disorder. Only after Ilwntlibu1:.lf uis-
LOOKING FOR AN EFFECTIVE PLANTAR AREA
orders have been cured. so that they no longer interfere with
postural tone. is it reasonable to usc prisms or microwcdgcs. Manipulating plantar input is easy: tcst the rotators in thc
) if the palien! still needs them. standard conditions. stimulate the sole at a particular spot. and
The back teelh-molars and premolars-have protrusions immediately test rotators again. The stimulation is done sim-
or cusps that engage the cusps of the opposite teeth during ply by applying light pressure with a finger. just enough to
closing movements or occlusion of the jaw. for instance. stimulate the baroreccplOrs in ttle soles-2oo g at most. If the
during swallowing. The positioning of cusps makes great resuhs of lhese IWO leslS differ. the plantar spot stimulated
demands on precision, with which occlusodontists are famil~ may be able to modify postural tone, and is wonh keeping in
iar. The posturologist need know only how to be sure that mind for a possible prescription.
some modiliciltion of lhis "imercuspidation" is not ahcring The entire area of both soles. onc after the other and spot
postural tone. by spot. may be tested, but spots under the scaphoid at the top
Testing Procedure. The principle of lhe lest ior imcricr- of the arch and under the cuboid at the lateral edge of the foot
encc by rnillocclusion is simple: the tone of the rotators must should be tested firsl. followed by spots in bars under and just
not alter when the intercuspidation is modified. behind the heads of the metatarsal bones and then spots in
To begin. tcst the rot:HorS with lhe subject's teeth in lhe bars under the anterior part of calcaneum.
, usual intercuspidation position. Ask the patient to swallow
J
spittle and keep the teeth in contact-the usual intercuspida- Prescribing
tion position; now. test the rotators.
Tonicitj' is such an elusive phenomenon that measuring the
Next. put a small piece of Bristolboard. cc~ to :.:zc, b~
gains of neck reflexes and testing rolators is. not sufficient to
twecn the back tecth and have thc patient walk around and
ensure that the correct manipulation has been identified.
swallow spittle several times before testing the rotators again.
Faced with 'his uncertainty. the practitioner has various
with the modified intercuspidation.
choices. depending on the circumstances.
If the results of lhe two tests are not the same. modifica-
If the piltient can be re-examined promptly. c.g.• within a
tion of the intercuspidation has altered the tone. To verify this
fortnight. it is acceptable to lry lhe simplest and most efficient
finding. use other tests (such as the Fukuda-Umerbcrger step-
modification (a press-on prism aflixed to the- patient's glasses
ping test or the thumbs test) and refer the patient to an ocdu-
or wedges made quickly). A therapeutic trial is one way of
sodontist.
making de.lr determinations.
The bitc planes can be more sophisticated and more ef-
If. however. the patient cannot be rc-e.x:lmincd soon. the
fective than the piece of BrislOlboard rccommended here. but
prescription must be based on the convergence of several
how to make them and fit [hem is beyond the scope of this
tests. From the billtCry of possible tests-po5-turologic. chiro-
c!wp[cr. Even if bctter options arc not 3vailable. this crude
practic. osteopathic. kincsiologic-each pra.:ritioncr chooses
method is useful.
lhe ones with which he or she is most comf~)nable. Nonnally.
After establishing that mandibular input is not playing
we usc the stepping test and the test of Ba.rrFs vcrtical (sec
havoc with the patient's postural tone. the practitioner then
subsequent discussion). \vhich we consider fairly reliable. and
considers which of two types of input into the fine postural
system to modify to effect treatmcnt.

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 direc-
tion. 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 posi-
tioned successively at each of the six orientations associated
with these muscles, the rotators arc tested for altered tone. Fig. 16.8. Device for Barre's test. Heels are 2 em apart and
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(Before testing the tone of the rotators. the patient should 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 ad-
jective 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 be-
tween the feet, with the heels 2 em apan for the sake of steadi-
ness (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 fig. 16.10. Thumbs test.
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 the head completely. then letting lhe.shoulders fall. and tin~l!ly
lines. the trunk. as if attempting to touch the fect with the hands.
The observation is repeated with and without the correc- without bending the knees (Fig 16.10).""
tive device-the prism or plantar insert-that is being evalu- The practitioner. meanwhile. notes whether his or her
ated (Fig. 16.9)63. Often, the result of this tcst 1S not immedi- thumbs arc dragged symmetrically. or if one is dragged higher
ately altered by a manipulation thnt later proves to be than the other. The tcst is rcpeated with the thumbs al variolls
effective. Therefore, we consider the tcst to be fairly reliable. levels of the spine. for instancc L3, 012, D7. D4. C7. ~lnd the
occiput. The rcsuhs obtained with ;md without manipul~lting
T: tUMOS TEST an input into the system arc written in a table for comparison.
Using a test thc mechanism of which is not fully under-
The patient stands upright, with feet apan by the width of the
stood has its dangers. but with this reservation. we can say
pelvis. The practitioner, from behind. puts his or her thumbs if,)
that the thumbs test is sensitive. revealing slight differences
gently on the patient's skin. without pressing (<1 pressure of
that other tests miss-the results of the thumbs test arc altered
about 10 g is appropriate), making sure they are positioned
by a change of only one diopter of the prism. This sensitivity
:)
symmctrically relative to the patient's body axis, starting at
is the reason we include it in our battery of tests.
the level of the posterior superior iliac spine. The patient is
Just which tests are used-Barre's venic;.I!. the thumbs
then asked to roll downward slowly, i.e.. to start by dropping
test, or some other test-maners less than the need (0 pre-
scribe on the basis of a group of converging arguments. so
A B c o E that on each test. the prescribed corrective device ;"lters the re-
sult 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 in-
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 sofar as possible. because postural tone docs not change con~
try either oculomotor input or plantar input without looking at the tinuously. as it tends to do in response to plantar stimulations.
spine, the mandible, and joints of the feel. E, A whiplash injury is Prisms must be used with caution, howcver. Small prisms an::
a possibility. (From Guillaume P: L'Examen clinique postural. powerful; they can modify nn ant;'llgic posture. and one can
Agressologie 29:687,1988.) imagine the effect on the patient's suffering.
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 ",....l... ul~uH.Ut::H::i U~ 1HE BODY AXIS 337

_.
. _" I

Contribution of Stabilomctry
"
Although we have mentioned only clinical examination. a
noteworthy means In record the functioning of the fine pos-
tural system is the ~Iandardizcd cmnputcrizcd platform for
clinical stabitomclry.'° The reason for nOllllcntioning this ap~
paralUs previously is simple: in effect. the platform reduces cs:;-~
the subject (0 a single point, the center of grdvity...md ,ma- ( 10 )
ly1.c~ the stahility of thi5- point rc!nti,,!= t':' the surroundings. II
is difficult for a clinician to accept such a reduction of pa-
tienls. Nevertheless. stabilomctry remains a basic tool. be-
cause it provides much needed certainty regarding the elu-
sive phenomenon of muscle lone. It provides documentary 100 250
evidence useful for treatment follow-up and also for COI11- Fig. 16.12. Changes in Romberg's Quotients at patients whose
piling statistics on groups of patients, making it possible condition did not improve. Each arrow represents changes in
to sce beyond the random variability encountered in everyday Romberg's q'uotient 01 one patient tram the start to the end of
clinical practice. In addition, stabilometry is indispensable follow-up. 250, normal value: 100. limit lor postural blindness.
to the clinician, because disorders of the rcgulation of onho- A, 54 patients whose condition did not improve and whose
static posture often arc not clinically apparent and are Romberg's quotients move away Irom normal. e, 10 patients
manifcsted only in patients' complaints a:'ld abnomlal sta- whose condition did not improve and whose Romberg's quotients
~ilnmctrk parametcrs. Without its stabilomctric underpin- shifted toward normal.·o
nings, posturology would not have the certainties It has at
present.
showed a shift of the Romberg's quotient toward normal
(Fig. 16,11).
ROMBERG'S QUOTIENT AND LOW BACK PAIN
The condition of 54 subjects. howevcr. wa:o; no( improvcd
The first objective indicmion that low back pain is improving by treatment; of these, only 10 showed a shift of the
is a stabilol11ctric criterion: a :-hift of Romberg's quOticnl to- Romberg's quoticntlOW<lrd normal values (Fig. 16.12). ;'\l1d
':..:::.i"d :::. :o.armal value. From 600 patieols with low back pain all 10 showed obvious stabilomctric signs of "o\'crcolHrol" of
who had been followed using stabilometry, Guillamon and their orthostatic posture (sinusoidal intcrcorrclation function)
co-workers40 selected 125 for statistical analysis because thcy suggesting malingering or "oversimulution."11
showed no other impairment, they had received thc same :\lthough stabilometry potentially is widely applici.\ble. it
treatment, and they had not received any other treutment thut can be carried out only by a specialist. the postllrologist. It is
could have modified their postumltonc. Scvcnty-one subjects in lhe intereSI of aU thcrapists to know abom stabilomctry.
of this group benefited from the treatmenl. and of these. 63 howcver. for all can benefit from its contribution.

o Contribution of Postural Orthoptics

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
A functioning. Postllrologists cannot work effectively without
collaboration with ncuro-ophthalmologists as well as neuro-
olOlogists. Neuro-oplllh<llmologists working with posturolo-
gists have developed orthoptic ex:uninatiolls useful in postllr-
ology. e.g .. tests of oculomotor balance in variolls postures

i 81,
0-h·
--=;:::f=:::;--;::==::::;---
(8)
(standing. sitting. hcad straight ahead or ro(at~d. eyes in the
primary position or in different versions) or tests of oculoll1o~
, I
.~
ii • tor balunce under the effect of pmaural prisms.': Casc man-
•
~ r,' 100 250 agement is greatly facilitatcd if the results of such tests and of

.~ Fig. 16.11. Changes in Romberg's quolients of patients whose

the clinical postural examination ;Ire consistent and in agrcc~
mcnl. Although it is beyond [he :o;copc of this chapter to de-
i~ condition improved. Each arrow represents changes in Romberg's
quotient for one patient, tram the beginning to the end of follow- scribc these orthoptic techniquc:, in marc detail. tile cOl1tribu-
~ up. 250, normal Romberg's quotient; lOa, limit for postural blind· timl of postural orthoptics dcser\"cs mentioll. \Vc never put a

!t ness. A, 71 patients whose condition and Romberg's quotients

both improved. B. 8 patients whose condition improved but whose
prism in front of an eye unless the p,i1icllt has had ;;111 orthop-
tic evaluation. In this collaboration. we arc fortlln,HC, and we
Romberg's quotient moved away from the normal mean.~o wish C\'cry thcmpist the same good fortune.
11
• .." )

~
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1------,-------------------------
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~,,,

Postural Training Platform of (011tro1 tWL'r 01l~':, hody. Phyl(lg~l1('tically speaking. ()

humankind is Ih~ OUh.'\ll1l(' or this impulse toward more
PoslUr.l1 rehabilitation can he accelerated hy the use of :l
freedolll. morc control. more powcr, To reduce the standing
wobbly platform. similar to that dcscrihc~ by FfC~l1lal1 el aF'
per.. . on W posturologic lCflns is to condemn ourselves to
but adapted to the fine postural system. The dOI1l~ on wllkh
lllisulldcrsiand the "lnis-"{~llldillg" person.
the platform re~ts has .1 large radius of cur\',lture and the plat-
~n longcr lX'ing ahk 10 sl,md lIprigJ1t is sh,uning. the op-
form construction limits its mean range of movement to -l nr
posite or being. upright and proud of it: to lose this ability is
50 (thc normal mngc of hody sway in (HlhoSI:ltic posturl' thal
III he powcrkss ;lIld dqll'lhklil. Wilh ,I postural p'llicnt, there·
is conLrollcd by the linc postural systcm). Therc!<lre_ a slIhjC(1
f\lre, wc IllUS! asse~s lh(' pSydlOlogi..: aspect of this dison.h.:r
standing on the pl'ltform commonly remains within these lim-
011 his or hcr behalf. for the patient will not be ",ware of the
its of tile fine postural system (Fig. 16.13).
The subject is askcd to stand upright on' the platform.
extent or
this break. We arc then faced with a difficult sitlla~
lion, because the ~igl1ilil.::'ll1ec of psychologic disorders that
keeping it as horizontal .md as stcady as possible for ahout
'\CCOlllp..m)' poslUral disorders is dOllblc·sidcd: the individual
I minute. The exercise is repented several times a day.
1ll:'IY havc experienced ;I'profound \\~()und to the bodily ego
Admittedly, this platfoml cuts down the plantar input inlo the
that is expressed ;IS depression and anguish. or the paticnl
fine postural systcm, because information perccivcd by plan-
may feel depression or anguish thal is being ex.pressed in bocl·
tar baroreceptors is not the stlllle as when the ~ubjeel is stand-
ily language. Some postural disordcrs can bc ameliorated
ing on finn ground. This condition probably increases the
with purely psychiatric trcalment. All pfilctitioncrs musl rc~
contribution of visunl input to the control of orthosultic
membcr thm a purely posll1rologic point of view docs not rc·
poslure.
ncct the entire person,
For whatever reason, we have observed that postural
blindness responds to this form of treatment within 3
CONCLUSION
months,7-~ As wearing a prism can result in iatrogenic poswral
blindness, it is advisable to prescribe exercises on a poslUral Everything said about the control or orthostatic posture seems
training platform every time a prism is prescribed, especially obvious, but we must l10t forgct Ih:'11 nn "obvious fact" may
in the absence of a stabilometric platfonn thai could be used <lssume its true weight only after gradually emerging. through
[Q detect the appearance of postural blindness, These exer- many experimcntal confrontalions_ Thanks to the pioneers of
cises also seem useful in treating mild low back pain. posturology. and in panicular of stabilometry. a few facts
arc now known abotU thc person standing upright, but there
Psychologic Aspect is still a long way to go before this knowledge comes into
its own.
How reductive it would be if the posturologist considered a
standing person as merely an assemblage of eXleroceptors and ACKNOWLEDGMENTS
proprioceptors. the infonnation from which is integrated to
produce the reactions needed for stabilization in his or her We thank Susan Millcr for her help with lhe English tr<lns~
surroundings. To stand upright means much more. To stand lation and Sylvie Villencuvc·Parpay for her help wilh illus-
on one's feet means to have the hands free to act and the joy trations_

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1965. tic BU$s:!c Clcollond·FaTJlld. dc Bms;I,·. l<1N'.I'P .'i7~(d. 7._. Frl'l~Ill;lII ~1 ..\R. \},,:all 1o.IRE. Ibnh:lIll IWF: 'Illc ctiology ,\lid prevclllion

70. Bi ....1.0 G. Guillci N. !lal;1l .-\. (1 :1.1: Sp\:cili~·;tli\ln., (,': t>:lildio;; :1 "cflic:! (If hll1,"I\II1::! In_~I;lhililY Ilflhl" i''Clt. J BllllC loim Stlrg IBr!47:(17S. 1(6).
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 1( Lumbar Spine Injury in the Athlete
ROBERT G_ WATKINS

Low back pain has b~cn a significant factor in many differenl ographic evidence of chnnges similar 10 Scheunnann's dis-
types of athlctic activity. Thc ~evcrilY ~\lld extent of back pain casc.'~

oftcn dctcrmincs the aClUal abilil)' to compete ;lnd is i\ worry Keene ct HI" found that 80% of back injuries occurred dur-
(() the athlete. the family, coaches. trainers, and those persons ing practice, 6"fcJ dliring competition, and 14% during presea-
': ! responsiblc for p::lying the bills. TrCallIlCn{ of thc athlete with son conditioning. Of thosc who sustained injury, 8% were
~
, a lumbar spine injury involves an lInderstanding of basic men mid 6% women. which was of no statistical signifi-
-,~ anatomy mId biol1lcchanic'll function of the spine. the diag~ C;Ulce. The n:lturc of injury usually was acute (59%)~ 12%
§ nosi$ of conditions ,lffecting (he lumbar spine. proper usc of \Vcre related to overuse and 29% involved aggravation of a
~
,
:;; diagno~tic ~tudics. and a syslcnmtizcd. all-inclusive history pre-existing condition.
-~
and physical exmnination. We must also recognize somc fac-
.~ tors that predisposc the athlcte to lumbar spine problems. as
ANATOMY
i well as training <lnd therapeutic techniques to prcvcnt lumbar
!"" spine problems in athlctcs. The vertebral column is a series of linked intervcrtebral joints.
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Dbtuining ;:\ proper diagnosis in Ihe athlete prescnting
with low back pain is crucial. It is thc key to initiating an ap-
The join! consists of the intervertebral disk, its two facet
joints. concomitant ligaments. vessels. and ncrves. referred to
I~ proprimcly aggressive diagnostic and therapeutic plan.l.~ A as a neuromotion scgment. A neuromotion scgment is consid-
\
-~ variety of pathologic conditions can be diagnoscd on the bi.\~is ered as onc of the basic units of spine an<ltomy and function.
'~
,', of plain fHm radiography ,md thcir relationship to the alhlcte The lumbar spine has a lordotic curve and plays an important
;1 and his or her sport can be addrcssed more spcciflcally..' role in the biomechanics of the lumbar spine.
~: Especially in the adolescent and younger athlete, a high index The spine comprises two basic columns~ an anterior col-
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of suspicion must be maintaincd to accurately diagnose COIl- umn consisting of the disk and vertebral bodics and the ac-
:\."
ditions such as stress fracturcs and spondolytic dcfccts,~ companying longitudinal ligaments. the anterior longitudinal
~
~ The bone scan is a vital diagnostic 1001 for the physician C;lr- ligamcnt und Ihe posterior longitudinal ligament. The poste-
~ ing for athletcs with lumbar spinc problems. An iJdolesccnt rior column consists of the facct joints. lamina. spinous
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athlete with significant back pain that persists for longer tlwn process. ligamcntum Ravun. and pars inarticularis. The disk
•,• 3 weeks should be evaluatcd radiographically and a bone scan
should be obtained. Unusual conditions ranging from oSlcoid
itself may be described as a circular, multilaminated ligament
that connects the two vertebrae. TI1C nucleus pulposus is the
! ,, central, morc gelatinous portion of the disk. The annulus is
osteoma. infections, and stress fractures of the sacroiliac
I joint, to the more routine spondolytic defects can be found. the mulliluycrcd woven basket with fibers at precise angles to

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Approximately 30 10 38% of young athletes presellli"R willt
significllw lumbar paiu have [Josilive bone seeUl..!·!>
resist torsional <lnd compression forces. This structure is
firmly anchored (0 the end-plale of the venebrae. The annu-
Predisposing f'lcwrs to back pain in athlelcs include increased lus. nucleus, nnd the accompanying end·plates resist com-
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trunk length and sliff lower extrcmities.f , There is an increased pressive forces well and torsional forces less efficiently.
(} prevalence of occulta spina bifida in patients who dcvelop The orientation of the facet joint is different at every level
~! lower lumbar spondolytic dcfects. 7 of the spine. In the lumbar spine, the facet joints are oriented
The study of exercise and back pain in athletics and in the in a transitional phase from parasagittal in the upper lumbar
:": spine to a more coronal orientation in the lowcr lumbar spine.
average populalion demonstrated no higher incidence of back
t
g
pain in athletes participating in orgnnilcd sports relative to This p,lrasagittal oricntation allows good motion in flexion
regular students. fairbank ct al found that back pain was more and extcnsion. and less motion in I.Heral nexion. The
ii
cOlllmon in studcnls who avoided sports than in those who parasagittal oricntation of the facet joints would naturally re-
I• participated. Fisk ct aP- found that prolonged sitting was the sist rotation~ high lorsional forces can overcome the strength

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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
or the joint, tearing the annulus and injuring the facctjoims.
\Vhen considcring thc anatomy of the spine. one must
consider the important role of the cntire cylinder of the trunk
I• study involving 500 17- and 18·ycar-old students showed that
56% of young men ~md 30% of young women had some mdi-
and iL'i supporting muscles. The static ligamentous structures
provide considcmblc resistance 10 injury, but lhis resistance in
I 341
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itsdf would be insunicicllt to pn~tlllce proper spine strength Isthmic spondylolisthesis most commonly develops as a
withom rhe additional supporl provided through (he trunk str~ss fracture. A hereditary predisposition to dt:vcloping the
Illusculature anti IUlllbodorsal f:ISl:ia. :V1usdc control of lhe stress fractur~ is likely, and there is certainly the predisposi-
lumbodorsal fascia allows gn.':il1cr n:sistal1ce to bcnding anti tion in conditions in which the bone of lhe pars inarticularis is
IO~lding stresses. The: rok of 111111!wsacral fasci,l Illi.ly be com· nO( sunicicrll to withstand normal stresses. Also, certain me-

p<trcd to {he anchoring dc\·iccs of a circlls lent, which pull 011 chanical activilies thaI expose the p<llicnt to rcpcaled biol11t:-
thc side of lhc t~nl lil ,q:lhilizc the pole in the middk. The !';IS· chanical challcng~. increasing stress concelllmlion on the pars
ci,] st;lbilizes· the spine :lntl allows it to right mechanically. inlcrarticularis. hav~ a higher incidcnce of spondylolisthesis.
The IUlllbodorsal f",\.·j:\ 'lIlt.1 the muscles allaching to il ,:rc 01" Thl: concept of repealed microtraurna with conccntration of
cqu.al imporltlncc to the ilion: sjli.:cialii'.ed function of the in- these strcsses in Ihe pars has become increasingly recognized
ter....ertebral disk and r:H:~( joints. ill adolescent athleles whe participate in sports such as gym-
nastics and weight lifting.
The most common site for spondylolysis and spondylolis-
DIAGNOSIS
thesis is L5-S I. 'Ille slippnge in the latter disorder results from
. In dClermining the exact ctiology of lumbar spinc pain in mh- the lack of support of the posterior clemct\(s produced by the
letes. age-is i.1ll important fi.1ClOf. l'ounger athletes arc more stress fracture of the pars. The spectrum of neurologic in-
likcly to havc slr~ss fractures and congenital predispositions VolVClllCnl funs from rare to more common with higher d~-
to slress fractures. Diseases that affect growing cartilage are grcc slips. The majority of neurologic deficits ;:Ire an L5
more common in young athletes. such as Schcurmann's dis· radiculopathy with an LS-SJ spondylolisthesis" Cauda cquin3
easc. In the m.Hurc athlete. radiologic assessment often in· symptoms are more likely in grade III or IV slips. Cauda
volvcs distinguishing between age-related, asymptomatic cquina neurologic loss is ran~.
changes <HId symptomatic reccntlmum:l. Is the L5-S I disk de- The diagnostic and thcrnpcutic plan for spondylolisthesis
generation.H (he symptomatic level in a 30·ycar·old athletc or begins with a high degree of diagnostic suspicion in the ado·
'¥
" is it an ,lsymptomatic finding? The diagnostic plan must be lescent athlcte with low back pain As lll'lny 'IS one third of
i organized to allow diagnosis of the most common conditions adolescent athletes presenting with l~w ~ack '~ain havc c\·i-
~ as wcll as such r'lre conditions as herniation of the inferior dcnce of a stress fracture on bone scans. Bone scanning h-
i lumbar space ll ) or o:,teoid osteoma. warranted for patients with low back pain that has not re-
~ Important diagnoses to make in the athlete with back and solved within 3 weeks. If the results·ul iilc bulle: Sl:al1 arc pos-
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leg pain mc peripheral nerve injury and peripheral nerve en·
trapmcnL Thc variety of peripheral nerve problems ranges
ilive, CT scanning is perfonned to detennine if there is a
demonstrable stress fracture or if the bone is "hot" because of
I from a generalized peripheral neuropathy to carpal tunnel an impending fracturc. If the results of the bone scan are neg-
i syndrome. pyriformis syndrome, peroneal nerve injury, ative and the patient persists with lumbosacral pain, magnetic
i remon]! neuropathy. and interdigital neuroma. The chief rea· resonance imaging (MRI) is indicated. Using a combination
.'i: son for clectromyographic and nerve conduction studies of of MRI. bone scanning, and cr. it is possible to diagnose
J the lower extremities is to identify a peripheral nerve prob· moSt signilkant pathologies in the lumbar spine.
:i lem. The nerve conduction study. combined with a careful The treatmcnt plan for spondylolisthcsis is rest or restric-
~o~ P!I~ysical .examination. can ~\t least raise the distinct possibility tion of enough :Ictivity to relicvc the symptoms. This pbn
.~ 0 a penpheral ncr\"(~ problem and heighten the diagnosti- may vary from simply removing the athletc from participat-
-B cian's skepticism concerning small. potentially asymptom:'ltic iog in the sport until the pain has significantly improvcd W
'I spinallcsiol\s in the role of the patient's extremity nerve pain. immobilization in a lumbosacr'll corset. Boston brace. or
i TLSO, or bed rest and casting.
{ S The goal is to SlOp the pain through whatever amount
~ 'pondylolysis and Spondylolisthesis of inactivity is required. For an athlete with <I "hot" bon~
1i
~ Age is important in the natural history of thcse conditions. An scan. we routinely prescribe a bracc and restrict activit)' for
M incidencl: of 4.4% ,J( age 6 years increases to 6% by ..dult· 3 mOnlhs. At the end of lhis period, if the bone scan is fl.>
:1 hood. It is unusua-' for children to presellt with spondylolysis peated and the results are negative. sufficient h~aling has OL'·
jj beforc the <.\ge of 5 years or with severe spondylolisthesis. curred to allow the patient to begin a rehabiliwtiol1 program.
i . grade III or IV. Most symptoms appear in adolescence. If the findings of the bone scan arc still positivc. and the .nh-
~.~.; Fonun:.llcly. however. but the risk of progression after adoles· lete is asymptomatic. it may be difficult to decide whcther III
i! cencc is low (about 15%). Symptoms cannot be correlatcd begin the rehabilitation program or to continue further r~-
i.1 wilh the degree of slip. Rapid progrcssion to spondylopt.osis
is more common in 9 to II year aids and in children with oc-
striclion. \"Ie usually initiate the rehabilitation progr'llll and
observe carefully for any return of symptoms. If lhe patieIH i~ 1 c)
~ cult spina bilida and doming of S I. Children with high degree asymptomatic in a full, rigorous, trunk stabilization progr~lIn I· ~
....)

~ slips may present with dcfonnily and minimal pain" Many (level II Back Class) and aerobic conditioning program. w t : J
i times, it is (he pain of an injury that leads to the identification allow lheir return to their sport and conlinue the rehabilitation \
~ Of:'1 signif1cant spondylolisthesis. program. J
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 CHAPTER 17 : LUMBAR SPINE INJURY IN THE ATHLETE 343

Pal kills wilh unilateral "hoI" h,Iill..' scans. wilh or wil1lOU( SOllie injuries fesult from direct blows. Certainly. sports
demonstrated fr:\I.:llIfc. have a rC:I'llllably high illL"iJL'llCC 01" slIch as football arc associated wilh muscle contusions, mus-
healing. and adnk,(cllt allllcl..:s ill ~l'l1cral should be (reilted dt.: stn:tchcs.•md lears of fascia. ligaments. and. occasionally.
!i with the idea o( hl'aling Ihe defec!. Bil:l\cral sln:s.", fractures muscle.
afC less likely to hL';11 c.kspitc l'olllj'n..·hL"n",ivl..' IltHhlpcr:lIivc Lumhar fractures can occur as a result of direct blows to
!, 111cr:lpy. tltl..' hack wilh fracture of the spinous process or twisting in-
Ir the hom: . . ..,-an lindings ,If\.' 11:.''::;lti\·l~ ill a palil'!H \~'i[h a juries that avulse the tnlllSVCrSl: process. Vertebral body cnd-
spondylitiL' tkt'c(1. lhl.' In:atmclH pLtn should be IikL' [hal for plate fracture from axial compression load on the disk is a rcl-
:lll)' patient wilh lllt.:l.:hanic:1I lnw h:h.:k paill. Tilis plan usually ati\·t.:!y common source of compft::ssivc disk injury. The allIlU·
~ involves a progl'cssi\"c1y vigorou" lfunk stahility rL'ilabilit.\- Ius is morc likely injured in rotation. The end-plate is morc
~ lion program. We put no rennan~nt r~stril.:lions on .ultk(cs vulnerable to compression than the annulus. Axial loading
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,, \\lith spondylolysis or srondylolisth~..is. Ckarly. p;'li~ms \\lith compression injuries can result from jarring injuries in motor
grade III to IV spondylolisthesis ar~ less likely (0 b.: able to sports or boating. Flexion rotation fracture dislocations of lhe

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partil.:ip:Jtc in vigorous sports ;ll.:li\'ili~s without pain and ois-
l.:omfort. Thcy should probably :l\"(lid lhe hC;l\·Y.. strength
sports. such as fO{.ltb;.tll. wcighl lifting. etc.
ccrvic;::tl and lumb;'lr spine arc certainly possible. In any sport
in which one athlele falls on another. the mechanism is simi-
I"r to that of the coal face injury with the rock falling on the
I, }
The lm;idcm:c of spondylolysi~ ::md grade I sp()l\dylolis~ coal miner while on all fours. An athlete can suffer an asym-
I Ihesis in sports participants is high, In the long term. this con- metric loading. rotational injury to the thoracolumbar spine.
")1 dition is not considered lo be a significant factor in an ath- The intervertebral disk is injured predominantly through
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klC's ability to pl~l)'. rotation and shear. which produce circumferential and radial
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§
lears. Initially. the layers may aClUally separate or lhe inner lay-
ers break. As the inner layers weaken and arc lOm, added Slress
j BIOMECHANICS
is placed on the outer layers. This increase can produce a radial
.~
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) The understanding of the basic biomechanics of Ihe lumbrar tear of the intervertebral disk. \Vith the outer layers lOrn, the in-
spine begins with ~n understanding of the forces ilnd stresses

i
ner layers of annulus break off and. with portions of the nu~
'Ipplied to the spine as rclalCd to its normal curvaturcs. deus. <Ire forced with axial loading to lhe place of least resis-
Because of the lordotic shape of the spine. lhe results of vce· tance. the weak area in the annulus. The ouler areas of annulus
toral force 011 the spine usually consist of a vertical axial arc richly innervated, producing tremendous pain and reflex
Ii loading compressive force perpendicul;:lr to the surface of the spasm when the annulus tears. The nuclear material can pro-
TI disk and one horizontal to the disk. producing <l shear strain. duce a chemical neuritis and innammation. The spasm and pain

i The combinution of Ihese two forces prodm:cs both lensile

slress in the annulus fibrosis and a shc<lr force on lhe neur.11
is mediated through the sinuvertebral nerve with anastomosis
through the spinal nerve llnd the posterior primary ramus. As

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arch.
The center of gravity of body weight is anterior to the
the herniated material extrudes and it produces pain from the
trans~ersing or exiting nerve root itself. the patient may de-
! spine. This weight times the distance back to the spine rm~ velop sci;:nica or radiculopathy. Jntradiscul infiltrali'1n of the

I .J duces a lever ann effect of the weight of lhe body. This effect
is reslsled by the erector spinae muscles. lhe lumbodorsal fas·
granulation tissue adds increased potential for painful senS:l-
tion in (he annulus. The annulus. with time. can heal. although
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oft
cia. and the gluteus maximu!'. Abnormal slresses applied 10 the healing annulus will not retain the same biomcchanical
,, this equation may result in annular tcars of the imcrvertebral function capability as the original intervertebral disk.
d disks or stress fractures on the neural arch related to this ex· Biomcchanical functioning of the spinal column and its
! cessive resistive force. The most common pl<lce for stress relationship to the biomechanics of nerve tissue involves sey-
B
.k fractures is the pars interarticularis. eral basic concepts:
j 111e basic mechanisms of injury produce a combined
I ) vcc(Qr of force that may be difficult 10 analy7.c in a force dia- I. Flex.ion of lhe lumbar spinc increases the sizc of Ihe intervertebral
" gram. Three common mcch'lIlisms of injury to consider arc: canal and the intervertehral fomminaY

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(l) compression or weighl loading to the spine; (2) torque or
rotation. which may result in various she<lr forces in a more
2. Extension decreases the $ize of the imervcnel'lral canal and the in-
lervcrtebral fommina. l :
3. Flcx.ion increases dumt sac and nerve rom h~n$ion.l.l
~ horizonl<ll plane: and (3) tensile stress produced Ihrough ex-
.f
4, Extension decreases du•.!1 $UC and nerve rOl)t h:nsioll,l.l
j cessive Illotion on the spine.
\1 5. Front Ilexion, axialloilding. Ilcxion. and upright postllrc incn:a:'~
\;, The compressive type of stress is more common in sports
intradisc;ll pressure.
~j that require high body weighl and massive strengthening.
.~, 6. With flexion. the annulus bulges- anteriorly.!'
<; such as football and weight lifting. Torsional Stresses occur in 7. With extension, the annulu!' bulges postcriorly.1J
I 'throwing alhletes. e.g.. lhe j<lvelin. baseball players. golfers. 8. Nude,lf shift in an injured disk is poorly dOI,:umcntcd. but prob:l-
I , etc. Motion sporls Ihm put Ifemendous tensile stresses on thc bly corresponds with annubr bulge.'~

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spine include gymnastics. bnIlel. dance. pole vaulting. high 9. Rotation ;,nd torsion pruduces annular ll::trs and disk her-
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jump. ctC. 11 niations. I '

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I Conclusion of these faeLs indicah:: that mOl ion docs have

an effect on the nerves and Lhe Ilcuromorion segments of an
The physical examination should address:
I. 1l1C prcsencc of sciatic strctch signs
i injured ..rca. For example. in the presence of a spinill ob-
structive problem. such .IS spinal stenosis. extension exercises
2. The neurologic deficit
3. Back .lIld lower c;(trcmit)' stiffness and loss of rungc of motion
can funhcr COlllprcss lhe neurologic slructun.::s ami make them 4. The C;('let lociltinl\ of lcndcmc~s and r:ldiation of pain or pares·
worse. I n the presence of a nerve root tension problem. such tht:sias
as disk herniatioll, fkxioll can produce incrc:Iscd tension in;1Il 5. Mallcuvcrs during tile cx'lmination th.ll reproduce the pain
already ten"e nerve alld im:rc.. lsc symptoms. 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 mechan-
IlISTOIlY ANIlI'HYSICAL IeXAMINATION
iC'11 activity or is it a constant resting pain? Docs the pain
The key 10 a proper history and physical examination is to worsen with maneuvers thar increase intradiskal or intraspinal
hayc a swndardi7.cd format that accomplishes the needed spe- pressure? Is there significant night pain? Do maneuvers thal
dlle objectives. decrease spinal diametcr increase the pain? Do maneuvers
that incrcase nerve root tcnsion increase the pain?
I. QuullIil<llC the morbidity. Usc a scale value of pain. function. Cla'\sic radiculopalhy is radicular pain radiating into a spe-
;1Ilt.! occupation 10 undcrsland how sick Ih~ patienl is. Cunvcrsc cific dermatomal pattern. with paresis. muscle weakness. loss
wilh tilt: palielH to hear tile infkctioll~ and mnnncr of pain dc- of sensation. and reflex loss. The radicular pattern of the pain
~cripliun. Dctail the tillle of dis'lbility and the time of origin of
and neurologic examination detcmlincs the nerve involved.
the pilin.
The cl~ssic hi£tory for radiculopathy resulting from a disk
2. Dclinc;.ltc Ihc psychosocial factors. Know wlmt psychologic ef-
feCi the p;.lin hilS had on the patient. Know the soci.tl. economic.
herniation is back pain that progresses to predominantly leg
and Icg:l! res~Jlts of the patient's disability. Undcrstillld wllal can pain. It is made worse by increases in intraspinal pressure
he g'lincd by his or her being sick or well. Derivc illl underslJ.m.l- such as coughing. sneezing. and silting. Physical examinalion
ing of what role these factors arc playing in the palient's com- shows positive nerve stretch signs. A derrnatomal distribution
plainls. of leg pain is made worse by straight leg raising. sitting .or j

3. Eliminate the possibility of tumors, infections. and neurologic supine; leg-straight foot dorsal flexion; neck flexion; jugular
crisis. These diseases have n certuin urgency that requires imme- comprcssion~ and direct palpation of the politeal nerve or sci~
diate attention and it diagnostic therJ.pcutic regimen that is differ- atie notch is characteristic of r.adiculopathy. A source of radic-
ent from lnnl for disk disc4lsc. ular pain not found in this description is that caused by spinal
4. Diagnose the c1inicul syndrome:
stenosis. Spinal stenosis usually lacks positive nerve stretch
Nonmcchanic.1l back and/or leg pain. Inflummatory. constilnt
signs, but has the characteristic history of neurogenic claudi-
pain. minimally affected by activity, usually worse at night Of
early morning. cation (i.e., leg and calf pain produced by ambulation). Pain
Mechanical back and/or leg pain. Made worse by activity. re- that docs not go away immediatcly on stopping is made worse
lieved by rest. wilh spinal extension and is relieved by flexion. The pain pro~
Scialic~. Prcdomimlntly radicular pain. positive slrelch sig.~s, grcsses from proximal to distal.
with or without neurologic deficit. The pain drawing. completed by each patient. is a major
Neurogenic claudication, Radiating leg pain or calf pain. won;e help in accomplishing the objectives of the physical cX<llnina~
with umblll:ltioll. negative streIch signs. worse with spine ex- tion. The pain drawing distinguishes organic from psycho-
tension, relief with flexion. logic pain fairly well. It also helps in localizing th~ symptoms
for future reference with pain r~productioll studi~~. such as
Pinpoint the pathophysiology causing the syndrome. with diskography "od postoperati\'c evaluations..
Important dClcnnin<llions are: (1) What level'! \Vhich ncuro~ The initial history and physical evaluation delcrminc the
motion segment? (2) What nerve'! (3) What pathology? What ;.lggressiveness of the diagnostic and therapeutic r('gimen. The
is. the exact structure or disease process in th"l neuromotion morbidily rating and the duration of Ihc problem arc impor~
s.t::gmcnt that is ciJusing the pain'!
tant facts that help to dctermine the aggressiveness and inva~
The history and physical examination represent the first sivencss of the diagnoslic plan. The leg pain versu:, back pain
step in determining the clinical syndrome. Some kcy fac- ratio is an impon:lI1t factor in determining which diagnostic
lars arc:
tesls are indicated. Leg pain IC:lds to tests for ner\'e function
and obstructive pathology in EfvtGINC. myelograms. contrast
I. TIle time of day during which the pain is worse
CT scans. and MR images. Back p,lin evaluation includes
2. A comparison of puin levels during \v;:llking. silting. and slanding
J. The effects on pain of valsalva. coughing. and sneezing bone scans. MR images. and diskogmms. The clinic<ll syn-
4. The lype of injury nnd dur.uion of the problem drome should be divided into predominantly mechanical pain.
5. A percentage of back versus leg pain. We insist on gelling an axial pain, and leg pain. An appropriate trcatme(\( program
nCCUr<:ltc estimate of the relati\'~ amount of discomfort in the can begin. based on the initial e\'aluation.
back versus the legs. There IIlUSl be two numbers tlln! add up to Most athletic injuries to tht:: lumhar spine fall under the
100%. \..'I~~gory of mechanic,,!. axial. back or leg pain, Included

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 "HA~ I cH 17 : LUMBAR SPINE INJURY IN THE ATHLETE 345

I \\ 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·
\'l,,'fl'. dis:lblill~ h;lI.:k ~pasl11 ,lI1d pain. The pain is usu<1l1y NONOPF:RATIVE CARE
,,\)r~L" ill Ikxion with coughing. sneezing. straining. upright
The nonopcmtive treatmcnt plan consists of sc\'cral basie
1'(I~lUn..·. siHing, ::i·ld <IllY other situations that iUCfe,lse ill-
rules.
lr:ldi.'-cal prcssul'l.'. Other clinical evidence includes referred
kg l'dill. low hal.:k pain with straight leg raising. and anterior I. SlOP the inl1:l\ullliltion
spillal 1L"lldcl"lle~s. Anllular tears can be p:-ouuccd wilh as lit- 2, Restore stn.:ngth
lit: :1:0. three degrees of high torque rot:.ltion. lI• F.lcet joint align- 3. Ri..'Slorc Ocxibility
1lll.'nt that protects the disk from rotatory forces may IC<1d to 4. Restore aerobic conditioniuf.
S. R~(ore balance "nd coordination
facct joint injuries as Ihe annulus faits in rot'llion.
. Seconu is tile raCel joint syndrome, more typically occur- 6. Adapt the reh3bilitution progmm to sports-specific training and
exercises
ring ill extension with rotation. reproduced with extension
7. Sian slowly back into the sport
rol<ltion during the CX'lOlinouioll. p.llients may present with 8. Return to full function
pain on rising from nexion. with a lateral shin in thc cdcn-
s,lon motion. Point tenuerness in the paraspinolls area over the Rest and/or immobilization arc often required to stop in-
fact:t joint is reponed and m;'IY be associated with referred leg flammation of thc spine in an injured athletc. We tf)' to keep
pain. the period of rest and immobilization to :'1 minimum. Bed rest
Third art: tl:ars of the lumbodorsal f<lscia und muscle in- produces stiffness and weakness, which cause the pain to per-
juries .1IlU (untusions prescllt with muscle spasm, stiffness. sist. Stiffness and weakness arc the antithesis of the body fune·
and many of the Ch;lfuctcristics of facet joint syndrome in <In- tions necessary for athletic performance. Every day of rest and
nular tears. immobilization may produce weeks of rehabilitation before
Finall y, ~thletic injury_may_result in_sacroiliac joint l?~~n the athlete is able to return to performance. As in motion lrcat-
and pain in lhe posterior superior iliac spine.Jhe mosu;om- ment of lower extremity injuries, i.c .. fracture bracing and
lllOIl area for referred pal~--from the annulus in the interverte- postoperative continuous motion machincs. rapid rehabilita-
bral disk and the neummotion segment of the spine. Sciatic tion of lumbar injuries in athletes requires effective means of
pain can hun in the sciatic joilll area as well as ,in t~~_.~~!~tic mobilizing the patien~. 1kd il3st fOi" longa than 3 to 5 days is
notch and bUllocks. Although injuries to the sacroiliac joint not of any bencfit in the natural history of the diseasc.
can occur, most sacroiliac joint pain is thought to' be the result Rapid mobilization requires thc use of strong anti·inflam-
of referred pain from a neur-amotion segment ilJ,Jhe spine:- matory medications, ranging from epidural steroids. oral
The mOSI imponam !!-oal in ttic physical examination of Medm! Dose pak. and Indocin SR to other nonsteroidal anti-
the athlete is demonslrati~g what types ormotionsrcproducc inflammatory agents and aspirin; icc: a TENS unit; and rnobi-
the patient's pOlin, \Vhere exactly is the area of tenderness? li7...ation with casts, corsets, and braces. Corsets and braces are
What deformity is prcsent in the spine? If there is a lateral used for only limited periods of time. Strengthening tech~
shift. in which direction? The chief advantage fo~ physic~I' niques begin whcn the brace is applied so brnccs can be rc·
therapists in th..:. treatment of thc athlete with lumbar spine moved as soon as possible. Bmces in themselves can cause a
pain is lhe hanos-on approach directed specificOllly Lo motions significant amount of stiffness anu weakness.
and activities thal produce and relieve the pain. Local tech- Exact timetables arc difficult. but determinations should
niques can be directed specilkally to localized areas of in- be based on infommtion obtained during the history and phys-
Oammalion and pain. Treatment of referred pain areas ical examination. As a gencral rule. our patients with acute
through loc,liizeo treatment in the area from which the pain is disk herniation are treated with 3 to 5 days of bed rcst: scc the
rcferrcd plays a major role in the relief of symptoms and rc- physical therapist within 7 days; usc a corset for nQ longer
llInI to performancc. Therefore. tcchniques of treatment of re- than 10 to 14 days; receivc Indocin. occasionally Medrol. and
ferred pain should be understood and used. including injec- less commonly. epidural injections. The therapist b<:gins the
tions of local anesthetic. cortisone injections. TENS units. neutral position. isometric trunk strengthening progr..un thaI.
ultrasound.•1Ild icc. depending on the response of thc patient. evolves into rc·
...) AnOlher important diagnostic goal of the physical exami- sislive strengthening, motion, and <Iaobic conditioning as
nation is to identify areas of contracture and weakness. The tolerated.
physician <lnd therapist can make the diagnosis by carefully Part of the key to being able to initiate early therapy is Ullp
examining the patient for areas of muscle atrophy and loss of dcrstanding. based on the physical examination. what makes
range of motion. Sophisticated testing techniqucs and dy- the patient symptomatic. Nonoperative care should ~ the
namic EMG function mmlysis have identificd localized areas basis of any therapeutic appro'lch to alhletes with lumbolr
of weakness in the shoulders as wcll as in the abdominal mus- spine injtlric.o;. With the exception of cauda equina injuries.
culature of ba'ieball pitchers. II' Recognizing these deficiencies this type of care should also npply for the athlete with neuro-
during the physical examination and designing a rehabilita- IOb:~ deficit. The key to effective nonopcrative care is well

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 ._._ ~ ,- OM " v l ' i c n . : ) MMI'lUI-\L,.

thought out, balanced biomechanical approach. Common It appean- th:H the place to bc;;in t:,c id;ab:!i~::.ti~~:~ i'::-:;·
questions are whl;;lher to do extension, nexioo, or twisting gram in an injured lumbar spine. with or without neurologic
exercises. what type of aerobic exercising should be done. deficit. neutral po"ition isometric !'trengthening. Th~ b:lsis of
when can someone lift wcights. what role docs Nautilus beau- the trunk st:lbility program is to havc the patient tind a neu-
tification exerciscs have in rehabilitation of the athlete. and tral. painfrcc position while supinc with the knees lkxed and
what type of nonoperative rehabilitation is bcst for the indi- feet on the ground. Not only is this beginning to rehabilitation
vidual athletc's spon? a.~ nomraum:ltic ;1" possible. but abu it forms the h:lsis ur :tn
A COllllTlon concern is the risk of producing or increasing imponant concept in tcrms of b01h athletic fUllction and :1\..••
a neurologic deficit through Ilonop.:rativc care. So often. non- uvuics of <.Jaily !Inng for cveryone. We retrain muscles to
operative care. in lhe face of a neurologic deficit, Ili:Is COIl- work to support tk spine while the patienl is using his or her
sisted of no carc. A shon pt.;riull uf bell rest is tlte usual. initial anllS and legs. It b nOl only theoretically ideal. but also prac-
stage of treatment of the athle[c with a disk hcmiation and tically possible. Teaching muscle control with tight. rigid
neurologic delicil. Bed rest is thought to protect the patient contraction of th~ muscles, controlling the spine through the
from increasing injury to the spine and therefore increasing lumbodorsal fascia. with the gluteus maximus, oblique ab-
neurologic delicit. dominals, latissimus dorsi, not only produces protection of
Unfortunately, bed rCst also produces profound weak- the lumbar spine. but also Can improve athletic pcrform<lnc~.
ness and loss of biomechanical function, which actually in- The power ~lIld strength of any throwing athlcte comes from
creases the risk of injury. If the purpose of bed rest is to the trunk. Liftinf: weight requires functioning of the IUIll-
decrease inflammation. the logical substitute is aggressive bodorsal fascia.
anti-innalllI1latory medication. If the objective of bed rest is to 'i'runk streng.th is an important treatment mcthod for ba('k
prevent lIlotion, braces and casts can be substituted. If the ob- pain, and it also can prevent back injuries. Although treatment
jective of bed rest is to prevent abnormal motion that could plans for symptomatic back pain patients may include simil;'lr
injure the spine. it is with Lhe understanding that cenain me- exercises. each plan should be designed to m:uch thc exami-
chanical functions have to take place. Patients get on and off nation and the symptoms. Any trunk strengthening plan pUl:,
of bed pans. they get up to go to the bathroom. They roll over strain on the spine and can produce back pain related to over-
in bed. They cough, they sneeze. and eventually have to walk. load. Therefore. it should be conducted in a controlled. pro o

it seems logical that if we could design an exercise system gressive manner.

that would prevent abnofiDa1 motion while restoring strength The key to safe strengthening is the ability to maintain the
and flexibility in a biomechanically sound fashion. we could spine in a safc. neutral position during the strengthening ex-
protect the spine from the abnonnal motion that produces in- ercises. For upper body strengthening. the spine must be well
jury. and possibly enhance healing. This enhancement takes aligned with the chest-out pos!'Jre. Doing isometric trunk ex-
place through normal biomcchanical motion in the injured ercises and upper body exercises emphasizing this chest-out
pan through increasing strength and flexibility in the adjacent posture strengthens thc support for the cervical spine.
portions of the body that Can ~lbsorb the stress potentially di- strengthens the postural muscles necessary for maintaining
rected to the injured pan and in preventing the atrophy, weak- proper body alignment. and prevents neck pain caused by bad
ness, and stiffness caused by inactivity. postural alignment.
Lumbar spine injuries in athletes demand prevention of For the lo\vcr body. trunk control plays a vital role in the
atrophy and stiffness and restoration to maximum function as ;'lbility to rotate and transfcr torque safely. Trunk strengthen-
early as possible. It follows that if this restoration can be ing exercises such as sit-ups and spine extcnsions prodw..' e
achieved in athletes. il can function jusl as effectively in steel· strength. Flexibility produces a protective range of motion.
workers. sccrctaries! weekend athletes, and housewives. The but often the key is providing trunk strength and comrol at th~
key to the program. obviously. lies in safety and effectiveness. proper moment during the athletic activity. For example. a
If you could summarize an overall basis to our preferred re- baseball hitter goes from flexion through rotation to exten-
habilitation program. it would tie in thc concept of neutral po- sion. If the trunk musculature does not maintain rigid control.
silion isometric strengthening for the spine. This program is despite these changes in the axis of alignment. the player may
derived from work by Jeff Saal, M.D.. Arthur White, M.D.. lose power or su~tiJin a back injury. An alhlcte cnn havc stron:;
and others illclluJiflg Celeste Randolph. AUJI Robiuson. Clire muscles. but ir th~y do not fire in sequence;,n the proper time.
Brewster and others at the Kerlan lobe Orthopedic Clillic. they offer no prot~ction from injury and certainly will not ell-
hance pcrfonnancc. A key to producing a safe range of motion
is to begin trunk control in the safe, neutral position. establi:,h
Trunk Stretching and Strengthening Program
muscle control in that position, and maintain control through
This exercise program concentrates on trunk strength and the necessary range of Illotion to perform the athlctic acti vity.
(runk mobility. balance. coordination. and aerobic condition- We begin our identification or the neutral spine positi(.'n
~ng. A practical app~i~ation of the .usc of trunk strcngthcni'1£ with the dead-bug exercises (Fig. 17.1). To perform these e:'\.-
In back trcaUllcnl, IIlJury prevention. and improved perro\'. crcises. the indi\'idual is supine with the knees nexed and fe~t
manc~ i~ :lthletes. on the noar. With the assistance of the tminer or tberapist. tht:
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 <.;HAPTER 17 : LUMBAR SPINE INJURY IN THE ATHLETE 347

The next stage for torque transfer athletes is resistance to

j rotation, first supine, then sitting. then standing. in which the
player maintains the neutral spine control position while re-
sisting 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
I actively rotating through a shon range of motion ag.ainst tlie
trainer's resistancc. 1l1is mancuver is done in numerous posi-
tions to teach trunk control rcgardlcss of the positions as-
sumed 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 po-
sition. the sit-ups and resistive sit-ups are done on the ball
(Figs. 17.3 and 17.4).
Lower extremity, tnmk. and upper extremity strengtl1cn-
ing must bc donc with conccmration on maintaining thc neu-
tral 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-neu-
Iml position-tense contractions. Trunk control is incorpo-
rated 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
Fig. 17.1. Begin identification of the neutral position with
better endurance and ball control for a pitcher. An additional
dead-bug exercises. The patient is supine with the knees flexed valuable benefit can be prevention of spine injuries and spinal
and feet on the floor. With assistance from the trainer or therapist, pain 'assoclated with the athletic activity.
the patient pushes the lumbar spine toward the mat until a mod~ After cstablishing neutral position isometric control of the
erale amount of painless force is exerted on the examiner's hand. spine, extremity strengthening can begin. Probably the most
The patient then maintains this same amount of force through ab- important muscles needed 10 protect (he spine ilself are the
dominal contraction while: 1. Raising one foot: 2. Raising the Olher quadraceps. The ability to return to work after a back injury
foot; 3. Raising one arm; 4. Raising the other arm; 5. Raising one is directly related to quadraceps strength. _Yet. qlladracep
leg; 6. Raising the other leg; 7. Doing a leg flexion and extension strengthening should not be done in the standard. sitting. full
with one fool; 8. Doing a leg flexion and extension with the other
knee extension position in a patient with severe lower back
foot. These same exercises can be performed with weights on
pain. The goal is to accomplish quadraccp strengthening with-
arms or legs.
out irritating the lumbar spine mechanical pain. Also. the abil-
ity to move a weight from 90° to zero may not relat<: as specif-
ically to lumbar spine function as quadmceps strength
player pushes the lumbar spine toward the mat until a moder- obtained through funclionul strcngthening. Functional
ale amount of painless force. not exaggerated, back flattening. strengthening initially involvcs wall slides-sliding down the
extreme force, is exerted on the examiner's hand. The player wall, holding the position for 10 seconds and back up at
then learns to maintain this same amount of force through ab- varying depths of slide. We begin this exercise immedimely
dominal and trunk muscle contraction while: after surgery for our patients. Throwing the medicine ball in a
flexed knee position. Exercise that involves the use of such
J. Raising one fool. devices as a Versiclimbcr or stationary cycle as well as other
2. Raising the other foot. techniques arc used to teach quadraceps function while main-
3. Raising olle arm. taining trunk control and during sports-related (I<.·tivity.
4. Raising the olher arm. Gluteal and hip extensor strengthening is important. but
S. R<lising one. leg. must be done without inadvertently hypercxtending the lum-
6. Raising the Olhcr leg. bar spine. Exercise bands that provide rcsist;;mcc to hip ex-
7. Doing a leg flexinn and extension with one foot. tension without mllch spine extension arc optimal. as are
8. Doing a leg nc:c;iol1 and extension wilh lhe olher foot. other techniques that de·emphasize spine motion while pro-
ducing isometric extensor strength.
These same exercises can be performed with weights on arms Weight machines. with a safe. protected range of Illation.
or legs. can be of value in extremity sm:ngthenillg. The key to Ihe

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 •. _." .~._•• , ,. ,...... ~...... •• ''- ..,. "~L;.. M r-n..... V II I lUl'it:1"1 ;::, MANUAL

,
n 8
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 con- of motion is the CAT/COW position on all fours. for ex-
trol in a painfrec neutral position. By first establishing trunk ample. a position in which muscle control can be easily main-
control. it is possiblc to dctcnnine a safe. protected range of tained.
motion and a good position for the spine. 1l1crefore. military The streIch exercises arc a critical component of the pro-
presses as well as lats, ann, and lower extremity leg strength· gram. Stretching increases the functional range of motion of
cning with machines can be of benefit white protecting the the trunk and legs. which in tum decreases the likelihood or
spine. Spine strength testing machines have been shown lumbar spine injury 'Juring lhe strenglhening program during:
to be of benefit in predicting return to work. The ability play.
to pcrfornl flexion extension exercises or resistance rota- Most low back injuries occur when the player exceeds (he
tional exercises on a machine, however. may not trans- strength of the spine and its range of motion. The stretching
late to functional spine :.lctivity during athletics. We have progr311l provides a greater area of painfrec and injury-Free
not recommended a specific back machine for treatment function. For example, if a player who is stiff. having 100 of
of lumbar injuries: we greatly prefer the trunk stabiliz:ltion spine extension and 20 0 of spine rotation. suddenly reachcs'
program. for a ball producing 25 0 of extension and 400 of rOlation. in-
Stretching exercises are an important part of any rehabil- jury to the bi:lck can occur through tearing stiff tissue. If mo-
itation program. The more flexible the legs. arms. and upper bility exerciscs produce a functional range of motion of 40;:'
body. the more likely the proportional decrease of motion of extension i:lIld jOO of rotation. injury is less likely to occur.
stress on the injured lumbar spine. If tnmk muscle control This is a protective range of motion.
is established flrst through the strengthening program. then The chief findings in our ball players with back pain an~
the spine can be held in a stable position while stretching weak abdominal musculature, loss of spine extcnsion. loss of
of the extremities takes place. It is important (Q nOle that rotation (usu~llIy more in one direction). and poor mechanics
hamstring stretching too often is takcn to the extcnt that in rotation. Once the back pain starts. the weakness nnd con-
produces abnormal lumbar spine motion. Stretching the leg tractions increa..e, This progrnm is designed for perform,t1h':~
pasl the point of pelvic motion only strains the spine and enham:cmcnt and injury prevention, as well as treatment of
docs not increase hamstring looseness. Too often. lumbar back pain.
spine conditions are irritated because of excessive lum·
bar motion during h<ll11string stretching. The spine should
Aerobic Conditioning
be held in a neutral, stable position during hamstring stretch-
ing exercises. Lumbar spine motion is important also. but it ~UI11CrOllS mcthods arc available for aerobic conditioning.
is not lhe initial stage of the rehabilitation program. Lumbar Often \\:e see athletes who prefer a specific techniquc. stich <lS
spine motion begins with good muscle control of the spine running. but ha\'e developed pain and problems directly re-
Juring the motion exercises. The most common initial ~l<1ge lated to its performance.
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 'CHAPTER 17: LUMBAR SPINE INJURY IN THE ATHLETE 349

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 strength-
ening rehabilitation progrnm. but also they must learn cross-
training for <lerobic exercise. Willer running. swimming. cy-
cling. crosscountry skiing machines. Vcrsiclimbcr. and
rowing machines can produce the nceded aerobic condition-
ing ou\si<.k of the injurious sport. The benefit of swimming
and water running program I'" should be obvious. The lOtal UI1-
weighting of the spine in water removes many of the com-
pressive loads and allows good physical activity without the
tremendous pounding and straining of running. The cross- Fig. 17.4. Extension exercises on the exercise ball while main-
country skiing machine builds tremendous conditioning with taining control ollhe ball and the lrunk in the neutral position.
strong usc of the arms and increasing cardiac output without
the pounding of running. injury, including lumbar spine injury. Therefore. aerobic cnl1~
The Versiclimber and cycling have ~everal things in COIll- ditiol1ing is an important pan of every spine rchabilit;\ti'on
man. First, it is possible to assume a beneficial position for program.
back protection while still getting good aerobic conditioning.
The cycling position is slightly bent forward. which helps the
Restore Balance and Coordination
stenotic spine. The Versiclimber position is erect, which
)
removes as much nerve root tension as possible. Both devices Restoration of balance and coordination is vitullO an effective
arc associated with the same potential hazard: lateral tilt of return to full activity and spans. Incorporation of balancing
the pelvis. For the Versiclimbcr, taking short steps should prc~ techniques into the strength program as is done in the Spine
vent a lot of pelvic tilting, and in cycling, the legs should nOl Stabili1...1.tion Rehabilitation Program. begins the process of
become fully extended when reaching for the peddles. The retraining muscles to lire at the right time with lhe proper
goal is to keep the pelvis .,lnd spine in a firm, neutral posi- strength. Balance and coordination are the key to friction~frec
tion with good isometric control during the aerobic condi~ pcrfonnance~ it is safer and more effective. Coordination is
(joning. the key to $winging the golf club, throwing a baseball. or even
Running stairs or stair~walking machines, produce good lifting weights. Using the S\\'iss exercise ball, balance beam.
leg strength and good hip extensor strength. Rowing ma~ standing positions for resistive exercises. exercises bands. and
chines can result in injury to the back. but if they arc used techniques such as one leg squats while resisting an exercise
properly, with muscle control of the spine in a limited range band pulling on the waist uses balance with strengthening ex-
of motion, the benefit of upper extremity and lower extremity ercises. Therefore, it is important to incorporate balance and
function and quadricep strengthening can produce good aero~ coordination into all strengthening. stretching.. and aerobic
bic conditioning without spine stress. The better the aerobic conditioning aspecls of a rehabilitation program.
condition of the athlete. the less likely he or she will sustain
Sport-Spccific Exercise
)
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 pro-
gram 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 fu-
cilitalion-type techniques of resistive rotation and others

o 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
Fig. 17.3. Partial sit-ups on the exercise ball while maintaining must take the time to test out the new techniques and the new
control of the ball and the trunk in the neulral position can be of awareness of trunk muscle function <1Ild body alignment. Too
I benefit fast a reLUrn is too fast back into tho: same old rut that often

;l~
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_
 have been emphasizcd: keep the pelvis stable, keep the ex~ T~1 p;':i·form <I rur\\'~IIJ lJClll Irlutil"i with the spine (Jut of
tension of the spine sYlllllletric over aHIevels of the spine. and proper position can be dangcrous. Lifting weights with the
obtain good extension through the hip jointsY spine flexed at 90", whether they arc lighter arm \veights or
Ballet involves lhe lifting of dancers. especially lifting in weights across the upper back, generatc tremendous lever ann
awkward positions. The outstretched hand produces trclllCIl- effect forces. The weight times the dislance back to the spine
dous level-ann stresses across the spine of the lifting partner. results in tremendous shear forces across the lumbar spine. es"
Off-balancc bending and lifting is a hallmark of back prob- pccially if weight is to be moved in this position. One cannot
lcms in industrial workers. and yet ballet, although a sport of imagine muscles that must be strengthened in this dangerous
balance. ohen involves some of the most difficult lifts. Male and mechanically disadvantageous position.
dancers follow the body weight of their female partners very A dangerous lime for weight lifters is the shift from spinal
dusely. flexion to extension that occurs with lifting the weight over
Spondylolysis and spondylolisthesis playa critical role in the head as in the clean jerk maneuver or the "snatch."
dancers and may often produce severe mechanical back dys- Making this transition must be done with rigid. tight muscle
function. control. Inexperienced lifters. especially, have no muscle con~
tral as the spine shifts from flexion to cxtension. A traincd
WATER SPORTS lifter, again, cOlltrols that shift with rigid muscle cOlllrol of the
lumbodorsal fascia.
In addition to injuries to the wrist and cervical spine. diving Holding weight over the head invariably draws increased
is associated with added strain to the lumbar spine that results lumbar lordosis. These tremendous cxtension forces of the
from rapid flexion/extension changes and severe back arching lumbar spine naturally lead to discussion of spondylolysis and
~tfter (:i"itering the water. Although swimming and water exer-
spondylolisthesis. The incidence of spondylolysis in weight
cises are a major part of any back rehabilitation program. cer~ lifters has been estimated at 30'10. and the incidence of
tain kicks, such as the butterfly. produce vigorous flexion/ex- spondylolisthesis is 37'7c.: 6 Many newer training techniques
tension of the lumbar spine. especially in young swimmers. in weight lifting emphasize the role of general body condi-
The swimmer must learn good abdominal tone and strength in tioning, flexibility, aerobic conditioning. speed. and cross~
order to protect his or her back during a vigorous kicking mo- training. in addition to the ability to lift \veight.
tion. Thoracic pain and round back defomlities in young fe-
male hreast-strokers (:an be a problem because of the repeated
round shoulder-type stroke motion. FOOTBALL

Football players lift weights. It is part of the sport. For most

POLE VAULTING ~thletes involved in the sport. football requires trcmendous

Pole vaulting is another sport that involves maximum flex- upper body forces and leg strength. Some football players rely
ion/extension and muscle contraction. The range of motion of on great agility and jumping ability. throwing ability. and
the lumbar spine has been documentcd with high specd pho- eye-hand contact. but strength is the backbone of football.
tography from 40 0 of extension to 130 0 of flexion in 0.65 sec- Every year, professional teams need heavier. s.trongcr ath-
onds. One can imagine the tremendous forces generated letes, especially for the offensive line. Players go through
across the spinc with these functional demands.~~ 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
WEIGHT LIFTING
for blocking in the offensive line. Extension jamming of the
Moving from the motion Spol1s-those sports that require spine produces facet joint pain. spondylolysis. and spondy-
tremendous flexibility and strength and involve large degrees lolisthesis. The effect is similar to the weight-lifting position
of changes in range of motion. we go to the "heavier"-those of weight over the head. except that it must be generated with
that require strength, lifting. and high body weight. The most forward leg motion, off-balance resistance to the weight while
common such sport is \veight lifting. trying to carry out specific maneuvers such as blocking a man
The incidcnce of lower back pain and problems in in a specific direction. Lumbar spine problems in these ath-
weightlifters is estimated to be 40%.1~ The tremendous forces letcs requircs specific training in back strengthening exerciscs
exerted on the lumbar spine by lifting weights over the head to prevent injuriesy,2x
produces trcmcndous levcr arm effects and compressive in- Safety in weight lifting is an important part of football.
jury to the spine. Weight lifting begins with the spine in tight Having a promising football player injured in the weightroorn
rigid position of llexion. and the lifter lifts with the legs. is a relatively common occurrence. It has been eSlimated
Tremendous extension force is exerted at the hips and knees that more injuries occur in training than cOl11pclition.~<) This
with the spine in a rigidly stable position. Success in this por~ situation can be avoided by using proper weight-lifting tcch~
tion of the lift requires the body to generate tremendous rigid niques.
immobilization of the spine in lhe power position of slight In addition lo extcnsion lifting-type forces. football in-
flexion. '.'olves sudden off-b:~lancc rotation. which may produce trans-

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verse process fractures, IOrsion<li ui:-i-.. illjllfil.::-. and tears ill the jQl'eliu Throw. The ja"clin throw requires an athlete to
lumbodorsal fascia. Sudden off-h'll'lIlce twisting is pan of lh~ gcnCr..1h:: .1 tr~m~lldous 'Huoum of force to go from a h)'p~rex­
game and may be caused by tr~ll1clldous I(Klds or a loo~c, llll- Icnded po:\ilion to .1 full lkxion forward through position.
loaded position. Football has Ihe ;H.1ded dimcl1:,iol1 of rccciv. Athletes do nnt throw il j3vclin 200 fcct with their <Inn.
ing unexpecLed, severe blows 10 the lumb.u :,pine Lh;.n may Ahhou~h :-houlda .IllU ;.\fIn injuries arc common in javelin
produce contusion or fracture: impact from a helmet to th,,' Ihr(.)\\'er~. Ih,,' k~y is rigid ahdominal sLrength thilt prouuces
ribs produces rib.fractun::s. and ~ill1ilar impact ill the nanK (,",Ill the ton_lllt: Il~,,·t:s~ary to thrll\v theja\'clin. Attempting to throw
produce renal contusion, relfopcritoncal hClHt.)rrhagc. ;'1110 wiLh the ;1fI1l only re:-uhs in :tnll i"njurr and in no way can gen-
fracture of the transverse '.lIld ~pinous proccSS6. lvtany <lCW' t:rate illly ty~ of distalH,'c. E'·cry arm injury in a javelin
batic receivers and runners suffer spondolytic ckfccts for the thrower lllUq be trcated with tfunk exercises and truilk
samc rcasons as gymnasts and ballet dancers. but the most strengthening. A rmittory lumbar spine inju!)' in a javelin
common cause of problems is the wcight lifting. The role of thrower is a completely debilitaLing injury that requires
the strength coach in teaching propcr lifting techniqucs and trcmendous (3re :lIld corrcction beforc rt;turning to the sport.
designing training schedules that prcparc the lumbar spine for Golf. Golfers notoriously havc Lhc- highc~t incidence of
what is expccte~ with football is important to prcvclll lumbar hack injury of .my professional athlete. In onc review by
spine injuries in football playcr~. Callaway and Jobe of injuries on the 1985-1986 PGA tour,
230 of 300 professional g.olfers were injured (an incidcncc
RUNNING of 77%). Of the total injurlcs. 43.8c;'(.1 were relatcd 10 the
spine: 42.4(!c were lumbosacr:lI. Lumbar spinc pain in golfers
Another SpOrL that produces stiffncss is running. Distance run-
results ill torsion.1! stress on the lumbar spinc, :md the key
ners must cross-train with f1::xib:!ity to prevent injury.
to p<1in prcyentioll is to minimize the torsion stress by ab-
Running involves mailllcnance of a specific poslUrc with
sorbing the rol:llioll in the hips, knees. and shoulders and
trcmendous muscle exertion oyer a long pcriod of timc. Low
spreading the rot:ltional stresses on the spine over the clltire
bnck pain as well as interscapular .md shoulder and neck pain
spine. Maintaining rigid, tight control through the power por-
are commonly reported by runners. The majority of runncrs
tion of the swing is critical. Proper technique in golf bcgins
with mechanical low back pain arc "cured" with stretching
when addressing the ball. The knee flexion of the address po-
exercises. Runners also have a natural tendency to develop
sition tenses the abdominal musculature. This tension is initi-
isolated abdominal weakness. Running docs not naturally in-
ation of the trunk control necessary for <I properly placed
volve constriction of abdominal and spine-stabilizing muscu-
swing. The cmphasis is on m.aintenance of parallel shoulders
lature. A significant inbalance is often noted between flexor
and pelvis through the majority of the swing. which rcquires
and extensor muscles. not only in the legs but also in the
rigid abdominal control and rotation betwecn shoulders and
trunk. Inlrascapular and back pain also results from abnormal
hips. Loss of this rigid parallclization of the shoulders and
posture during running. As statcd previously, the key to pos-
pelvis can generatc rotational strain on the lumbar spine,
ture is good isometric trunk strength that holds the body in an
upright chest out position. Rotation occurs between the hips and shoulders in (he back
swing. and the amount of back swing is nOI as ·imponant (0
Treatment for runners with low back pain should include
the following: the power of the swing as the ability of tilt; golfer to regain
tight muscle control as he or she proceeds from maximum
I. Vigorous stretching program thaI stretches trunk as well as lower back swing down through the power ponion of the s\ving. h
extremilies
is the ability to obtain and maintain tight control and paral-
2. Cross-training and lTlu:-c1e strengthening Eedmiques lhal also
strengthen the antagonist muscles. such as hip extensors and knee lelism that produces the powcr and protection for the lumbar
eXlensors. spine.
3. Abdominal strengthening. using isometric trunk st:.lbility exer- Advice for any recreational golfer with back pain is as fol-
cises to enhance abdominal control lows. First, cut down the back swing and the follow through.
4. Chest-out strengthening exercises. beginning with abdominal Concentrate on the power portion of the swing. Concentrate )
strengthening and adding upper body :-houldcr shrugs, arms be- on tight abdominal control during the power ponion and min-
hind the bilek-type exercises 10 emphasize chest-out posturing imize the exccsses of rotation with .back swing and follow
:llld tight abdominal cQmro!. The basis of bOlek pain prevcnlion in through. Keep thc golf swing symmetric. The same arnount of
runllers is stretching exercises. extension on back swing and follow through is imporwilt.
5. Proper fOOl\Ve:lr for cushioning .md enhancement of foot
Avoid lateral bending, especially in the follow through. There
functillll.
is a tendency to bend to the left side: an aff-balancc lateral
bcnding position and .lsymmctric I();jding of the spine pro-
ROTATIONAL AND TORSIONAL SPORTS
duces injury. Golf is usually self-restricted according to tile
Rot;Jtional and torsional spans have ccnain charactcri$tics in player's symptoms.
common despite the exact span itself. Baseball. golf, and the There is no condition of the lumhar spine for which we
javelin all require rotation and have distinctly different de· specifically restrict golf. Many peoplc with spondylolisthcsis,
mands Oil the spine, through superb conditioning and care, can play rekllively

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 painfii:e. Prem~i;ure..~ymjitoni,ltic UC'::Clll.:r<liiv(; Ji~k di~easc (y)(,:;, 1. t~nnis(219C l. and badmiltoll (20S~'). It has been re-
is common among golfers who playa great deal. c~pccially portcO thaI 3~W(1 of professional tenni::. players have missed
among professionals who not only p1.:ly. but also practice long tourn:.nllcnts because of back pain. Trunk strengthening
hours. People can return to golf after dccompn::ssi\'C lumbar should ~ a major part of the tennis player's regimen.-II
spine operations or spinal fusions. The effect of a spin:l1 fu- Tennis involves spt:'cd. rotation. and extremes of llexiotl.
sion on an adult. professional golfer raises significant _lues- later:d ;~lldillg.. and extension, as well as the pO\ver aspects or
tions. The effect on adjacent segmcms and on overall spine tile (l\ ~'rhead serve-lhe effect of lfunk strength on shoulder
function may not allow any better function. Under these cir- t'UllCtl( l i1-many of the aspects brought out in other sports.
cumstances, a fusion should be a last resort. The rn~ht consistent ami important factor in protecting the
Baseball. Torsional problems dcYelop in both pitchers spinc m lennis is bending. the knees. Leg strength. quadricep
and hitters. Throwers require a rigid cylinder of strength to strcll~th. and the ability to play in a bent-knee. hip-flexed po-
transfer torque from their legs to their throwing arm. Trunk sition \\ hile protecting the back is the key to prevention of
and leg strength generate the velocity of the throw and the back p:.tlll. In the servc. trllnk strength in proc,!:cding from the
arm provides the fine control strength. Fatigue reduces the back c\tended to the follow-through positioil requires strong
control of the pitching motion and ball location. A major fac- abdOll1lnal control. Ciluteal latissimus dorsi, abdominal
tor in ball control is a loss of tone and strength in tk trunk obliquc~. and rectus abdominus- strength control the lum-
caused by trunk muscle fatigue. A loss of the rigid trunk cylin- hodor<:l fascia and deliver the power neccssary through the
der produces a loss of synchrony between the legs and arms. legs up into the ann.
which in turn causes abnormalities in pitching mechanics.
Our initial attempts at scientific stLldy of the role of trunk
musculature in throwing athletes started with throwers and
The b:~ '.; to proper management of lumbar spine problems for
progressed to professional pitchers. We used cle('tromyo~
athlcte:,:
graphic evaluation of muscle activit),.
As abdominal Illusculature weakens because of fatigue. I. tvt:.k.: <.l comprehensive diagnosis.
lumbar lordosis increases and the back arches. The subtle 2. Prcn ide aggrcssive. effectivc nonopcralive care.
change of a few degrees puts the amI behind in the pitching 3. Pinpoint operations thai do as lillIe dam'lge :lS possible to normal
Illotion, promoting earlier ball release. and the pitch comes tisst.::: but correct the pathologic lesion.

up. Arm strain increases as the trunk musculature fatigues.

REFERE."CES
Attempts to compensate for loss of trunk strength'and a "slow
I. Ket~;~ 15: LI1\\" h'u.:k pain in thl: ;llhlc!c from sptlildylogenic injury dur-
ann" increase the use of the arm musculature and predispose in t ;~;:realilln (lr competition. Postgr'ld Med 74:2t}9. 19~G.
the shoulde .. to injury. Developing power in torsion depends 2. Sp<:,,~::r CW. Jackson DW: B,lCk injurics in the athletc. Clin Sports t-.-kd
on trunk strength, i.e.. strengthening abdominal, back. but- 2:1'Ji. 1983.
tock, and thigh muscles. Trunk strengthening exercises arc 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.
designed not only to enhance the performance, but also to pre-
4. Mi.::h-:li U: Back injuries in gymn:lstlcs. C1in Sports Med 4:8S, t985.
vent ann injury. Trunk strength is superceded only by balance 5. P'lp::.nicolaou N. Wilkinson RH. Emans JB. ct al: Bone scintigraphy and
and coordination. The firing sequence of trunk muscles in a radiography in young <Ithlctes with low h<lck pain. AJR Am J Rocntgeno(
professional baseball player follows a consistent median pat~ 1~5:HJ39. 1985.

tern. Any alteration produces an inconsistent, uncoordinated o. !'<IirDank Jc. Pynsent PH. Van Poortvl!!:! lA. ct al: lntluellcc of :nllhw-
pom::lric faetors :mu joint l:l.\ily in thc im.:idcIKc (If auo!t.'scCllt baek pain.
pattern that leads to arm strain and back injury.l'
Spin:: 9:.:161. 1%4.
Hitters arc required to initiate a violent lumbar rota- 7. Jack;ot! OW: Low back pain in young alhleles: Evaluation of stress rc-
tion based on instantaneous accular infomlation. and so the action and dis<.:ogcnic problems. Am J Sports Med 7:364, 1979.
role of the lumbar spine in a baseball hitter begins with 8. Fisk lW, Baigent MI... Hill po: Scheuerman's discase: Clinical and radi-
visualization of the ball. If a hitter docs not see the ball ological survcy of 17 and 18 year olds. Am 1 Sport.s 1\'1cd 63: 18, 1984.
9. Keene JS.Alhert MJ. Springer SL. e! al: B>lek injuries in collcge aLhletes.
properly, the mechanics of the swing are disturbed. The most
1 Spinal Dis 2: 190, I\)%
common situation is the delayed recognition of the ball 10. Light HG: I-krnia of the infcrim lumbar ,pace. A causc of back paill.
producing a rotation with the hips in front of the shoulders. a Areh Surg 118:1077. 1983.
loss of parallelism of shoulders and hips. and increased 11. Keene J5, Drummond DS: Mcchanical back in lhc athlete. COl1lpr Thcr
torsional strain of the lumbar spine. The successful player II :i. 1985.
12. Sdmebcl BE. Simmons lW. Chowning J, ct al: A digitizing tcchniquc for
sees the ball properly and initiates a symmetric swing. The
the qudy of movcment of intradisl.:al dye ill respollsc l\) llexion and cx-
trunk should move quickly as a solid unit, through the base- len<ion of the lumbar spinc. Spine 11:309. 1988,
ball swing. 13. Schnebcl BE. Watkins RG, Willin WII: The role (If spinal lle:o::ion and ex-
tcmion in ~'hanging nerve r<x); ,oTllprc~sion in disc hcrniations. Spine
14:835. 1989.
TENNIS 14. Whi,c AA. l\lIljabi 1\1M: Clinical BiolJ1echanies of the Spinc.
Phil;;.delphia. Lippinc()t!. 1971'.
When reporting on racquet sport injuries. Chard and 15. Farf<tn HF: \kchanic:II Disorders Ill' thc l.ow ItH.:k. Philadelphia. Lea &
Lachmann·1o separated inciden-.:c data according to squash Fcbiger. 197.~
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 1(" brIan HF: Muscular lII'·':-:..llIi~llI tIl" [hI; htlllt-Jf 'rilll' ;lud Ihe rn~illt\ll uf 2..\. G<linor B1. H::lgcn Rl. Alkn WC: Biomcch::lnics of the spine in the flOle-
(low~r and cfficicllc..·. Cniwp Clin NUrlh Am (.: 1.;5. 1975. vault...' r ;IS rdah..' (! 10 spondylolislhcsis. Am J Sports r-.1cd II :53. ;983.
17, F;lrf:11J !"IF: The bio;ll... .:h.~:~i,;l1 .1l1~-;11\Ia;:~· ,It" l\'r,h\~i~ and hip nlO:lIsillll 1.'1. Aggrawal. ND. Kaur. R. Kumar, S. ct al: A siudy of changes in weight
fllr upright 'll':livily. Spine' .~.~.j6. ItJ7S. liners ami olher alhklcs. Br 1 Sports Met! 13:58. 1979.
IX. Walkins RG. J).:.:nis S. Dillin WII. ..'I ;11: ll~n;llllk EhlG ;1ll:lly"i" 26. Knl;tui 1'1', khikaw;t MO. Wakabayashi MO, C( 31: Studies of lipond)'-
of IOlquc Ir:Hll'fa in r~,';·.:"illll;\1 h:hd'.lll ru.:ho:rs. Spilll' IJ;JIW, IlIlislhc.:is found all1(1n~ weight liflers. Br J Sports Med 9:4.19$1.
19~9. 2i. Cantu RC: LUlllhar spille injuries. In Canlu RC (cd): 111e Exercisiu~
19. \Valbll~ RG. Buhkr II, L,'\~·m\.:k 1': Thc" \\';Il~'r Worlw\1t R..:~',\\·.:ry Adlilt. !..C:.. illg.hHl. CnllalllOrc I'ress. IYSO.
Pwgrarn. Chic:l';;'''_ C"n:,,' ;,;,,'r;U) Bnob. P.l,".:" 1X. Fcr,t:usllil RJ, IvlcMa'l<:r JH, SI:lIliski CL: Low back pain in <:ulkge I"oot-
20. Sicm;lIl Rl.. SI':III!:=kr D Ti,..: "i!-=llili'":lIlrl' of tUlIIhar spOllllyl{lly,j, in halllincnlCIt. j Silurts ~kd 2:63. 1974.
,i collcg.: (oolh;11I playa.... S;'inc 6:17·1. 19~1. ::!lJ. D:I\'ies m: "11,,:;- spine in sf'>ons injuries. prcvention :lntl In':;llll1ent. Br J
!
I 21. Schnook GA: Jlljuric., in \\\)J\lcI1's g)'I1lIl:l\II(\: ..\ Ii\'c YC;lr study. Aml Sruns Mcd j·UlL 19$0.
SpurtS ~kd 7:1..\::!. 1971),
I 22. (iarric:k lG. Ih'qua RK: ErlJcrniulo~y Ill' \\\,nh.:I1\ gylllll,lSlics injurics.
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.
:~

I, AI111 Sll\Irb ~lcd S:1(d. 19S0.

23. l-hlWS~' A1G: ()rth\lpcdht'~ ;:iJ h;llkl. CORR S9:;'i~. )'171.
.11. ~'Iarks MR. Haa.~ 5S. Wcisel S\V: Low b:lck pain in the competitivc Icn-
nis pl:tycr. Clin Spons :""1cd 7:277.1988.

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 I tj ACtIVe KehabllltatlOD protocOls
CRAIG L1EBENSON

----------- ---- -----_._._-----_. . _-_._---

Symptomatic treatments for pain relief <Irc imptlilant. but they 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
<In end in themselves. I.: Rehabilitation is of value for the pa- 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
functional restoration and reducing illness behavior. not tilL" cbssilkd into one of three categories u (Table 18.2) (see
promotion of son tissue healing. The goal of rehabilitation is PaticlH Classi lication. p. 3(1). As stated previously. those
to control ralher than clire symptoms. This changes the doc- with red flags identified by a medical history and physical ex-
tor's role from one of heakr 10 helper. Functional restoration amination should be referred to the appropriate specialist
takes place within a biopsychosocial context, in contrast to (emergency room. oncologist. rheumatologist. etc.). Simple
the pathoanatomic model. which emphasizes treatment of in- backache accounts for the major.ity of patients who seck care.
jured tissucs. Most spinal pain syndromcs arc nonspecilic Their prognosis for recovery is good: 80 to 90'!c of these in~
conditions that may become disabling because of physical dividuals recover spontaneously within 4 to 6 weeks. Spinal
and psychologic deconditioning. The <lim of rehabilitation is manipulation is advocated because it hastens this process.
to address the pain. impairment. and disability of the suffer- Other pain-relieving approaches. such as activity modifica-
ing individual. Accomplishing this task requires a new para- tion. over-the-counter pain medication, light aerobic exercise.
digm and new protocols. and reassurance arc recommended for usc within the acute
Rehabilitation involves more than just exercise. It is a stage. Unfortunately. the recurrence rate is high. Therefore.
comprehensive management approach incorporating patient active rehabilitation principles arc important to improve the
education, physical training. and identification of complicat~ quality of care. 2
ing factors (i.e., psychosocial issues). Passive interventions Persons with signs of nerve root compromise also have a
such as chiropractic adjustments arc useful as catalysts for high rate of resolution (80%).1.2 For these individuals. hmv-
functional improvement. Rehabilitation permits the usc of eva. bed rest as many as 7 days and stronger pain medication
passive interventions if they arc used with the goal of pro- may be required until the severe pain or impainnent abates.
moting functional restoration. \Vithin the biopsychosocial Management strategies similar to that for nonspecific back
model. it is possible to direct treatment at both functional pain arc recommended. but progress is usually slower. High-
restoration and providing pain relief. \Vhat is important is to velocity thrust manipulation is lIsed with caution in these
make functional restoration the primary aim and therefore ac- patients.
tive care the primary method. Rehabilitation is the highest Patients whose recovery progresses rapidly (within :2
quality approach because it <:lddresses disability prevention by to 4 weeks) do not need a sophisticated rehabilitation
promoting patient reactivation and functional restoration. approach. Patients with chronic or recurrent pain. those
considered of subacute status but \vith significant sympto-
FUNDAMENTALS OF REHAIIILlTATING THE matology after 2 to 4 weeks. and postsurgical patients.
MOTOR SYSTEM however. are ideal candidates for aggressive. active rehabili-
tation. Rehabilitation involves a functional and biopsycho-
Identifying Appropriate Candidates for Rehabilitation
social approach. Functional testing to identify \'alid retum-
Patient selection is crucial to successful functional restora- to-work or activity outcomes is important. Other functional
tion. Those paticnts with serious pathology (spinal or non- tests that can direct the choice of therapcutic intervcn-
spinal) should be referred to the appropriate specialist. tion. such as identification of specific mcchanical sensi-
individuals with traumatic injuries should be stabilized before tivities or functional pathologies, arc also necessary. A
functional restoration is attempted. Patients with nerve root biobchavioral approach is stressed. because the longer the
conditions also require aggressive conservative care to reduce patient surfers. the greater the likelihood that illness bc-
their nervc tension signs before rehabilitation can be pursued. havior will become entrenched. This approach involves

J
in gencral. once the status of a patient is subacutc. restoring patient reassurance, education. and promotion of self-
l
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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'" that nothing is wrong with many of our patlcnts (false nega-
tive result). Grabiner addreSsed this point when he found ab-
Fracture
Trauma normal asymmetric muscle activity during bilateral clcc-
Strain in osteoporotic individual trom)'ographic (EMG) assessment of trunk extension on
Medical pathology patiellts who passed Cybex dynametric extension c"allla-
Infection
Tumor lions.~ The Cybcx lest proved to have poor sensitivity (high
InUammatory false-ncgative ratc). Limiting ourselvcs to only quantitative
Cauda equina syndrome
examinations may result in mismanagement and an ovcrdiag-
oasis of psychogenic disorders as a result of the low sensitiv-
ity of lhese tcsts to truly idemifying meaningful functional
Table 18.2. Low Back Classifications U
pathology.
Simple backache
Nerve root pain «5'%) CompHcating Factors of Recovery
Se,ious spinal pathology «1%)
Complicating factors may interfere with patient rccovery. Our
history and examination should uncovcr these factors to allow
Functional Testing us to form an accurate prognosis. No one has a crystal b:.\ll
for seeing when a patient will rccover. but various clues
Functional testing is the first step down a rehabilitatioll path-
can help to identify who might take longer to do so. Such fac- ...
way. Functional testing secks to uncover various functional
tors are helpful in making projections. which are increasingly
pathologies and mechanical sensitivities (Table 18.3).
important in the utilization rc.... ic\'.,· process associated whh
fuJ\t.:tional testing performs two basic functions. First. it
managed care. Table 18.4 summarizes the Mercy. Agency for
provides i.I bi.lsclinc level of functional capacity, Second. it
idcmifks targets for functional 'restoration, The baseline func-
tional deficits me objective. quantifiable. and measurable.
Table 18.3. Functional Testing Evaluates
Thus. they arc ideal outcome assessment [Dais. The most
valid tests relate specifically to relevant job trailS. They do Joint mobility
Muscle flexibility
not. however. usually tell us what dysfunction in the motor Muscle strength/endurance
system is causally related to the patient's symptoms or "pain Movement coordination
generators:' Such information is obtained through a rigorous Static and dynamic balance
Posture and gait
analysis of bioll1cchanical and neuromuscular links in the Lift capadty
ilrthrokincm<uic chains of the body. These all-important func- Weight-bearing sensitivity
lional chains arc concerned with our most important activi~ies Movement sensitivity {I.e., flexion or eXlension bias}
Postural sensitivity (i.e.• sitting intolerance)
(sec Chapter 11). Examples, include gait, sitting posture,
standing posture, prehcnsion. respiration, mastication, and
lifting or bending..'
Depending on the patient's work requirements or lifestyle Table 18.4. Complicating Factors
activities. Olher skills may also be targets for analysis, such as History/consultation
overhead reaching. pushing. pulling, kneeling. crouching. and Previous history of low back pain~
the likc. Tlte thrusl of.mclt lHl analysis offimctiof/al chains in More _than 4 episodes"
Total work loss in past 12 months"
the body is to link. a specific dysfunctioll or series ofdysfunc- Heavy smoking?
tiollS to lhf! patient :\. area of complailll. Sllcce.\,,\fullrelllment Personal problems: alcohol, marital. financial 2
hinges on !in ding the key jlUlclional pathologies lilli' are bio- Adversarial medicolegal problemsi'
Longer than 1 week of symptoms belore presenting 10 doctor.:.
mechanically or kinesiologically re/ared to the symptomatic Low education attainmenF'
area. Unfol1unmcly. the results of these tests are often "soft" Heavy physical occupation?-
Questionnaires/pain drawings or scales
and only qualifiable. Because many outcomcs related to re-
turn la work al.'c valid. they often arc mislakcnly considered
Radiating leg pain (pain diagram)'-H .,
.,j
Severe pain intensity"
<.1n aid to the clinician in decision making. This infonnation Low job satisfactioni' 0:.
docs provide a quality check for the clinician. but the practi- Psychologic distress and depressive symptomsl.:'~·l>
Examination
tiOiler "in the trenches" with the patient must have the free- Pre·existing structural pathology or skeletal anomaly (Le .•
dom to use tcsts of a "softer" variety if they can change the spondylolisthesis) directly related to new injury or conditionl>
course of lreatment. Reduced straight leg raisingl.Z
Signs of nerve root involvemenl 1. l
The utility of a functional test is bascd on :.tn overview of Reduced trunk strength and endurance"
its safety. validity. and reliability. Rissanen found that "non- Poor physical fitness (aerobic capacity)2
dynametric tests correlated beller with disability than did dy- Disproportionate illness behavior (Waddell's signs)l.i',1i
nametric tcsts."~ If rcliability overshadows validity as a crite- 'Only sJighlly increase ·ite risk or chronicity, but significantly increase the
rion for a good functional tcst, then we may falsely conclude dillicullyof rehabiiil<uivr•.

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 Hl"ahh Care Pt\li.... y and Rcscan:h (AHCPR). and British Table 18.5. Prognostic Factors
Guiddilll"S t"Olh:lu.;ioIlS with respect 10 this yit;ll issue in C<1SC
High risk activities
1ll:lllagl"lllClll. Prolonged sitting
Driving
Findin~ the h.t·Y Link Heavy lifting
Repetitious bending and lilting
Rl'~;lrdkss of till' ,Irucwral diagnosis or "pain generator" Torsional sports (tennis, hockey, baseball)

if:IL"Ll. myot'asl.,j;!I. disk. C[l:.). rehabilitation im'olvcs the cn~ Pain-provoking activities
After prolonged silting
IiI'\.' !1ll'Pllllllor ~Y~h.·l1l. Un(ovcring key functional pathologies Alter prolonged standing
that ;1l"C linked patient's symptoms is the goal of func
[0 lhe w
After prolonged walking
tional !<c!labiliw(ioll (1 the !,wiell! with spinal
aSSCS.\llh,,'tll. With bending
In the moming
SIt'tWX;s. a r<'c(ln'rillg sciatica. or {llacel syndrome involve... When changing positions
idcIIlU)'j"g 'he ..dusters" of!um:li01wll'alho(ogy of the loco- With weight bearing
mO/or -,".".\'fem 11/(/{ arc rclar£1/ biomeclulflically or Ileurophys·
) i%gie-olly /0 ,he hyporhc.'l;z.f'c! I'oill ~ell('r(l/or. When a key
functional palho~('Igy is found. its successful improvement has PHYSICAL EXAMINATION
far-reaching cff~('t,"
Once a fimClional evalualiOll Iw.'O becn pc/formed. it is essen·
Biomechanil.:ally. the hody consists of a series of fune·
rial to attempt to differentiate rhe key functional pathologies
lional chains. The lower extremity functions in human beings
from those that are secondary. Lewit said we must not mis-
as a dosed kinetic chain. Any dysfunction in the foot, such as
take the pain for the problem, but ~nstead identify and then
poor ankh.: dorsiflexion. inevitably involves the knee, hip, and
treat the dysfunction responsible for the pain.' First. we must
lumbar spine. A sliff hip joilH nwy develop as II result of
tap the patient's hislory for all relevant information. Pain lo-
hip nexor tightness. in turn leading to compensatory lumbar
cation and what aggravates it often helps make the diagnosis
hypcfmobility and parnspinal trigger points. The result may
before any testing is performed at aiL Therefore, this infor-
be low back or bUllock pain Of. even worse. a lumbosacral
mation is the crucial starting point. The next step includes
nerve root syndrome. In reg.mj to b'lck or bUllOCk pain, local
various tests to localize the source of the pain (palpatar)' and
trcatme11ls invoh'ing manipulative (joint or soft tissue) lher-
mechanical). It is validating for the patient to have lhc;ir ex-
apy may impro\"c the situation. To prevent recurrences or to
" aminer find their pain cither through palpation or spccilic
treat chronic pain. however. a more comprehensive approach
provocative testing. To be able to provoke the patient's pain
is required. Treatment aimed .Il relaxing a tight psoas and
experience is to hit "pay dirt," This information gives the doc-
strengthening a weak gluteus maximus may be the primary
tor and patient a baseline or ideal outcome assessment tool
treatment for lumbos'lcral f.lcet pain or par'lspinal myofascial
) that can serve as a "barometer" of the success of our inter-
pain. Although Ihcorctical. this model incorporalcs biome-
ventions. It also helps the examiner "zero in" on what tissues
chanical and neurophysiologic rationale into the transition
arc involved. Although trigger point palpation or McKenzie
from manipulative therapy to active :"chabilitalion. While eli,,·
; or Cyriax provoca~ive testing is not as reliable as an anesthe-
icio"... should (Idhu(' ro newly e.'irablished guidelines. they
siologist's needle. such an assessment can be useful in day-to·
J/lOuld /lot become pri.<i(Jl/er.\· to rhem. In fact. futurc research
day practice.
\' questions emc;rgc as a result of the creativity of clinicians.
Provocative tests. whether static (e.g.. prolonged sitting).
I HISTORY
dynamic (e.g., lumbar flexion), or palpatory (e.g.. trigger
point identification). are invaluable as signs of irritability or
Functional improvement is diflicuh if not impossible to dysfunction'~'')These results, however. should not be mistaken
achieve unless inappropriately handled extemal demands arc for the dysfunction itself or its cause. Once a pain gencrawr
identilied. f-or example. any <.lctivity. sport. or work demand is found. the all-important job of hleJllifying why that lissue
) that is unusually repetitious involves great external load. Of is irritated ("the perpetuating factors ") begins. 9•10
requires a biolllcchanically improper movement (i.e., bending For instance, if a patient has buttock pain and a triggcr
; and twisting) must be tlushed out. Such factors can be uncov- point is found in the quadratus lumborum that refers to the re-
ered during the hi.Hory by asking the patient in what activities gion of the primary complaint, we may have found the "irri-
they arc involved. whcn they typically get their symptoms. table focus" of pain. but we have not necessarily found the
and what aggravates the p<lin. Examples of key information "problem" or source. To find the key link. we must discovef
gained arc provided in Table 18.5. what could be responsible for the quadratus lumborum be-
External demand and internal functional capacity arc coming an "irritable focus," Evaluating gait and movement
equally important in the prevention of recurrences (sec Fig. patterns may help to identify this patient <lS a "hip hiker" with
2.4). The individual involved in ma~lY high risk activities will a muscular imbalance involving gluteus mcdius weakness and
require gre.lIer funclional c<lp<:lci(y~.ln contrJst, the sedentmy overaelivily of the piriformis and quadratus lumborum:
individuallllay only fequire;'1 slight increase in functional ca- Recurrent sacroiliac dysfunction may also be explained by
pacity and some basic advice.' this kinesiopathology. Th~ entire kinetic chain from the foot
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i~,
f
<., '. l' -----------------------------------~----------------
 up should be evaluated with the goal of finding the joint or motor systcm. the associated dysfunction of \;:hich can !:.:ad ~~)
muscle dysfunction that is "upstn:::am" of the "irritable focus," mechanical ovcrload aI a distanc~ throughout a kinetic chain
This t'lssessment is the only way in which we can separate the of a particular posture or movcment. \Vc 1l111~l cardully ana-
adaptive compensations of the locomotor system from the lyze historical data ;lite! observc the mOlor system of our pa-
true source of functional pathology. tients in ,Ictian to identify the kcy function,,1 pathology. Thi~

I
l
i
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·
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
~ chosocial or high external demand). analysis for chiropractors and those involved in manualmcd-
I icine is that specific muscle imbalances (tight and weak mus-
I CASE MANAGEMENT clcs) that ;.lfe functionally relatcd to the painful area can be.::
identified. Thus. wc can fonn a prescription of which muscle
I! General Principles nceds to be stretched or rclllxcd. those that need to be
I According to recent American and British back pain guide- strengthened or facilitatcd. and the joints th:l! nced to be .it!-
justcd. By finding the specific patllOkinc.'iio!ogy reilltcd to (/
lines, patient rca~5urance, pain-relief methods. and exercise

I! 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
pain/ul area. (III exercise prescriptiolJ (:(1U be ratio1/ally linked
to lhe mallipulable lesion.
Pathokinesiology in' a kinctic chain can be nushed out

II prognosis if back pain is managed properly. Pain-relieving

methods such as time·limited passive care (i.e., manipula-
tion). pain medication. avoidance of biomechanically delete·
rious activities. and reactivation with light exercises arc ap·
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 trig-
II propriate. Exercise or active rehabilitation gains in impor· ger point may be discovered. Trcating thc local functional
pathologies mllY be all that is necessary. If the condition pCI'·
tance us the acute pain phase subsides. Exercises should be

I aimed at restoration of function and prevention of dccondi-

tianing. In particular. trunk strength, cndu'rance, flexibility
sists. however. further evaluation of the locomotor system
will be required. The problem may be found in a dysfunc-

i and cardiovascular fitness should all be addre.c;sed.

Treatment aimed at pain relief should not be the only gOlll
tional chain of C\'enlS involving a biomechanical foot faull.
shortened iliopsoas. gluteal inhibition. and lumbosllcral joint
dysfunction with accompanying trigger points. Finding the
of care. Even if a primary pain generator is identified. it is im-
portant to restore function in the locomotor system to reduce chain reaction is CruCi~lllo removing key perpetuating factors
the likelihood of painful recurrences. Rehabilitation has two for motor system disorders. A further and more difficult situ-
primary goals: (I) through education. ergonomics. or training ation arises when longslantlin~ abnorm4l1 posture and move-

1 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 ca-
mcnl patterns ha\'c been learned by the cerebellum. This situ-
ation requires treatment of not only periphcral tissues but also
the central nervous system {e.g.. proprioscnsory retraining).'·'
pacity of the spine or its stability. Each stcreotypical movement pllltCm is important for its
Patient education helps to decrease mechanic..1 stress rcl.nionship to basic skills performed many Limes each day.'
plilced on a painful region. The combination of manipulation These skills include l:ait, sitti"!: postft1'(,. ",randing posture,
and exercise restores function in the locomotor system. thus prehension. respiratiOIl, I1lll.'iticatioll. {//ul lijiillJ.: or bClldill~
improving thc ability of a painful region to adapt to increascd (T.able 18.6). For instance. hip extension {psoas, hamstring!
mechanical stress. Essentilll inerediel1ts in achievin~ a suc- gluteus mllximus muscle imbalance> rdates to gllit (toe olT
cessful outcome are finding the key sources of tissue ~verlo3d and forward propulsion). stllnding posture.•lOd lifting. Hip
J
and identifying the key functional pathologies to address. 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 sta-
Key Link
bility). Trunk flexion (erector spinac. hip Hexor/rectus ab-
It is casy to become overwhelmed when attempting to sepa- dominus muscle imbalance) relatcs to lifting and trunk
rate important from trivial function..1 pathologies or deficits. stability in general (during carrying. reaching. pushing. and
.So many sfr/u:lIlral and jUfIf.:tiollal pmh%gies are preselll ill pulling). Shoulder 3bduclion (upper and lower fixmOfs of (he
as)'mpro!JIatic individuals rlwlthey may /lol be clinically sig- scapulae muscle imbalance) relates to prehension. reaching.
nificant whe" secII ill symptomatic patients. Lc\Vit and Jandu gr'lsping. and holding 4.lctivities. Trunk lowering frulll a push.
outlined a biomechanical and kinesiologic appro<.lch that up (pectorals/serratus anterior muscle imbalance) rcli.lte~ to
"culls out the wheat from the chaff:· 7. 11 The primary goal of pushing and pulling activities. Head/neck ncxion (stcrnoclci·
assessment is finding tht: t..t::)' functional pathologies of the dornaslOid (SCM I. sliboccipiwlldeep neck llexors muscle im-

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·....3
-------------- lIb.·
 Table 18.6. Chain Reactions in the Locomotor System

Weak or
] 5;';111 Movement Pallern
Tight or
Overactive Muscle Inhibited Muscles Stiff Joints Hypermobile Joints
i,, Gait/loe off. lilting. and Hip eKlension Psoas, hamstring. Gluteus maximus Hip joint Lumbar
standing posture erector spinae
GaiFslance Hip abduction TFL. QL. adductors. Gluteus medius Hip joint $1 joint and LS joint
pirirormis'
. Lifling and trunk sla- Trunk flexion Psoas, erector spinae Rectus abdominus Lumbar flexion Lumbar extension
bilily
Prehension. reaching. Shoulder abduction Upper trapezius, lev- Lower and middle CfT junction, SIC joint CS-C6. GfH joint

i
~
grasping
Pushing/pulling Trunk lowering from
a push-up
atar scapulae
Pectoralis majorl
minor, subscapu-
trapezius
Serratus anterior CIT junction. mid-
upper Ihoracics
GJH joint
i laris
.~ Maslicalion and siUing Head/neck Ilexion SCM, suboccipitals Deep neck flexors crr junclian in lIexion, CS·C6
I poslule
Respiration Respiration Scalenes Diaphragm
TMJ
Rib cage. lower

i cervical-spine

iI
·TFL. tensor lascia lalae: OL. quadratus lumborum: 51, sacroiliac; LS. lumbosacral; GfH, gleno·humorJI: err, ccrvicothoracic; SCM, sternocleidomastoid: TMJ,
'i tcmporomandlbular join!. SIC stcrnoclaviculJr.

j
hal'IIKe) rdate~ to sitting and mastication. Rcspiration Table 18.7. Trealment of Key Functional Pathologies
, '~ (s<:.il~nes/di~lphragmJ relates to breathing. Other important
Advice (patient education)
I ~lcli\'ities pcrforlllt:d include squatting. stooping, crouching, Head set for neck pain in receptionist

I overhead reaching. 'and the like. depending on the particular Ice and 90190 rest position for acute pain from lumbar strain
Lifting advice for recurrent low back pain sufferer
work or SP0rl ,lctivity in which a person is engaged.
Ergonomic workstation modilication lor carpat tunnel syndrome
" Weaknesses of spt:cific muscles, such as quadriceps i:lnd crce- patient
~ lOr spinae. that occur with dccondilioning arc also key links Manipulation

I to c\'aluate as arC<1S of high risk during activities like lifting or

squ<1lting.
Trigger point therapy 10 upper trapezius muscle for neck pain
Adjustment to lumbar spine lor back pain

i , Manual resistance techniques OlrecteO at scalenes or pectoralis

Oncc lhe mechanical relationship between certain pos- minor (or thoracic outlet syndrome
Adjustment 01 foot far low back pain
tures. activities. muscles, joints. or kinetic chains and the pa- Exercise

I
) tient·s symptoms has been revealed. a treatment program can Strenglhening abdominals for low back pain
be outlined, Intcr\'cntion involves three levels of care, Advice Improving muscle imbalance between hip flexors/exlensors and
) paraspinal muscles for back pain
(patient education about biomechanics and ergonomics), ma-
Propriosensory retraining for chronic back pain
nipulation (manU'll or reflex therapy), and exercise (Table Trunk stabilization program for chronic back pain
p
,I 18.7). In general. advice is the easiest intervention followed Improving scapulohumeral rhythm for rolator cuff syndrome
i by m'lnipulalion and lhen exercisc_ Chiropractors have Improving laleral pelvic stability by restoring muscle balance to
gluteus medius, tensor fascia latae. and quadratus lumborum

I ,,
thrived on the powcr of m<lnipulation. and physical thcrapists
on advice and exercise. The usc of all thrcc clements in com-

1 bination with a complcte cvalu.ltion constitutcs the highest.

quality of C'ln.: a\'ailable 10 thc public.
Table 18.8. Addressing Functional Pathology in the
Kinetic Chain

I~
)
A good guidelinc to follow for improving the clHirc ki-
netic chain linking key muscle or joint pathologies is listed in
T<:tblc 18.8. Table 18.9 outlines principles of case 1l1anagc-
merH for nonspecific back pain. which includes asscssment
Relax/stretch overactive/tight muscles
Mobilize/adjust stiff joints
Facilitale/strengthen weak muscles
Re-educate movement pallerns on reflex, subcortical basis
~ (red ll'lgs. diagnostic Iriage. complicating factors. outcomes,
••
; , functional pathology) and treatment (advise, manipulation,
exercise). difference between hurt und hann. and. if ll~ccss<:lry. refcrral
I~;
to a pain psychologist. Flexibility deficits arc <H.ldrcs~cu by
.;t, chiropractic adjustments. joint mobiliz:.ltion. muscle relax-

I• --_.
Complicating Factors Encountered \Vith
alion. and stretching. Incoordination, if present. will lead to
Exercise Trnining
.~
'
poor training fC.1wlts. Simple exercises should be prcscribt:d

I Such f.lctors include low mOlivation. poor flexibility. incoor-

dination, or a mechanic,tl scnsitivity (postural, movcment.
that can be carried out with proper motor control. It is helpful
to limit the training range to reinforce the proper quality of
~ or weight-bearingJ. Motivational problems arc addressed movement and kinesthctic aW,]fcncss (see Chapter 1-.+).
I <) through appropriale goal selling. gradual conversion of the Focusing on the quality or form of Ihe exercise anti not on th~
i patient from .1 pain avoider to a pain manager. www.bodywork.su
explaining lhe qu~~~:!j' of repetitions or resistance is I:~s~ntial. Restoring
•• t
''-;

,~ I
I

~
~
~
,?
\

*
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 Functional assessment Special studies (biologic)

• Simple backache • Quantifiable. outcomes • Radiography
• Nerve root pain • Functional pathology • CSC, ESR
• Serious spinal pathology Exercise (temporary increase in Bone scan
Rule out red flags pain acceptable) MRI or CT if tests indicate
• Trauma (fracture. instability) Stretching specific nerve root com-
• Medical pathology (tumor, infection, etc.) > urgent referral • Strengthening (not within the promise
«3 weeks) first 2 weeks) Psychologic assessment
• Rheumatologiclinflammalory > urgent referral «3 weeks) • Propriosensory • Fear avoidance beliefs
• Major neurologic compromise (cauda equina syndrome) After 6 weeks • Distress, depression
> emergcmcy referral • Active care> Passive Care • IItness behavior
Diagnose nerve root compromise • Consider alternative sympto- Social assessment
• Molar. sensory, reflex testing matic measures • Family attitudes or rein- "
• Nerve tension tests (Le., SLR) ff unresponsive after 6 weeks, a forcement
Evaluate for complicating factors biopsychosocial assessment is • Job satisfaction
• Abnormal illness behavior (distress, depression) indicated. • f:lhysical demands 01 job
• Job dissatisfaction • Other lactors rclating to
-1

I
• Past history of more than 4 episodes missed work
Preconsultation duration 01 symptoms> 1 week If unresponsive afler '2 to
• Severe pain intensity 16 weeks
• New conditionlinjury related to pre·existing structural pathology Disability management
or sketetal anomaly • Job modification !
Aggressive, conser:vative care (~i'mplom control) (6 weeks)"
• Rest «2 days. unless sciatica <7 days)
• '!'hrk hardening
• Vocational re-education
,
-)

• Manipulation (ioint dysfunction, soft tissue dysfunction, and/or Pain management

trigger points) • Multidisciplinary approach
(Maximum of two different 2-week trials if no progress documented)
Advice (reassurance, earty activation, activity modification)
Exercise (light aerobic activity, McKenzie. gentle stretches) (in-
crease over time)
Physical agents and methods (decrease over time)
Medication (NSAlDs, acetaminophen) (more import~nt if nerve
root pain)
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- Releasing Patients to a Private Health Club
!aling enhanced perception of the "weak link" will contribute
Much has been said about chiropractors working with priv:lt~
to improved coordination.
health club facilities. Although this praclice is certainly good,
A mechanical sensilivity, like gravity or weighl bear-
a few points are worth mentioning.
ing inlOlerance, is no bar to exercise therapy. Non-weight-
bearing exercises can be performed on {he floor. All major
Proper spinal posture must be l~lUghl
muscle groups can be challenged before gmdual reintro- NautilwHypc machine!> arc open kinetic chain and thus uo nOI
duction of gravity forces is ullcmptcd. A person with a pos- tr.tin rcOex control
{Ural sensitivity, such as to silting, can exercise while upright Nautilus-type machines and Olhcr health club exercises often
or recumbent. Another common sensitivity is to movement cncou(;.\ge "frick" movements. Be on the lookout for the fol-
in a ccnain direction. A paticnt with pain on flexion that lowing:
is relieved with extension (extension "bias") is a classic -Hip flexors SubslilUt~ng for the :lbdominals

McKenzie pillieot (see Chaptcr 12). Othcr patients who have ....:.....Lumbar hyperextension during hamstring curls. seated leg ex·
pain with trunk extension, but relief in the slump posture tensions. and stairclimbcr
can be trained to identify their "neutral rangc" and to learn -Slumping during. bent·over rows, lunges, st.tirclimhcr. inclin\.'
Ircadmill. or bicycle
10 stilbilize their back from potenti31 harm. They also may
-Chin poking during pull downs. bench press, abdominal excr-
havc a common altered movement pattern-hip extension, in
cisco bicycle, or squats
which they extend their thigh <It the lumbosacnll joint rather -Shoulder shrugging durin~ ovcrhcild lifting. arm exercises. tlr
than at the hip (because of hip hypomobility andlor ilio- rowing
psoas tightness). Improving coordination simulwncously Free wcights arc preferable but require spcciric instructions
elirnin:llcs this movement sensitivity and expands the fune· -Lunges should be performed with proper lumbosacral siabilil.;l·
tiollul range. lion ("ncUlml position")

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 vV'

-Avoid shouldl.:r shrugging with biceps curls Table 16.11. Quebec Task Force Classification oi
-Avoid excessive shouldl:l .:xtemal rotiltion during bench press Spinal Disorders
Aerobic exercise is I:xccllcnl, but wilh certain exceptions
Pain without radiation
-Slaircli11lbing is ddelerious if paticnt has wC:.lkness of gluteus Pain + radiation to extremity. proximally
m:lxilll\ls or gluteus medius or o\,cr<lclivity of erector spin~lc. Pain + radialion to extremity. distally

i,, qU:ldr..lIUS Iumborum. or tl.:llSOr fascia lalac

-Stationary bicycle may not be aJ\'isablc after day of desk .md
<luto sitting
Pain + radialion 10 exlremity + neurologic signs
Confirmed neNC rool compression (advanced imaging or clec!rodi-
agnosis)
i Spinal stenosis
-Floor Illust be properly p:ldded Postsurgic~1 status <G months
II -Introductory classes must be 41v,lii"blc to prevent knce injuries
in Ihe novice
Postsurgical status >6 months
Chronic pain syndrome
Other diagMsis (tumor. infeclion, fracture. rheumatologic disease.
i Typical posturJ.! faults and clinical cOl1Sequc:lcCS that result from
etc.)
I! improper exercise programs (as described in T'lblc 18.10)

~ FUNCTIONAL RESTORATION OFTHE

,I
l
LOCOMOTOR SYSTEM 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

i,
~
Different classification schemes for back pain patiems have
been proposed. Those dealing with pathoanatomic diagnosis
standard to adjudicate less expensive physical examina-
tion procedures as diagnostic lests for specific spinal syn·
dromes.

I
were rejected for lack of proof. The Quebec Task Force pro- Moffroid "and colleagues subdivided group~ of patients
posed the following classification ~cheme for spinal disorders with nonspecific back pain into discrete functional Cale·
(T<.lble 18.11 ).I~ This c1as~ification has been simplified by re- gorics. 21l These authors arc studying the effects of stretching:
cent British and American guidelines (sec Table 18.2).1.2 versus strengthening exercises on both flexible and innexible
!
,l• Most patients (70 to 90%) fall into the back pain cat-
egory.l.:! This nonspecific label replaces pathophysiologic
patients. ~,
The Quebec Task Force also classified patients according

I
hypOlhcsis such as facet syndrome. sacroiliac (51) syndrome. to the duration of symptoms. Acute was defined as less than
myofascial syndrome. or radiogr.lphic diagnosis such as disk 7 days; subacute as 7 days to 7 weeks; and chronic Cl..'\ greater
or joint degeneration. Usc of lhi~ iavd uut:~ nut mean that than 7 weeks. TIley also recommended classification by work-
most low back pain has no cause. just that the cause is not ing status-working or idle. An important development in the
m yct known. Recent evidence suggests that some of these classification of spinal syndromes was revealed by Dclino
; causes are becoming clearer. Using a double anesthestic in- and Erhard. 22.23 who found that nonspecific back pain could be

I
jection technique (one is a control block), it is possible to subclao;,siflcd into a few catcgories that rcsulted in improvcd
')
identify thc primary pain generator in more than 50% of treatment outcomc. An extension and an Sl category were
both chronic neck and back pain patients.IS.IC.-I" Sacroiliac identificd by specific provocative movcment and functional
joints arc pain generators in 13%. zygaphophyscal joints in tcsting. respectively. Cntegorization and customized treat-

I
15%. and disks in 39% of patients presenting to specialized ment resulted in improved results over gencric trcatrnem for
spine centers. IS.I:t.19 Unfortunately, no physical signs Imve all patients with nonspecific low back pain. Using reliable
tests, they showed lhat they could subclassify cases of non-
•~ Table 18.10. Typical Postural Faults and Clinical
Consequences that Result from Improper
specific back with pre~criptive validity.
11lc Qucbec Task Force recently published a promising
~j Exercise Programs classification scheme for whiplash·rclated disordcrs_1~ Neck
complainls were divided into four categorie.o; as follows: C;,ll-
I Posiurai Faulls Clinical Resull
egory I: neck complaint without musculoskeletal signs ti.c..

i
Overactive slernocleidomastoid in CeNicocranial syndrome and mobility tenderness); catcgory II: with musculoskclctnl signs:
women performing sit-ups incor- headaches category Ill: involves neurologic. signs; category IV: invo!\'cs
rectly
~i Rounded shoulders in men doing Thoracic outlet syndrome, a fracture or dislocation.
100 much pectoralis work without shoulder impingement

I
working their upper back syndrome. cervicocranial
syndrome Spinal St.<'lbilily, PathokincsioIogy, and the Importance of
Shrugged shoulders from too much Headaches and shoulder im- Muscular Imbalances
upper trapezius work and not pingement syndrome
enough lower trapezius strength Spinal stability depends on three intact clements uf the loco-
~( Mililary posture (anterior pelvic tilt Low back pain
~ with chest Slicking out) Irom ab- motor system. 2S First is the centrul nervous system. in partic-

i
dominal and gluteal work without ular the cerebellum. which conlrols posture and movement.
lumbosacral stabilization (poste· Second is the articular and ligamentous structures. which are
~- ~ rior pelvic Iill)
the major passivc structures involved in the locomolor sys-

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 tem. And Lhird is the muscular system. whkh n::prcsI.:!l!S !h" ical cvidcm:c :-ubstantiah.:s this mood fur pres(.·ribing. exer-
active part of the motor system. This system is under the di- cises (T:'lbks t S.I:? and t S.l.'!.
rect control of our will during conscious activities. but it is The grouping of muscle imbahlllcrs described by Jallda
also responsible for rene;.;, subconscious Ud'lptations to irrita- arc not isol;lt~d dinical phenomena. Patienls Iypically //(/\'('
tions or injuries. "wlly./i'llefitllld /'atlln/ogie.\" alld .\"(J!l'iflg tll(' mysrclY (~r ('(lch
Any internal structural pathology or excessive external !'min/{ \ illtli·.-idl/o/ .lil/Wliollo/ I'(lt/wlng." 1"('(Juil"(,s .IiI/ding (l
biomcchanic<llload causes pcnurb;uions in the motor syst~lIl. eltaill r('(/('Ii(ll/ in lite moto,. .\".'".\r('l/1. Ul1lh:rsl<luding. the lllllsde
I,• An intact mOlor system can adapt via centr..11 nervous system imb<ll'lIll:cs ;IIlJ the rcl:ttinll ... hip hctwccn muscle and joint
" control <lnd muscle system activity_ Over time. however. dysfunction cn;lblcs the practitioller to quickly ''<.:r:'H.:k tlte
1
repetitive overload Icads to perturbations 10 which we cannot cotlc·· 01" the p:Jlicllt's dysfullction.
~ ! ,
"'1.
adapt, and instability results. The adapt<1tions of the molor
system are represented by muscle imbalances that can be as· Chain n.cactions in the Locomotor S.ystcm
sessed simply. These adaptations signify that "old" trauma or
LOWER CROSSED SYNDROME
repetitive strain has perturbed the spinal stability tlnd caused
an adaptation by the motor system to adapt and prevcnl fur- One of the mo~t clinic'llly relevant patterns of muscle dys-
ther ins~abi1ity. Unfortunatcly. these ad;;lptations arc less than function is (hc lower crossed syndrome. which is typified by
ideal .md lend to new pathokincsiology. The joints t bcing the Ihe following pain: of tight and we"k muscles Crable nU-l-).
passive structures. arc along for the ride. They arc not only Awareness or lhis pattcrn is important for low back and pdviL'
bony shields to the spinal cord and vital organs, but also mo- conditions related to abnormal sitting. standing postun:. g"it.
bile Icvers that allow the muscles to perform a variety of ac- bending. or twiiiting <.lctivilies. Table 18.15 shows the signs
tions. They also serve the critical function of providing affer- related to various dysfunctions associated with the lower
ent feedback to the motor control cenlers of the central crossed syndrome.
nervous system to maintain efferent muscle function at an ap- The combined result of this posture is that tilt:' tUIll-
propriate level. bosacwl. thoracolumb'lr. 51. hip. and knees joints arc :'111 o\'er~
Pathokinesiology of the locomotor system develops as an stressed. Joint dysfunction ,HId trigger points naturally result
attempt to adapt to injuries, improper alignment or posture, or from lhesc Illu:\c!e imbalances. accompanied by low ba<.:k
perturbations such as from rcpetitive strains. An injury or in- pain. buttock pain. pseudo-sciatica. and knee disorders.;,lIAI .. I~
flammation may lead to reflex muscle inhibition or muscular Each of the threc muscle imbalances that contribute to the .)
splinting. Poor foot posture. such as hyperpronation. may lower crossed syndrome are discussed in the context of the
alter the arthrokinematics of the entire lower extremity and
result in pathokinesiology. For ifl<:;tance. hypermobility in
the foot may result in compensatory hypomobility at the knee Table 18_12. Clinical Evidence for Muscle Imbalances
and hip joints and then hypermobility and instability in the
FOlWard head posture and decreased isometric sltenglh and en·
lumbar spine. Typical pathokincsiology associated with this durance of neck flexors correlated with headache patients~~
chain reaclion would be a muscle imbalance involving tight! Upper cervical joint dysfunction, weak neck flexors. and tight
suboccipitals correlated with postconcussional headache pa-
overactive hip flexors, hamstrings. and erector spinae and tients:;-
weak/inhibited gluteus maximus. These muscle imbalances. Cerebral lesions result in poor descending control of tonic pos·
the result of adapt.nioIl5 to dysfunction, pathology, or over~ tural reflexes'"
Most reflexes involve reciprocal inhibition~8
load themselves, perpetuate a dO\vnward spiral affecting Hypertonia with antagonist paresis is the norm u
spinal stability.
BOlh clinical and scientific studies have generated much
evidence supporting the importance of muscle imbalances as
kcy functional pathologies. \Vatson and Trott demonstrated Table 18.13. Scientific Evidence for Muscle Imbalance
that muscle imbalances in the neck can distinguish chronic Increased tension or tightness
headache and nonhcad<1chc 5ufferers.=/l Trcleaven and lull Relative type I muscle fiber hypertrophy on symptomatic side
have shown that lhe same Inuscle imbalances occur in post· in chronic low back pain (LBP)29.30
Prolonged nociceptive bombardment can lead to flexion reflex
cOllcussional headache patients. but not in normal individu· from excessive contraction 01 skeletal muscles in the vicinity
als.~7 According to Janda. muscle imbalances occur in a pre- of the nociceptors 31 ,n
dictable mallner (see Clwpters 2 and 6). Fibroblastic proliferation occurs in injured tissues if inflamma-
tory stage is prolonged33
Certain muscles tend to become inhibited. whereas other Muscle inhibition, weakness. or atrophy:
muscles tend to become overactive. Postural or antigravity Reflex inhibition of vastus medialis oblique aller knee inllam-
muscles arc those that tend to bccome overactive or short· mationlinjuryJ.l.-3G
Unilateral, segmental lype II muscle fiber atrophy aller acute
eneu. Phasic muscles have a predisposition 10 becoming in- onset 01 LBP):
hibited or weak. This muscle imbalance seems to be rein- Bilateral. type II muscle fiber atrophy in chronic LBP~!U"
forced by reciprocal inhibition of ,lOtagonist muscles. as well Atrophy of type II muscle fibers in multifidus patients wilh her-
niated disks)l)"'o
as by Iwbitu,11 patlerns of stcrotypic:'ll usc. Scientific and din-

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 Table 18.14. Lower Crossed Syndrome (See Fig. 2.22) Trigger Poillls
Imbalance in the following pairs of muscles: Gluteus Jlluximus
Weak gluteus maximus and short hip flexors • Coccyx
Weak abdominals and short lumbar erector spinae

I
Iliopso;ls
Weak gluteus medius and short TFL and QL·
Seen commonly with gait. lifting. sitting. kneeling, crouching, push-
Erl'ctor spinac
ing. pulling. ele. (onlrable-raJ uprx:r trapczius and/ur k\';l!or sCapUI;IC
j "TFL. tensor fascia lata.. ; QL, quadratus lumborum. Mo!)iliry (j oim [).",~rltllcJi(J/IJ
~

• Hip joint
Table 18.15. Postural Signs of Lower Crossed Syndrome

,
• Lumbosacr~ll (US) junction
Postural Finding
• Thoracolumbar (Tn~) junction
Dysfunction
Contrnlalcral ccrvical spinc
I, Lumbar hyperlordosis
Anterior pelvic lilt
Shortened erector spinae
Weak gluteus maximus Altered Hip Abductiou (Table 18.17Y·II.0
~ Protruding abdomen
Foot turned Oul
Weak abdominals
Shortened piriformis
Hip abduction is !Illportant for its rdationship to the

I Hypertrophy of thoracolumbar Hypermobile lumbosacral stance phase of gait and any balancing activity.
junction junction \Vcak agonist: gluteus medius
Groove in iliotibial band Shortened lensor fascia lalae
Ovcractive antagonist: adducLors
1, Ovcractive synergist tensor fascia latac (TfL)
.j Overactive stabilizcr: quadratus lumborum (QL)
key movement pauem that is affected-hip extension, hip ab:
I duct ion," and trunk llexioo. Overac.:tivc neutralizcr: piriformis

I
SympJomJ (ue Figs. /0.10. 10./1. {/wIIO.13J
Altered Hip Ex/ellsioll (Table 18.16)',11,1)
Hip extension is important for its relationship to the Lew back or buHock pain (51 or myufascial syndrollld
I propulsive phase of gait. lifting. and the standing posture. Pseudo-sciatica (m)'ofascial syndromc)
i Lateral knce pain (knee cxtensor disorder)

I Weak agonist: gluteus maximus

Overactive antagonist: psoas. rectus fem"ris Postural Analysis

II
Overactive stabilizer: erector spinae • Prominence of the iliotibial tr.1Ct
Overactive synergist: hamstrings Lateral prominence of patella
• Turned Qut foot (sec Fig. 6.11 a)
Symptoms
Gait Analysis
Low back or buttock pain (facet or myofasciill syndrome) (sec
Figs. 18.1 .nd 18.2) Hip hiking gait
Coccyalgia • Asymmetric pelvic rotation (blocked SI joint)

• Recurrent hamstring pulls

II Recurrent or chronic neck pain

A-Illscle Length Tesls
Shone ned hip flcxors (sec Fig. 18.5)
Poslltral Analysis Shonened QL (sec Fig. 6.12)
Forward-drawn posture (sec Fig.. 18.3) Shoncncd adductors (sec Figs. 6.IOa and b)
Anterior pelvic tilt Shoncned TFL (sec Fig. 6.7)
~:

I.)
Hypertrophic erector spimle (sec Fig. 18.4)
Hypotonic gluteus maximus Table 18.16. Treatment Approach for Altered Hip Extension

Relax/stretch ipsilateral hip flexors

Gait Analysis Relax/streich overacLive erector spinae
Relax/stretch overactive hamstrings
Decreased hip hyperextension
Adjustlmobilize tow back and hip
,~1 • Compensatory incre<lsed lumbar lordosis Facilitate/strengthen gluteus maximus (bridges, squats. leg raises)

I Muscle Lenglh Tests

AbdominaVgluteat stabilization exercises and biomechanicaV
ergonomic advice 10 correct lumbopelvic posture

I
M
)
Shortened hip flexors (sec Fig. 18.5)
Shortened hamstrings (sec Fig.. 18.6)
Shortened erector spinae (sec Fig. 18.7)
Table 18.17. Treatment Approach for Altered Hip Abduction
Relax/stretch thigh adductors

I,-' \
Conlralateral upper trapezius and/or lcvu(or scapulae
I I £\'aluarioll oj Key Movcmelll Pallems
Relax/stretch tensor fascia latae and quadratus lumborum
Relax/stretch piriformis
Relax/stretch hip flexors
Adjust/mobilize sacroiliac joint, low back. and hip
Altered activation sequence during hip hyperextension (sec Facilitate/strengthen gluteus medius (1 leg bridge, P·S retraining)
Fig. 18.9)

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EVlIJUlll;OIl oj Key MOl'cme,,' Plltl<:nl.'" II is important to I\\~ntion lhe psoas paradox. According
to Janda and Schmidt. the iliorsoa~ normally lkxes Ihe hllll-
• Altered coordin,llion during hip ahduction (~l;C Fig.. 6.17)
h,ll" ~pinc:I.\ If. h()\\"('\cr. thl.: erector spinae ;.Irc shortened.
the psoas wil! instead :i-Upport the rc~ultant hyperlordo~is. The
Trigger Points
Gluteus tJlcditl~
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
I
GltllCUS Illinimll~ Cl"l..... lOf spinae. llle l11\lrl' the pSO,lS pawdox is ill clTe<:!. Thu:,.

I1 Pirifonnis
QL
• TFL
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·
I'
I
cisc:, thai <Ire performed with an' ,1l11~rior pelvic lilt or with
Mobility (laim Dy.t!/tJU:lioll) I
the fect held down cnl.·our.lgc activation of the hip J1cxors.":.1
• 51 Such exercises maximize lumhar compressive alld shear
• Hip internal rotillion !"(lITCS ..I·1
~ TIL ilnd L2/L3
I$ Altered Trullk Flexioll (Table IS. IS!""'" UPPER CROSSED SYNDROME

I Trunk Oexion is important for its rdationship to lifting.

trunk st;]bility. standing posture, and spinal statics.
Muscle imbalances alY~ct the neck i.lnd upper extremity just
as deleteriously .IS they do the low b<lck :.Inc! lower ex·
\Vcak agonist: reClus abdominus tremity.~/,·n..I~ Janda identified :.in upper crossed syn-

Overactive antagonist: erector spinae drome wilh typical p~irs of tight :'1110 weak muscles l :
Overactive synergist: iliopsoas Crable 18.19).
Knowledge of thi:- paltern is ImpQnallt for neck, shoulder.
Symptoms or upper back conditions rcl:.ltcd to abnormal silting. respira-
--~
lion. masticmion.•.md prehension <Jctivilks. Tnble 18.20 pro- ;
Low back or bUllock pain (facet syndrome. inslability) (sec
vides lhe signs rdated to various dysfunctions associated with
Fig. 18,1)
Neck pain the upper crossed syndrome.
The combined result of this posture is that the ccrvicocra-
Postural Analysis nial. ccrvicothoracic. glcnohul11cml. and tcmporol11undibular
joints (TMJ) arc all o\·crstrcssed..\.7·'~ Joint dysfunction and
Increased lumbar lordosis
trigger points nuturally result from these muscle imbalances.
Protruding abdomen
associated wilh headache, neck pain. shoulder blade pain. and
I
Gail Allalysis:
• Increased lordosis
TMJ and shoulder disordcrs.I:.:I,.~1.~~..l6 Each of the three mus-
cle imbalances that contribute to the upper crossed syndromc
arc discussed in the context of the key movement pattern that
1°I
l~fllsde Length Tests
is affected: scapulohumeral rhythm. neck flexion, <lnd trunk
lowering from ~l push·up. Rcspirmion, which is also affected. j}
Shortened lumbar erector spinae (see Fig. 18.7) is discussed as \l,'cll.
Shortened hip flexors (sec Fig. IS.5)
Table 18.19. Upper Crossed Syndrome
Evallllllioll of Key Mm'emclIf Pallertl5
Imbalance in the following pairs of muscles:
• Ahercd coordinalion during trunk flexion (sec Fig. 6.18) Weak lower and middle trapezius and short upper trapezius and
levalor scapulae
Trigger Poillts Weak deep neck llexors and short sUboccipitals and sternocleido-
masloid
• Erector spinae (sec Fig. 18.2) Weak serratus anterior and short pectoralis major

MobWly (JO;1I1 Dy,'ifIlIlCt;OIl)

Table 18.20. Postural Signs of Upper Crossed Syndrome
• Lumbar-spine
POSlur31 Finding Dysfunction

Round shoulders Shor1ened peclorals ,,

-'
Table 18.18. Treatment Approach for Altered Trunk Flexion FOTward-drawn head Kyphoti(: upper thoracic spine -~,y
CO·C 1 hyperextension Shor1ened suboccipilals
Relax/streich erector spinae Elevation 01 shoulders Shortened upper trapezius and levator
Relax/stretch iliopsoas scapulae and weak lower and
AdjusVmobilize low back middle trapezius
Facilitate/strengthen abdominals (dead bugs. trunk curls, sit backs) Winging 01 scapUlae Weak serratus anterior

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Altered Scapulotlzoracic alld S'capuloJrumcral RIlJtll111 Taole 18.21. Treatment Approach for Altered
(Table 18,2/)"-',"''' Scapulohumeral Rhythm
The scapoluhumcral rhythm is impol1ant for its n::I:Hion* Facilitate/strengthen lower and middle trapezius
ship to prehension. rcaching. grasping. and carf),jng aCli\'itics, Relax/stretch upper trapezius and levator scapulae
Relax/stretch subscapularis
Weak ;\gonist: lower and middle trapezius ':"dj\.tsVmobilize cervicothoracic junction and slernoclavicu·
lar joint
Overactive synergist: upper tmpc.zius. levator sCilpula\..'. and
3 r eathing correction and ergonomic advice
rholnboids
, Sympto/1/s (see Fi.~s. J0.6. 10.7, 10./4)
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~
Neck pain
(II/(/
Table 18.22. Treatment Approach for Altered Neck Flexion
"
Relax/stretch sternocleidomastoid

,~"
HC:ldachcs
Rotalor cuff syndromes (i.e .. impingement syndrome) Relax/streich suboccipitals
AdiusVmobilize CO-C 1 and cervicothoracic junclion
Shoulder blade pain
I Facilitate/slrengthen deep neck flexors
Correct poor sitting pos!ure
~ Postural Allalysis Lumbopclvic stabilization exercises
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
• Altered (oordilwlioll dllril~g lied flexion (see Fig. IS.34)
• Altcr~d·;.trlll SWillg
" • Shoulder de-vatian \'::th aml flexion '/i'iggl!r Paims

~ Muscle Lengt" Tesl.5 SCM

:<
Suboccipitals
,
~
~
• Shortened upper trapczius 'Hui Iev,Hor scapulae (sec Figs, 6,1
;;md 6,2)
Middle trapC7.ius
; ) Maslicalof)' muscles
1 \ £valllarion of Key MOI'cmcllt Pallems
l' , Mastoid process
I, ;
i • Ahcrcd sC<lpulohumeral rhylhm (sc<lpular fixation) (sec Fig, 5.20c) MobiliTy (joilll D)'sjtmclirm)
~
z, • ParJ.doxical respiration
CO-CI and err junction
~
;~ Trigger Points Lower cervi cui spine
I Upper. middle. and lower tr<lpczius
TMJ

I
~
Lcv:.JIor sc;;spulac
Subscapularis.
Altered Scapular Fixation during Trunk Lowerillg from
a Push-up ITable 18,23)'-',1','"
I,< Mastoid process. C2 and C3 aHachmenl points
Scapular fixation is import'lIlt for carrying. pushing. mu.l
i. Mobility (Joint Dysjimcfioll) pulling activities,
~
'i
~ Upper cervical spin~ \Vcak agonist: serratus anterior
Ccrvicothor.acic (Crr) junction Ovcr;]cti\'~ ~mtagonist: rhomboids
Altered Head/Neck Flexioll (Table 18.22Y7,,~,~Ii,!7,.J,' OvcrJ,cti\'e synergist: upper tmpczius. Icvator st:apl1\;;!e. and
Head/neck flexion is imponant for its relationship to pectoralis major. minor
standing or siuing posture and mastication, Symptoms
Weak agonist: deep neck flexors Neck and shoulder blade pain
Overactive antagonist: suboccipitals • Rotator cuff syndromes
Overactive synergist: sternocleidomastoid (SCM) • Ccrvicobruchiul syndrome

Symptoms (see Fig.\'. /8.29 alld /8.3/) Postural AfWlys{\'

Head'lClte Round \houlders (see Fig, 10.20)

Neck and shoulder bludc pain Winged ~c;;splliac (sec Fig. 6.24)
TMJ

Postural AlUllysis Table 18.23. Treatment Approach (or Altered Trunk

lowering from a Push-Up
• Head-forward posturc (sec Fig. I S.l2)
• Prominence of SCM (sec Fig. 6.4) Facilitate/strengthen serratus anterior
Relax/stretch pectoralis major and minor
Muscle Length Tests Relax/stretch upper Irapezius
Adjust/mobilize upper thoracic spine
Shortened SCM (sec Fig, 18.33) Postural re-educalion
I
f<
Shortened suboccipilals

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 Gail Allalyxis CLINICAL APPLICATION OF

• Winged :;capulae with ;Ifill JlhnCllIClll

REHABIl.IT.HION PROCEDURES
L
Differential Diagnosis of J\·tyofasdal Trigger Points and
Muscle Lel/gth Ti'xts Joint Dysfunction ),
SI,OrlClled pt:cloralis lIl;\jm {... ~'\.' Fi::. (1.31 II is dt=ar Ihal l1HISC!t= ;IlKl joint dysfunction are imer-twined, If
Shortcned upper It";lpCJ;ill .. ;llid k\,:llor scapula\.' t .. \.,\.· I':i,t:s. (l.J you take IlIl' \l-=w th;lt muscles ,Ire responsible for reflex COIll-
and 6.21 pensations 10 joint Of disk stress, then evcrylhing possible
should be done to feduce joi;H stress before addressing trigger
Ewtfuluhm (~,. f..('y Mm'ctl/cllt !'afferl/.,·
points. In g~ncral. triggcr points require little directtreatmcnt
Altcrcd scapul'lr li.\:llillll duril\~ trunk 100vcrill~ (wm a push·up (needling. isch~mic compression) if joints are treated first.
(!'ce Fi~. 6.19) Oftell, howcwr the muscle imbalances must be addressed to \
prevent joint slress. The proof ~f the success of the therapeu- i)
Trigger Poi",.\" tic intervcntion is disappearance of the jump sign on post-
Pcctmalis lIl;lj{lf treatment checks.
Upper trapezius It is still important to be able to differentially diagnosc
levator ~l:apul;lt: Illyofascial from articular sources of palpable tenderness.
Pel'toralis minor Bogduk .1I1d Simons discussed this issue.'" Trigger points sar-
i.\!\' lite lo/lOll"i1l8 (:rilaia: (I) a palpable band with :1 local
Mobility (Joilll Oys/wlClio,,) twitch response (+ jump sign); (2) reproduction of pain on
DCCrl.':t!'cd uppcr thoracic !'pilk' c:\tClIsiml palpation of the trigger point: and (3) relief with trigger point
ther'lpy. If a joint is cOl1sidered tlte .WJ1lrc,~ of!Jain, the follow-
Respiration (AbNQrmal or /Jarad(JXiclll Uespiratiol/) illg ,:,-ileria apply: (I) abnormal passive movement, espe-
(Table /8.24) cially of cnd-fecl: (2) reproduction of pain when moving the
Agonist: diaphragm joint: and (31 relief with joint anesthesia or manipulation. It is
Overactive ~yncrgist: scalcllcs. imcrcostals, upper trapezius not possible to differcntiate betwcen joint and muscle sources
on the b3Sis of the location of the pain. Both muscles and
Symptoms (xee Figs. 10.6 aI/(/ !O.S' joints can cause local or referred pnin.
Neck p"in and headaches
Chest wull pain iVl)'ofascial Pain Syndromes -.j
Thoracic outlet syndromc i
If an active trigger point (TP) is found (taut band. twitch
response, + jump sign, referred pain to larget area). lhe ap-
\.)
Posrtlml Analy:iis
proach is as follows 6 '''l\:
• Round shoulders
• Forward-dmwn head I. Assess for muscular imbalance
• Thoi..lcic kyphosis 2. Assess for joint dysfunction
1 Identify work or lifestyle factors
Evaluation of Key Movement Patterns 4. Aim trclltrncnt ai restoring muscle balance and rcmcdi:lting joint
dysfunction
P:lradoxical breathing (chesl bre:llhing. prcdomillate~ o\'cr abdo- 5. If treatment fails to eliminate TP use
minal breathing) Ischemic compression (5 to 10 second!' of sufficienl pressure to
recrcate referred pain)
Trigga Points Postisometric relax'ltion
t • SC~llenes Nutritional or metabolic factors m<lY also undermine success
I Rule out fibmlllyalgi<l and corticalization of p~lill (sec

1.,. Mobilily (Joi"t Oy.\/WlClioll)

Decreased laleral bcnding and extcnsion of lower cervical spine
Chapler 2)

Del.:reased lateral excursion of the rib cage F~lcct and Sacroiliac Syndromes
Manv of Ion back dISorders of the 80% presently labeled
nonspecific are undoubtedly related to problems of the facet
Table 18.24. Treatment Approach for Altered Respiration or SI joints. The 51 syndrome is prescnt in 1010 30CJc of pa-
tients with chronic low back pain.'~ Unfortunately. anesthetic
Relax/stretch scalenes
Relax/stretch upper trapezius blocking technique is the only known way to make the diag-
Facilitate/train diaphragmatic breathing nosis. and it has not been correlated with any physical tests.
Adjust/mobilize lower cervicals and thoracic spine Similarly. zygaphophyseal joints have been proven 10 be rc~
Postural re-education
sponsible for low back puin in at least 15% of pati~nts, al- {]
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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.)

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
i 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
!
)
I with pathokincsiology involving altered hip extension and
(funk nexioo. Improper loading in the sagitlal plane. espe-
I cially in a hypcrlordotic individual. would be the probable

I
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)
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 (hypomo-
! bile), and lumbar spine (hypcnllobile). Pain provocation of
?I
it the hypcrmobile joints and trigger points (in both the tight and
weak muscles) will be present. Typical flndings include a for-

I
\. !
\V<lTd~drawn posture (weak glutei and tight hip flexors) and in-

) creased lumbar lordosis (tight erector spinae and hip flexors

with weak abdominals and glutei).

Ii ) Altered hip extension synergy leads to overstress of the

lUl11bm facets because of load tmllsference from the stiff hip
., ..J joint to the hypennobilc lumbar spine. Extcnsion of the thigh

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occurs through a fulcrum involving the lumbar spine rather
than the hip joinl. Thus, the lumbar extensor muscles, in par~
licular the superficial erector spinae group, become ovcrac-
tive during hip extcnsion mOlions, such as gait, standing from
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ji a chair, climbing. and jumping.
Pain referral c.an be exPected from lumbar facet and erec-
•~ I, lOr spinae trigger point sources (Figs. 18.1 and 18.2). A for~
ward drawn poslure (sec Fig. 18.3) and erector spinae hypcr-
Fig. 18.2. Erector spinae trigger points. (From Travel! JG. Simons
DG: Myofascial Pain and Dysfunction: The Trigger Point Manual.
(
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I ,) I Iwrhy (Fig. 18.4). as well as lightness of Ihe hip flexors. Vol. 1. Ballimore. Williams & Wilkins. 1983.)

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 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 re-

duces pain l'fOvot:.uion (lendcr point or movcmcnt) ~lItd/or fa-
l"ilil;IIC", Ihe "wt:ak lill"" {glutt:us m;lxilllllsl.
EX-':fl.'.";'·" fnr illlpn)\"in~ slrt:nglh. endurance. ;:Ind Ikxihil-
ily 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 <Figs. I::L26 and 1:0':'27)
Ellliuranel.' exercise I,)r Imnk eXlension (Fig.. Ilt2X)

Pathokin~si()logy involving altered trunk ncxiQI1 al~o ,,

()\'crstress~~ the L51S 1 joints because of poor IUlllbopclvic
sl.,biliziltion, Trunk S1<lbiliwlioll through impro\'~d co-
,)
,
cll:m.lctiol1 of abdominals an<.1 glutc;ds is essential to preVCI\! !
fUrlher lumbar overstrain.
/)
The 51 ~yndromcs <lrc intertwincd with uhcred hip abduc-
tion. Weakncss/inhibition of the gluteus 'mcdius will resull in
ill(:r~'lscd lateral shear forces .1CfOSS lhc pelvis. Often. O\.'Cl'ac-
tivity or :-.hortcning ofthc adductors :Idds torsion to lite pelvis
through the pubic bones, which ,Iggravatcs an SI joim prob-
lem. The gluteus mcdius insuffic:icnc)' is .11 sa often <.:ombincd
with pirifomlis ovcractivity. which '1lso C;:IUSCS rotation of the
pelvis and odds [0 the 51 woes. The QL nmy substitutt: for glu-
teus medius weakncss wilh excessive hip hikilig, 'iih.L ,il()iig
wilh concomilanr lumbar problems. will refer pain into tht: 51
joint from its trigger points.
It is always best to look for dysfunction in the feL'1 when
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Fig. 18.3. For\'lard·drawn posture,
the glutcu!l mcdius is weak or inhibited. Hyperpron'llion is the ')
most common problem and with it come many manipulable

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
<Fig. IS.S,. The hip cXlcn:"ion movement paucrn may be al-
tered with ovcr'H.:tivily of the ereclor spinae and h'111lstrings
cOllpl~d wirh inhibitillll of th~ ghueu:-; muximus (Fig. 18.91.
Rehabilit<ltion l11:lIlagemcnt includes o.ldvicc. mo.lIlipula-
tion. and e.xcrci",c (sct.: Tahle Ig,7). For a typical facct sytl-
drolllC. simple ilJvicl.' includes lilc following: ..."
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<ltion (i.e.. adjustmcnl~, !llObilization. Inanual rc-

sistam:e techni<jlll;S) may address allY of the following func:-
lional pathologics if pr~sent:
Ci\-rr lumbar spine J
~h)hilizchip(rig. IS.I.1)
1vlvbilize libular head lFig. 11$.14)
Rl'1;tx/slrclt.·h iJ1\"lll\-...' d hip rk.'<ors lFi:;:>. IS. IS <.lrllJ l}i.lfl)
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 369

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Fig. 18.5. Test for shortened hip flexors.

lesions in the talocalcancona\~icular region. Evaluation of the function and reduce pathokincsiology acts as a catalyst
lower extremity kinetic chain is esscntiallo solving the riddle for reducing nerve root compression. C<lfC should be taken
of many 51 and [<leet "yndromcs. to emphasize extension motion of the three-.ioint com-
plex. McKenzie techniques have been l'hown to quickly
Disk Syndromes
Regardless of the C<luse of a clinically signific:ant disk syn- Table 18.25. Disk Protocol
drome. the start of relli:lbililJ.tion must wait until conservative
care has succeeded in reducing the irritability or compression Conservative care until nerve tension signs disappear
Nonweight·bearing exercise
of the nerve root. As soon as nerve tension signs decrease. ex- Aerobic exercise
ercise is highly beneficial (Table 18.25). Spinal extension mobility
Quadriceps strength/endurance
Advice to avoid positions of increased inlr~ldi.sc;:i1 pre.s~ Traction assistance nonweight·bearing exercise
sure. such as silting. arc important in thc carly stages Isometric trunk slabilization
(Fig. 10.1 S). Patient" should also learn (0 avoid any bend- Quadruped, kneeling, ball. standing stabilization exercises
Address muscular imbalances
ing Of twisling 11l0\'CIllCnls to which the disk is particu- Seated exercises
Inrly vulncmblc (Fig. 10.5). Manipulation lO improvc joint

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 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 fore-
head 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<ln the suggestion Ih:lt adjustment~
:llonc will do the job. or worse. 'IS sl<ucd by many neurologists
(after brain scans and the like). th'lI there is nothing wrong.
except stress (the p:1l diagnosis or
a psychogenic disorder III
Fig. 18.6. Test for shortened hamstrings. explain typical symptoms of l"ullctiomd patholug.y of lllL'
motor system!).
centralize symptoms relatcd to nervc root compression (sec From a rehabilitation perspe·~·ti\'c. hcadachc syndromes
Chapter 12). arc likely to correl<lte with pathokinc~iology i:~n)l\'ing allercd
neck nexion and scapulohul11eral rhythm. Pn::dict<lblc fUI\(,:-
tional pathologies elffect the SCi\.'1. suhocl:ipitals. uppcr
Head"che
trapezius. Icv:ltor scapul;lc. ;md pcct(Jr<lb (tightness). decp
The variety of types of hC<ldachc includes cervical. myof<.ls- neck flexors. lower and middle trapezius.•1I1d serratus anterior
l.·iaL nutritional. vascular (migraine). other (cluster). The ccr- (weakness). ccr\'icolhoracic junction (hypol1\obilc). and C4-
viGil and myof<.lscial hcad<.lchcs arc ;1n1cnable to chiropractic C5 joint (hypcrrnobile). Pain provocation of the hypcfmobik
nnd rehabilitation. Most headache sufferers have chronic or joints and trigger point5 (in both the light and weak muscles)
recurrent symptoms and thus rehabilitation should be in- is present Typical findings include a slumped. heOlu·forwaru
cluded in the chiropractic care of <lny headache paticnt, rc- posture (weak lower fixators of the scapulae and tight pec-
gardless of the degree of cervical or myofascial involvement. tom Is) and increased cervicocranial hypcn::xtcnsion (tight
As mentioned prc\'iou~ly. Watson and Trott dcmonstrated that suboccipitals ,lIld SCM with weak deep neck Ilexors).
Illuscle imbalances in lhe neck can distinguish bc(\.. .ccn Altered neck ncxion syncrgy leads to overstress thc or
chronic.: headache uno non "headache sllfrcrers.~(' Trclcaven cervicocmniaJ junction because or
the ..ulterior carriage (11"
and Jull showed lhat the SiJlllC muscle imbalances occur sig- the hC'ld. Also. the middle to lower cervical region (C4-5 and

Fig. 18.7. Test for shortened erector spinae.

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Fig. 18.10. a, Incorrect overhead reaching with back hyperex-
tended. b. Correct overhead reaching with posterior pelvic till.
Fig. 18.11. a, Typical ironing position. b, Use of a fool stool to re~
duce lumbar lordosis.
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I Fig. 18.12. Harmful hamstring

exercise.
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Fig. 18.13. Post-isometric mobilization of hip joint. Fig. 18.14. Mobilize fibular head.

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Fig. 18.15. Post·isometric relaxation rectus femoris. Fig. 18.16. Post· isometric relaxation iliopsoas.

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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. Fig. 18.21. Sell-streIch for light hamstrings.

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Fig. 18.22. Basic bridge. Fig. 18.23. One-leg bri'j:;~-; ("'dipS").

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Fig. 18.24. Bridge on the ball. Fig. 18.25. Superman

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Fig. 18.26. Squat.
Fig. 18.27. Lunge.
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 Fucilitate/slrengthcn lower .. au ;:lidd1e ~rap;.,'/.i(;:-; ;Fib'.~. I ::.~..;
10 t8.42)
,, Remcmber. it is time saving to find lhe "key link" which
,~ if manipulated can affect improvement in provocative tests of
I the inhibilcd muscle (deep neck ncxors).
I 'nlc following exercises arc recommended (0 improve
1 posture ,lIld promote strength, endurnnec. and ncxibilily:

Ii Fig. ~ 8.28. Back extensor exercise.

• Postural 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)

I! C5-6) is affected by the flattening of the lower cervical

• 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)
i curve and resultant biomcchanical change in the spinal stabil-
~ ity of the cervical spine. Patients experience typical pain When the scapulohumeral rhythm (SHR) is ahnorm,,1, any
,r: referral from trigger points in the SCM and suboccip- reaching or grasping movement can trigger ~\ he~\(lachc.
itals (Figs. 18.29 and 18.30). Joint sources of referred
I pain may also overlap with common referred pain pat-
Prolonged static overstrain from keyboard or writing work is
also a common culprit. Muscular imbalance involving ovcr-
I terns from muscles (Fig. 18.31 ):(1 Some patients may have
a head-forward posture and prominence of the SCM
activity of the upper trapezius and Icvator scapulae and inhib-

I (Figs. 18.32 and 18.33). as well as tightness of the sub-

itcd lower and middle trapezius arc usually responsible.
Upper cervical and cranial ::lttuchmcnts for the upper trapezius
I occipitals. pectorals, upper trapezius. and levator scapulae
(sec Chnptcr 6). The neck flexion movement pattern may be
and levator scapulae can become hypersensitive and Iheir
joints become hypcrmobilc. These headache patients sense
I ahered (Fig. 18.34).
Rehabilitation management includes advice. manipula-
most of their pain in the back of the head. but occasionally
they describe pain over the eyes.
tion. and exercise (sec Table 18,7). For a typical headache Advice about an ergonomic warkst.uion helps immeasur-
\, syndrome. the paticm is advi~ed !c: !.!s!= :: hcad~et if on lhe ably to improvc SHR. One intcrvention involvcs the usc of
lclcphone for prolonged periods, make available an er-
i gonomic computer workstation (sec Table 10.2). and correct
ann rests. which allow the arm to rcst in a relaxed position,
Secondly. the writing surface. typewriter. or keyboard should
i
I
poor sitting posture (Fig. 18.35).
Manipulalion (adjustments, mobilizalion, manual resis-
be at a height at which the wrists function in their neutral
rnnge. the elbow is flcxed 900 • and the shoulder girdle is re-
tance techniques) involvc the following potcnlial functional laxed (sec Table 10.2). Manipulation should focus on relaxing
pathologies: the upper trapezius and levator scapulae. Specific joints in the
• CMT ccrvicocranial and ccrvicothor.lcic junctions ccrvicocranial or ccrvicotharacic areas may need adjustment.
• Relax/stretch SCM (Fig. 18,36) Exercises to strengthen the lower fixators of the scapulae are
• Relax/stretch suboccipit.l1s (Fig. 18.37) necessary to avoid further ovcr.activity in the clcvmors of the
Manuallraction cervical spine (fig. 18.38) shoulder girdle.

,
'----'

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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.)
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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.)

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Fig. 18.31. Referred pain from celVical spine joints. (From Dwyer Fig. 18.32. Head forward posture.
A, April C. Boyduk N: Cervical zygapophyseal joint pain pattems:
A study in normal volunteers. Spine 15:453, 1990.)

Abnormal "respiration should also be evaluated in all downward shift of the ccrvicOlhoracic junction:I'J·~1l f\ccording
headache pntients. Those patients with weakness of the deep to Janda. the ceryicothof:.lcic junction can move as low as
neck flexors and upper thoracic kyphosis may have an aggra- T3n·4. This positioning is not biolllcch'lllic.llly sound, and
vation of their pain if we adjust their necks too aggressively
certainly is unattracliye.
or too frequently. As the upper thoracic spine extends more Unfortunatcly, such posture certainly can lead to the lho·
(and the lumbopelvic junction stabilizes), neck adjustments racie outlet syndrome (TOS) from scalene anticus or pec-
will be more successful. lOf<Jlis minor entrapment. easily verified by lhe AER (abduc-
tion. external rotation, lest of Roos.SI.S~ M:.my "authorities"
say TOS is an example of a psychogenic disorder. yel the dys-
Thoracic Outlet and Cervicobrachial Syndromes
thcsia is so prcdictil.bly on the pinky and not the thumb sid\?
Shoulder blade pain. chest pain, ccrvicobrachial syndromcs. and is reliably reproduced by the AER test. Indced. its origin
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:.md headaches can all come from a forwan.l·drawn head and is neurogenic .md not vascul<lr or psychogenic.
 · .. _ ..• _ ·._......... ' ... "I"\I'V'~ r-nvlul.-VL:> 377

Fig. 18.33. Screening test lor sterno-

cleidomastolCl

Fig. 18.34. Altered coordina:ion during

neck flexion.

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Fig. 18.35. Corree! poor sitting posture.

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Fig. 1&.36. Post· isometric relaxation sternocleidomastoid.

Advice would include avoiding slumping. cspcci.l!ly other neck or back complaints. Trauma involves inflamma-
when silting. Manipulative treatment may sian with the pcc~ tion. and a~ such, treatment follows a slower coursc/'
toralis minor and scalenes, but progresses often to include Rchabilit.ltion C<1Il1101 begin until the "chemical" signs of ill¥
middle and lower trapezius raciliwlion. Exercises to improve fiamm"ltion decline and thc pain becomes morc "mechani-
posture. strengthen the lo\\'er fixators of the scapulae. stretch ca'" (sec Tables 2.15 and 2.16). The usc of physical agents
the pectorals and hip ncxors. and stabilize the lumbopclvic (ultrasound. electrical muscle stimulation. heat. icc. etc.)
region may be necessary. Improved rC\piralion. hC"lcVncck may be required until completion of the inflammatory ph,lsc
flexion coordination. and lower cervical extension mobility of soft tissue healing.
are also esscnti:.l1. Overly cilgcr fleck adjusting may aggr,l- Both muscles <.lod joints have becn identified .IS sources
vate lhe complaint. especially if the patient has a cervical rib of chronic pain after whiplash injury or concussion. 1(,.~7 From
or \\'eak deep neck flexors. The soundest principle to follow 50 to 70% of patients with chronic ncck pain havc been
in TOS involves stabilizing the b.ISC of the spine and im- shown to have posterior zygapophyseal joint syndrome, If>
proving the mobility of the upper thoracic spine. Typical muscle imbalances invQlving weakness of deep neck
flexors and tightness of the suboccipitais have been identified
in postconcm.sional hcadache paticntsY
Cen'icaJ Acceleration-Deceleration Syndrome
In patients who arc victims of trnuma, it is imporwnt
P.;ui~nls who havc suffered Illotor \'chiclc accidents auto- to be alert to psychosocial problcms that could intcrfere with
Illaticnlly must be considered difTerently from those with a full rcco\:"cry.~-· A biobchavioral approach is a nlll:-i.
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Fig. 18.37. Post·isometric relaxation

suboccipilals.

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 cer-
vical overstress. Calf strctching and dorsal cxtension l1exibil-
ity exercises (cats, doorway, ball stretches) and strengthening
exercises (back extension on the ball, supenmms) also arc tol-
erated well in the subacute stage, and should reduce cervical
ovcrstress.
For paticnts in whom excessive muscular guarding is
Fig. 18.38. Post-isometric traction cervical spine.
maintained for more than 2 to 3 weeks, regaining lower ccr-
vical extension becomes a key to improving o\'erall function.
Overemphasis of the usc of passive means (physical agclUs) Adjustments, joint mobilil<uion, and gentle stretching tcch-
10 treat pain and promote soft tissue healing promote illness niques arc important in such cases.
behavior. especially patient dependency. A rch'lbilitation ap· The question of resistJncc exercises to the ncck is an im-
proach should begin as soon as mechanical symptoms pre· portant one. Physical therapisls havc advocated that the pa-
dominate over chemical signs of inflammation (radicular tient apply isometric resistance to the neck. Recently, chin.l·
complaint subsides and relief positions other than rest an: praetors have begun 10 incmporate resisHlI\c~ exercises to the
present). The goal of patient education and advice is to reas- neck (i.e.. McdX or Neck Sys programs). Bt:c.H1sc of the in-
sure the patient aboullhcir overall positive prognosis and Ihe herent instability of the neck. such exercises should not be un-
benefits i1nd safety of carly mobilization and activity. dertaken unless the patiellt is clearly out of the acute, inflam-
,, \Vhen the inflammatory phase is subsiding, within I week matory phase; has no periphcralization of symptoms; is' per-
in cases of mild 10 moderate truuma (sec Tables 18.26 and fonning movements that minimize joint compression (avoid
2.20). aClivc rch<.lbilil<.ltion may proceed. Manipulation may uncoupk:d movements like side bending with (,'ontralalcral 1'0-
stan wilh gentle musclc relaxation tlnd joint traction or mobi- talion); and has no aggmvalion of local p'lin. MOVCIllCIll pat-
lization procedures. Typical functional pathologies targeted terns described by Janda should be assessed before the st.H1 of
include overactivity of scalcncs, SCM. upper trapezius, leva- any resistance training, and post-treatmcllt checks should
tor scapulac, suboccipitals, and the pectorals. Early rehabili- confirm that incoordinatcd movement patterns have not wor~­
tation efforts should bc directed toward preventing the "pro- cned as a result of overaggressive neck exercises. Pre- .Illd
gramming" of any of these typical muscle imbalances. Gentle posHrcmmcnt checks of trigger points should also adjudicate _
PIR (no strelching) 10 the overactive muscles helps in thb the merits of these exercises by clearly showing that sort tis-
regard. Gentle mobilizntion, adhering to McKenzie princi- sue lendemess is decreasing as a result of the wlining.

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Fig. 18.39. Facilitation 01 the lower fixalors of tile scapulae. Fig. 18.40. Facilitation of the middle trapezius.

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Fig. 18.41, Facililation of the middle trapezius. Fig. 18.42. Facilitation of the lower and middle trapezius.

The SHR is the pancrn of joint and muscular aClivity oc-

Rotator CulT (Impingement) Syndrome
curring during shoulder 'lbduction and nexion. Its purpos~ is
Imping.:mcnl syndromes in the shoulder represent one of (he to kecp the glenoid fossa in a biol11cchanically optimal posi-
more iruriguing rehabilitation probk:ms. The shoulder girdle tion !O receive the humeral head. If the ann is internally
functions as pan of a kinetic chain linking the neck to the rotated (impingemcllt test). abduction will be limited by tile
hand. ~lany mus(,;1cs in this region.mach 10 the ccrvic.;;al spine grc,ller tubercle striking the acromion process and l,'or;l-
and thorax: thll .... addn..'ssing the shoul(kr is crucial to many coacrolllial ligamcnt. Total abduction is 1800 • The gkllll-
spin.1I disordl:rs. The shoulder is an inherently lHlstablc humeral contribution i... 120(.1 :.md the scapulothm:.u.:ic c{)lltri-
joilll-·;l large h<tll and :t small 'Ockcl-in cOlllrast to the hip. nutioll is 6()o. Thus. there :'Ire two degrees or glcllohulll..:r~11 "i1
\vhich has many related joints and muscles that acl in COllcert nHHion r(lr evcry one degree of scaplllolhoracic IlH'lioll. In tllC
10 allow a wide v:.tricty of 1ll0\'Clllcnls. \Vhcn we speak abollt first 30(' to 60 0 -thc .selling phase-virtually all mOVC1ll\.':l1t is
the !'ilwuldcr we should begin by discussing the sc;\pulo~ glcllo!lulllcml. Afler that ph'lsc. 'lb<.luction occurs roughly
humeral rhythm (SHR): Especially in cases of impingcmcnt. equally hctween the two functional joints. Two other j~lints
in comrast 10 instability. the SHR is tilL: most important fUllc.:- also participate in this .symphony 01" motion. tmmcly. til,,' sl..:r-
lion.1! ph~nomc;na rchued IU clinical problems in the shoul- 1UH.:1'lvicular ;In<.l i,l(;romioclavicular joints.
dCI'.-t" It rel:'lICs W the movemcnt!\ of Ikxioll. abduction. and i\S lhe arm moves into ahduclioll. thc scapula rotalc" up-
"SGlplil1ll" (scapular plane abduction). wardly (inferior/medial bordcr 11l0VL:~ iater:.lIly) 10 p()sitipl1

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Exccssiv(' dC"iltion of the shoulder girdle caused by too

!
i
much upper trapezius. levator scapulae. and rhomboid activ~
! it)'. along with 100 little lower trapezius and latissimus dorsi
~ activity, GIU:\t.:S impingemellt.
,I \ TIlC rchahilitation of shoulder disorders is complex but
! n;\\';mling bCI'~llISC of the v<lriety of muscles and joints in-
teracting in a far from str;'lightforward manner. Much more
is involved than just strengthening the rotator cuff muscles
in the manner laid out by orthopedists and their physical
therapisls (in fact. the f<.lmous "empty can" internal ro-
lation scaplion exercise is contraindicated). The key to
success is focusing on thc SHR, as well as joint mobiliza~
liO!.1 and muscle relaxation and training. Muscle stretch-
ing aimed ;l[ improving shoulder external rotation (in-
fr:lspinalus. pectoralis major and minor) often facilitates

I
the rehabilitation. The role of a tight subscapularis (inter-
nal 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 ex-
"
H Fig. 18.43, Proper postural sel of head and neck.
I ercises for this !lon·weiglll·bc<.lringjoinI.J<-·~.l\Yall pushes may
be lead to exercises on all fours. The practitioner should
~ the glenoid fossa at the proper angle to receive the humeral \.....ltch for proper scapular fixation. Patients may then progress
t
~ head. The serratus anterior. upper trapezius. and lower trape· tn tripod positioning and. eventually. the hand may be placcd
! j'jus help to achieve this movement. Downward rOlation is on a balance board or other labile surfacc.

~• promoted by the rhomboid major and lcvalor scapulae. For

the prime abductors of the shoulder-the deltoid and
The second dcvclopment is the usc of medicinc balls
and a rebounder to plyometrically train the shoulder gir~
~,i,'
. supraspinatus-to operate near capacity. the trapezius and dlc.~ Throwing and catching is a simple. fun activity that
serratus anterior must act synergistically. The upward rotation can be varied to reintegrate the muscles into a coordin-
il
F: of the scapulae allows the deltoid and supraspinatus to keep a ated. stable functioning. The main advantage is that eccen-

I
proper IcngtlHcnsion rcl:.ltionship. so they do not lose their tric and concentric actions are combined in this powerful
strength. approach.

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 Hand wt.:'i!!hl~ ,mtl t:abks .Ire m'linst<lys fur shoultkr tr"ill-
in!!. Excrci!'c -tullin!!. avail •• hk ill a variely of resisl;,uKCS. is
al~u "Ill incxpcnsive-. simph: Ir:lillill~ 1001 r(lr home lise.

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 CUlll-
monly 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 over-
ilctivc TFL sllbstilUting for a weak glutcus mcdius. Comlllon
muscular problems asso<.:iated \\'ith knee problems indudc

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Fig. 18.46. Posterior and anterior pelvic lilt while Kneeling (but-
Fig. 18.45. Home exercise for middle and lower trapezius. locks on heels).

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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
adductor:-. <ll1d pirirorl1lis.~·~ and weaknt.:ss or the hamstrings tighler. Ikfon: an iliolihi.d hand friction syndrome de\·d(lpS.
,lIld gluteus mcdius. Proprioscnsory and other bioll1cchanical km.:e pain can occur. Re:,1. icc, and the usc or
1Il1llslcrllidai
faults from the ,"ecl ,Ire also prohlcllwlic. Lumbar spine, as arui-in!l,11lll11"t\ory :lgCllts arc nol Ihe solution. Along ",ilh
well :I:' Sl. IalpUufal. ,lilt! hip joint dysfunctions must also bc looking til the fecI. .Iss('ssing lhc glllll..·IlS medius for In\\'cr
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lilllh 1..'I\1I1rol durin.:; olll..'-k.:; weight he•• rill~ is e:-.selliial (the

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 \"onJ-u- I t:.H 10 : J4.L. J I Vt: Ht:HAtilllTATION PROTOCOLS 383

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i.i Fig. 18.49. Upper back cal.

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".' hip abduction \~S( is an casy screen). The key is not to wait matoscnsory affercm system depends on the soles of the feet.
~ unlil cartilagt: or meniscus damage occurs or for the surgeon the neck. and the lumbar spine for input.

I, to pri.IClicc Ihdl' l,ltcr'll rclc~lsc pro<.:cdurc.

Lilllih.:d r.mgc squats and lunges can be <Incmptcd. If .the
tracking docs not allO\\' Ihis 1ll0VCmclll 10 occur painlessly.
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.
j several steps arc n::collllllenucd that obviate retreating to open lion and then treating thc related muscles or joints. Post-
~
chain exercises. 51> Streich out the light mllscles. sran pro·
,i prioscnsory balalll.:c training. and facilil<.llC the gluteus
whiplash injury dizziness is most likely ccrvic;,11 in origin as
well. 6 I.l'! Gugey developed a systematic way of studying the.

I ~
medius. Then. rclUrn (0 squ..us 'lIlU lunges ,tIld gradually in-
crease the depth of knee flexion. The training or functional
connection between the poslural system and the balance sys-
tem. 5'> Differentiating between primary feCI. lumbar. and cer-
y range should quickly expand. vical disorders is crucial.
I Vestibular dysfunction is known to be related to poor
,~ Dizziness ~lIld Bal.anl·c Disordcrs motor development in children. Children with vcstibular
i l
The mOlor ~y"lcm lk'pClld~ Oil appropri,lIc inpul from so-
deficits cannol stand in a darkened room (you need two of

I
three afferent systems to maintain motor function). Long-
malosensory, \·cstihul;'lf. ;'lIld \"i:..ual pcripheral alTcrcfll s)'s-
standing vestibular exercises for the trerltInent of dizzin~ss in-
lems.~~·~s Without one of these sy.. tcm..... sud\ a!'o in bli·iluncss.
clude thc usc of hammocks and gyill balls lO help train th~
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
labyrinth <.lnd tracking exercises for the eyes while the hC>1d is
moving.
I cnsue. Classic examples ;'Ire the nausea that dc\"e1ops on a
boat whell lht: vestibule notes the motion hut the fcct <lnd eyes
The visual "'ystcm C;,1I1 be an interesting area in\'oh'cd in
j do not. or when lying on the ,grass on a breezy day \\lith big.
dizzincss or neck pain. Optokinetic reflexes can be trained
(e.g.. lighter pilots and figure skaters). Gagey found that a
puffy clouds floating by. The skin and vC.'Hiblllc rcgislcr no
mapping error of visual fields often results in increased ten-
movement whilc th(' eyes do. Dizziness or n;'lllsca may result
sion in the upper lr:lpezius. 5') Following correction with spe-
from such a ~cnsory eonl1il'l. Neck pain or C\'en low back pain
cial prism;,nic lenses_ the trigger points dissoln~ :-pOIlW-
can result jf ~uch ;\ sensory conflict is maintaincd.~'· The so-
neousl)'.
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 feed-
back 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<ld back (laking the otoliths Ollt of their fUJ1l-lioning
range).
In different ways, bOlh Lewit and Gag.ey reponed on lhe
relationship between the fect. balance. ;,uH.i vestibular prob-
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Fig. 18.50, Upper thoracic spine extension stretch. klllS. 5'IN.r-l Lc\\'il ;11"'0 found th,lt corrcclion of a pmhol(lgic

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problem involving the. cervical spine plays a role in improv- est error in the treatment of paticnts suffering motor vchide
ing standing postllwl dysfunctions.'oO Corrcdion involved PIR :lccidents is the a.~sumption of a moderate to severe injury
to the SCM or masticatory muscles or the CO·C I joint. when in facl the injury is only mild to modcrate.~·' It is difli-
cult to differentiate between a mild and a moderate injury/'7
Without proper documentation. a mild or mild to moderate in-
ETHICAL OFFICE PROCEDURES
jury must be assumed .\ltd. with it. the appropriate type and
Soap Notcs duration of carc (TJble 18.26).
At the initinl examination, be sure 10 rc('ord the: presence. of [f an insur.mce adjuster or auomey questions your servicc
any rcd flags. Then. perform the necessary tests to identify codes. SOAP noles. or neccssity for active carc. sevcral points
nerve rool or inflammatory conditions. Fimlily. review all po· can be raised to legally defend your treatmcnts. Standards of
tential complicating factors (sec Table 18.4). Thc hislOry, care or guidelines have emcrged in neuTOl11usculoskclctal
physical examination, and sholl form questionnaires arc all medicine, and this political hot potato has not been a welcome
that is needed to identify these complicating factors. The use sight to many practitioners. Guidelines, however, arc an ac-
of expensive pathophysiologic diagnostic testing equipmcnt curate representation of the state of science if not the state of
the art. As such, they arc not meant to be applied \Vilhout ex-
i or seeking special psychologic expertise arc unnecessary.
ceptions. but to serve as guidelines. These guidelines for care
~~
Our SOAP noles for each paticn! should rcflcci Ihal our
management strategy is rehabilitativc rather than traditional. have been established as a result of review of scientific evi-
To 'Iccomplish thi!'i t<l!'ik, the p;:llient"s .mbj(xti\·(· complaints dence and. where evidence is !:Icking, expert consensu!'i opin~

i arc objectified by recording a visual analog scale and a pain ion. Many practitioners arc s.urprised to realizc just how help·

~ diagram every 2 weeks. Objective lindings arC' ql!2!'1!ified by ful guidelines can be. In the past, reviewers could SlOp
payment on an insurance claim without good reason. Now,

I
i
i
using functional capacity mcasuremcllIs. which arc quantili-
able yet incxpensive (sec Chaptcr 5). Even lenderness can be
quantified without needing to purchase an algometer.
Functional changes and results of provocative tests arc noted
you can defend your practice and quote the guidelines. There
arc no longer any secrets. which can only work to the advan-
tage of the honest. ethical doctor. Quality assurance is a go"ll

I
so that treatment has some b"1Sis and progress is noted. of managed carc. Thus, providers practicing to the highest
Assf.!ssmeflt should indicate the presence of a functional standards will be sought.
disorder as opposed to a pathoanatomic problem. The treat- The Mercy Ccnler Conference was an example in which
ment plan should address functional changes naled in the ob- such a guideline process occurred.6 Active care wa.'\ dislin-
guished from passive care in several ways. First. they ad-
I jective section. Active care procedures should be clearly de-
dressed stages of treatment and their goals (p. 120):

I
scribed so they arc not mistaken for passive procedures.
Passive Care
Report Writing I. Acute intervention

I ~
Billing procedures should also renect the use of active ap-
proaches. Therapeutic e::ercise (97110) and thel'dpeutic activ-
ities (97530). arc excellent examples. Medicolegal repoTts
Active Care
I. Rcm()biliwtion
2. Rehabilitation
a. Re~toring slrength and cndurance
~ should clearly state the positive results of orthopedic or neu-
n rologic tests along with findings of functional assessment. It
b. Incrc"lsing phy<,ical work capacity

II is improper to assume that long-tenn care is Ilccess<ll)' or ap-

propriate for the majority of our "whiplash" patienls.~·' Under
3. Lifc:'lylc ~ldapla(iuns

Second. thcy clearly sWlcd lhat aClive carc was essential

our care, mild tmuma should resolve within the samc time (p 110). ··It is beneficial (0 proceed to rehabililation plmse ~IS
~
i framc as would be expected without any treallnent (6 weeks). rapidly as possible. and to minimize dependency upon pas-
~ Unless we can demonstratc that a moderate or severe injury is sive forms of trcatJnentfcarc." Again (p 125). "AII cpi!'iodcs of

I present, it is hard to justify treatment beyond the time of spon~

taneous symptom resolution.
symptoms that remain un<,:hanged for 2-3 weeks should be
c\'aluatcd for risk factors of pending chronici.ty. Patients at

I
This statement does not ignore the f'Jet that some patients risk for becoming chronic should have treatment plans altered
take longer to get well. nor docs it imply that symptomatic re- to de-cmph:lsizc passivc "arc and rcfocus on active care
lief is the only goal; restoring function is an extremely im- approaches." ',,)
portant goal in rehabilitation. According to the Rand rep0rl on
spinal manipulation. if a patient is progressing v,:ith nmnipu- Table 18.26. Grading Injury Severitr '

I
lative intervelHion. then tremmeot should nol be cut ofLI'.\ This
conclusion is in fact an albatross to insurance adjusters. If. Mild Pain on stress 01 tissue, local tenderness. mild
=:
swelling. no gross instabilily
however. a patient is not making objective improvement. lhcn Moderate = Pain on stress of tissue. generalized and marked ten-
manipulative treatment C"1Il be cut off after 2 to 4 \\,-·eeks.l'....folo derness and swelling, mild laxity, no gross instability
Severe = Gross instability. generalized swelling, disruption ollis·
it Be prepared to document the patient's progress and to de-
fend lhe aSSC!'ismcnt with rcsjJt;l;l iu injury scverily. The great-
sue, sometimes minimal pain

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 385

Th~ British St;mdarus Advisory Group for Back Pain sim~ itatian is esscntial for all palients, including those considered
llarly slalcd thm <ll.:livc rare \\,<\s a distinct and impor1ant type.;· candidates for surgery. Saal and Saal said, "Failure of passive
or case lll:lnagcJ\\clll.: On page 38, "At prescnt, the main em- nonopcrarive treatment is not sufficient for the decision to 01'-
; , or
phasis physical therapy fOf back pain is on symptomatic re- crmc:' In it randomized, controlled trial looking at exercise
lief or pain. despite e\'idence thallll<lny of the modalities used and passive care in failed back surgeI)' patients. Tim1l1 found
an: incffective. Symptomatic measures to control pain are fC- that 100\·-tcchnologic exercises (stabiliz'ltion and McKclli'.ie)
lluin:d hill lhis should be lIscd to embark on active rehabilita- were of greater benefit thiln were high-tcchnologil.: exercises
lion rather than he seen as an end in itself:' TIley went on to (Cybcx). physicalmcthods. or joint mobilization. 7-4
state (p 46) "We recommend.... There should be a change of
clllph~lSis ,111<..1 rcdin::ction of resources from symptomatic CONCLUSION
treatment. to the provision of active rehabilitation and patient
education... Rehabililation is .m exciting new way to practice. This para-
digm allows us to evaluate regional conditions in light of dys-
The American guidelines from AHCPR were emphatic
function in lhe entire locomotor system. It is also a highly eth-
in their criticism of physical agents: "Physical modalities
ical way 10 practice because it reduces patient dependency on
such as massage. diathermy. ultrasound. biofeedback. and
passivc. pain-relieving approaches while leaching patients the
tr~tnscutaneous electrical nerve stimulati~n (TENS) also
sclf-treHtlllent techniques needed to develop control over their
have nu pruvell efficacy in the treatment of acute low back
symptoms. By focusing on functional restoration (instead of
symptoms.
promotion of tissue healing). we can achieve quicker and
COIl\'illcing scientific evidence is beginning to emerge
more lasting results with spinal adjuslments. b~'cause we are
ahollt the usc of active c~rc before the chronic stage. Refer to
:ldd... ::~:-.:ng tl1:: underlying cause of most pain syndrornc~.
Chilptcr I for a full revicw, including the topic of chronic
Future neuromusculoskeletal specialists will not only bc ex-
carc. Linton dcmonstrated that carly aggressive treatment (p'l~
pens in manipulation. but also know how to transition from
·Iienl education. exercise instruction. physical therapy) WOlS
passivc to active care. and evaluate the biobch;l\'ioral compo-
superior to traditional treatment approaches (rest and anal-
nent of musculoskelet'll illness. Improved results in our prac-
gesics without physical therapy for 3 months). "Properly ad~
tices and accompanying cost savings in the health care system
ministered Eurl)' Activc Intervention may therefore decrease
will be rcalized by the improved managcmelll afforded by the
sick leavc and prevent chronic problems. thus saving consid-
new rehabilitation paradigm.
erable rcsourccs.·· hS This study is particularly powerful in lhat
the risk of dcvcloping chronic pain was eight times lower in REFERE~CE••' i
the early active intervention group than in the traditional I. Bigos S. BowycrO. Braeo G.C( al: Aculc Low Bad, Problems in Adul!!'.
group. Clinical Pmelice Guideline. Rockville. MD. U.S. Depanmenl of Hcallh
In a comparative study of passive physical therapy versus and Hum,1ll Servicc:s, Public Health Service. Agency for HC<llth Care
Policy ;.lnd Rese.m-h. 199-1.
rehabilitmion. Mitchell found. "Active exercises to provide
:?:. Clinical Sl:tntl:1rds I\dvisol')' Grollp: Had POlin. London 199-.1. HMSO.
mobility. muscle strengthening. and work conditioning lUIS 3. u-wit K: Chain reactions in t1istllrhctl function oi lhe motor !:ystcm.
shown superior results ... substantial saviofs have been real~ ~1<mudle Med :3:27.1987.
izcd in the number of days absent from work .md savings in -I. Ri,,<,:mcn A. Alar.mta H. Sainio t). 1.:( al: Isokinclic and non·dynamomct-
the dollars expended for compensation benefits. There WaS an ric Ic\IS in low back pain palicnts rd:\lcd to pain and dijal:tility index.
5. Grabiner ~·lD. Koh TJ. Ghaz'lwi AE: Decouplinp. of bil,ller:tl paraspinal
initial incrca~c in health care costs resulting fromlhc intensity
e:\cil:ltioll in suhjccts Wilh tow bal'k pain. Spine t7: I~ 19. 11)91.
of the treatment. but these costs were morc than offsct by sav- 6. ilaldeman S. Chaplll:IO-Smith D. Pclersc:n DM: Frequcncy ami duration
ings in wage loss CO;-;.."/I.I of care. In Guiddjnc~ fur Chiropr:ll"lic QualilY A~sur:mcc and Praclice
Lindstrom ct al compared a group of patients trealed with Paramelcl'$. Proceeding of the ~lcrey Cellier COIlSC(\:'U:- Confcrclll:e.
exercises and education to a marc traditionally treated control Gajlhcr~burg. Aspen. 1993.
7. Lc\~it K: Manipu!:llivc Therapy ill Rch:lbililaliol\ (If lhe- \tt1lOr Sysfem.
group <lnd documcrHed earlier return to work and decreased
2nd Ed. London. Butlcrworlhs. 1991.
rc-injury in the rehabilitation group.111 The notion that active [oi ~kKenlic Rt\: The Lumbar Spine: ~lcdHmie:ll Dja£m'~i~ ;md Thcr.:tpy.
exercise can be harmful to an individual experiencing pain is \\'aibo,u;. New Zeal.md. Spinal P\lblic:uions Ltd .. 19801.
incorrcct. Guided exercise by a properly truined rehabilitation 9. Tra\"el! lG. Sinwns DG: Myofasd:ll P'lin ilnd Oysrull~'lioll: The Tri,!;ger
specialist is the optimal treatment program for lhe subacute Poim MilllU31. Vol 2. B<lltimurc. Willi,lIlts & Wilkins. 199~.
10. Lcwil K: The funclion,,1 approach. 1 Orlhop Moo t6:i.~. 19940.
population. A key is exercising to a pre·established quota
II. Jull G. Janda V: Muscles and Molor Conlrol in Low B:ll"k P:lin. In
rather than to a pain Iimit.~·71 Waddell stated. "There is no cv- Twomney LT. Taylor JR (cds); PhysiC'll Therapy for the Low Back.
idence that activity is harmful and, contrary to common be- C1inie~ in Physical Thcrapy. New York. Churchill Living.slone. 1987.
lief, it docs not necessarily even aggravate the pain."n 12. Janda V: Muscles and ccrvicogcnic pOlin syndromcs. In Gr:tm R (cd):
Saal and S~l<Il trcated a group of patients who had back Physical Therapy of lhe Ccrvil-al and Thorneic Spine. New York.
Churchill Livingstone. 1988.
and kg pain ilnd were referred for surgery. They concluded
13. Hul1ock-Saxlon JE. Janda V. Bullvek MI: Rellex a':Ii\':l1i~)[l of glutcal
"All patients had undergone an aggressive physical rehabili- mu~cJcs in w:llking.. Spine 18:70..1. 199).
)
lation program consisting of back school and stabilization ex- 14. Spiller WOo Lel31:mc FE. Dupuis M: Quehec T:lsk Forcc un Spin:lI
ercise training ... 92% return to work ratc.".,.·1 Act:·:~ :-ehabil- Disorders: SCicl\lilie :lpproaeh In Ihe asscs:-menl anLllIl;lIl:lgclIlent of :tC-

www.bodywork.su
 li\'ity-rclalcd spinal disorders: A monograph [or clinicians. Spino.: ~8_ M;,;;II;I::. ~I~r.:...: ~:_ .-'.::1,::::::: ~!. :: ;:~: ~;r:;:..: 11 :731. 19SCI.
12(SuppI7):SI.1987. 39. Lehto M. Hum,.: ~1. ..\lar~lI\t<l H. ct al: Cillllh:Cti\"c 1is.~IlC l'll'lllgCS of til....
15. Schwaner AC. April eN'. Bogduk N: 1111,: s;lcroili;lc joint in "hronic Illw llIultilidu.~ lIlu_,·L· in r;llil'lIl.~ with lum!l:lr dis,' hl'rniati'l\\: All ilHllllllll1-

back pain. Spine 20:31. 1995. logic SlliUr l.j ":"".1~~"n Iypes I :md III and libmnectin. Spin... I·L~lI~.
16. Bamslcy L. Lord SM. Wallis IlJ. et 011: The pre\'3Ielll"C of chronic cer\'i- 1989.
calzygaphophysc..11 joint p"in ;.ftcr whip1:lsh. Spine 20:20. 1995. -Ill. Zhu XZ. Paml..:!"ur \1. Nmdill M. el :11: I-lis!o,:helllislfy "ml morphol.
17. Jackson RP: TIle [acet syndronh.:-lvlyth or realllY? Clin Orthllp Rel Res ogy Ill' ..:r\,~·t('r -]'1ln;I<.:: muscle inlullIh'lf di~l' hl'nli.:ti(JI1. SpillC 1·1:.~()I.
279: 110. 1992. 1'lX\).
18. Schwar£cr AC. April CN. Ocrh)' R. CI al: Clinical features ()f paticnts J I. bnda V: Mu_,·k _!r':I1~lh in ,,:l:Iti"l\ It. IIllhdo.: lenglh. p;.in :llu!lIlu._,·k
with paill :.,cmnliii£ from :hc 1:J::lbr ... j't;:r:~~\r:!:j':O:::~! ;c:ltts. SrillC illlh,tIOlIlC":. In H.i.nll,,-Rindahl K (\'dl: ~lu....:k Slrcn~lh. New l'''rl...
19:1132.199-'- Chtlrch;ll t.i\-in~_1(lnl'. 191).'1.
19. SchwarLcr AC. April eN. Dcrby R. et al: 111c relative contributions ~lr 41. S,.hrlll:tn SA: P,1'QUrC and muscle illlh"I'lllce. hlllily IUlIIh<lr pdvic .lli:,:t1-
t:'c disc amll.yf,OIj>ophyscal joim in chronic low back {Xlin. Spine 29:l'iOI. IIll'IUS. Ph)'S Th.:r 6i:Il'i-t 11)87.
1994. ..0. Janda V. SdmllJI HJ:\: to.'lusdc" as a l":lIhogCllic fac1\lr in hack p:lin.
20. Moffroid MT. Haugh LO. Hcnry SM. cl OIl: Dislinguishable groups of Intcrnalion:.1 F~'lkr:ltiull llr M:lIlipulali\'c Physic:.1 Ther:lpi~I"
museuloskeklal low back pain patients :l.nd asymptonlatie control suh- Proceeditll;~. Chrhtchurch. New Zealand, 1982.
jects based on phYSlc:l1 lIIeasurcs of tht: NIOSH low b:lck atlas. Spinc 44. JohnS(lll C. Reid JG: Lumllar cOlllprcssi\'c .1111.1 ... hear fmces dttril\~ \"ari-
12:1350.1994_ OilS tru':!k ...url-up ..:\creisl's. Clin Biolllceh (1:97. 1991.
11. Mo[froid MT. Haugh LO: Prospl:ctive mndomi1.L-d excrcist: trial in two -15. Janda V: Smnc J..-j'<:C'" or c.'(lracr.lIli;JI cau,cs 111' J;lcial p'lin. J Jlrmth~·t
p;:l\icnl groups wilh LUll. V~nnonl Rehabilitation Engincerins and Delli 56:4&1. 19$6.
Rcs~arch Centcr. 1994-1998. --16. KiIlllkar A. lrrg;:n~ JJ. Whitncy SL: NUlIopcrali\"c lIIanagerll\:nt 01' s\.',;-
22. Deliuo A. Cibulka MT. Erhard RE. et ill: Evidence for usc of ;Ill exten- ondary shoutd::r impinf:t:lIlcnt syndromc. J Onlwp Spuns Phys Thl'r
sion-mobilization category in acule low bilck 5yndrome: A prescriplivc 17:212.1993.
\'alidation pilol study. Phys TIler 73:216. 1993. 47. Bogduk N. Simon" DG: Neck p<lin: Joint pain or tri~.£er poinls·.' In
23. Erhard RE. Oeliuo A: Relali...c erfecti\·cl\c:-~ of an cxtension prog(;llU Vocroy H. Mer,J.:e~ H (cds): Progress ill Fibromy:.lgia and MY{lfa~,;ial
and a combined program of manipulation anti nt::(ioll :lnd ex lens ion C.'(- Pain. Ncw York. EI,cvicr. 1993. pp 267-'113.
erciscs in patients with acme low !:l;lck syndflllllc. Phys 111cr 74: 109:'1. -IS. Tr;l\'dl JG. SirTwn_ D(j: Myofasci:ll P;lin ;lml Dysfun';lion: The Trig::~'r
1994. Point Milnu;ll. Baltimore. Willi;lflls & Wilkin.~. 19~.'I.
24. Spitzer WOo Sko\'rom ML. S.:Ilmi LR. et .:II: Scicntific monograph of Ihe 49. Licbcnson CS: Thoracic outlet syndrome. J Manipul;llive Pltys Th~'f
Quebec T:lsk Force on whiplash-rel;lIed disordt:rs: Redefining 11 :6. 1988.
"whiplash" and its management. Spine 20:8S. 1995. 50. Manhews 11.1: The T.+ ~yndrollle. AilS! J Physiother 32: 123. 19~('.
25. Pilnj.:lbi MM: 111C slabilizing !'ys(em of lhe spine. Pan I: FUll"tion. 51. Ribbc EB. Lindfrcn SHS: Clinic;.1 diagnosi!' (If "l"OS. l\1;tIluclle Mo.'J
~r~fl1n<:tion, ad<lptation. and enhancement. J Spinal Oi:-ord 5:383. 2:82. 1986.
1992. 52. Roos DB: I\e\\ conct:pts ofTQS th~t cxpl"in c\iolo~y. !')'mptotlls. di:.~·
26. Watson Oli. Trott .PH: Cervic;ll heatJ:1che: An investigation of Ilalur.ll nosis. and trC:ltml:nt. Vase Surg 13:313.1979.
head posture :lnd upper cervir,:<ll ncxor muscle pc:rfomlance. Cephalgi;l 53. Tarola G: Whipla...h: Contempowry considcr;ltions in "sscs.~ntcnt. man-
13:272. 1993. ascmenl. trealm;:nl and prognosis. JNMS .:1: 156, 199;\.
27. Trcle:lven J. Jull G. Atkinson L: Cer\'ical musculoskelclal dysfunction in 54. Wilk KE. Arrigo C: An integmled appro:lch to upper c~trel11ity c.'(ercis\'s.
post-concussion:l\ headache_ Cephalg.ia 14:27.1. 1994. Onhop Ph),!. Thcr C1in Nonh Am u.n, 1992.
28. Hagb;u1h KE: E\'aluatiOIl of ;md methods 10 eh,mgt: muscle tone. Scaml 55. SOllltller HM: P:llcllar chonJropathy illld ;lpidti". and musclc jmhalam·c.s
J Rehab Mcd Suppl 30: 19. 1994. of Ihe lower c'trcmitic.~ in competitivc sports. Sports Med 5:386. 19S5.
29. Stokes MJ. Cooper RG. Jayson MIV: Scleeli\'c changes in muhilidus 56. lippel SR: Clo~ed ehain c:\crcisc:. Oohop Ph)'s TIler C1ill Nurth Am
dimensionl' in palients with chronic low b"ck pain. Eur Spinc J 1:38. 1:253. 1992.
1992. 57. SchiabJc HG. Grubb BD: Afferent and ~pinaIIllCch;lIlislllsof jllilll p;lin.
.30. Fill.lllauricc R. Cooper KG. Freclllont AJ: A histollwrpholllctric comp:lr- Pain 55:5, 1'J4.~
is(J1\ of musclc biopsics from nonnal subjccls and p'llicrus with allkylos- 58. Proske U. Schi:lolc HG. Schmidt RF: J(,lint rel'cl11ors amI kirwcsth,,~i: •.
int; spondylilis and ~e\'erc Illcchanicallow toad. pOlin. J I'athol 16.):182. Exp Brain Re- i~:219. 19:-:8.
1992. 59. Gagc)' Pr-.·1; PO"lllf,,-1 disordcrs among workcrs Oil huilllill~ sill'S. In Bks
31. Dahl JB_ Eridl!oCn CJ. Fu~Is.1.ng-f:rcderibenA. cl 011: Pain !iensatiOIl alld W. Orandt T h.-d,': Disordcrs of Posture and Gait. New York. Els\.'vicr
nociceplive rcllc.>: excitahility in l'urgic:11 paticlltl' and human voluntccrs. Science.. 1%6
13r J Anacslh 69:1 17. 19l)~. 60. LCW!1 K: Dj,tud:...:d balafl~'e Jlle If,) 1c_~ilJll.' or the cr;miol'ervical jllll"'li"lll.
32. Woolf CJ: Long Icrm ahef:lliolls in lhe e~cilability of lhe f1e~ion rcncx J Onhop r-.·lcd 3::'8. 1988.
produccd by peripheral tisslle injury in lhe chronic decerebrale ral. Pain 61. Odk\'isl I. Odb i~t LM: Phys;othcrJpy in \·cni!=\l. Ael3 Otolaryn,;:t1\
IS:32S. 19S..L Suppl (Stockh! ":55:74. 1985.
33. Lchto M. Jarvinen M. Nclilllarkka 0: Sl;:lr ftmnatiol1 after skclelallll~s­ 62. B(lf:UCI J. 1\-'loofe :So B()i,~l1larc F. et al: Vertigo ill Pos!·concu.~.~i()nal :llIti
elc injur)". Arch Orthop Trauma Surg 1(}';:366. 1986. llIigr;linl' p:Jticnb: llllplie;ltioll of thc autonomic Ilcrvous S)"SI~·Ill.
34. Dt:Andrade JR. Granl C. Di~on ASJ: Joint dislen!>ion and rene.'<. muscle Aggrcssologie ~J:2)5. 198J.
inhibition in the knee. J Done Juint Surg IAmI47:313. 1965. 63. Brandt T. Krufczyk S. Malshcndend I: I'o\lural imto"l:lIlcc wilh he:ld \.\-
35. Brucini M. 1)1I101nli R. Galleti R. et al: l';tin lhresholds and electrolll)'o- tension: ImpRlH:ment by tr.linillt " .. a model fllr ataxia therapy. Alln;,\Y
gnphic katures of periarticular muscles in palients with oSleoarthritis of Acad Sci :636. 1\18 t.
the knee. P:.in 10:57. 19~1. 64. G;*cy I'M: :"on·\-eslibul:lr diaillcs~ ;md "Ialit: postumgraph)'..·\\·Ia
36. Spencer JI). Hayes KC. A!ex'lIlder 11: Knee joinl t:ffusion <lnd quadriceps O\(lrhillolar~n{J1 Belg 45:335. 1991.
rene~ inhibition in man, f\rdl Phys ~-lcd RchahiI6S:J7I. 1984. 65_ Shekel Ie PG...\d;Jffis AU, Ch;l... ~in MR. el al: Spin:.l Illanipulalinn f\lr
:'17. Hides JA. Siokes t-.-U. Saide M. Cl al: Evidence of lumbar lllultilhills IllIlS- kl\v-back p~ill ...\nn Intern Metl 117:59IJ, 1992.
c1c.~ W.ISlillg ipsil,lleralln symptoms in palief\ts with ;lcutchllh:\cutc low 66. Shekcllc PG: Spine updale: Spill:11 manipul<lti\1\1. Spine 19:H5~. 199·1.
h'1Ck pain. Spine 19:1(15. 1lJ94. 67. Co:\ JS: Injury rlorncnc!:lturt::. Am J Srons Med 7:211. 1979_

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fiX. Linlon 51. Hellsillg, AL, Andersson D: A controlled study of the effects 71. Fordyce WE, Fowler RS, Lehmann JF. et al: Operant c0!:ditioni;:;; in :~:~
or an early intervention Oil <lcute musculo~:":cletal pain problems. Pain treatment of chronic pain, Arch Phys rvlcd Rehabil 54:399. 1973.
54:353.1993. 72. W,lddell G: A new clinical model for the treatlllellt of lOW-hack pain.
NJ. Mitchell RI, Cmllcn Glvl: Results of a multicenter trial using an inten- Spine 12:634. 1987. ."
sin:: active exercise prog,ram for the tre,llmen! of acute soft tissue and 73. Sa,ll JA. Saal JS: Nonoperative treatment of herniated lumbar interverte-
ba<:k injuries. Spine 15:514, 1990. bral disc with radiculopathy, Spine 14:431, 1989.
70. Lindstrom A, Ohlund C. Eek C, el ,II: Activation of subacute low back 74. Tillltl\ KE: A ralldomilcd-colllrol sltldy of activc :llld passive trc;ltnl\.'nts
p:llicnls. Phys Thl.'r ::'93. 1992, for chronit: low bJck p:lin rollowing L5,

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 19 Psychosocial Factors in Chronic Pain
I GEORGE E. BECKER
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----------------------------_._--
Psychological .md physical ["clors arc incxlricably involved Th::...e characleristic.. inclmk: (I) ,-ague history, confused
anti imcrrdatcd in virtually every case of chronic back pain.' (·hronology. or illtfOUlH.::tioll of matcrial ostensihly h;n-ing
The art of healing begins with recognition of the se\'eral dc· nothing to lIn ",ith the injury and SYlllptOIll!«: (2) ~:fpressiol1
tcrminants of chronic back pain, and 1Il1dcrst<lnding tlmt a of OpCIl or veiled rcsclltlllCIl! low.lIll Gll\'~I<lkers hecausc
good mall)' of them ;ue totally unrecognized .lI1d outside of of alleged mismanagemcnt and Ilegkd: (:;) dl':lmatil: dl,.'-
the conscious aW;lrcncss of the paticlll. The goals of this chap' scriplions 01" the symptoms and thc p;l1icnt's rcactions 10
ter arc as follows: them: (4) difficulty in 100::lli'l."tioll and description of pain and
other symptoms ... or a complaint of p;lin in lllallY arc:!:--.
to define :-;OTllC of the terms helpful in describing alld understand· obscuring ;1 pain that might originally have. had an ana·
ing the patient with a chronic back pain syndrome tomie focus: (5) f:'lilurc of the usual forms of treatlllent to
10 describe those charilclcrislics lhilt will alert the clinician and en· gi\"(; sigl1ilh:'1111 relid of pain: ,1Ild (6) Olccompanying neu-
able COlrl)' recognition of tht prohkm'lIic patient
rotic symptoms: acute and chronic 'lllxicty. insomni'l. irri-
10 review <I comprehensive hislo')' format encompassing psy-
tability. prcssure-like hC<lda<:hcs. deprcssion. crying spell:--.
chosocial ;IS well as biological issues
to dc~cribc thc Jdjuncti\'c diagnostic usc of sclc=clcd ps)'chologic;\1
chronic fatiguc. aClIte anxiety atla... ks or chronic anxiety
tesls and pcculiar gaits suggesting hysteria_ Al Ihc samc tilllC'.
to rcvicw trc~ltlllcnt strategic::. for helping this extremely challeng- thes~ authors ullderscored the faci that ill 12 of 12 1';\.
ing and orlcn frustr~lIing grollp of p:tlicnts tiCllts, the "clinical picture \vas frolll hoth somatogenic
and psychogcnic causes:' Thl; first sentencc of this char-
The notion of a mutual intcraction bctween mind and ter is meant to dispel once and for all the either or
body in health ..IS well as in illness is not ncw. It is likely notion-that chronic pain is of either org'lI1ic.: or psychogcl1ii.·
\ that some of the miraculous cures ascribed to the man Jesus origin.
I in the New Testament <.Illest to his charisma .lIld the em-
powcnncnt transmitted through him to the unheahhy believer.
I (Clearly all healers possess the ability 10 empower patients
DISABILITY AND CHRONIC PAIN
with whom they have established a healing relationship or The problem of chronic pain and uis;.Jbility. which is gro\\"il1~

I therapeutic working alliance.) In the seventeenth century.

Sydenham recognized and described syndromes [hat. de-
spite the outward appearance of physical maladies. in reality
...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
were related 10 identifiable, heavily emotionally charged life Gordon~ wrotc that low back pain disabkd 5.4 millil'll
event.s and circumstances_ He described but did not name 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

i
sOl1latiwtitm. which is the experience and expression of psy-
chological stress and connict in physic;:i1 rather than in emO- patients have /10 objective t'\'ide/lce of phy:dcal disease_ {The
tional terms. Bunon latcr described the physical (somatic) ,lUthor's cxp~ricncc suggests (hm 10% is a low cstill1at~"1

I~
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;·
Lipowski l • described an evcn higher percelltage of functional
illness. especially depression. among patients prescllling ((I
primary carc providers with physical, nol psychological. ('Olll-

i~
!
tic approach to h~alth and illness. Alexander: wrote: "Onc~
<lg<lin. the patient as a human being \I.'ith worries, fears, hopes,
and despairs, as an indivisibk whole .lIld not merely tltt.'
plaints. 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<lL'L they usually
~;;. bearer of organs of a diseased liver or stomach ... is deny vchclllclHly any psychological or clIllHional L1imcnsk'n
~1 becoming the legitimate object of medical interest. In the in their clinical picture. Their massive uCllial. lack of insight.

! last two dec'ldes incrc'lsing ,Ittention has bccn paid to thl.'

causative role of cmotionnl factors in disc'ISC." Brown ,md
and resistallce to accepting and ~onrn.lllling psycholog.ical
factors involvcd in their chronic pain makes Ihem p;;Jl1icularly
I colleagues·\ wrote an insi.ghtful landmark paper identify-
ing six striking charactcristics appc<lring repeatedly in "
difficult to IrC'It.
Thc faL'! that .WJl1lmi:.e,..\" often !!o wccks. momhs, or C\-l,."11

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number of patients 111,lI1ifesting obvious functional overlay_
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391

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cates thal somclhim! is wrong wilh our appro,ldl lO cllnmic \111bcing dis.ahk'J. On..' doL'S nOl1k'cd;1 proks:-oional tkgrcc to
pain. Misdiagnosis ~f lhe ~oll1atiz~r is thi,; ineviwble precur- understand thaI ;~ i~l'r.;()n :-ouing ror an illjury-rclatcd disahility
sor to prolonged and ineffectivc tn:allllcni. and frequclltly to willles:-o likely pr\~lit linallcially it"lhc disability rcsol\'es. Thi:-o
lllultiple and inappropriate chcmical. elcctrical. and imaging ~itt1atinn kilds n:ltur~llIy 10 a cOI\~idL"r,llinn of gain (scc suhsl.>
studies: inappropri:Hc mcdic ..llions. induding ll<.lfcotics ljUCI\! section).

(which frequcntly compound the prohlem); or. worse yet. to

invasive procedurc$. including surgical intervcntion. After COll1pliallrt·
(lvcr 40 ye:lrs of experience caring for bac.:k pain. it is dear to
Some patient:- f~lil hI ((,Imply wilh trc,lll1lt,'llt regilll(lls tk-
this author that ,mrgay i,\" rarely i/ldicmccl. ~,tost ''failed
siglled for their r.;:lh:liL This f;tilufl: may hest he ulHkrstood
backs" arc found in unfortunate indi\"iduals who should never
as an illlpeuilllelli h_~ or as UlKolhL'ious fesistallo: 10 healing..
have hud surgery in the first place. or who, necding sllrgery.
These lInfor1Ullat~ sOllls. for reasons they themselvcs ran:ly
did not have the right procedure at the right timc and ;,It lhc
understand :md llf which they usually arc un:lW:lrc. Il('('t! to he
righllevel. Frymoyer 1 states thut the "failed surg.ical back" is
in pain. /1('c'(/ 10 ~\IITa. /1('('(( to rccllikc powcr1css victims. i111tL ~
usually the result of poor surgical judgmenl.
Il('rd to he cared for \\';111(",1 foxing fact'. Olhers. a smaller
TIle purpose of this chapter is to .describe and dclinc the
subsct. arc at k~l ... t partially ;\\\';11\' or their motivcs: They ex-
dynamic and psychosocial issues involved wjth ;'lntl frc~
hibit pain behavior fllClcl.l by anger. n:sclltl1l..;llI, or ;1 wi:-;ll 10
quently fueling chronic pain syndromes, to rC\'icw Iho:-oc
rcwhate.
presenting signs and symptoms that should alert the astute
clioician to the issue of functional o\'erlay, (0 outline bricny"
Denial
comprehensive hislory format. to review the adjunctive
usc of psychological testing, and to describe management Individu::i1s who !'onwlize typic;lIly deny that they ;Ire cxpcri~
stmtcgies for this frustrating and often passivc. rcsistant. and cncing signific<.Jnl emotional or psychological stress. much as
noncompliant group of paticnts. Typically, many of thcse pa- an alcoholic dcnic:s having a problem with <llcohol. Denial
tients simultaneously proclaim ardently how much they wanl blinds an im.li\·idual to the psychological problem and pre~
to get better while conveying, with their mixcd~message be- eludes insight. Denial can and frequi,;ntly does constitute a
havior. that they really are going to (and unconsciously wish tremendous barrier to recovery.
to) remain disabled. Timely recognition and appropriate treat-
-~

ment of the chronic back pain patient not only is cost effec- Depression ~-

tive, but also ultimately benefits the doctor spiritually and ma~
Many persons who arc deprcs:-ocd neilher look nor feel de-
terially. In the highly scrutinized health care environment of
pressed. If <.IS ked <.Jbout their mood. thc)' will deny <.Ieprcssion.
today. the practitioner must cSlablish a reputation for the kind
Instead. they exhibit chronic pain <often chronic b;,\ck pain} or
of comprehensive treatment protocol that gets !J0lieflfs back )
other somatic complaints. :'lS an ;llitill/lIllIllUt'-"llIlicJIl of their
to work (am/to life ill full) and keep.,· them there.
depression:J often deluding Ihe well-intentioned doctor. Their
pain allows them to seck and to receivc IllcdicallchiropraL·tic
TERMS AND CONCEPTS
care and anemion while simult<.tneously denying Ihe mood
Several terms and concepts frequently encountered in the disorder and onen [he life strcss. Ch"IOS. and conn il.:l fueling. it.
chronic pain vocabulary arc defincd or discusscd in the fol- Emolion<.ll neediness is a hallmark of depression. UnfOrltl-
lowing section. nately. the unrecognized depression remains untreated.

Alexithymia Dreams

Sifneoss coined this tcrm to describc those individuals who Dreams havc been described as-:tilC to,",,,/ mad to the lCIl('CJ1/-
(literally) have no words for their feelings. Lex is the Greek sciou.... ,o.:ccrtainly. thc dreams ~)f patients oftcn rev~al ('in
r~ meaning word. ~he thymus is the g'-Iand thought by the their sYmbolism) conflicts. fears. and wi:-ohes tiwI lie buried
vnclcnts to he the seal' of the emotions. hence Ihymia. Persons outside of conscious'-a\varcncss. They Illay crard). issues <:011-
troubled by aICXilh)lliia. i.ither than recognizing their inner- stitutiilg'b::uTIers to recovery.
most feelings. bury and deny them only to have them surface
as physical symptoms that seem to. but do not. have ::1 physi- Fear
cal basis. At a conscious Ic\"cl, fe;.Ir fre<.]uently bespeaks a wish at all llll- .J
conscious level. particul<.trly in th~. p~!!i~J}J .. \..Y.h.Q~.ejl~.til.l!lS-;llld
Compensation and Litigation words signalj~JlQUbk..Quamn!£~.l!lL!~::~"<tge ..
If the benefits (or potential benefits in fantasy) derived from
Functional Overlay
staying ill outweigh the bencfits of regaining health, the p'l-
ricllt will not Iikcly gct well. It is gcncmlly recognized in the This vcnerable tcrm in the 1l11.:dical vernacular is not part of
healing professions that some patients seem clearly (0 thrive official mcdical nomcndalUre. Nonetheless. it is useful in
www.bodywork.su

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 .... , ,,·w I eM 1::1 : .... ::iY(.;HOSOC1AL FACTORS IN CHRONIC PAIN 393

describing (hose nonphysical (i.c., psychological and emo· walll and nCL'd til be carcd foro-or lovcd. Thus. the double
Lional) f3clors lhat color th~ way in which patients present Illcssa,::e Ihat iJcmilics the: ~oJ11tltil.er. These patients. in their
thcl11sch"es. It is also accurate bCC<llIsc it docs not su!.!uCSl :In passiyit~. :Irc oftcn misllnderstood as poorly motiYilted. The
either/or dicholomy between physical :lJld psych~;iogi(:t1 dinician "h\\uld remain mindful thilt ;\Ctions speak louder
symplOllls. thall \\'\\rd:-.. :tnJ underst:llId that what appcar~ 10 bL: poor 1110-
tivatil'l1 11l~IY in n.:ality he a powerful (uncollscious) cOlllliclo
Guin
Parallel History
For pr;u":li(al pllrposcs. gain can be thought of as primary. Se'C'
ol/tlm:\', and Tl'I'Tiary. The parallcl history is th~ r~( ord or important psychosocial

! )I PRIMARY GAIN
evcnts and circumstanccs e perienced during and bcfore
tho~e lypically indutlctl in the history of present condition. II
~
,
R
Primary gain addresses psychological needs: bcin2 taken care
When vic\\'cd against the b;lckdrop ,-)f the formativc YC;lrs. th~
parallel history often makes clear the C\'Cllls and circum-
t of while feeling independent. Primary gain is entirely within
stances that may bc fucling ;1 chronic pain syndrome ill the
the individual. and involves self image and self esteem. Il al-
vulncmblc persoll.
lows 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 rc- Somati7.ation
I, sponsible member of society. The person unablc to work be-
Somatization is lhe expression of unconscious feelings and
cause of dis~bi1ity can see him- or herself as absolved of re-
emotions in physical rather than emotional terms. The soma-
sponsibility by the illness, which is not their fault.
tizing patient. believing \vith a conviction of delusional pro-
portion that his or her symptoms arc solcly and totally of
SECONDARY GAIN physical origin. typic;;l1ly seeks medical rather than ps)'chi-
This term describes those material benclits (special attenLion. .uric carc.'~ Unfonunatcly this con\'iction often leads the un-
care taking. sick leave. relicf from some if not all responsibil- suspecting doctor to inappropriate and rather far-nung diag-
ities to others such as alimony or child support payments. noses and equally in'lppropriule and unsuccessful treatment.
compensation payments. awards. ongoing payments from dis·
ability carriers. and the like) derived from oUlside the indi- Somatization Diathesis
vidual. The ministrations of othcrs to one who is disablcd arc
C~rtain individuals. clllotiorwlly sh()l1~changcd or scarred
secGildary gains. Although sccondary gain figures promi-
during their formative years. evidence a proclivity to soma-
nently in chronic pain syndromes. it is often not 41S potent :.l
lize in the face of strcssful urltow;lrd events or circumstances
force as primary gain.
of adult lifc. espccially onc~ that awaken fc~lings buried in
the unconscious and rooted in the p.\st. These individuals ;'Ire
TERTIARY GAIN
said to harbor a JOII!(lt;z.atio/l dial//('...;s. I
This relatively new teml describes those material and psy·
chological gains enjoyed by those caring for the disabled onc. RECOCi\ITIOi\
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 It is proverbially true that if one chinks of the right diagnosis.
maximize winnings. a doctor may need to keep the patient de- onc willlikcly make the right diagnosis. Nowhere is this morc
pendcnt on ongoing care and manipulation (in more than one apt than in the recognition of back pain complicated and col·
sense) rathcr than to teach the patient self-sufficiency. and the orcd by ps)'chologicol1 factors. Unfortunately. even tOday.
psychiatrist may nurture ongoing passive dcpendcncy for ill.lIlY textbooks fail to include a discussion of psychological
considerations that have liule to do with the welfare of the pa- faclOrs as the)' apply to chronic musculoskelctal symptoms.
tient. Tertiary gain usually involves a conflict of interest. all including neck. shoulder. and back pain. The aim of this sec-
issue that behooves all hcalLh care and legal providers to self· tion is to spotlight the characteristics of this group of r~·HicIlIS;
monilor. to olltline an interview format helpful in identifying the 111. and
to review the use of the Pain Drawing. the Minnesow Multi
Motivation Phasicz, and other select psychologic:lI tests.

Vinually all patients state that they want nothing more than to
Red Flags
get belter. Most of them do want to gct bettc; and most of
thcm do get better. The rcmaining fe~v. however. with their The following listing of reel JllIg.,·-signs. symplol1b-. and
ongoing complaints of polin and their problematic behavior. other clucs that alert lhe clinician lO the likelihood (hal psy-
bespeak a conflict of which they havc littlc if any 'lwarencss: chological and emotional factors ligurc significantly in the
consciollsly, they wanl to get bctter. but ,,,,consciollsly. they clinical prescntationl-arc 'lrrangcd in groups relkeling his-
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tory, psychosocial issucs. disturballCl:S 01 mood. and l:xami- \'i:;itillg Cl1\erg~lll:Y r,"lms ror narcotics. escalating drug needs, in-
~TL'asing akohul ;lbu'L'. Ill' gaining weight may represellt a thinly
nation findings.
\eikd elliotillnal hun;a and neediness in concert \vith <I proclivity
hl address til;\! lIull;L'r \\ itll drugs or fond
RED FLAGS I (HISTORY)

Vague, inconsistellL and implausibh,' history of illjur~. (l(lell lIll·

R::D FLAGS IV (EXAr.Pi,...T10N FINDINGS)
witnessed
Symptoms that pwlifcratc from (Inc body arca (ll' SY:;ll'!ll \II :;cv- Tht,'alricl! ]lI'<.'s\·nl;1111 ,1 walkin~, wilh all llhvio\1sly Ulllll:ccss;lry
1

eral, often culminating in tolal botly pain I.·allc (often carried in lhl' \\T\ln~ hand), a strange limp, or main-
Highly emotionally charged pain descriptors: torturing, .;ufrocat- \,lining a bizarrc po"turl'
ing, cutting, wrelched, blinding, exhausting, scaring . .;caltlin);. \'\)(lanatolllic sens\'r~ lindings. such as glove~slOckillg or half·
stabbing, wrenching, punishing, gruding. cruel, vicious. I~elletrat­ nndy bypesthesia
ing, piercing, terrifying, fearful. crushing, gnawing. !lnunding., \'\lnanatolllic lI\otur tilldings, such :is giveway weakness on mus-
beating, and the like de h:sting or Ol1lOe llr hed walking, or oh~vio\1sly suboptimal grip
Obvious hyperbole in history: "... I couldn't ll111ve .. ,my kg:; alleillpts
collapsed ... I was numb all over . . I couldn't or can't dn any- Significant diffen:rKt: bet\vcell observed and formally tested
thing ..." r;lI1ges of motion
Obvious discrepancies during evaluation: the patient \\ 110 reports Significant difference >d\veell straight-leg raising ill sitting versus
an inability to sit for more than 10 minutes but sits for an hour or recumbent postures
more relating the history Inappropriate ccrvio.l compression lest (e.g.. causing low back
A lengthy history of life-long hard work and responsibility with a pain or causing legs 10 give way)
professed desire to return to work. which, unfortunalely. is llOW Inappropriate \vithdrawal {)f exagger:.ned tenderness response on
precluded by pain gentle palpation or percllssion, especially if the paliellt grabs thl:
Marked passivity, inappropriate activity curtailment. fr~quelltly (',aminer's hand in th~'atrical fashion
with concomitant weight gain illid marked physical deconJilioning
Accept•.H1CC of disabled status: "l'vc just 1cmned to accqll m), lim- :"lone of this information is n::ally new. In 1940.
itations." Fctlennanl,l identified symptoms. including dramatic pain de-
History that only narcotics afford pain relief. with gradually esca" scriptors. preoccupation with pain, fcar of increasing help-
lating narcotic usc lessness, and lhe utility (i.e .. secondary gain) of the symp-
toms. that have a "neurotic ring." More recently, WaddcIP-l·I.~
RED FLAGS II (PSYCHOSOCIAL ISSUES) described physical signs and symptoms that bespeak func-
Externalizing responsibility or blame for occupational. r~lation­ tional overlay. In essence. when the examiner encounters any
ship, mood, or financial problcms of these red flags, he or she should document them and make
Emotional constriction: keeping feelings inside an anempt to account for them. All too often. they arc men-
Tearfulness or weeping during interview tioned in a medical report. only to be ignored in the discus-
Denial that the manifest somatic problem is in any way related to sion of findings. En',-yt!tillg in a comprehensive evaluation
life events and circumstances, except to blame life failures on the has meaning.
purported physical illness: (e.g., "but for my back pain. cvcrything
would be A-okay") Depression
A verbalized fear of ongoing disability. Such aiNu' frequently rep-
resents un unconscious wish to be taken cure of. especially in per- Eighty percent of persons suffering from depression art?
sons emotionally short-changed in their youth. evaluated by primary care providers: chiropractors, ram~
ily physicians, intcrnists.(' These patients usually do not
RED FLAGS III (DISTURBANCES OF MOOD) realize that they <Ire depressed, because their particular
Dissatisfaction or frustration with job or anger at a boss kind of depression is manifest by lJhvsica! SVfIlO!O!!)S
or doctars frequently represents unrecognized (displaced) anger at rather than by a wood r!iI''''''/'WlCC. Back-pain frequently is
parcnting ligures, which mllY culminatc in verbalized resentment an initial manifestation of depression.(The patient whose
at the way the claim is handled, the way a disability is (not) ac- depression prog~~-.:~.~~_~()~?~~~~.~,~~I inic'all y cvident YI1~~r­
commodated, ar the way treatment is rendered standably (albeit usually incorrectly) concl.uQ.Q.;i-!.b.m_lb_~~
Failure of reasonable treatments, in the face of which patients lIlay depreSSion was caused by the chronic pail~ Terms such
report worsening symptoms. Such failures may reflect resentment as dejJressimr-wirhorw71iY7Jres.\·!(J!l, masked depressioll, and
at authority figurcs displaced from parents or supervisors onlo the paifl w' a depression equil'a/ellt have been used to describe
unsuspecting and often bewildered doctor.
this particular group of patients. Othcr common somatic
The doctor begins to sense his {)f her own anger directed at the pa+
symptoms of depression are headaches, fatigue (including
tien!. This "countcrtransference" frequciltly signals thc passive-ag-
gressive behavior of a smiling, manifestly compliant. but latemly pseudo-chronic .((ltjg/ie syndrome), weakness, shortness of
angry ar enmged person. TIle challenge for the doctor is then to breath, dizziness, palpitations, gastrointestinal complaints
rccognize his or hcr feelings to bettcr control behavior. It is :I such as nausea and diarrhea, parcsthcsias, blurred vision,
grievous error for the doctor!o return in kind tbe anger of passive- ternporomandibul<lr joint problems, ringing in the cars.
aggressive patients. www.bodywork.su diminished libido andfor sexual dysfunction, and gen-

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~[':lli/l'd pain (including pscudo-JilmllllY(llgia or filnomyosi- • Worked at hard jobs a long time before becoming dbablcd by pain
tis l. It i:-; axiolll;lIic that no person should be givcn a diagno- • Family role model for pain ;Illdlor di.':.lbilit)' (idcntilicalion)
sis()t" chrol/it, jtU;gl/c syndrome'. jil)J'olllya(t:ia. or jibrol1l)'o- • Often school drop·out
.'ii/is wilhout 'Ill ~"alll'l1i(ln lhat includes C;\fl:flll psycho- These authors cxplain lhat, "by virtue of providing for others
dia~lh)Slic .ISSl'SSllI.:1lI hy a profession.1I who lllldCl'SI~lnds .lHd 110t being fully able to depend on their own parelHs as
lhat d1l'Ollic p;tin alltUm chronic fatigue may be (and not in- children __ .Ihc)' Imd postponed gr;'\Iilic.. ~tioll of such needs
fl'l'qUl'lltly ;lrd lh~ initial manifcswtions of an occult and c1in- unlil a minor injury provid<::d a mtional and socially accept-
ic;.II, il1:1PI);ll'\"nt th.'pression. able means of depcnding on othcr!' for emotional ,u1d eco-
S(llll:tlizil1g/dcpr~sscd individuals (who are usually highly nomic suppon:' Chronic (back) pain, in stich inst<lnces. is an
r6i .. t;llIt 10 psydl{llogic;jl interpretations of their symptoms) expression of eJ1lOlional and psychological pain, totally out-
llfh.'u arc so cOI1\'inccd thai their problem is physicnl, nnd offly side of the conscious awareness of the patient
physical. that they persuade their doctors of their delusional
misconception. Because th~sc pOltknts have a mood (i.e., psy- Pain (emotional) begets Pain (physical i.e. psychogenic)
L'hologiL'al) disorder, thC)' do not get better in response to Because the pain-prone patient is one who seeks and
Ir~:lll11~1lt dirccteu at a I,hysical problcm, Typically, thcy re·
usually receives endless nnd costly studies or imenninablc
(jllL'SI and rccci\'c t.:.\lcnsion aftcr extcnsion of their disability.
treatmcnt and doe.'lllot get beller, it is important to recognize
One: ..hnuld beware of the patients who st"lte: "The doctors the dingnosis of somatization early. In 1959, Engel't> out-
jllstl,:an'llind out what's wrong with me," They rrustr;,lte their lined his understanding of psychogenic pain and its rela-
~h':lOr~ who, nol recognizing or cven suspecting that they are tionship to depression: ",' ,a common error by the physi-
dcpr.:~~cd, unwittingly colludc with them. seeking consulta-
cian is to assume lhat lhe patient is depres~~d bcc:!use he
lion~ and diagno!'tic tests directcd at discovering a physical
has pain. Investigalion will usually make clear that lhe
explanation for tilC pain. The astUlc doctor, howevcr, may rec- experience of pain serves to atlenuate the guilt and shame
01.!IlIZC carlyon that these patients will remain disabled. They
of the depression .. :' PsychogclJ.iL(or somatofonn or idio-
d~li\'cr a double message: mouthing words about their inde~ pathic) pai.n.Jather than being a cause is more frequently
pendence, their lolcran~e of pain, ;nd their frustration with a manifestation of depression. This IS to say that pa·
their physical problem. their pussivc. dependent behavior be~ tiefi1s whose psychogenIC pain represents depression do not
speaks emotional need and dependence, intolerance of and in~
fe~ch, if3!!Y' depres~~~, Instca~.. they ~x~erience
capacitation by pain, and complacency in accepting the in- pain. Engel also recognized that narcoHc addictIOn fre-
valid status. quently complicates the management of these patients.
The double message of the somatizer is as foHows. Their Unfortunately, some well-intentioned but ill-informed
words S;'IY: lawyers will object to psychological examination of the
'i
f I started working at an carly age and I have worked hard all my chronic pain patient (in accident-related litigation) on the
life, grounds that the client is making no claim for psycho-
I havc ~dw:lYs been very indcpcndenl. logical injury. Whenever chronic pnin is a manifestation of
I (,'an Ii.Ikc a lot of pain. , , rm nOI one to complain (deni:ll), an unrccognizcti (i.e.. unconscious) depression or other
I jU~1 want 10 £el better so I C<ln h~l\'e Illy life back. mood -disturbance, the patieoJ ..9OCSJlOL_c¥cn-_kuQW of the
,\11 I want 10 do i<; return 10 work. mo~-(fl.'iturbancc,__Thc Illost effective way to prevent and
whilc their behaviors say: obfuscate 'accu~;(C diagnosis and impede optimal trc3tm~nt
is t~ preclude pSy"chqLogi~ilt inycstigation of chronic pain
Becausc I had to fend for myself a~ a youngslcr. I W,lIlt the care that has failed to improve in response to treatment directed
I didn't get (In'".
II(JII'
at a physical disorder.
My p:Jin forces IIlC to be pa.<;sivc and dependent <legitimizing in-
'·alidisl11).
1am a victim. disabled and helpless in the face artltis terrible pain. Substance Abuse
I need (0 remain disabkd because now I am being laken The chronic pain patient frequcntly dcmands, and th~n re-
carc or. ceivcs, prescription after prescription for narcotic analg~sics.
I don't W~lIH to go back-to work, , , (maybe) ... I want Ihc educa-
reporting that nothing else relieves the pain, Such p~Hi~nts
tional opportunity (vocational n:habilililtionl I forfcited when I
arc at risk for drug dl:pl:lldency and iatrogenic addiction.
dropped oul of school.
The addicted patient invariably denies such addiction. as-
Blumer <llld Hcilbrolln'l described the lypical characteris- serting, "I only lake the narcotic for my pain. _. I only take
tics of the person with a chronic pain syndrome: i( when I reall)' need it ... nothing else (but the narcotic)
helps, .." This lil<lI1Y. or its equivalent. indicates that Ihe
Limited 'formal education
Holds overly strenuous routine or otherwisc dissatisf)'ing job
sensatio/l of pain has become a witlulrawal .'iylJl[1(C)JIf·
Has had Ulllllet depclldem.::y needs since C~lrly in life equivalent. which requires the narcotic for its relief. The
Began work.1t ~11l carly agc (i.e., had no opportunity to really In: a patient neither realizes 1101' understands this concept.. il~­
child) sisting only that the p~iii"1 is "rcal." It is. Almost all pam IS
www.bodywork.su
 r~aJ. but tilt: sufferer ha~ Illl way of kIH1wing whether il ALCOHOLISM
is physical or psycIJOlo:.:.il"ol Of hoth. Pain is pain. POlin The child of an ::tlcohoJic parent is. at the- very least, cmotion~
rcprcsCIllS a final C()I1l11Hlll p:lthw<l)'. Wht:n pain becomes ally shon·changcd. not only by the emotional unavailability
chronic and inc<lpacitalill~. decimating li\'t:s or workers of the parcnt (le.wing residu::tl neediness within the child),
and their f'lll1ilicl'. it is thl' t;lsk of the spt'..:ialist to lIIuler- hut also by Ihe negative role model that alcoholic behavior
stand the diq:rsc factors causing it. no math:r how dirliclih pn;sc.:nts.
lhe challenge,
SURGICAL OUTCOME
Som:ltizatiol1 Diathesis
Schofferl1l~m <lnd colleagucs 'J observcd (h:lt patients who had

Ii Becker ' identified a .'ilJllltl1i~(;riml diatll('.'.is in those individu·

als who, in one significant way or another. wac cmotion<llly
short-ch.mgcd during their formative years. I(knlifying these
experienced abandonment. abuse, and alcoholism were more
likely th::tn those who had not experienced such emotional
trauma to havc poor results aftcr back surgery. They identified
I individuals involves looking (,/,. a history of a!Jw/{/OJlIIICf/l. fivc childhood tr::tumas that are risk factors: physical, scxual,
i abuse:, or a!<:o/zo!islIl ill a p;m::nting figure. Because these in- or emotional abuse, abandonment, and nlcoholism (or other
I~ dividu;d:,. in their routh. h~ld to fend for themselves when
they lVere ilJ'r,rcpared to do ;0. they arrived in adult life jack·
drug abuse) by or on the P<lft of a primary caregiver. and re-
ported an 85l7c chance of nn unsuccessful surgical outcome in
ti ing the coping and emotional resources lO m:mage the ordi· those individuals with thrce or more of these risk faclors. This
~ nary demands and responsihilities of daily occupational and information has clear implications regarding both history-
social functioning. to say nothing of signitlcant additional laking and trcatment approaches. Most "failed backs" renccr

I
stress. Should such individu:tls suffer lhe loss of a person on unwise diagnostic decisions o::tsed on incomplete (VI" ignuu:J)
whom they depend. they 'Ire prone to develop physical symp- psychosocial histories. Frymoyer and Gordon 4 identify poor
toms lhat garner for them some levcl of c:lr~wking. evcn if it patient selection <IS the reason for poor surgical outcome.
is not cxactly what the)' need.
t
Factors Predicting Disability
ABANDONMENT
Low back pain typically is a self-limiting symplom. MOSI pa-

t Ab<lndonment rakes Illany forms. A parent who. because of

illness or occupational demands. must spend weeks or months
tients with acute low back pain respond promptly to appro-
priate treatment and are back at work in short ·order. In a sub- -.....

I
M
away from the home may well be abandoning his child emo-
tionally. The parent who. because of chronic illness. inllnnity.
set of paticnts, however, pain becomes chronic. The tcnn
chronic back pain was used in the past to describe pain of
i)

or chronic pain. curtails aCli"ities .lIld time \\'illl the child in more than 6 months duration. but FrymoyerJ redefined

I effect emotionally abandons the child. The parent who leaves

because of separation. divorce, or de'llh abandons the child.
chronic back pain as pain of more thafl 3 mOfllhs duratiofl.
Becker ' commented that. in most cases. chronic back pain can
I N
Loving means /ull'i"g time for. No subs~itu{e. material or oth-
erwise. can compensate when a parent is unable to be with
be identified in even less than 12 weeks. Frymoycr identified
several factors that arc important in predicting prolonged dis-

Ii and {O be "there for'" the child. A child abandoned during

the formmive years is ill-prepared for the demands and re-
spomdbilitics of mature aduh life. The process of parenting
ability after back injury. They includc the duration of the cur-
rent disability; a history of previous disability; psychosocial
factors; occupation::tl requirements; job dissatisfaction; ::tnd

I involves the gmdual (not sudden and c•.ltaslrophic) with-

drawal of caretaking and th~ simultaneous nurture of emerg-
ing independence.
whether or not the patient has retained a lawyer.
Other factors idcntif'Jed with back pain and/or sympto-
m:llic disk disease that frequcnlly prolong disability or serve
}
,

I I
ABUSE

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.
as barriers to recovery include obesity. inactivity. decondi-
tioning. lack of aerobic fitness, smoking and other substance
(alcohol. marijuana. cocaine. legal or illegal narcotic) ::tbuse.
exposure to vehicular vibration, and a troubled family situa-
tion (e.g., children leaving the nest. illness. de.uh. marital
discord, divorce. or other losses). A shan period of employ-
.~

..J

I
yelling. screaming.•HId inappropriate favoritism. Abusc. how· ment before ::tn olHhe-job injury often bodes ill in terms of
ever. can also be physical, involving inappropriatc or frequclll prognosis.
corporal punishment. beating. or actual haltcring. Lastly.
abuse can be sexual. either as a single episode or on an ongo-
Examination Format
~ ing basis. Adults who were abused as children commonly har-

I
bor both unconscious guilt and unconscious rage. either or The cornerstone of evaluation of an injured persoll is an ac~
both of which can fuel nOl only abusive and rebellious be- curate description of the person and of his or her work. Such
havior. but also a chronic pain syndrome. a description is possible only aftcr mcdic,,1 and other relevant
;
,~

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i1 ---- _ ~
\I;

i
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 "''''
nX\lrd", ilrc rc"icw..:J. and the individual is inlcrvicwed and D:lle of evaluation
cxamill~d. Al lim~:-. il is necessary 10 interview a spouse or Dale of injury. ;f relevant
other family mcmha. The procc~s or c\"<lluation lakes lillle Job description. inclUding physical demands
and ~hould ncn;r bl..' rushed. Employcr and dale of hirc
, . Th~ n;\'h.:w of fl'l.:ords is 1110st rc\'t.:aling if it is arranged
Hislory of prcvious Worke~' Compensation claims or personal in-
jury litigation
;Illd pn=~cl1(cd dm'lllologiGilly. This process may take the
a Time periods mil of work. current income source (ascertain in-
form Ill' handwriuL'l) notes, but a lllOre.: dficicl1l I11CilllS is come while working versus income while disabled)
lhn)ufh dil:l:ltioll lor subsequent word processor input. A Nole any job or work hid changes bcfore injury
dnonolngic rC"lc\l,: of the records "ffords the hc.<>1 opponunity Ask about rumored layofrs or plant closings
to ull{krSlalld sOllh.'thing of lhe backdrop ~lgainst which an A~k aboul an}' suspensions. or censures for unsatisfactory work
,i injured PCf:-:OIl Illusl be viewed. Record review is the task pcrfonnanc'~
or a d~\(':lOr and should not be delegated. Sometimes ex- Reason for evalu<ltion
trcmdy sulHk medical record entries provide vitally impor-
tant Chl#CS to the comprehensive understanding of an illness II. Present Condition
and disability. List all symptoms attributed to injury-their onset. frequency. and
A ("(1/II/Jl'elwlISirf history is the foundation on which an sevcrity. Note symptoms present before injury of focus.
lllltlcr:-'l;lIlding of an injured person rests. It is important to es- Chronologie history of prescnt condition. inclUding all prcvious
IrCiltment methods and responses.
tablish r;'ppaTt with the individual being examined as quickly
If an injury is involved. a detailed hislory of that injury is needed.
as po:-.siblc. The good doctor is first and foremost a good lis-
with particular attenlion paid to discovering and understanding the
tener. The HISk of eliciting a good history is both a challenge probable mcch.anism (in tenns of biomcchilnic:J1 forces) of injury.
10 and ;lrl opportunity for the examiner. Othcf\visc. as dctililcd as possible 3. history or onset of symptoms
Imcr\'ic\\'ing is ll. skill. Almost all persons coming for an should be documented.
initii.11 examinatiolf after an injury (and virtually all those
t.:omil1£ for ;, medicolegal e\'aluation) arc anxious. A gentle. ll/. Pas/ Medical His/ory
reassuring. kindly approach helps to calm them. Some injured Describe prcvious accidents or injuries. ope,.uions. medical con-
person~ .Ire angry. It is particularly important that the doctor ditions. hospitalizations. and any pre.cxisting disabilit)'.
not respond (0 them in kind. Frequently. if the doctor simply 1\ole current usc of medications. appliances. :md physical therapy
listens quietly. the anger dissipates and patients are better able or similar lechJljques .. :~'\ ~v~!! :\~ dini('<!! resp()n~es.
to talk abollt thcir problems. Many patients, particularly Note prcvious chiropractic treatment with clinical rcsponse.
Describe current and past use of alcohol. tobacco. caffeine. <lnd
chronic pain patients. have gone through life viewing every
other drugs of abuse.
human being with whom they come in contact as an adver-
History of current or past psychological difficulti~s and treatment.
sary, These individuals have a way of "setting up" the doctor
Ask specifically about anxiety. dcpression. ilOd suicidnl lhoughts
<IS an adversary llS well. The doctor should communicate in
or auempts.
word and deed his or her detcnnination to listen to. to under-
stand. and to \vork and collaborate with the patient in the
IV. Review of Systems and Psychological
proce:-.s of hC:Jling, Occasionally. an individual will become Symptom Inventory
tearful or wccp during an interview. At such times. 'it is best Ask about general heahh and pose approprii,\t~ly focused que:,-
(0 maimain a brief !'ilcnce while trying to understand what lions pertaining 10 the hC<ld. eyes. C'lrs. nose. and throat. as well
triggered thc tcars. Remember. everything in such a setting a... the cardiorespiratory. v3scuklr. gastroinlestinal. musculoskele-
has mC:Jning. which emphasizes the need for the doctor. and tal. neurologic. and urogeniwi systems. Ask a~out sexual flllK-
not a lay "historian," to obtain the history. lion. In females. ascertain number of pregnancies. live binhs.
An ovcmll structural framework for the history assures illld misc~lrriages or abortions with datcs. Ask ,lOout prcmenstru;11
thoroughness and minimizes the likelihood of serious over- J,\'lldromc.
Ask spccificail y about depression. sleep problems. crying. difli-
sight. The follo\ving evaluation format. which has undergone
culty with concentration or memory. loss of energy. casy fatigabil-
many revisions. has proven useful.
ity. irritability. temper outbursts. physical viL'Ilellce. social with-
drawal. dre~Hns. self-esteem. sense of guilt pill' bias. panic attacks.
HISTORY FORMAT bypcrventil;ltion. fainling. dizziness. lremors. (,'xccss swe;i1il1~.
childhood bedwelting. history or shoplifting \lr stealing or gam·
The history format cncomp:'lsses material appropriate for bOlh
bling problems. and hallucinations.
chiropraclic as wcll as mcdical or psychosocial evaluation.
All areas are imponam for a comprehensive understanding of
V. Chronologie, Educational, alld Work Histor)'.
the individual being examined.
Ineluding Military Experience
J. Ideuti!.villg Data Note schools attendcd. interests. performance. \,·,\tracurricular :Ii.,'-
Namc of patienl. ilddrcss. marilal status. age. occupation. and em· tivitics. disciplinary problems. diplomas andlL'r lkgrccs. If schO\'I1
ployer drop-out. i1sccrtain why.

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 NOll' .tll major johs. wnrk d:lll'S. jnh s;Llisfm:tioll. and n:asOIl makc rcasonable judgmcnts. ;.tnd recent and remote memory.
for leaving. Ask :.p..·..:ilir.:;tlly ahoul ...· xll'n<kd periods of uncm- M:tny of these functions ~re partiCUlarly import::tnt in elderly per-
ploymcrll. sons who may. because of mcmory difficulties, be unable to com-
~ COlllprdll'lIsi\"l' desr.:riptiol1 of til\.' w\lrk pl;\Cc and duties, ;IS well ply with complic;\tcd treatment routines.

I
as qualitr of relationships with employers. supervisurs. and
Xl. Physical Examination
<:o-workers.
Ask spccilic;tlly about jllil satisl':lCli(ln. The format for the physical examination is beyond the
Jc' Specifically d(JclLlll~'nl allY work lash pn:dtldcd by till: physic.L1 or scope of this chapter. It is clear, however, that thc corncrstone
, psydm·lllgic:ll (.:ondili\ll\ of Iii..• individual. wilh rr.::.ISOl1S for sm:h of a thorough cvalualion of a person with chronic spinal pain

i precilisillil. is a comprehensivc history (which does not neglect the psy-

chosocial arena). and a careful physical and mcntal statliS ex-
I,
~
\!I. Personal History
Note composiliollufhmlsdtolJ. any rCl'Cllt or illlpending changes,
alld rCI:CII! <.bllhs or scri.ous illness in family or fricnds.
amination,

~'
Psychological Tcsts
I Assess changes jn ;md stability uf living arr..lllgcmel1ls.
Ask about i1H:r~asing l..k hIS. financial problems, and b;mkruptcy.
Just as radiography and other imaging studies are diagnostic
I Check inICrpCrs()Jlal relationships: marit;tl or spousal: childrcn. es·
tools that work in concert with the history <lnd physical cx~
I pecially l.:hildrcll by (llhcr marriages: parents: in-laws: and sib-
lings. 3minntion to refine the doctor's ability to establish accurate
Obl"in hi~tory or invC:~lig'Hions and :UTeS(S (including driv- diagnoses. so also does psychologicaltcsting. aid in establish-

tI
ing while intoxicated), ;\llc.l notc any periods of incar-
ccration.
ing ;lccuratt.: diagnoses in the psychological arena. Nothing
from a physical standpoint is as valuable a diagnostic instru-
ment as a comprehensive history J.i1d physical examination.
~ Vll, Family History
So also nothing from a psychological sumdpoint is as valu-
Note signi(ic~nt medic'll or emotional problems. specili-
J ~
cally depression, ner,'OllS breakdown, ~lcoholism. suicide.
able as a comprehensive parallel history and a mcntal staws
examination. II Imaging, laboratory. elcctrical. and psycholog-
t! psychialric hospilalizmion. or disability involving
m~Jllbcrs.
f~mily
ical tcsts are important and necessary adjuncts to the comprc·
hensive assessment of the paticnt with chronic pain. The psy-

I
Vlli. Biographical In/ormation chologist interpreting the tests serves as a consultant to the
Developmental history. nOling quality of bond to parents, siblings. chiropractor. much as a radiologist interpreting imaging ~tud­
step-parcnls. or othcr~. ies is a consultant to the primary practitioner.
Ask specifically aboul harsh or unusual punishment. physicJI or Of the hundreds of psychological lests available, only
sexual :Ibusc.
a few arc of general utility by lhe nonpsychological pro,
Ask person 10 describe lJIother ... fOllta.
fessional with regard to chronic pain syndromes in general
Asscss quality of bond to siblings. parcnls, and other family mem-
bers.
and to chronic back pain in particular. These few tests. how-
Determine whcn the individuallcft home and why. ever, are immeasurably helpful. They have been described in
Obtain affectional rclatio·nship history (inclUding history of abuse) detail and discussed by Southwick 1ll and by Bccker and
to assess :loy difficul1y in mainl:lining stable and malun.~ intimatc Smith....)
The MMPI (currently the MMPI-2) represents lhe gold
)
relationships.
If divorce ha~ been invulved, inquire about alimony and/or child- standard. \Viltsc and Rocchio?O showed Ih.. t u certain MMPI
I ,1;
support paymenls. profile (plottcd on a gmph) is associ~ttcd with a poor result
following chcmonucleolysis. It is my experience that nn

I ~
IX. Social and Recreational History
NOle r•.lUgc of interests. hobbies. pursuit of sports. rccrcatiomtl ac-
tivities Wilh fril.:llds and family.
MMPI profile ch~lractcristic of somatization usually is associ-
ated with evidencc of a somatizatio!l diathesis in the history

i Specifically dO<:lllllClll any ;;IClivilics Ih'lt the Il:tlienl fecls arc pre-
duded because of physkal or psychological conditions ;Ind the
and suggests that a poor result is likely after back surgery for
pain. regardless of thc underlying pmhology. Certainly. an
"

iI 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 ini-
tiative, mOlivation. and pen;cvcr.mcc in maintaining a comprchcn~
:-ivc fitness or physical rehabilitation program.
MMPI·2 is imperative in any c.asc of back. ncck. or shoulder
pain that fails to respond to reasonable trc:tlmcnt in a timely
fashion. or onc in which "the doctors just c,mllot find out whar
is wrong," No patient with a "failed back" should havc further
.--~

i X. Mental Status Examination:

operative procedures without first undergoing thorough psy-
chological assessment.

I,«'"
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 ob-
served as well as reported r<tllgc of mood. Ask about suicidal
Southwick"~ dctailed the evidence supporting appropriate
usc of the MMPI. The tcst is used widely and appropriately
so. The MMPI-2 (1989) has largely, if 110t totally, supplanted
the MMPL
I! Ihoughls or behavior.
Check spccilically: orientation, calculation, digit span, ability to
In addition to three scales that assess the validity of the in-
dividual test protocol. the major MMPI-2 scales include:
1,
'f
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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 istering an MMPI-2); (b) self-report measures, such as
Dcprc:-sioll (D): dy:-phoria. won·y. discoumgcmcnt, low ::~lf- the pain drawing; (c) a personality test, such as the MMPI-2;
and (d) projective tests. such as the Rotter Incom~
Hystl'ria (1-1)'): inappropriate happy :lcccptance of ndversc or
plete Sentences tesl, in which the patient completes a rull sen-
qn:ssful cvents or t'irCllll1st:IIlCcs in general (deni<:t1)
tence. given only one or two words. Examples from this test
l)s~'dl(IP;llhic dcvi;lIc (Pd): moodiness. resenttncnt. mal<ldjust-
lUl.·llI. ddialll.:e uf authority. anger
include:
~·t;lsclilinity-li.:lllillillity(Mf): Aesthetic ,"ocatiomll interests. artis-
.. Back home - - -
IiI." inlcrcsls. sCXIl<l1 orientation
• \Vhal ;.. nnvy:- m..: - - -
Par-lnni .. (P;l): pcr~cculion. being easily hurt. suspiciousness
• A mother - ..
Psychasthcnia (Pt): narcissism. :mxicty. self-concern, self-doubt,
.. My greatest fem - - -
feelings of being forced. constitutional inadequacy
.. When I was ~I child - - -
Sl:hiwphrcnia (Sc): alienation. delusions. influence of external
.. The future - - -
agents
What pains me - - -
Hypom;mia er..
t a): expansiveness. irritability. egotism. the other
side of depression My father - - -

Thes~ descriptors arc simplistic and not intendcd to cncour- Use of appropriately seleclcd psychological tesling de-
age the i.llllalcur interprclalion of MMPI-2 profiles. The inter- rives several benefits. including. revealing evidcnce of depres-
pretation of the MMPI-2 requires an extremely broad under- sion. factual misrepresentation. and the psychological asscts
standing of that specific (cst instrument. Normally, the and liabilities of a patient. In terms of the clinical prognosis.
MMPI-2 and other psychological test measures are inter- thcse tests demonstratc the ability of the inol\'idualto benefit
)
preted by a clinical psychologist with special tr.lining 'and from psyehothernpy or counscling and the likelihood of eom-
specific expertise in the area of psychological test adminislm- pliance with exercise regimens or of persevering in functional
tion and interpretation. Validity scales are built into the restoration or vocational reh;lbilitation progr:.lm~. The markct-
MMPI. Lees-Haley" devised a fake-bad seale for the MMPI- place is repletc with so~called "self-report" test me:'lsurcs. In
2. which has proven useful in identifying patients who may bc general, lhese arc not tests that look bene.nh the surface. but
consciously misrepresenting fact or even frankly malingcr- rather they indicate how the patient wishes 10 be perceived.
itlg.~l Full-blown malingering is. in my experience, infre- They have, therefore. limited usefulness.
qucnt. A more common situation is unconscious or to some Becker ~nd Smith1\l point out that although psycholog-
dcgree cOllscious embellishment of symptoms wherein the ical tests can be scored blindly (e.g.. by a computer or a psy-
hyperbole is part of the patient's theatrical (i.e., hysterical) chologist who has not interviewed or even seen the patient),
character style. At thc other end of tile continuum is pure som~ the conclusions are most accuratc when the interprcting psy-
:i ariz-arion. which is almost as uncommon as purc malingering. chologist has performed a screening interview and a mental
Most chronic pain patients represent a mix of somatization status examination to provide a backdrop against which the
1: plus underlying organic pathology plus somc symptomatic hard tcst data nrc best interpretcd. The chiropractor who
5
l' cmbellishmcnt, not necessarily in any ccnscious aucmpl to bc wishes to use psychological testing for chronic spine pain pa-
!i
~ deceitful. tients should establish a rclationship with a clinical psycholo-
"f gist who is knowledgeable about chronic pain. somatization.
~
depression. symptom embellishment. malin2cring. and the
I
-~
PAIN DRAWING

A piclUre is worth a thousand words. Mooney and co-work-

like and thcn work with that individual on :1 rcg-ular basis.
This working relationship is panicularly cfkctiv~ v,,'hen the
~
~ ers2~ described a means of evaluation in which the patient chiropr.lctor and (he psychologist confer to fonnulate appro~
,
I draws. on the front and back of a body outline. the precise lo-
cation of pain, specifically using symbols to indicatc numb-
priatc management strategies for each patient with chronic
pain.
i• ness, burtling, pills and needles. and stabbing. The pain draw- Patients, particularly those who may harbor a somatiza-
j ing is remarkable in its correlation wilh the history. cspecially
the p,lralle! history. and the MMPI-2. Brown~·' concluded that
tion diathesis. are frequently resistanl to undergoing psycho-
logical evaluation. They tend to dislort the mC~\Iling and V~lll~ -.
~
~ the pain drawing (along with mugnetic resonance imuging) is of such testing with interprctations such as "tltt: doctor thinks
~ }
especially useful '1S a diagnoslic adjunct in cases of back and it's all in my hcad," "the doctor doesn't bdicvc me," or
~ lower cxtremily pain. "the doctor thinks I'm cr<1zy." Explaining to the patient
•
I
i;:
<
CHRONIC PAIN TEST BATTERY
thaI hc or she is to undergo a chronic paill f!wduafioll is
less threatcning to an cmmionally fragile and rigidly dc-
fended person than is a psychological et'a!tullioll or. worse
,~ I3eckcr and Smilh',} outline a sm.11I psychological lest batlcry yet. a pS)'chiatric evaluatioll. MOSI paticllls readily ad.:nowl-
,f:,
~ useful in chronic pain evalumion. including: (;.t) an
gence assessment (it is imp{)nant to know if <I patient
intelli-
is liter-
edge chronic pOlin. and most can accept lhe rCillity that
chronic pain and mood and behavior arc rdalcd. It is often
~ <lte .md how effectively the p.ltient can reason b::::forc admin- helpful to review with the chronic p;'lill pmiclll his or her
t
R
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~---- --_._---_.__.._ ..__._ ••..... __ ...._.... _...._-

failure to reg~in health despite reasonable {re~tlllenl, and to viduals arc less susceptible to incapacitating chronic pain
Le
poilll OU! that a chronic pain cvalumion mOlY yield findings
that suggest additional m:atment stralegies. Using patience,
syr.Jromes.oI
I
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
Chiropractor as Thcrapistffeachcr I
c"aluathHl. Psychothempy is the praclice of listening to the patient talk in i
,~

The usc of psydlOlogic;11 tcsting as a diagnostic adjunct ;;I supportivc, underslanding. and appropriatcly interactive ~ ;;

in the evaluation of chronic p:lin is :'lcccpled as standard

practice. Failure to consider 'psychologic:il evaluation (in~
way that leads to a doctor/patient bond within which healing
can be facilitated .md nurtured. It has been around sil\CC
L,
eluding. testing) in the face of a rcfraclmy chronic pain syn~
drol11c. particularly before perfonlling inv:lsive proccdurcs. is
recorded time, antedating Sigmund Freud by several millen·
Ilia, For m.IllY pain palients, especially those who remain pro·
l~
llcgligcm" duetive. the doclOr may be able to serve effecti\'ely in lieu of
:.1 therapist. Living with a degree of chronic pain means fo·
I, )
cw:;illg increasingly on the resumption of as many activities of I~
I;
TREATMENT CONSIDERATIONS
daily occupational, family. social, and recrcational function·
The carc of many paticnts with chronic back pain can be ing as possible. Simply because an exercise or activity (done
satisfactorily managed by the treating chiropractor, e:thcr by a deconditioned individual) causes an inCrC3s.c in pain is
alonc. or if mcdicmion is indicated, in concert with a
physician, Chronic back pain, especially the kind that ling-
no reason to stop the activity. Indeed, unless the chronic p:'lin
patient pushes on with an appropriate functional resloration
L,
'J
ers or smolders. w:'lxing <lnd wnning with time. can be
cxtrel11~ly frustrating to the doctor. Somctimes "cure" (mean-
program. despite some pain. little if <lny sustained progrcss
wift likely follow. Patients must understand this fundamcntal
I..)
"
ing long-lasting ablation of pain) is not possiblc. When principle. (Many patients have no understanding of the: con·
it is not, the palient should be so advised and assistcd in cepts involved in progressive conditioning or aerobic tmin·
establishing realistic goals. This preparation is best done ing, and need ongoing guidance and supervision.) ",,
.T
in a way that cn::lbles thc patient to understand in a posi~ If a chronic back pain patient can maintain;) rcl<llivcly
tive light the implications of living with back pain. The high level of musculoskeletal function through the ongoing.
doctor may say, "You will just have to Icarn to livc with infrequent (Le.• once a month or with time, only three or four
it. rvc done all I can do:' Thc response of the patient, times a yCo.It,/ C("H:.i~i. , ... Ji.1l a trustcd chiropractor. the ongoing
panicularly one who is depressed. may be 'Tm never go- chiropractic visits require no other justification. Many pa·
ing to get better ... I'll have to go on suffering .. , I'll tients respond positively to ongoing and infrequent supportive
never be able to do anything ... I will nOl get my life psychotherapy. The parallel is aplo The chiropiJ.ctor with a
back." Thesc sentcnces reflcct what typical chronic pain healing touch usually knows how to managc th~se challeng-
patients tcll themselves, and illustrate considerable cog- ing individuals, teaching them patiently every St~p of the way.
n;ti\'e distortion. a kind of negative and defeatist thinking The proof of effcctiveness is the resumption of optimal phys·
thai is characteristic of depression, It is essential, to enable kal function.
the patient to understand that he or s~e should live (with III Latin. "doctor" means le:'lchcr (hence w(.'rds like doc·
the pain) to the fullest, Living with rather than suffering trine and indoctrinate). The effective chiropractl,,"'lr understands
lI'itll ;md being incapacitated by the pain is the vital con·
ccpt to instill.
that he or she must function as a tC:'lcher to enable patients to
heal themselvcs, Tcnching p~HierHs with chronil..' back pain
I ."
..
One talk with a paticlll is rarely. if ever. cnough. Patients how to develop and maimain conditioning <lnd fitness, as well
wilh chronic pain arc. as a group. morc needy (i.e.• depen- as how to become relatively self-sufficient. is a aitically im~
"""\
dent) than most. and they respond best (0 ongoing and repet- portant task of the doctor. Motivation. initiath"t:. and pcr~
>"
itive SUppOTt that can bc diminished in frequency as they get severance are vitally import:'lI\t ingredients of sut.:h a program.
Ihe message and begin to act on it. The injured worker who stops a cOl1lprehcnsh"~~ physical fit·
The treatment approach to :'l chronic pain syndrome must ness maintenancc program :.\ft('r returning to \\'('Irk soon be·
be goal directed and time limited. It is also counrerproduc- comes a candidate for rcinjury or re-cmcrgence 1.."11 symptollls. "")
,}
ti\'c to help the p~ticnt "accept" the chronic pain. because For the patient. the boltom-line measure .."If the effcc·
"acceptance" is invariably misunderstood by the patient as tiveness of a treatment protocol is function: at home. at
me.ming ongoing passive incapacitation, helplessness. and \\lork. with the family. and at play. In morc r~::.i~tant cases.
\'ictimizmion, The most effective treatment strategy is the .1 treatment tcam C'lI1 be cffcl.:tiye. whcrein the chiroprac·
sports medicine (no pain-nl;) gain) approach of working lor works collabor<ltivcly with the family phy:,ici:.m or the
through pain to optitml1 flexibility, strength. stamina. en- psychologist or psychiatrist. These providers $hould con·
durance. and aerobic fitness. The role of cach and every mem· fer regularly to share insights and undcrstanlting and to
bl:r of the treatmeTH team must be supportive of such an coordinate, unify_ and manage;.' care. If psyclh)logic.at eval-
approach. Physically conditioned and aerobically fit indi- uation reveals Ihe likelihood of a masked depression or

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 ..... ' " " ' .... ', ';' .... v, ..... "V..,)v..... I .... L rJ·H.... luM~ ll~ \.;nHUNIL; PAIN 401

loll'p;tin :,... :\ \h.:pn.:~si(ll1 cqll;\'~I~n!. or if the patient complains ACUPUNCTURE

\11' in:-'llillnia 1X'~aLJ~~ or pain. a trial of ,ll1tidcpressant I11cdica-
Acupuncture hi:ls been used by Chinese practitioners for CCl1-
liun is \\'arr;lI11~d. Dctaib of '\Heh (hentpy :.IfC he)'ond the
lOnes. Recent work suggests it may have some value in
scope of thi . . ,,:hapler. hut lh.:~ have been outlined by Becker'
chronic pi:lin syndromes,2 4
and othL'l".'i.
i\llllllll~h lllallY patil.'llls who somatii',c can be s;uisracto-
BEHAVIORAL THERAPY
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 This type of therapy is rooted in the pioneering work of
rdcrn..:d for P'~ chmliagllo~liL' c\'aluatiul\ lind. if indil::HCd. for Skinner, who recognized that behavior is shaped by its conSt;'
smgi!.:al L'\';l!llalion ;IS well. The ('riteri" for sJtisfactory man· qucnccs. Stembach:2~ describes an approach that identifies:
agelHem illl-lude: (I) undesirable (maladaptive) pain beh:wiors that interfere
with the patient's life and constitute barriers to recovery; (2)
Pn1gn:ss in llll.: '1r~lchillgf;.,lr~'Il;;thl.:nilig/li\lli;SS progralll withollt desirable (adaptive) behaviors that the patient has but fails to
r~~urn~nl "t:lh~kks ~ltld l.:lltll~ss r~tllrn'lO-work date ex- usc; (3) working with family, reinforcers that encourage the
h;llsions desirable behaviors (2) and strategies to discourage, if not to
I'rH~rc:\:. in r~;t(hin~ it pcrnl~lll'lH and slatiollary status and salis- eXlinguish. the undesirable behaviors (I).
f:'lch1ry maillkn;uKc or th,,1 "l;.itll\
Eith~r rl.:lurning (0 work on a \u,wined hasis or entcring and com- COGNITIVE THERAPY
pJ..:lin~ ;1 nl>::.llional r..:habililaliol1 pru~nllll. finding appropriOltc
l;ilinful cmplnYlllclll pn:.Hr;tining. ;lIld sustaining work per- This fonn of Iherapy is based on the work of Beck and col-
fllrnl;ll'l"\.' leagues.~(, Cognitive thcr-apy helps .he patient to recognize
Disl:ol1linUilli\ln Ill' Ilarcolil.' anall!csil:s. Only in rarc instances the cognitive distortions characteristic of the thinking of deM
an: n;lfl"Oli(, indil:(ltl.'d in l.:h.ronil" bal.'k pain management. A pressed persons, and to acquire the inner resourcefulness to
small SUbSCI (\f paliel11S funnion more salisfaclorily willi it low overcome passive dependency and the "viclim complex."
Ic\'eI of mailllen"nce narl.'Qtic th~ln willtout the narcotic.
klclHilicati<1n of such patient' n:4uircs considcmble skill and
RELAXATION THERAPY, BIOFEEDBACK AND HYPNOSIS
expcrience in assess me 111 and mana£Clllcnl of chronic pain
syndromes and is bcsi Ilnd::naken hy it physici;m skilled in Alone or in combination. these methods have shown limited
alg<llugy. success. Those patients who mallifc:-.i iilt;: l:ydc illustrated in
Resumption of family, social. and recrealional physic,",1 activity Figure 19, I, a fonn of tension myalgia, may respond to a
appropri;llc for ;,lgC and spinal condition. Ongoing passive depen- treatment approach that involves the therapist teaching and
dency. bcspca~itlg psydlOlogic<.J1 regression, is lln<.Jcccptuble and,
the patient JcaTlling skills that culminate in a high degree of
in and of il<o;df. is a reason for rdcrml.
patient self-sufficiency. Relaxation. accomplished through
At the outset. wilh " chronic bac~ pain patient, IOllg-range gOClls
medication, biofcedbnck, or selfMhypnosis may increase a mo-
{rcsumption of most. if nol all activities or
daily family. social.
occup;lIion;tl. and rel'rcat~Ol1ill functinn: m;lintcnancc through a tivated patient's sense of self-sufficiency and control while
Inunc cxcrci...c :md aCf<\bic fitnc~~ program of filne!>s. 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 PAIN
a high dcgrcl:: (If self-sufficiency wilh infrequent monitoring:

i wcaning 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
deprcs- or

I
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 re-
MORE MUSCLE
co\'cr promptly. Wh.:n Ihcy do not. S\llllClhing Illay be seri-
, ollsly wrong. and thaI something may escape definition if the
MUSCLE SPASM
:~
SPASM
psychological dmnain is nOl included among thc uifferclllial

I di:lgnosli..- cOIl,idcrali\llls.

I Ps)'chiatric, Psychological, and Supportive

Treatment j\ lcthods

I
;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
MORE
PAIN

~ resources that ;Irc ilvail'lblc. Fig. 19.1, Pain· muscle spasm cycle.

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diminishing or extinguishing maladaptive thoughts of hclp- agents. including fluoxet::lc. :;~:1ra:iae. <;,,,c i~~~:-~~;:;lil~:::. !~:~\'c
lessness and victimization. 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.
FAMILY THERAPY
pear to hav~ J more favorable side effect profile lhan the lra·
Rowat and Jcans:.!7 st,He Ihat "learning 10 live with pain is a ditional tricyclic compounds.
family affair." Certainly. when a major wage curner or Mu.w:h' r('laXllfl!S may help whcn idcmiliablc and ongoing
provider becomcs dis~lblcd for an extended period oflime.lh~ muscle spasm is .\ P:Ul or the (.'lillie:ll picture. This c!;ISS of
impact on thc family Illay be devastating. In the worst casc medication IS Illost apl)ropriatt.: in acute cases and when uscd
scenario. the passivc/dependcnt patient can become a virtu- regularly. like sedative hypnotics. may diminish cllcrgy. mo-
ally helpless invalid. indeed. some chronic pain patients arc tivation. nnd initiative. TIlc efficacy of these drugs has bl:cn
as much of a demand on families as is a newborn infant. questioned. Carisoprodol has acquired .1 repul<Ition as an
Additionally. most chronic pain patients manifest depressive aphrodisiac.
spectrum symptoms. including insomnia. irritability, fatiga-
bility. lack of motivation. diminishcd selC-es(cem. social with· Street Drugs. Nutrition, Alcohol. and Tobacco
drawnl. and diminished libido. It is not unusual for families to
collapse and marriages to fail when an overworked spouse At[arijllalla has an effect similar to the benzodi'lzcpincs.
cannot shoulder yct another cx(ra burden. Frequently. Illount- \Vhen used regularly. it is a'isociatcd with the af1lOliw"iollOI
ing bills lead to bankruptcy and somctimes homes arc lost. syndrome. Alcohol abuse signals a self-destructive behavior
Family therapy can sometimes help the family understand the pattern that may effectively undennine the best-intended ef-
underpiilOings of the chronic pain syndrome and to learn fofts of the caregiver.
strategies that may avert disaster. The family that learns to en- M;my chronic pain paticnts are overweight. It behooves
courage and reinforce the patient's active lh'illg and to extin- the chiropractor to teach these individuals somcthing abollt
guish Ihe patient's passive sufferillg has a greater chance of nUlrition. including lowering intake of dielary fal, and ill-
survival. creasing 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 CUf-
PHARMACOTHERAPY
rent knowledge sometimes helps. Refractory patients may
The chiropractor should discover what medications the pa- have success wilh a fonnal weight reduction program. The
tient is taking. Narcotics, except under special circumstances. role of diet in conjunction with exercise in a weight loss pro-
are inappropriate for chronic pain patients and may only di- gram must be instillf'd.
minish energy and motivation. Patients with chronic pain syn- Many patients with chronic back pain have never been
dromes are at risk for developing iatrogenic substance abuse infonncd about Ihe relationship between smoking. back
disorders. They frequently seek narcotic prescriptions from pain. and disk degeneration." Pan of a comprehensive attack
several providers. Appropriate team management of such pa- (Le.. educational program) on chronic back pain should al-
tients designates only one provider to prescribe and manage ways invoh·c encouraging the patient 10 stop smoking.
pain medications. Ongoing regular usc of narcotics dimin- Indced. lhe patient's willingness or resistance (0 do so will
ishes endorphin production. thereby robbing the palient of serve as an excellent index of moth·"tion. Ultimately. of
a biologic mechanism intended to help cope with physical course. patients do what they \Vant to do and what they arc
pain. Aspirin is one of the best analgesics in the entire motivatcd to do.
pharmacopoeia. The practice of taking aspirin with a full
glass of water effcctively minimil.cs gastric irritmion in most
Functional Restoration
individuals.
The use of (lllxiol.vtics and sedative-hypnotics (benzodi- Many persons with chronic pain syndrome arc not at all
azepincs. barbiturates) is inappropriate in most cases of psychologically insighlful and their care is beSI manag.ed
chronic pain syndrome. Especially in the presence of depen- with (l func~tional restoration approach as described by
dent 'lOdlor somatil.ing. dynamics. these agcnls lend to dimin- Polatin.~11 Such an approach involves careful assessment of
ish energy levels and motivation. lhereby effectively sabotag- the paticlll's clinical condition. particularly with rcgard {()
ing recovery cffons. Like marijuana. when used regularly. flexibility. strength. and aerobic conditioning. The in-
they may be associated with the ltmotil'atiollal sy"drome. a jured worker with chronic back pain usually has restcd for
serious barrier to active recovery. ::l long period and has becomc incrcasingly out of con-
Amideprcs.mlll medications arc among the most useful in dition with each day of passivity and rcst. The patient mU5t
chronic pain syndromes. Insomnia attributed to pain by the be taught to recognize decolldirioning. and to addrcss
patient often signals an unrecognized depression. Therefore. that state. rather than pain. as Ihe focus of concern. A
in this group of patients. antidepressants are more effective functional restoration progwm is most effective when led
than sedative-hypnotic medications. Newer antidepressant by a temn. which im:ludcs the prin~ary provider (dliro-
www.bodywork.su
 4U;;S

pr:h.:lnr. family physician. or internist), the physical and oc- CONCLUSIONS

1.:Up:ttiOll:11 1Ill..·rapi:,t. and the psychologist. Optimal Illan~
It is imponant for the practicing chiropractor to recognize.
agl.'ll1Clll prL'Sllll1l.':\ ongoing tcam conferences, at least by
,
j

.~
h:kphollC.
evaluatc. {cst. and trcat patients with chronic b:tck pain in
whom psychological .md emotional factors arc adversely col-
j Th(: important ph;lscs of a functional restoration progr.tl11
I oring the clinical presentation. thereby constituting barriers
aflL'r illiti;,l ill-depth evaluation include stretching. progrcs-
I, ~i\'\,' fl'sisl;lIlCC l'\t,.'rciscs. work simulation :a."ks. and aaohics.
to reco\'C:'y. Prompt recognition and comprehcnsive suppon·

,,,
~
TIl\,' p:llil:lll kant .. wlwt In do on his or her own (without f<lnt)'
111" l".'.\pt:llsivl.' l'qlJiplllCI1l) ,1IId ·:s monitored until at Ieasl prc-
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
j dcpcndcl\cy ;md Ill<lladaptivc pain behaviors .1I1d regain a
injury (if nOI optima) function is restored. A typic:\1 func-
I, more :.tcti\·~ lifc~tylc.
tion:11 restoration program for a refraclory patient (which C;.111
§ I:lc mndili~d for more ilctive (lr for wcll-motiv4.ltcd palictlls)
~ cOl\:"ists or four phases: nEFERENCf:"~
,~

,I
1
Phas~ I. EvaltJillion and tklaiJcd physical asscssment. including
r;lllg~ of llIo1i(ln and strength measurement.
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.
Ph:lse II C! [(l nwaks). Supervised stretching. TIle focus is on im·
i prnvil1~ ;llIY lll<lhility detidts ;lIlt! overcoming ;lpprehension. The
1950.
:t Brown T. \"cmi;lh Jc. Barr JS. Cl al: I'sychological (aclors in low rad.:

i P;\\iCllt1ll1IS\ undl.'r.. . lalld thill hurt docs not equal harm and thilt suc-
l:~ssfull.:(llllpJctimlof tilt:. program c;lnnot occur without "pushing
pain. N Er.fl J Med 251:12~. 1954.
4. FrYlllu~'\.'r lW. Gordon SL (cds): New Perspectivcs in Low B;]~:" Pain.

I
lhrough" pain l.'OllSCtjUClit to rCllIobililatioll of tired. flabby Ill11S- Ameri'an A.;adel1ly of Onhopaedic Surgeons. Workshop. Airlie. \"A.
(:uliltun:. The p:uicnt must be tauglu and. through support and en- 1988.
ClIUr;Ij;l.'lIlCnl. llHltjv;lIcU in ,Ill inl.:rcment:lll)' gr..luuatcd home pro- 5. Ford CV: The role of somali7.;]\ion in medical pr.lctice. Spine 17:S:-38.

I ~r;lln:l11c palicOl is hest cvaluated weekly. 1992.

6. Lip(lw~1.;1 7.J: Som:lti7.;\lion and depression. Ps.ychosom.nie:, ~ I: I~.
Phase III (3 wccks wilh progressive lime incrcases).This
1990.

i
c'xcn:isc and rehabilitation program gradually ;md incre-
7. Frymoycr JW: BilCk p;lin :llId sciati::;t. N Engl J Mcd 318:291. 19$$.
mcnlally incrcil"'c~ 1I111il function;.1 rcstonllion (or optimal restonl- it Sifneos PE: Shon Term Psychotherapy and Ellloti'lnal Cri:,i:,.
tion) is achiC\"cd. The patiellt is repelitively taught Ihe need 10 Calilbrid~::. Hal"'.ard Univcrsily Press. 1972.
~
mainlain gains hln.:ngth. :-;tarnina, and ;Icrohic fitness) madc in the f). mume~ D. Heilhronn ;'1.1; Chronic pain a,. a \';triant of dcpresslw Ji~~·a..'e,

I I
pro~r.lln, so thilt de:cunditiuning willlUlt s;lbotagc the physical re-
Iwhilitati(lll. The pc:rson OUI of work on temporal)' disability must
understand thai c!'tablishing wcllncs:-; through functional restora-
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..:):'~.

I
tion is the ji,..\1 (lml fori'mast priority. p60S.
Phase IV. 'n1t: follow-up phase. ~'lost paticnts with chronic pain 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.
l1Ianifest rctunHC)·work ;lpprchcn:-;ion and require fiml. dircctive.
12. Lipow:-ki ZJ: Somalizali\lIl: The conccpl and its clinical applic~ni('ln...\m
blll undcrstanding support. At this stage. it may be appropriate to
J Psychi;)'lr 1-45:13%. 198ft.
!, ricgotiatt; with the: cmployer if:l residual disability requircs special
:ll.:comlllodation: to pursue job plw.;t.:ll1ent if the patient has lost
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
~ cmp!oymelll: or lo pursue ;\ vocation;11 rdmbilitation program if low b:u:f: ;:.::in. Spine 5: t t i. !()SO.

I -,
Ihe p;ltknt h"" rcached ;1 IJefinancnt and stationary status with
residual disability thai would preclude return 10 the previous elll-
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.

ir!
ploymcnt ~cHing.

Timely identification of those individuals who arc vulner-

1989.
16. EllJ;c1 (;1. "Ps)"ch{l~:l.'ni~·" pain ;md thc p;lin·rronc palicill. Am J ~kd
26:899. ! ~,~'j.

,
I able 10 develop chronic pain syndromcs. and working with 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
them to tt:ach and CllCOur;lgC them aboul thc importance of
\Sllprl,:S:::~. 1992.

I
thcir active in\'oh'cmcnt in and responsibility for Iheir recov- IS. Soulh" l~;. 5\1. While A'\: 'Illt: u"e of pS.ydl\llogicilllcsts in llk' <,'\;11113-
ery. \viU result in more clTcctivc and faster physical rchabili- tion of k:··bad; p"in. 1 rhlllc Joint Surg lAmI65:560. 19S.'.
union. Impediments and !'itlllTlbling blocks to rccovt:ry should 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

I
be idcl1litkd early on .md <lddrcssed. Thc fundamental impor-
Ytlrk. C::.~~hilll.i\'ill:,>hUle. 1992.
tancc or cmpl13~izil1g conditioning (and not focusing on pain) 10. Wih.. . c LL Rflcdlilll'D: I'rcllpcr:.l\i\·c p~ydH,111~icallesls as rr\'Ji,'h'r~ Ill'
is underscored. The injured worker must learn 10 work sun·c...... I.: ~hcllll)lIudcolysi .. in the lrcallllelll \'1' lilc low·b:lCk "~II,lr\'I\l~'_
throug.h the pain with <l no pain-no gain philosophy. The J 0011(; J:.;~;; Sur,.: IAml 57:479. 197:;.
temporary aggravation of pain when lhe patient \vitll a 21. l.ecs·H;.:!~:. PR: A fake bad \(;;.:1.: on lht: ;'I.1~tPI-2 for l't:rs"ful Ill.iury
fl chronic pain ~yndrolllc cmbarks Oil this program should bc dailll;lIlt· P,yt.:hlll Rl.'p 6S:203. I'NI.
i ~
anticipated and identilicd as a rC<lson to prcss on. rather than
2~. !lhKlIlC~ '" 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.
~ to slack off. The physically supple. strong. and ncrobically fit 2;\. Brown.V The P;)lhtlrh~'sinlogy :Illd Di;I~lIt,~is til' I.ow Ibek P.m~ :md
~ individu<l1 is not likely to devclop much less sustain a dis- Sciali(":J ';mcril;;lll .·\\.';ukmy <If Orlhllp;\l.'di~· Sur~C()IlS. tn~lru.:ti\'\l;ll

~" abling chronic pain syndromc. Course L;·;;uro.:s Xl.I. 1\11)2. pp ]:0)·21:;.

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 24. Dcyo RA: Non-opcrnti\'c Irc.;Ilmen! of low oack di~ordcr~. In FrYnlo)'cr 27. Rowa: KM. l;:a...~ :.11:.. \ ,:o::::~·.;;:;;;;·. .: io;....:,: "I' can.:: 1':lliO:III. f;llllilv.
JW (cd): The Adult Spine: Principlo.:s alld PraClicc. No:w York. Raven and health profcs::ion:.tk In Wall 1'. ~kl~;ld R lc~h): Text!>,,,.,, tll" 1':li;1.
Press. 1991. 211d Ed. Etlinburgh. Chur..:hill LivingslIllh:. 1%9,
25. Sh:mbach R: Behavior therapy. tn Wall P, t-.ldnd, R (cds): TC.'l:lh(\ok of 2X. Pllblin PH: The rlllH:liNUI rcslw;llillll appa':lo:h to d1f',}Ilj,,: In\\ h;ld.
Pain. 2nd Ed. Edinbursh. Churchill Uvlnsslonc. 1989. pain. J ~l\lscu[(\s~d }o.kJ 7:17. 1990.
-.~
26. Beck AT. Rush ,\J. $h;\w OF, cl :11: Co~nili\·.:' Tlu:mpy of lkl'rcssion.
New York. Guilford Prc!\s. 1979.
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Ed
LU PatIent/Doctor interactIOn
WILLIAM H. KIRKALDY-WILLIS

SCOI'I-: OF OLR RELATIONSHIPS different parts of the ellvironlllellt. A simple practical <lpplic~l­
tion follows:
The interaction between medical doctor and patient. chiro-
pmctor and patient. and medical doctor and chiropractor leads '111C diagnosis mllst include 1101 (lnly the phy~ic3l or mental
to an integration, a oneness that embraces these three and problems within the individual, but also how the patient feels
their environment. The resultant combinations arc addressed .Ibnut life al work. at hOIllt:-. and in the exlernal ellvironment. A
throughout Ihis chapter. Relationships matter morc than noy facct syndrome may be a minor problem in ;1 person who is
individual factors. happy ,It work and ilt humc. A silcroilj;lc syndrome may prc:,ent
il difficult problem for" person whose spouse is ullsymp:lIhctic.
"'n the rcalm of science. lhe unbiased observer record!> tlCIS
from the world around us __ . In the field of ..n. the observer is In prescribing treatmcnt, lhc ;Jllswer lIlily be found by illlroduc-
involved in 3 pcrsunai assessment of the objects studied ... III ing a change in the workplacc or adjustment to life 111 Ihe home
Ihe sphere of religion. two or more people arc im'olvcd in per- f:1(hcr lhan in chiropraclic manipulation or dntg. injection. or
sonal intcr;,.ction:' olhcr Ihcrapy. The wriler rcc;Jlls the ";Ise uf a yuung mall with
These words of Macmurryl.2 define the scope of human symptoms suggestive uf a cauda equina syndrome wtw rccO\··
ered r;Jpidly wben plans were lllade for his mother-in-law to take
relationships. In the work of any health care professional, all
three areas of study-science, art, Hnd religion-arc impor~ a long vacation in iI dist'J1l1 pan of Ihe country.
t~UH. Chiropractic embraces all three ,Jrcas, which is why it The wise physician. chiropractor, or physical therapist
IIns so much iO offer. sees the patient as someone with four parts to their make-up
living in a four-part ellvironment. Practitioners cannot help
THE INDIVIDUAL every patient with all possible aspects of their problem, but
they may need to approach the problem in greater detail
Each person i" made of four differellt. yet interconnccted, sometimes. Often it is helpful to allow the patient time to tell
parts: the physical, the cognitive (logical), thc emotional, and all he or she wants to say about hil1l- or herself. \Ve should be
the spiritual. This image can be illustrated simply by drawing <IS prepared to refer a patient to a soci:11 worker. industrial ~Id­
a circle that represents the individu:ll. dividing it into four viser, or psychologist (Is we would to a neurosurgeon or or-
quadrants. and imt.lgining t.l door bet\veen each division to il- thopedic surgeon.
lustr:lle the conncction between the parts (Fig. 20.1). A pr"lc-
tical application follows:
LISTENING: A BASIC SURVIVAL SKILL
E"1Ch (lilt' (l:'lh~ four p:lrts innuellcc~ lhe others. A hig dillercllcc
A study at the University of Minnesota suggests that 60'ic of
is nOlc.:d !Y.:IWccn a disk hernialioll ill a person who is in good
misunderstandings in business result from poor listening.
mClllal. cm(,rional. and spirilual heallh .llld one ill .Ill individual
Eight percent of all business commullications must be re-
who h;\~ m::nlal or emotional problelll:'. A complete diagnm.is
peated. Rarely is morc thtln 20 cK., of what (01' mal1<lgcmcl1t
includes th:: other Ihree component:' ;IS well as the physical
says understood five levels below. Sixty percent of customers
lindings.
who stopped buying from a comp;;my did so because of poor
The same <lpproach is required for tremment. It is often listening, an attitude of indifference to the client. Eighty pcr~
easy to trem <:. woman with tl sacroili:lc syndrome who is oth- cellt of the day in business is spent in communication. but
erwise in good hcalth. but the s,lIne lre..ltll1ent is diffkult in an time spent in listening is often <It only a 25e;t" cflicienl'Y level. \
individual who is resentful Loward her employer. Poor listening skills ,Ire responsible for Illany of our failures
and for much dissatisfilctioll felt by our patients.
Fmnk discussion of religion has often heen difficult. awk-
THE INDIVIDUAL AND THE I£NVIIWNMENT
ward. and sometimcs taboo. It has taken lhree or four hundred
The cnvironm:::m also can, for conYcniencc, bc considered in years Lo recover from the dicHlln propounded by OCSC;lrles,
four parts (Fig. ZO.::!): the workplacc: home: social gathering. who taught that the Mind and the Body :lrc (wo scpawlc enti-
consisting of <:.clivities in the elub or the church; and hobbies. lies in any individual. For mallY years. both doctor ..Ind patient
The;,..: is funher interaction between lhe individual and Lhe have felt uncollll'orl ..lbic di~.;;.:~;ssing religious maltcr~.
www.bodywork.su 405
 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\'iron-
llI\,.'IU. il is easy hl ~I..''''' thl' common ground between the busi·
lIt'" l'XLTllli\'l' ;lll{! Ill.: kallh em; professional. In helping his

PHYSICAL EMOTIONAL {\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;lll-
p: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 ad-
ditinn. it .... n:lhk:-. him or her 10 ullth..'rsland llHlrc easily the
MENTAL SPIRITUAL 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
Fig. 20.1. Four aspects of personality.
"11)1..':-<' more l"lHllpk'.x,
or the many \\'ay~ to dcal witllthis ··mess." the Ill()!'l valll-
This attitude is etwnging. however. Many of us now feel :,blc is l'-'llghter. H'i," and nol against someone else. often
at ease when talking about our world. our universe. and our about something rirJindolls. Wt.'. can ~it beside our paticllts.
Creator. The approach of many. p~lrticularly younger people. chauing naturally, gClling them 10 l<.lugh. laughing \\lith thcm. . '.,~

to this subject is often one that differs from tellr.:ts once con- ~(llllctil1lcS wlH:n llcl.'cssary bt.'ing oursc!n;s the butt of the )

sidered orlhodox. As physici..ms. we need (0 keep open minds joke 10 enhance the intr.:raetioll.
with respect to different ide..ls and beliefs. The good physici"ll1
sits beside the patient prepared 10 listen. rather than standing liAWTllORNE EFFECT'-'-
over the patient or sitting behind the desk. prepared to make:
Mal1<lgcment at the Westr.:rn Electric Plant at Hawthorne in
pronouncements about the individual's health.
the western United St..ltCS W<lS anxiolls to improve the output
of thc workers, They employed ~l team of sociologists who
MANAGING SEVERAL PROBLEMS AT THE
\'isitcd the plant. !;lIked to tllr.: workers. :lIld inspel:ted Iht..'
SAME TIME
workshops. Among other Ihings. they dcci<kd to ilH.:rease the
Although a great deal of our work helping people back to lighting in several areas. At onl:c. the OUlplU from Ihe work-
health is quite straightforward. it often can be difficult ancll:lX er" ilH.:reascd dramalically. Everyonr.: was dt:lighted. At thb
our capacities to the limit. Ackhoff. an expert adviser ..md point. one of the \"i~itors :mggcstell a funher changc., They
writer on the subject of business and industrial m..magcment. told the workers that they planned 10 help thcm further hut
commcllled. as quoted by Dixon.~ Ihal problems in these. areas were careful not to ~'IY whal lhey intended to do. They Ihcll
rarely occur in isolation. In <l plant or facwry. several prob- decreased the strength or lhe lighting (0 iI point below till.'
lems typically exist al the samc time: they arc constantly original level. To the "'l1rprisc of the m.lIl,tgcment. the output
changing and intcracting with another.l\ckhofr calls this con- of the workcrs incrca~cd still furlher. In fact. the workers h;ld
tinuing proccss "mess:' In his opinion. a good chief cxccutive been innucnc<:d no! by the strength of the light but by the
-.,

HOME AND FAMILY

•t
HOBBIES
(INTERESTS)
•
• @ •
•
SOCIAL
(CLUBS,
CHURCH)

Fig. 20.2. The individual and the en·

vironmenl.
tt
WORKPLACE
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 .... __ ..• _ ........ "",., ,,~, c:nl"\v IIVI\( 407

, feeling that both m:,magcmcnt and the (cam of sociologists ios:. of wl&ulctlr.::-:' ;'IIIU unelh';~:-, iv:-:-. ,,;' ... ouirol. vulnerabililY,
~ (
were interested in their welfare. and isol::uion from friends. relatives, ::JIll! colkagucs.
In commellting 011 the Hawthorne effect, Dixon nOlcs that Symbols and mctaphors ..II'<:: vcry pcrsonal. E~ICIl illdi\"id-
the scientist. in designing experiments, docs his or her best to u<ll has thc ability 10 m"lkc his or hcr own symbol<;.
minimize or eliminate this phenomenon, which is one kind of Somctimes. cxh:rnal CVCtHs o\"er which wc sel.:1ll 10 ha\"c 110
placebo effect. Dixon thinks thaI using this effect forms the control I1wkc ~~ I1lbols for liS. Groups or pcopk ;111d rwtions
bOlSis of a good deal of his practice and is a central feature of also havc their:-~ mhols. A symbol often. pcrhap:- alway'" \,.';11'·
family medicine. The author concurs in regard to his pwcticc rics I11me weiglu than logic.
as well. The situation in which we lind Olllsd\c, IS not .l!\\.l'·'
friendly. Friend:,. acquaintances. doctor:-:. nurses. cven l:hin l .
OUTAINING THE PATIENT'S CONFIDENCE practors C:Ul disturb the working of our symbols and
metaphors by their .mitude. their thoughts. their words. and
The effecI of putting the preceding principles into practice in
thcir actions. All of us call rccall examples of being abrupt.
our office and clinics is to build up a patient's confidence in
unkind, or unfeeling in treating a p.Hient. Reminding our-
him or herself as well us in the physician or chiropractor.
selves of sucl~ occurrences cncourages us to do better in the
Our interaction with each patient should begin with a
future.
friendly greeting. a handshake. walking with him or her from
TIle following scenario oCf.:urrcd in a major tcaching. hos-
the waiting room to the office. sitting beside him or her and
pital. Cystoscopy W ..1S to be performed in a large room with
not behind our desk. These things arc little but very impor-
bright lighting in lhe presence of several uoctors. /lllrSt:S. ::llld
tant. and represent the invaluable combinati(;n formed when
orderlies. The patient was taken to the room from the ward
Pc.liir.;ilt and therapist work together.
without any prcopenllivc mcdication. He had to get himself
Legend has it that in teaching his apprcmices. Hippocrates
across from the stretcher to the operating table. His legs \\"e-rc
stressed the value of obtaining the patient's confidence. It is
placcd in stirrups. all of him in full view of all persons in the
reported that he went so far as lO say that evcn in cases of the
room. The surgeon then injected .1 local .Ulcslhctic pt:r ure~
direst of diseases. the comentment engendered by the pa-
thram. A few minutes later, the cystoscope WtiS passl:.":d. a
tient's conviction of the real concern of the physician could be
painful procedure. This experience of both pain and embar-
the main factor responsible for a curC.
rassment affectcd the patient adversely. IC:lVin£ a pcnllant:1ll
Chiropraclors have all advantage in that their particular
scar, with fear of and dislike for the urologist. A few changes
skill requires them to lay hands on their patients. This action
in procedure. a few minutes of explanation by the surgeon the.::
itself induces confidcnce. The rest of us should share this ad·
previous evening. and some arrangements. for more pri\"~H':y
vantage. by touching the patiem with our hands during the ex-
could have made the whole proccdure less traumatic both
amination and placing a reassuring hand on his or her shoul-
physically and symbolically.
der 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 RESTORING THE PATIENT'S SELF-RESPECT
resident to tell him what he had found. Then he (old mc i Fortunately. it is usually not difficult for the caring phy:,icbn
would need a CT scan. a myelogram.•1I1d an operation. I was or chiropractor to help tile patient regain his or her feeling of
nOI satisfied. 1 said 1 would think it over. I didn't go back to wholeness. belonging. and \....orth. The physici::lll or chiroprac-
sec him ag'lin." tor can listen carefully ::uld with concern to the patienl's ac-
count of the assauil on his or her dignity. Some sanlpk cx-
HOLISTIC DIMENSION changes follow:
Obtaining Ihc paticnt's conlldcncc stems from our regarding Hc or she can then S.~IY "1 agrt.:c. Ihis is thoroughly bad. k(~ sc~
him or her as an entire. integrated being. a unilY. somcone of ,\'hal we can do about it together:'
valuc-the physical, mCIHaJ. emotion.d. and spiritual working The patient can be se~1l as oftcn as is nccessary l(l help him l'f h~r
in combination. The tem1 draws attcntion to an imponant fact. fcel happy. free frolll cmbarrolSSmCnl, .llld al case again .
already considered to some extent: 'IS we look on our patients, • The praclitioner can put him- or hersclf in the p'lticnr's Shl'C:'. ~:IY·
set Ollt to diagnose their ills. and attempt to treat thcm. we ing "Yes, if that happencd to me I would be really mad."
must think of them. '1l1thc time. as a whole man or woman in 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
their own p::lrticular environment. In so doing. we try to get
fclt...
alongside the paticnt. with or almost ;1 p"lrt of him or hcr. 10
Another paticnl s'lid. "Once I had" catheter passr.:d by a r\lufh. in-
help solvc the problem.
expericnced a..sislal1L It WilS vcry painful. In my C<lse, I \\"~l:' wid
not 10 be a sis,",y. I decided lIot to go to that surgeon evcr :lfain 1111-
HOW SYMUOLS AND METAI'HORS WORK less driven 10 il." Thc physici;ul replicd, "I'd lll'lkc the S:UlIt.' d..:ci·
sinn myself."
The use of symbols :md mClaphors has a powerful effect on A physician s,lid to;1 p"ticnt. "Yes. SOIllC years ago. like y<,u. 1 had
the patient. They help the patient overcome the feelings of (Ill one occ'l.~lon to I;Ike ,Ill my clolhes ol"f mid wail l"or Ihc dO~'lOr

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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 Fitnl'ss Cl'ntcr

I:\"\.·n sm;lll Nonh Am;.'ri.:an citi~s ha\'l' on~ or t\\"o litness

All of these silllllliolls sound ridil,:ulously Silllpk·. Till' Cl.'llll.·r~. ;lnd large ci,ll..''' have many. Thb type or vcnture is
reader mav think thaI the\" an.': IHH 1\l..'II'l'u1. I hclil:\'c llh'~ :11\.' lIsu;dly fUll by a lr;lill:..'d tlH:rapisl or exercise physiologist.
cxtrCl1lcly· irnpOrt<lllt for ','llsllrillg it l~rlJilrlll illll'r;ll'lip!l 1'1.'- Thl'ywl·rl.· startl.'d fnr Ill-.' henclit or IIH\~C cngaged in o.Itlllctit:
tween p~l{icll( and phy~i(iall!l... hir(lpr;l\.'hlr. Ccrwinly. tk p:!. ;ll.·ti\,itil.·.. Ill' :.11 kiml-.. ;,' hoth prnm(ltc litl1ess and help the
tiClll call do some lhillp rill' tilL' dOl..'!\lf \)1' l'hiropr;ll'!(lJ": !~.!\ . rl.·Stl!1l1i\11l or minDr l11tl'l'llh\~kcklal illjuric~. The dielll
in!! a h:lth berm..:- thl..'ir :Ippllinlllll'lu: w;lshing Ihl' (.. . \...\ ;1l1L'Il(b ;11 his or hl.·r ,'\\ 11 Qllitiol1. docs his or her own

Ih~rollghly: and wc"lring dCOIli tll1tlcrw\'ar. 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
PREVEl'TION: I'!W\IOTING IIEAl.T11 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
The most important mcasurcs for the flHurc ..In: ill thl.." 1'1.':11111 p;tticlll 10 lhe lhcr;lpi~t in.':harg.r.:. bcing careful to kt tile
ofprcvcnlion. Fortunately. individuals now invol\'ed in 11I"~llth lalll.:!' know by pholle or wrillell IH)\e the nawre of the
care arc concerned with the promotion of active he'llth ;1I1tl prohlem. with l)Crhap~ "Ollie sugg.estions as to the type of
110t jusl with the <.:orrcction of a disease process. This n\~l.'l1t L'xl.'rcis(' li!,dy 10 bL' u,cful. The therapist has free rein to
lesson has been lcarned mostly in the lieltl or sports 1llcdil,,:illC. dirl.:<.:t and advise the pJticnt and to control his or her ac-
The resl of us owe a debt of gratitude 10 the pioncers in lhis tivity.
field_ Our mono should be "health through activity'" While the patient i~ allcnding a litness centcr. the health
Thc 100is and resourccs nccded for disease prevention are care practitioncr ~lIld IherJpist C.1Il have frequent dis<.:ussions )
well known. \Vc need now to reline ::Ind develop lhl.'lll. about lhe progress made. The chiropractor or physi<.:ian sees
ChiropraCIOr5 and medical practilioners teaming to \'.. or" 10- the patient at regular intt:fv.lls. Somctimes. thc professional
gether in harmony is probably the most signili<.:alll advancl.' in personally attends the .,amc fitness center. \vhich provides <10-
[he field of musculoskeletal illncss and tre::Jtmenl. These pro- dilion;J! \';dLJablc <.:011l<l(;t wilh both pmient and demollstr;ltes
fessionals havc diffcrent yet complemcntary skills and alli- Ih:.1t Lhe doctor does the things that he or she ad\·i~cs patients
tudes. For the last 25 years of practice. my work in incrc:t:,ing to do, E\"l~ry chiropractic or medical orticc should have access
cooperation with chiropractors has turned oul to be of great to such .1 supportive progmm.
benefit to chiropractor. physician. and palient. and W3' of Coulchan 1 outlined the dimensions of treatmcnt outcome.
great assistance in teachim! and in resc'Jrch_ Whcn chiroprac- The doctor-patient illlcractioll is expresscd in thrce W:'lyS:
;or and physician work together. almost in symbiosis. the rc- (I) focal. the treatmcnt method: (2) symbolic. r6ulting from
suit is something of far greater power than the sum of the two both cognitivc and affectivc intlllences: ;lIld (:.) behavioral.
working alone. An analogy can be helpful. The power re:;uh- ag.ain from these two intlucllI:cs. The routine of the fitness
ing from fusion of interests on the spiritual pl:.mc is compara- (,:enter affords <lll three. It pro\·idcs the incenth'c to develop
ble to that relcased by the fusion of hydrogen :.Homs on the both the physic.lI and the spiritual well-being of the client.
physical.
Sometimcs the chiropractor takes the lead nod sometimes
it is the physician. Each should leam from the other. Th~ chi- EIOlstic Uodysuit
ropractor can help lhe physician by making treatment simpler
and more cost effectivc. Quick. almost immedi:.ne intcf\ en- The ratiol1;.J!c for wearing an clastic bodysuit for the preven-
tion by thc physician makes things bcltcr for both paticnt ~l1ld tion and tre.llment of 10\1. back pain is similar III thai Pllt for-
chiropwctor if somelhing suddenly gocs wrong in the man- ward by athlctes eng.tged in many different kind:-: or sporting
agement of a disk herniation or spinal stenosis. or sudden de- ;lctivitics: downhill lind cross country skiing: bt'bsledding;
\'e!opmclll of cauda CqUilHi syndrome. water skiing: and sl:uba diving. among other things: c1:'lstic
trunks or suits arc often worn by footb;.tll. tcnni~. and basket-
hall players <tlld by cycliq~: wdght lifters wcar a ~imilar gar-
Back School .. ~

ment. This type or garnlc_nt suppons trunks and r~"'is (focal). i ,.:J.

The availability of Ihis f:.lcility is essential. The physician or

I .. · ,?
gives conlidcn<.:c .md cnour.mce (behavioral). ;tnd expresscs
I
chiropr:'lctor should be <lblc 10 send .1 patient at any time with ~hc idea that the alhlete i\ .. triving for on~ness.lllldy. mind and
dday of no morc than 2 or 3 days. A back school In:Jy be spirit combined and intcgf<.ltcd (symbolic)."
staffed by physic~i1 and/or occupational thcnlpists. sometimes Physician and ,hiropf<.lctor~ have been slow to grasp the
with volunteer help. or by two or three chiropr:'lclOrs. II may
be in the orlice of a chiropractor. physical therapist. or physi-
f~lCt that an el,lstk body\uit is not a rigid corsel but something
thilt cnhanc~s activity exactly a~ the corresponding g:lfIl1ent
,
).
cian, or in it gymnasium or hospital outpaticl1I departlTlcnt In do~s for the ~lthlele. \Vc need to r~think this means of making
many instances. educational alh-anccs from the back ~cho()1 l.'xtra provision f(lr prc\'cntion :lnd treatmcnt. In thl.' conlext of
bc:nclit the COllllllll11ilY. The back school has bC~1l disc.:u~~cd doctor/p:.lticllt interaction. it i~ the symbolic aspc ...·t that is the
cxtensi\'cly elsewhere. l1\ost cogent.
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 _ v •• r\, ' · v v ' - ' I v n 11'lII:HI-I.L.IIUN 409

ASCENT OF TI II', SI'lkITlJ,\L 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
1\ series or steps lead upward from what might be cOl1~id~r~d gl"l.';II b:..'ndil. An illlcgral pari of thi:, proCI.'SS is how to
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
t1l;U1a~1.' :'Ircss. This subject is discus:,ed at length by
Z'lhollTl'k. t,·
j hc"hh can: pracliliona5.. we arc conccrnt:d with the sp:.'(trum
l.;'.\/' (.r the ilJlOgil/Clrio" should h~ cuhi\·all.'d. Sanford"

,1, i Ihal Iic:'\ bctwccn these 1\\"0 extremes.

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 foot-
~
! I Religiun and Healing hall. Sh:..· ,aid. "Let's pl;l)' <l gamc." He nodded ,lIlll agreed_
"Billy. illl~l~ine lhat you arc playing football and lhat you arc
Abdul Baha writes. "Religion and Science arc the two \\ ings
getlinf! beller and hcacr <it it. Onc day -your team is playing
Oil which man's intcl1igctlcc can soar to Ihe heights. It if. not

Il !
possible 10 fly with one wing alone. With the wing of religion
'llooc an individual \\!ould fall into the quagmire of supcrsti~
agail1~t Ihi: best l~am in (he Icuguc. You pl;:l)' so wcllihat yOll
score more g.oals than anyone else and win !.hc game for your
sidc. You hear some of the onlookers say -'Just look <It Billy.
lion. \Vitlt the wing of science nlonc he or she would 1'.. 11 inw
I ,i the despairing slough of materialism.""
Edison patented 1093 invcntiolls Olnd turned the iJl\'cn-
110\\1 fa~t hI.' C<1I1 run. how well he tacklcs, how strongly he
kicks the ball. We' d like to be likc him. He IlHI:,[ be so fit <Iud
i well: Bill\' was thrilled'" Sanford continues. "Can you make
!
, lions of others into a success. In 1879. after many unsuccess-
a picture ~f that in your mind three or four time:, 1.'\'1.'1")' day:'
)I ful 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
Once again Billy. nodded vigorously. He did this every day.
After a few months. be became perfectly fit and well again. no

I smile and point 10 the sky.

Quite ordinary men and women like ourselves belie\"(:: in
problem with his heart, He later bc,ame <I great football
player.
The IIISIitutl' for the A(/V(lllCellleIlf of Hili/Ifill Bdwl'i()r, an-
the existence of a God who is all powerful and prepared under
olher resource, is in Stamford. Connecticut. This. organization
certain conditions to intervene in our affairs. provided thi~ in-
of psychologists. psychiatrists. and other practitioners plnns
tervention docs not compromise our frce will. We seek this
seminars and mcclings dealing with the psychologic and im-
help through what we call "pw)'cr:' It i~ wise to do thi~ lllorC
munologic aspects of both \vellness and dise:l:'L'.
often than we do.

Puhlications
Either/Or: Both/And
Siegel \\TOIC of lessons learned about sclf-healin~ from a Sllr~
Somcthing is lacking in the way we think. Perhaps it has geo;'s cxpcricnct: \!"'ith exceptional p;,llicnts. ' : Hi:, approach
always been that \\'~IY. In most situations. we think in terms combines orthodox medicine with Ihe spiritual. The Americ<ln
of either/or. The ehiropraclOr or osteopath thinks in h::rms Cancer Society Il:lS produced a pamphlet cll1itl~d Say it \I·;tll
of manual thcrapy. thc physician in terms of medic.lIion or the Hcart to help thosc'suffering from callC('r. It. is full of
)
surgery. In S;'lskatoon. the process of chiropractors and ortho- helpful ~uggcstiol1s and empha:'izcs the imponan...· c of lhe pa-
,! pedic surgeons learning to work logcthcr \Vas at lirs! p~inful tient's .lititmlc <lnd feelings. Another book b~ Simonton.
for both sides. Out of lhis elTon c"me a "both/and" tlpproach M<tlthews-Simonton. and Creighton <lppc<tls t:'ljually LO health
resulting in a synthesis of both disciplines. something new for care profcssion.I1s and patients with cancer.l.' ThL' underlying
us. to thc benefit of bOlh ourselves and our patients. philo\ophy is th;,11 we arc all rt:spollsible for l)ur l)\VII hc"lllh
,II Turning to consideration of the physical and the spirilUal.
we encountcr the same difficulty. r\'1~ny spiritually minded
and iIJnc~ ... cs. and thaI we particip,ltc. cOllsl.·il,.)lI=,ly or uncon-
sciousl~. in crc;lling our own physical. clllotilmai. and spiri-
1
)1 health care professionals sec no need for anything other lhan tual health. The ktlO\\'lcdge gained from n~ading this book
physical and material methods of treatment. Priests and min- can abo b~ applicu to the management of many ~)[l1cr cOIlui-
isters who have ;,\ concern for healing often tend to lhink in lioll~. b;;: Ihey physical. emotional. ;lIld spiritual. \ Gt'uillg Well
spirilucli tenns onl)'. The best approach is a synthesis of the AgClin j, also ;\v~lilable in videocassette.
,' two. Intermediate steps on the journey from the Phy~ic ...1 to
! the Spiritual contain clements ofholh, <.lnd are mentioned only
I Power or Prayer
briefly.
M;'II1Y of liS believe that the natural indwdhng defenscs
a"ainq forcil'llc invaders and disease, incllldill~ Ibc immune
s;slcm. wcre giycn LO us by God as part of our ~makc-up: lhat
Othcr Rcsources
/Jack sc.://Ool. already mentioned. deals not only \vith material our CIl\"iro111l1cnt contain~ many resources for hl.'aling. sllb~
facts but also with the interaction of instructors and clients stal1c.:c~ like pcnkillill and digitalis: and thai h~;l!th care pro-
.1I1d with the \vhole group ill the class. Discussion of their fessionab ;lIld (lthers have their source of tr;lining directly
problems dming breaks is as important as <lny instruction from Him-it is no accident that hospitals :lnd dilli,s had
g.iven. their origin in lhe mona~tcric:' of the Middk .-\;;e="
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 h is not too !.'!.r~at;l strell'l1 pf the i1llagillatinn to believe in The combination or these sources with the grcatest signifi-
the existence of~lI1 all~po\\'errlJl king, prepared uncler certain cance arc those with a strong symbolic content. GOOD' rela~
circulllstances to intcrvcnl' ill \)\ll' ;tllail's. Again. wc seck this tions stem from our seeking the best for onc another. The
help through prayer. It is l':l'~ to ignore thl' l..'.'\istcllcC of a search Illay involve us in efforts to understand aspects of a
power "reater than ourse!\'l', \\ hell till' Still j, .;hining. Thl'n person's psychc thaI range from slight differences in dress to
our bomfmav• well bl' -~{)Ir. nur ':l\'ior the computer. Ol:r illSpi. grasping the nature or an individual's reaction to a situatioll of
ration gained from though!" (It" "<..'.'\. Wlll'll ill health and dis- life and death. At timcs, it is not difllcult for the discerning
aster loom ahL'ad, \n,' ;1I"t~ lllPrl' indillClf!o h\\l]..: above and hl'- physician to empathize with the distress felt by a patient. sh'lr-
yond oursch'L" for help. hlrlllllate is !hc man or woman. ing the symbolic contt~llt and the behavioral aspects of the sit-
health care pwrl'" .. ional or p;l1il'l\!. who seck, lO take advan- uation. The practitioncr must shift from time to tillle from
tage both of the natural pro\'isilltls for health :\Ill! well ness and close identity on the stage to standing back in the wings.
of those from lhl' supernatural realm. In lhe process of travelling with a client from a state of
One exalllpk makes the POllll morc dear. '~hc people in- distress to one of complete well-being, we should be prepared
volved were lOugh sturdy lishermell. The c.iptain and four 10 seek help from other sources. Complete rapport between
members of the crew of a sm:dl craft Iivcd for II days with- the physician and the chiropractor is of greatest significance
out food in a rubkr rart after their ::r9-llleter fishing boat sank. and also is rewarding. The convergence of ideas and beliefs
They werc evclHually rescucd. When ljuesti(\I1ed later. one of held by students and teachers from two different backgrounds
the crew said. "We did a lot or praying. I Jclinitdy belicyc produces within them the stimulation required to conquer new
that God was watching ovcr us. Every timc \~'e made a stupid areas in the spectrulll of musculoskeletal illness.
mistakc or something went \\Tong wc would just slump our Given the large a nUlllberof different approaches to spir-
heads and stan praying hcavily·-and bingo something would itual healing. it is essential to respect beliefs that arc different
happcll. Wc did a lot or soul searching and now I think wc'rc from our own. It is good to be aware of the presence and in- .
going to cnjoy the simpler things in lifc. Inswad of shootiJ'lg volvement of the Creator in any and every scenario in which
for the stars we'rc going to sit down and smell thc flowers." client and helper seek health and wholeness. This statement
The samc sort of rcyclation can occur when somcone is docs not imply that we arc always talking about such aware-
suffering from severe low back pain. at a time when both pa- ness. \Vhen we ourselves do not have access to the "throne of
tient and doctor are at wit's end. A priest in the Episcopal grace:' we should feel free to refer the client to someone clse
Church developed severc back and leg pain of sudden onset. who has. The One who sits on the throne is able to come
He contacted a friend who in !Urn called his friend. an ortho· "alongside" us just as we arc taught to come alongside our
pedic surgeon. The surgcon examincd the man and thought he clients in their need.
had an acute L4-5 disk herniation. This suspicion was con-
finned by a CT scan. Members of the priest's church prayed
for him that night. On his next visit, the surgeon prayed for REFERENCES
him as well. with some reluctance (surgeons do not usually I. t\1anllurry 1: Re;mm ;ll11d Emolion. London. Faber and Faber. 1935.
pray for priests!). In the middle of that night. thc patient' woke 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
up and realized all his pain had gonc. From that point, he had
for C\I1;ldian Plus. Toronto, Grant N.R. Gcall. June, July and August.
a rapid and unevcntful recovery. Thc priest later said that he 1992.
had experienced two miracles: the first, that a surgeon had 4. Dixon 1": TIle philosophies of family medicine (editorial) Can Fam
visited him in his own home, and the second. the healing of Physici;lll 35:743, 1989.
his back. 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
SUMMARY Physician 35:703. 1989.
7. Coulchan L: The lre;lllllet\{ act: All analysis of the clinical art in chim-
Interaction betwecn physician. chiropractor. and patient is pr:lctic. J l\-Ianipulali\'e Physiol Ther 14: I. 1990.
both fundamental and complex. The resulting relationships 8, KirLlIdy· Willi" \VH: Energy stored for aClion: The clastic lwdysltil. In
KirLlldy·Willis WH, Burton CV (cds): Mmlaging Low B:lek Pain. New
arc the phenomena of most importance. They depend on
York. Churchill Livingstolle. 1992.
something more than science alone. The raw materials of 9. Abdul Baha: P;lris talks. London. Baha'i Puhlic Trust. 1973. r 14.'.
which they arc built come from a variety of sources: 10. Zahourck R: Relaxalion and Imagery. Philadelphia, WB Saunder.s.
1988.
A careful study of science and its br:lllchcs
! l. S,mfonl A: The Healing Light. New York. B"llanline Books. 19S.l.
TI1Chumanities
12. Sil.'gcl US: Love. ~kdkil\e and 1'vliraek.s. New York, Harper & Row,
Philosophy 19S(I.
Mylh, lhc story with a meaning' 1.1. Simonton OC. Mall!ll.'wS S. Creighton J1.: Gelling Well Again. Nt,\\,
Behavior, symbol and Illclaphor York. Bantam Books. t980.

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*
Ll Place ot Active Care in Disability Prevention
VERT MOONEY

The difliculty of defining and treating a sort tissu!.: in.iury to injurics, No matter where the soft tissue injury--disk, facet
the back is well known. Nonetheless, the.: primary thcr;lIk~Ulil: joints. Iigamcnts. or muscle tendon junction-progressive ex-
focus is now changing from relieving pain to rcswring func- ercises Sllould be of I]enefit. Anolher importtlnt concept is that
tion. The ability (0 measure fum:lional capacit)'. cspct:i;dly for when ex.ercises an~ ·used as the Ill<ljor trt.:atment tool. thc mea-
the returning worker. becomes im.:rcasingly illlpOrWIll. surement or fUllctional capacity replaces the patient's assess-
ment of pain as the b~I~·\iS for evaluating progress.
Spons medicine cxperience also showed that rest pro-
MEASlRING FUNCTIONAL CAPACITY duces dcconditioning of cardiovascular as well as peripheral
Most back injuries. whether industrial or n,:crcational. occur lllusculature. Similar information began to emerge from the
withom :t verifiable sile of injury. No rcpcal;:tblc. valid lest is space program. in which the reduction in physical stress as-
available to pinpoint the location of the painful soft tbsue in· socimed with gmvity-rcduccd spilce travel produced measur-
jury. It must indeed be <I sort tissue injury. bCl:ausc radi- able deficits in function: ' The space travel model also re-
ographic and bUlle SC;,1rl changes arc consislclllly nbsClll ill vealed not only that the absence 'of physic'll stress hinders (he
what has been classified "motion disorders of lhe spine." i.c .. healing of injured soft tissue. but also deterioration in func-
p05tinjury back pain. Degencrative changes may be seen ra- tion of otherwise healthy tissues could be expected 10 foHow
diographically. but these findings arc nonspccific. In no study prolonged rcst. It is rationaL therefore. to lllrn to thc mea-
h.lvc these changes been corrchllcd with specific back pain. surement of function as a starting puint in an appropriate ex-
Without specific nerve root signs. therc arc no repro- ercise program. We nced 10 cstOlolish the currenl baseline of
ducible physical findings. From the chiropractic and physical function. Aerobic testing can supply baseline of performance
therapy \·iew. the previous statcmcnt is incorrect. but currelll (Fig. 21.1).
Illcdicallheory holds finn to this tenct. Because of this differ-
ence in opinion. the consensus report of the Quebcc Task PERFORMANCE LEVELS
Forcc on Motion Disorders of the Spine 'vas forced to classify
the back ailment strictly on the basis of pain location and its Objective measurement ufo function is accomplished fairly
duwtion of compl<lint. 1 This document .!lso proposes that no easily in thc rcalm of sports testing. Performance 1c\'e1s in the
mattcr what the soft tissue injury, problcms typically resoh't.: athlete arc measurable. and norms against \vhich to asscss
within 7 weeks. If spontancous recovery docs not occur. the performance can be readily cstablished. Athletic pcrformance
problem should be defined from a multidisciplinary perspec- is a summation of many physical charactcristics. including:
tive. Intensive investigation of cause should be initiated early. strength. endurance. neuromotor control. <and Illoti\·ation. To
before a long delay allows thc burdens of deconditioning to make the best lise of pcrfornwnct.: measurement. specitic
emerge. components. arc identified for lesting. Furthermore. no one
Because the specific site of injury is unknown. palliative (est Ciln reliably predict IOta I performance.
care was considered appropriate. Until the last decade. rest.
physical ther~lpy techniques that reduced p'lin. muscle relax·
R~HlgC of Motion
ant medication. and analgesics were the standard of care.
Certainly. manipul~l[ive care can speed the rate of healing. but Earl)' in the analysis of performance. range of Illotion was
Ihe mechanism is nol known,1 The emerging concepts or recognized as a measurable entity. and the 'lbscncc of normal
sports medicine. however. Icd us all to realize thai soft tisslIt.: range was llsed as a possihle predictor of delicicm perfor-
injuries arc not bcst treated passively. rorinjuries to extrem- mance. Range of morion of the extrcmities is nicely measured
ity joints. gradual progressive exercise programs to enhance by goniomctcrs (lnd thus became a standard of physical thcr-
the organizalion of scar repnir in the strained connectivc tis- "py assesslllent of extremity fUllction; the validity nf such
sues have become the standard methods of care. A combina- measurcment can be verified in the opposite limb. For the
tion of exercise with treatmcnts such as the :Ipplk:.uion of ice back. however. r.mge of motion of the hips l1:1d to be sepa-
to reduce the pain reaction is now recommended for ankle rated rrolll that of the lumbar spine. Thus. in the bte 1960s.
strains and simil,lr injuries. It is therefore reasonable that sped lie discrimination of IUlllb~lr range W<lS cSIOlblishcd using:
exercise is equally appropriate for individuals with low back inclinomcters..1 This method of evaluating lumb.lr capacity is
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 Age definitely innucnces the strength of trunk muscles: older II
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 mea-
suremcnts 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: sig-
nitkmllly stronger than the ncxors. As in most of th~ early
studies. the number of subjects was small. Furthennore. fac-
tors 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 equip-
ment 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
Fig. 21.1. Aerobic lesting using bicycle ergomelers is a relatively realistic cv'lluation of lifting performance. The investig<ltors
inexpensive measure of pertormance. Consistency of elfort and also used the weight of the subject as a method of nOnllaliz-
attilude toward physicallunction can olten be detellTlined by eval- ing the data (torquelbody weight), making comparison among '"~

uating aerobic perlormance. subjects more valid. Again. extensors were stronger thun Hex-
ors in normal subjects, but extcnsor musclcs proved signifi-
cantly weaker than flexors in individuals with chronic back
now standard. ~ccordillg 10 the AMA Guidelines for pain. At higher speeds. torque production was signitknntly
Impainnclll."' In facl. the delineation of lumbar r.mgc is the less in individu<lls with bClck pain thml in normal sub}:cts.
only objective measuremcnt of function for thc assessment of The study also dcmonstr.lted the e)•• lrCllle variaoiiity of
)
spin'll impainncnl in these guidelines. This measurement initial evaluation in back pain paticnts. Consistcncy of per-
does not give a tolal picture. but no other functional capacity formance in spite of pain. however, can be expected whcn the
tests for the spine have been judgcd reliable C1nd valid by con- patients are fClmiliar with the mach inc. The study showed that
sensus. Also. some clinicians believe they can recognize in- pain docs not limit consistency when the pnticnts me making
tersegmental vari~tions in motion. but such a finding is not maximal efforts. The equipmcnt bec.lIne av'lilablc- as a
Illcasurabh.:. 1• mcthod for idcntifying willful submuximnl or mislending per-
Rang.e testing is insufficient to evaluate the functional ca- formance on thl"' part of the patients. The concept that only
p'Kity of the cxtremilies. A signilicant innovation in the late maxi'!1a1 effurt could provide consistent performance \vas
1960s was thc dcn~lorlllcnl oftMe capacity locontrollhc vari~ proposed in this study. This theory assumes 110 perfonn;mce
uble of speed in muscle function.] This isokinctic testing <.II~ fecdback to the subject is being lcsted. It also assume:;. an ac-
lo\vcd an individu<J1 (t) cre'He as much torque as feasible. curatc mcasuremenl tool.
while allowing forcc to be mcasurcd throughoul the range by Another variation in the objective of back musck perfor-
controlling velocity. This type of measurement proved to be mance was the asscssment of trunk rOl<ltory perforll1~uK'e with
an excellent guide for sports medicine physicians trying to isokinctic torque measurcment cquipmcnt." Torque measure-
evaluate the rdmi\"c strcngth of ncxors and extensors and sta- mcnt was ~Iccomplishcd with thc subjcl:t siuing. RaIOltional
tus of rehabilitalion after injuries to various joints. The lise of torque in normal subjccts was about 50t;.,. of extensor torque.
isokinctic dcvicc~ ..\S tr;tining/cxcrcisc tools has come into Torque production W"IS signilicantly decreased in bal..·k p.tin
question. howcver. because the incompletcly controllable im- patients. to about 65% of extensor torque. Patients \\"~r~ not
p;tct forces may cause ""Idditional injury. tested lIntii lhey hud achieved normal r..mgc, which w;\::. ~as­
Not until tlu.: early 19S0s WilS the conccpt of isokinetic ill' defin'lble using this equipment. The authors of thi:, study
testing .applied 10 the b'lck. Using converted extremity equip- also mtel11plcd to COl11p..lrc myoelcctric performance with dy-
ment and normal subjects. the first study was conducted in mimic pcrform;mee using i:mkinetic equipment. but they
Japan in 1980." Although the invcstigators did not have a could make fcw correlations. No study has yel been able to
mcthod ef normalizing the torque curves. and the equipment use clcctromyogmphy as a specific predictor or discriminator
required that subjects he recumbent for testing. several points of individuals with low back pain.
~lI1ergcd that arc cuntinned by current studies. In normal sub- All of these studies involvcd the lise of cquipl11l..·m from
jects, the extensors are s.tronger thun the flexors of thc buck. Cybcx (Ronkonkoma. NY). the only manufncturcr (..If sll('h de·
~llId the differencc is more signific'll1t in mcn than in women. vices at that time. Othl..:1 tnanufacturcrs have emerged since
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~
I-------~---------------------------
 ... _ ..• ~''''''.''''''''''' ",'-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.
Such evaluation of lateral bending and rotation simultane-
ollsly with llcxion and extension is a unique property of this
equipI11cnt.l~ The point is that different systems of measurc-
Fig. 21.2. Example 01 a strengthening circuit manufactured by ment can provide alternative perspectives on human perfor-
Cybex. In the far rig f)! corner is the lumbar testing machine for mance. It Hlso underscores the emerging awareness that onc
evaluating sagi,Wlllexion and exlension isokinetic lorque. specilk me.lsure cannol totally summarize or diagnose with
certainty the incapacity resulting from soft tissue injury in the
Ih-.: lap,ing of SOIllt: Cybt:.x p;ltcn1s. which h.ls led to a virtual back.
L'xplo~ioll ill lht: lllark\:'ling or l'unL'lional testing equipment. Various other methods can be used to evaluate free lifting.
In addition. mallY manufacturers supply exercise eqllip~ The subjects arc tested in such a way' that they can lin or
11lt:1\l modeled 011 tht: origin<ll Nautilus equipment designed lower <lny weight lhal lhe computerized equipment defines.
~O y('ars ago (l':ig. 21.2). They can lift straight or in a twisting mode to \'arious heights.
:'\ limitalion or all the carly studies was lhat the individual Numeric representation of performance. graphic feedback.
was constrained to the ~allle position on each occasion of test- and .1 printout of performancc arc available.
ing in :1I1 l:llorl 10 achicve rcpe'll'lblc dm.1. Each of us has a Simplcr mcthods of cvalu:ning free lifting involve having
spt:ciflc stralegy 1~lr lifting and lowcring thal is based on our the individual lift graduated weights. Perfornmnce is then
unique configuration of hiolllcchanic<ll factors. When me.lsurcd in terms of increasing amounts of w(':ght !:ftcd C';cr
strapped illlo a silting or standing. position. we do not lift the
way we normally would (Fig.. 21.3). Another isokinctic tcst
i.lllows the pmiclltlo lift in any posture desired. This simulalcd
lifting t<1sk was performed from a slanding position. In the ini-
tial repon of this tesL 10\'..- back pain patients could lift only an
average of 67C;f: of Ihe value liftcd by normal subjccts. l:
Again. at higher speeds. pmicnts performed poorly in com-
parison \\:ilh normal subjects. The equipmcnt seemed 10 be
sufe. and the re~ults of isokinelic pcrform<Jllce testing were
more consistent than those of single position isometric testing
using the same equipment. Patients tested isometrically ill
incompletely isolated postures sometimes complained of
pain. whereas thosc individuals tested isokinctically USU~llly
t1id no!. Finally. a poor correlation existed between isoki-
netic performance and i\OmClric performance. Isokinctic test-
ing was therefore advocated .IS <l safer. more reliable means to
test lifting pcrl~mnance. h had the potential to provide spe-
cific numbers ill !erms of torque and work pmduction. but
with the equipmellt u~cd in this sludy. anatomic isolation was
poor.

Isodynamiclisolllctric Testing
An alternative !o isokillctic tt:sling is a computt:rii'ed system Fig. 21.3. Device manufactured by the Lordan Company with an
l'lbcled isodynalllic. Manufaclllrcd by Isotcchnologies (Hills- adjustable platform allows testing while sitting or standing.
borough. NC). this constant~load device simultancously mea- Unfortunately. stabilization of the pelvis cannot be fully achieved.
sures change ill torque and vdocity in all three planes of mo- Also, intense. variable resistance concentric and eccentric exer·
lion (silgilt;ll. frolltal. and tralls\'t~rsc). With ~o many variabks cise is not available.

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 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 resis-
f, tance 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 com-
plaint.:!1

PAIN TREATMENT

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
Fig. 21.4. Design of this equipment completely stabilizes the earlier investigators for not dividing patient groups into diag·
pelvis so that testing accurately documents lumbar extensor mus· nostie categories; howcver. the diagnostic catcgorics they
cular strength. Also, variable resistance concentric and eccentric suggested arc non verifiable. Le., ~acroiliac strain versus facet
strength training is provided to the lumbar extensor muscles. This syndrome versus disk pathol.ogy.1~ This problem is identical
equipment provides the most significant am\?unt of isolation. and to that which plagucs the treatment of chronic back pain: most
thus. specific training of any device currently available. 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
time. For safety and to avoid overexertion. limits on perfor·
capacity that may result from prolonged pain~limited bell..1 \'·
mallCc can be identified. For instance. in the Pile tcst, 5- or
ior--eannot easily be evaluatcd with a simple physicJI exam-
lO-lb weights arc added ill 30·second intervals. and the sub·
ination. Such barriers to undcrstanding have led to the deve!·
jeet lifts and lowers the weights four limes in 30 scconds. If>
opmcnt ef pain clinics with .1 focus on the perception of pain
This lype of tcst provides an alternative to methoJ:i icquiring )
f'lthcr than on the sources of pain. Behavioral control of pain
expensive equipment. Normal standards and comparisons of
has been the project in these centers. but restoration of func-
the performance of back pain patients against such standards
tional capacity and return to work have not been mC:i.lsured
for thesc tcsts have been recorded. An improved weights in a
goals.
box test, known as Epic, has been developed that defines
The focus on treating the pain alone has led to a general
deficit rclative to normal ability.17
suspicion. particularly among third-party payers. that rchabil·
Allhough isomctric testing was the first functional tcst
itation for chronic pain may be ineffective and in fact m:.lOY
mcthod with which to assess lumbar performance and thcn
be no beHer than a placebo in attaining specific societal goals.
compare it with the expected performance of worker. this sin-
such :-lS return to work.~·1 Fordyce and colleagues noted that
gle-dimension'method has not maintained its primacy .in lum·
pain clinics tend to treat the experience ofp<.lin but not the dis-
bar assessment. l~ In simple. unconstrained isometric testing.
ability associated with pain behavior. Pain often is associated
the posture of the tesl.subjcct is difficult to cOOlra!. In addi-
with the deconditioning syndromc. and technology now al-
tion. the significant weak link cannot be easily identified-
lows us to measure this extent of deconditioning. III the case
unconstrained isometric testing depends on arm strength.
of the back. objective lumbar function testing has been of
trunk strength, and leg strength, but standard test methods
gre<lt value in Ihe trcatment and rehabilitation of individuals
cannot readily separate the contribution of each of these
factors. with chronic b'lck painY
It is a great improvement to base evalmltion on fUllctional
Another isometric lumbar test. the Sorenson test, requires
and strength testing rather than on simple :'Iltcratioll in the pa-
th~ subject to hold the trunk parallel to the floor while the
tien(s repan of 1><lin funclion. With this morc objective
torso is unsupported. In industrial populations in Denmark,
methodology. the focus is on returning the patient 10 work and
the inability to hold such a pO!'tufe for a minute or more cor·
normal life activities. But how C;.lIl we lise this improved abil-
rdated with an increased incidence of back injury. I') This find·
ity 10 measure to enhance .lctive care?
ing implies that strength has something to do with back pain.
New equipment has been developed, however. that speed'·
REHAUII.lTATlON
iCi.llly segregates lumbar isometric performance from that of
the arms and legs. This equipment. made by MedX (Ocala, One 01" the most imponant areas of community knowledge
FL). identifies isometric perfofllwncc at spccilic equidistant has emerged from the availability of widespread observ'ltion
points in lumbar range from full flexion to full extension. The of sporting evenls. With lelevision covewge. man)' more peo-
thoracolumbar spine is totally !s~b!ed from all other an<llomy. ple wilness injuries suslained during various professional
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 ~ptlns. Tk~ abo obsern:: the rapid r~lum of this athlctc to ac- aled by the Canadian Inslitule for Workers Health and Safely.
lioll within -'L'veral day.. . or wecks after ~ignificant injury. Thus, the Quebec T~ck Force on Spinal Disorders was con-
Thus. thl.' rr..,;t1ily or cl"kcti,'c can.: in SP0l1~ medicine is rcacl~ vcned. Included in this task force wcre a wide arTay of experts
ily t.,:\·idenl h1 the publ;t.' 'II large. in mcdicine, law, and therapy.2s
What ;1;"(' lhe priuciples of SpOilS Illl.'dicinc'! Put simply. This extcnsive consensus report identified various factors
pm~fL'~S in tre;\(lllCIiI is b:ls~d on measurcd chanu.cs in fUllc- that would increase costs, e.g.• exccssive, unnecessary diag-
tion. Thl..· ;Hhktt.,: vicws discomfort as im:!c,"ant in~'crms of re- nostic testing. such as magnetic resonance imaging. CT. and
ltlrn "ur hlll..:tlUIl. Moreover. Ihe c<lsily understood principks c1cctromyogrJphy withoUl clinical justification. Surgical in-
or stlff li:-:-'ll( repair arc .. pplied 10 these athktes._Gr:ldu:ll pro- (ervclllion with lillie c1inic31 justificalion also was .. oted. One-
grc:\.sivc I.:.\l..·rciscs Ih;lt challenge thc sofl ti"sues consistcntly of the most important factors in increasing costs was the usc
;!Ild progn..':-.-.ivcly constitute a rcli'lblc ther;lpeut;c l11;l11CU,"cr. of ineffective physical thcrapy techniques, such as ultrasound.
This pnll.:r..':-" is the way we all learncd (0 trem a spr<1incd The usc of the therapies was "hit or miss" in large part be-
ankh.::. Tral1:-.fcrring thcse principles to otha joints, including cause few objective data wcre used to support the benefits of
the bat.:k. b~;;implc. Are these principlcs applicable to indus- .my type of treatment program. Finally, the report noted that
tri;1! injuri6 as wcll'! cmployers often arc reluctant to allow an employee \\'ho is
J\ reasonable approach 10 the injured workcr is to consider still having pain to rcturn to work. This siluation led to pro-
that illl.li,·iJu;s! an inuustrial athlete. The l)fOj~ct is to convince longed treatment .1I1d. of course. cnhanced legal costs. Delay
Ihat indi\"idu;t1 th.t( the principles are just as applicable to his in receiving effective care ,vas also noted as a factOr in dri-
or IlL'r injury as they were to the injured mhlcte they saw on ving up costs. What is effective care?
televisiun. Outcome in lhe treatmcnt of any joint. including This repon revealed that most complaints were nonspe-
Ihe h'lt.:k. can be measured by using various tests of function. cific in that no anatomic ..:au~c \,.uuld Ix: identified (0 explain
As de:-:cribed previously. exccllent cquipmcnt is aVl.lilnblc for the patient's complaint. Even though thc source of the prob-
lllc;l:\.urin~ qrcngth .1Od "cndurancc in a rcproducible. objec- Icm was unexpl<lined. however. bed rest turned out to bc an
tivc scnse. It is <lbo possible to idcntify It::\"els of consistcnl inappropriate form of treatment. This study also reported that
performance and effort on the part of the injured individual. surgery alone is not predictably effective in treating back
The injured worker must want to £oct txttcr for the treat- pain. Associated with this concept is that the dccis.ion to usc
1l1Clli progr;sm to be of benefit. Certainly. most people truly do surgical care should be made only after thc patient has partic-
\\';Ill! to gCI better and to avoid pain anti disability. Their de- ip<1led in an active rehabililatinn program and has demon-
sires for recovery arc usually enthusiastic if the tre.Hlllent is stnned lack of improvement. It was 'llso noted that residual
initialcd early. With prolonged delay in rational tre<llmcnt. chronic pain was not a contraindication for return to work.
howe vcr. f<lctors of deconditioning of the soft tissues. as \\fcll This concept was further reinforccd by an excellent prospec-
a:-: of the psyche, cmerge. Habituation to pain develops. tivc study that documented a greater than 80% rate in the abil-
,; Perhaps some pleasure with absence from work may occur. ity to return to work for chronically disabled people even
f though they had some residual back pain. Z('
.~
Under these cin.:umstances. significant social disruption also
t;
can occur. Litigatio'n perhaps can develop wherein the sue- The task force also found that the majority of ('osts asso-
t l'r..':--~ftll litigalion depends on proof of sc"crity ~md levcl of ciated with back disorders are incurred by 10 to 1.5'7c of the
1• ) pain and disability. Once thcsc psychosocial problems are: in-
vol ved with Ihe rep<lir process. chances for success arc con-
patients with symptoms lhat have lasted longer t.han 7 weeks.
Thus, lhe concept proposed from this consensus. report is lhal
i,
1"'!
)
:--iderably Iimitcd.
Even under these circumstances. hO\llCver. modern tech-
scven weeks is the time at which a problcm i~ considered
~hronic_ Chronicity may be defincd as the time at which a soft
~ niqucs offer a tool 10 urge the deconditioned worker back to tissue problem no longer can be expectcd (0 he31 sponta-

I,
~
he;lhhy behavior. Thc progrmns arc gcnerically known as
work hardcning ('('IIle,..... Hereto. the earlier the disabled
ncously. This document also idcntified the milcsh,...ne of acutc
injury as 1 week, and subacute injury from I week w 7 weeks.
worker panicip.ues. thc more sllcccssful the approach" What This differentiation is valuable in that if onc expe':-ls sponta-
I, :Irc Ihcs~ principles? neous resolution of a problem in the acute and subacute
I phase, developing a morc vigorotls and cxpcnsi'-e treatment
plan during that phase is inappropriate in most (';\Ses.
I
-~
<
QUEBEC TASK FORCE: PRINCIPLES FOR
EVALUATION AND TREATMENT
There is somc support for the: concept rut forth by
McKenzie that a mcthod to prc\'cnt the back injury from de-

I
~
~
-;
Certainly. the back injury problem is one that has been ad-
dr~ssed by many experienced c1inici.lOs and scientists. A wide
~lfra)' of concepts and various areas of cmph.lsis havc becn re-
teriorating into a more significant problcm can ~ imple~
mcnted by a spccific exercise program that eVaIU;l{eS physical
maneuvers by which the pain is (:(l;l1lged. Studil;.·s h:t'"C shown

~
poned. A:-. mentioncd previously. a consensus of these COI1- Ihat if this program is initialed within the first ..1 wccks. ex-
CCPIS is now availablc. In 1987. a document was publishcd cellcnt or good results C.1I1 be t:.'\pcctcd in 9};(""(- \,... 1' Glses: if.
I$. stoning tho~e principles dcemed most appropriate for the ev..l- howcver, the progwlll is inilimed after 4 wCt.'ks. the pcrccnt-
'lge of success drops to abollt Sock .~?
u:ltioll and treatment of back injuries. The projcci was initi-
t
"'-¥,
t
www.bodywork.su
 A relatively simple exercise progm.n1 was documented by Table 21.1. Treatment of Medical Bac;<, Prot~cm::;

Choler ct aPR At this acUlc· and subacute phase. some meth-

• A program 01 progressive ex:ercise should be initiated after no
ods in the form ofhcat or cold likely arc useful: however. the more than 2 to 3 days of bed rest. Passive melhods (either ice or
literature includes no justification. as supported by the hot packs) are only useful as an adjunct to exercise, Other tech·
~' niques are not appropriate.
Quebec Task Force Study. that other techniqucs such ;;'s
1 diathermy, massage. and repeated hot packs offer any benefit
• 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 \
to enhance the rate of recovery. It must be emphasized that
treatment is to a nonspecific problem. and the only definition need a lormal program of physicallherapy. When physical therapy
is indicated, rll)r~linn ~holJlrl nol exceed 6 weeks and frequency
of improvement in the McKenzie concept is centralization of should not exceed three treatments weekly.
the pain to the mid-low back. I r the pain progresses funher in • Diagnostic radiographs are seldom appropriate initially and, with
rare exceptions. are not appropriate at intervals during lrealment.
a peripheral manner. the therapist must recognize that thc ex-
• Unless neurologic function has deteriorated or progressive exer-
ercise program proposed is inappropriate. The exercise may cise has failed. specific diagnostic techniques (e.g.. CT scan. mag-
be extension. nexion. or side·shifting based on what happens netic resonance imaging, bone scan, EMG, nerve conduction stud-
to the pain. At least, this type of program has the benefit of ies) are not appropriate.
• More than 75% of employed patients with medical back problems
some relatively objective measurement of progress. Indeed, a relum to work within 4 weeks of.on581. Careful re-evaluation of the
method to measure progress should bi! at the core of (Ill eDi- treatment plan is warranted it the patient has nol progressed sig-
dent. efJecri\'e rreatmtllf plans. nificanUy in 4 weeks.
• If treatment lasts 6 weeks, the patient should be evaluated by an
appropriate medical specialist. The evaluation should include ob-
jective measurement of funclional status. reassessment 01 treat-
PROVIDING CARE IN TODAY'S HEALTH ment goals. and confirmation of appropriateness of treatment.
CARE ENVIRONMENT· • If the patient has not return":!d to work within 3 months. the patient
shOuld be referred to a specialized center for computerized re-
The reason for interest in the sports medicine approach. i.e.. assessment and care planning.
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 docll- of treatment by objective testing is justified. These tools were
ment:.1tion as to the levcl of dysfunction is the basis on which described previously.
reimbursement is more likely to be provided. The system re-
sponds more specifically to paynlclH for IIlcuit.:;,11 care that is SUMMARY
focused on documenting how (he parient is functioning beuer.
rather than how they might be feeling better. Il is apparent to Active excrcise programs arc effective in disabilit)' preven-
the providers that even though the patient may feel better tion. It is important to separate the concepts of impairment
briefly. no benefit has been served in tcrms of reimburscmcnt and disability. Impairment is the physical we~lk link(s) that
for medical ClIrc without long-tem change in function. limit function. If we can isolate anatomy suffkiently. we
Documentation of progress is lhe essence on which billings should be able to test thc deficit ;;.lOd evaluatc progress and
are reimhurscd. Lack of measurable progress is the documen- treatment by further testing.
tation on which lIseful medical care for soft tissue injuries has Disability, on the other hand, refers to thc limits that pre-
()

I
ccased. This is essentially a sports medicine approach. It is vent retum to thc previous level of function. In addition to lhe
unlikely that the future health carc dollar will pay for mainte- ··weak link" is an array of personal and human factors thm
nance level care for benign. nondestructive disease. create disability. including age. sex. educ;.uion. secondary
A plan of care that reflects this attitude is noted in gain. and overall attitude. Some factors of disability may in-
Table 21.1. This treatment guideline has been accepted by volve acquiring b;'ld habits such as substance abuse, obesity.

I
scveral preferred provider org,lIlizations in the SOllthern marital and family upheavJI. and anxiety and depression. All
California area. It speaks specifically toward documeIHalion of these f<lclOrs seem to be enhanced by diminishing physical
of function. activity. Physical activity th.u is focused on improving
In indu!'trial back injuries. experience shows that the pa- healthy behavior is the anecdote to these disabling problem$..
t{ tient seldom arrives at an appropriately oriented trcatmcnt Frequently. coaching in positive health habits is llecess;'lry.
program wilhin thc first scver;;l1 weeks. In those patients for This coaching docs not necessarily rail into the patient com:

II
."..".
whom treatment is delaycd. somc dcconditioning occurs. In realm of any specific clinician; all practitioners \\'110 come in ,~ . J
this group of patients. and those that have not improved in the contact with disabled patients need to focus on these positive
McKenzie type of program. one may expect <l relative loss of faclOrs. Active exercise. not preaching, seems to h.lve th~
range and strength. The reality of this phenomenon is docu- greatest opportunity to effect a significant change.
mented by the fact thot an ICD-9 Code 728.2 makes aVililablc
a dctlnition of deconditioning by the diagnosis of muscular HEFERENCE.,,)
wasting and disuse atrophy. This diagnosis cnn be objeclively 1. Sril7,cr wo, LcBl:lIlc FE, Dupuis 1\'1: Scicnlilic ;'rpmach Hllne assl.'ss·

iI demonstrated by specific testing. Therefore. a treatment plnll

that strcngth~l1:'i i:iC soft tissues and can documcnt lhe benelit
www.bodywork.su
lIlelll :md lIlan:lgcmCllI of ;u:li\'ily-rclalcd spinal dis(lrdcrs. Spine I ~:S t.
19K?

(J
~ ......;

I --------------~--------_.....
+
 ll:thklll;l1\ S. Phillips RB: 111e spinal manipulati\'c theory ill the man- 16. Mayer T. Kishing ND. Nichols G. ct :II; Progressive isoincl1\'ll llfling
;1~':11I<':11l ~lr low hack pain. In Ft)'llIoycr JW (1.':0): "lC Adult Spine: evaluation. L A standardized prolocol ,\lid nonnalive dalaba...e. Spine
I'rjll~'jpk~ and Practice. New York. Raven Press. 1991, pp 1581··1605. 13:993. 1988.
Lamh I.. Johnsull RL. Sl. Jens PM: CanliO\':lscubr conditioning during 17. Alpert J, M:llhesOll L. Beam W. et ill: 'nle reliahililY allli v,!Iidil}' or
~'h;,i .. r..:.'1. ,.\..:mspat'c r.·lcJ 35:646. 1964. two new leSCli of maximum lifting cap:lcity. J Occup Rehahil I: 13.
!.od-j w: ~k;lsurCUlcnts (If spinal poslure and f:l.llj;C in spinal nnm:- 1991.
1II~·nl'. :\la J Illlys ~kd IkhahiI9:IOJ. 1967. IR. Chaffin DU. 1);lrd; KS: A longitudin:ll study {If low h;lt:k (uill :IS ;Issud·
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.
<lh:d wilh lll:cupatiun:lt wci!;ht !if1illl; f"chlrs. J
10:5 n. 197 J.
"Ill lod I-ly,;: ..hsu;.:

<ii,,:lm:m R: "chimpra":lic approach in biomedical dil'mdcrs \)( the lum- 19. Bit'rin~-Sml'IlSIlIl F: Physical mC;lsurCIllClll." :IS lisk indicators fllf b\\"
b:,! -",'111\' '1Il1l p\=h'is. In I-Jaldcmall S (cd): Mot!.:nl Developmellt!' in the It.1ck trouhle over OJ OIlC ye;\r period. Spinc 1):-15. 1984.
I'rincipk!> ;1IIl! I'r.n.:licc of Chiropr.tclic. New York. API)!clnn Century 20. Gra"cs JE. Pollock ML. Carpenter OM, Cl al: QU:lIllitali\"C: aSSl'ssmCIlI uf
Crufl ... 11)l\t1. full range of mOl ion isometric lumbar cxtcmion strcngth. Spine 15:2l.'i9.
l11isloc H, Hislop HJ. MofTord M, CI al: lsokinetic contraction: A new 1990.
CllllCCpl of resistivc exercise. Arch Phys Med Rehabil 48:279. 1967. 21. Gr.wcs JE. Pollnd ML, FOSler D. ct ill; Effcct of training frcquency
Ilasue M. Fujiw:lr:I M. Kikuchi S: A new mcthod of 'lu:llltit:lti\'c mea- :lnU spccilicily on isometric lumbar c:\tcnsion strength. Spinc \5:504.
suremenl of :lbdomin:ll :lfl(l b:lck Illu~clc ~lrength. Spine 5:143,1980. 1990.
Smidl G. et :l1: Muscle strength :11 the (nmk. J Onhop Spons Ph)'5 Ther 22. Ha....son SM. Wisc D1): Instrumcnted teluing of thc back. Surg Rounds
1:165.19S0. Onhop 10:28, 1989.
:o.1:l)'cr T. Smilh S. Keele)' J. et :II: Quantification of lumbar function. !'an 23. Fordycc W. Roherls A. Slcrnbach R: 111e bcha\'lorJ.\ managcmcnt of
2: Sagiu:11 rhine trunk strenglh in chronic low·b;lck p;,in patienls. Spine chronic pain: A response to critics. Pain 22:113. 1985.
10:765. 1985. 24. M:I)"crT. G:Hchell RJ. Kishino N. el :II: A prospcclivc shon-Icnn study
~h)w T. Slllilh 55. Kundrd-<ikc G. el :II: Quanlilit::Ilion o( lumbar (UIIC- {In chronic low b:lc\.: pOlin p:ltiencs utilil.illg no\'c1 objt.~tivc (uncCioR:d
li,ln. l~an J: Prdimin:uy data all isokinetic 10NO rOlation lesling will\ my- mca.<;urelllenl. Pain 25:.53. 1986. .
ockt:lrit: sp'-~tr;11 anal)'sis in norlllal ami low-b:ld: p:iin subjecls. SPIIlC 25. Spill.Cr UO: Thc scienlilic apprc,xlch 10 lhe a.<iscssmclU and managcmenl
10:912. 19K5. of acli\'icy rdOlled 10 spinal disorders. Spine 12: I. 1987.
Kishino N: QU:ll\tiliciltion o( lumbar funt'li\lll. Pitn 4: lso111elri,· and i~\l. ~f•. M:l)"cr ,,.. G:llt:hd R. M;sycr II. CI :II: 1\ pro,"pcctivc 1WO YC:lr study of
kinetic Iifling simul:ltion in nonnal suhjccts ;Jlld low hOld: p:lin dysfullc- functional restor:\tioll in industrial low bOlck injury. J.-\~1A 250:450.
lion p:llients. Spine 10:921, 1985. 198-7.
Sceds R. Lcvinc J. Goldberg HM: Nonnative data for is()st:llion B·IOO. 27. Donelson RG. Sitv;\ G. Murphy K: The centralization phcnomenon:
J Orthop Sports Phys 'Iller 9: 141. 19S7. Ils uscfulncs'\ in evaluating :1l1d lfe,lIing sciatica. Spine 15:211.
Sccd~ R. Levinc JA. Goldberg HM: Ahnonllal palicnl d:lta for thc iSOS.I· 1990.
tion B-IOO. J Onhop Spons Phys Ther 10:121. 1988. 2S. Choler U. L.rsson R. N:u.:heIllS(lll A: Back p'lin attempt at ;I slruclur:ll
l'arnianp\Jur ~-l. Nordin r.t Frankel VB. el 'It: Triaxial coupled 1~(Jmctric lrealmcnt program ror paticnt.. with Ill\\" h:ld: p:lin. SPRI Report ISS.
lrunk mcasurcments. Presented al Orthopedic Hcsc,tH:h SOCiCl)' Meeling, Soci;ll PI;l1Icrings-och R:ltiollaliscringsimsiHII Rappon. Slockholm,
Allanta. January 1988. p 379. \985.

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 Index
I
\
I
i ,
, Abdominals lhig.h lI1:lnagelllcnt guiddincs, .]:.:>
exercises illhih;led. eV;llll:lIillll \If, IOi-: Illl11opcrati\'e care. 3~5-3~6
crunch, JO'; muscle ilTlh;ll<lnc~. 9S-9IJ, 100 patient history, 3-1..\
lkad but; pnslisollictric rclaxalioll, 259-261. 2M physical c;.;amination, 34.\-3·15
description. 300. JOI tighlncss c\·alu;ttiol1. 98-99. 100. IOZ predisposing f;H:IOr.~. 341
illuslratiun, 347, 382 trigger p(linls. 259 rehabilitalion prosr(llilS. 3.48
isolllclrk. 306, JOi Ad~l1osill": lriphnsph:lle, roli; ill111usculm ninlf,K' spmltl)'lolisthcsh tx:curn:llC~. J·e
SI:lbiJi~\ioll, 303-304, 304-305 tions, 50 spondylolysis OCC\lrrCllce. 3..l:!
gymnastic: tM11. 307, JIO-11 I ADL. (5c'c' Al.:li\'ilics of l..laily li\'ingJ t01ll1.: sll\:lIgthening pro!!r:lIJ1s..U6-J-li
ohliquc. wcal.:llCss cV:llualions. lOY, 110 Acruhic c:lpal.:ity. erfccl 011 lifting. capaCil)', 1..1-l ATI'. ISt'c' Adclllisine triphosph:u':J
Abnoflll;ll illncss bch;wior Acrobic condilioning. for atltktcs. 3..18-349 U;lh~
chronicity 'lOd. :!5 i\crob;c procc>.~es, locomotor syslem. 48 l.:<ln)'ing, cum.:ct mclhod. ISJ
l1eltncd. () Aerobic tcstin£. fur p:rforl1lam.:c Ic\'c1 d~tcr11lin:I' dl:lIlgin!; slat Ion hClghl. 185
cffcCI on ncurolllusl.:ular system, 18 lions, 411~11, -112 pUlling in car. IS~
indicalions fur, 6 Arf~rcllt libcrs [bel.: p;lin, lllw. I.St"(· Low h:l(:~ p;lin I
nonorganic ",i~I)"', 6\) mech<lnorcccplOr, p;lin cre:llion. 2.\.-25 Rack P:I;lI CJ:lssilk:lliun Scale. description, 65
pain and, 17 nociceptor. musdc h)lJC :lIId. 2(J B:Jck relief. 1.":6
Waddell's si);lls, 73 spinal sl<lbilil)". 17 Ibel.: school
Abuse Agg.rcssivc carc b<lck s:tfety trailliu:;. 1;7, 160
cmotional, 396 carly retum \(l work. 7.165 back tr:tining and CxeN."isc pro~r:llll:'. 156-1:'7
sC."U<l1. 396 cx'lIllPlc.~ of. <> California, 155
subs!;Jllcc. chronic p;lin patiel1\s :ll1d. :W5~3lJ6 Allodyn;:l Canadian Back E~dlU.:ali(lll Units. 1:'5
Accelcralion·del·ckration syndrome, rehahilita· dclined, B company interview. 159-160
lion l11ana£emcl1l. 378-379 symjlWIll". 23 curriculum. l5X
Acromiocl:l\'icular joint. traclion-rnohiliw· Alla~d mo\'emcnt p:Utcms disability prcvcllIion. X
tion, 2/'; chronic p:lin and. 25-26 formats. 157-159
Active carc, (S('t' 01.1"0 jvlanipulatin: lherapy; no:· erfcc( on mowr S)·st~lIi. 30 injury response lraining. lSi
habilitation) lJ)usl.:ul"r imbal;ll'Ices :mu. J I principal goals. 15,'
for disability prcn:ntion, 411~ 16_ -116 IrCal1ncnt for. 31 prog.r.llU promotion. 159
nOIl:'ipcl.:ific b:lck pain. 300 Amotivational s)"lIdrom.: . .\02 purpose. 153-154
passi\'c care and. l.:omparison. 1.":-1 An:lcrubic capacil)', cffl'cl on lifting c<lpacity. 1..t4 rcquil\:lllents for. 158-159
role in rchabilitation, 32-3.\. 13 All:laobic prtKc:-ses. 1tX:1I1110Wr sy!\lelll. 4S safely orientations to indu~try. 1:'6
sci:l\ica.360 Annulus Swcdish. 155
lre,l\lllenl £.11:1Is. 33 descriplion, 3..1 I (J:lI:mcc b:llls
Acti\'e prept.lsili\millg. ddin...'u. 2\):, injuric.... 10. 34} dcscriplion. 320
ACli\'ilies of daily li\'illl; Anii-inllamm<llory lU~·dk:\lions. low back pain :.1- purpose. 326
evalu;itioll \It". t)3 lc\'i3Iioll.3':5 Balance sh,'lCS
improper ;md pml",.:r po\ture ,\RCON ST. /-17 dcscriplion, 320. 323
c<lrrying it...' I"s. IS} Afln "b<.Im;tloli. ill p;ltil'nt with shor1ellcd upper guidclincs for using. 3D
dressifl~. 18S lrapczius. 135. 135 il1uslrati(1ll.321
dri\'ing. /77-·/78 Aniculol1luscular :llllJllitllde. (SC(' Flc.'(ibilily) standin~ 011. 327
gelling in am} ()Ul or bl:d. 188 Asymlllctry. pOSluwl llllli.... Ballel. low back IlImh.lr ~pin .... il1juri~:,. 350-351
ironing. 186 id~ntirying. 3:\1-.'.': '. Barre's test
overh~:ld r...' :Khing. 182 palholo,gj(,.·. 331 devicc for. 335
pulling,IS.J physiologic, :n I illuslr:l1ioll.330
pushing. ISo4 Athleles. (St·t·III.WI Sptln~l Harrier phCllilll1CnOn
risin~ frolll ..::hair, /.'W lum!l:lr spine injurk,. illustratioll. 19,'\
:-itting. 167. 17.'\-17fJ. 179. J..1I, .m.; :lcruhil.: (,.:"tJlldititll\ill~. 3.\X-341J rn;lllipulalivc ther:lpy. 19S-1(1)
:-kcpill!!, ISO :Igc·rdated facl(lr~. J.\:! palpaliull Icsliug
AcupuIKtur~. dlrtlllic p:lin tll.:atUlenl. ·HlI ll:tl<lncc r.:'turalioll. ,,"'9 connccti"c ti~~uc, lOU
Acute p:lin. ,,'!In-nic pain 'llld. tf:ll1silinl1;11 ht:d 1\:'1. J.I{. pressurc aprlic:ltioll-:. :!Ul. ~Ol
sIers. IS . . \)/1111\(111 'ymlrtllll...·,.. J..15 shifting :lIld Slfctching l·as...·i:l, ~lll. 201
,·\dUUClvf:- comdin:ltilill. ~'\I) skill. 200
referred p:,in. ~51) diagno,i:-. 3'11 prolei,'lin~
flllll;lion,. 19IJ
!'c1f-streh:hin~. :!:(,l. 262 injury JlIech:mislll~. J·12 ,un lissue p..in S~lldHlllle:,. :tl.:

www.bodywork.su 419

..I.
Ba~cball, lumbar ~pinc injuries, 353 Care standards prillcipal !!\lals. l:'i~
Bcd, gcning in and out of, propcr fonn, 188 low hack pOlin, 34-36. l61J !JHlgr;11ll rrPlll111ioll. 159
Bcd rcst reimburselllent for. 37 pllrpll.'l,'. 1=',~-15·1
di$advantagc~, 346 C'lrpaltunncl s)'1Idl'Olllc. IhnJ,t Illanipllla1iI1l1'. rcquiremcnts for. 15X-159
low back pain allcviation, 345 215.216 sat"cty llri..:nt;ltinns tll industry. 15(1
Bchavioral t~crap)', chronic pain trcatm<:nt, 401 Ctrr)"ing. corrcct posturc. }."'',I Sw..· di,h. 155
Biarticular mu~c1e~, tr.lining specificity for, 51-52 C.lse management dlll\lli..· !Jilin p;lIicnls
Bias sourccs, 011 pain mcasurell1CIl! quc:>lioll- gencr.l1 principles. 3;;S Cdll<.:;ltiolJ Ilf. ,j')
naircs, 59 for nonspecilic back pain. 3M) motivalioll ul'. JI)
Biccp~ fcmoris, (St'" also Hamslring) pain and disability quc,tionn;lirc usc. (II). 69 trcatmcnt ;lrpro;Khcs, .j()O-...j(}1
functional an'ltomy, 120 Cat cxercise. 187. 383 manipulativc therapy
gcncral charactcristics, 120 Ccntral controllllcchanislll. tScc Fecdhlrward harrier ph..:nomellol\. II)X-199
postisometric rclaxation. 259. 260 mcchanism) hcnclils of. 222
shortcned Ccntral intcgration facct joint ~Ylldrol11c. ~6X
body contour changes. 122. 122 exteroceptivc infonllation. 329 for low h;lck p;lin. 7. 36-.~7. 1(15,359
body statics impairmcnt. 120. 121 visual input disorders. 329-331 McKenzie approach and. 225. 2:'10-251
disturbcd motor pattcm~. 122./22 Ccntralization fl?spomc, in derangcmcnt syn- recovery r;ltes. 166
Biochemical mediation, (See Infiammation) drome,247-248 thrust. ~13-~15. 217
Biofcedback. chronic pain trcatment. 401-402 Cerebellum. movemcnt control oflic.: pwcti.., c,. }X4,-~H5
Biomcchanical coupling. effect on lift-Iowcr involuntary. 26 pain ;md dis;lhility questionnaire me. 69. 69
tasks. 144 voluntary, 26 patient sati,Jactinn ratings,
Body contours Cervical extension. disturbed movcment pattern,. subluxation. defincd. 22
changcs in due to shortcncd upper trapezius, 135. 136 Chronic pain
shortcning Ccrvical extensors, post isometric rel'lxatiol1, 206 ;ICllte pain and. transi1ional '>lCp~. 18
biccps fcmoris, 122. 122 Ccrvical fascia, barricr phenomenon. palpation ddined. ~%
piriformis, 124.127 of,202 disability and. )1) 1-)1)2
quadratus lumborum. 128. 130 Ccr.'iealllcxion. (Sa also Seck l1exion) dnlg usage and. 402
stcrnocleidomaslOid. 137, 137 disturbed movcmcnt pauerns. due to shortened ftlnctional re'>loratioll programs. ·102-403
tcnsor fasciae latae, 124. 124 sternocleidomastoid. 137. 137 lifestyle changcs dllc to. 39
upper trapezius, 134. 135 Cer.·ical musclcs. (Sec alw ~eck musclcs} movelllel1! pallcrn ;lltefiltion~. 25-2<)
weakening postisomctric rcla:.:;ation. 271-272 p;ltients
glutcus maximus, 120. 120 refcrrcd pain. 271 motivation increases. 39
rectus abdominus. 133, 133 Cervical spine rehabilitmion education. 39
inspection of, 113 dynamic tests psychogcnic di;lgnosis .md. 5. :195
Body oUllines. (See Body contour~) illustration, 238-239 psychological tcsts. 398-399
Body static~ 1:;peS, 238-239 psychosocial faclOrs
abnonnal. 116. 197 joints. referrcd pain. 78-79. 79-80.175.376 alcxithymia. 393
case study loading of, McKenzie approach, 237, 237-230 compensation, 392
back view. 140, 141 mobilization techniques. 2/2 compliance. 392
di~turbed statics. 142 position of, aftcr side bending, 217,218 deprc.ssion. 392
front view. 138, 138 postisolllctric rel'lxation. 379 gain. 393
sidc vicw, 138-139,139 rangc of motion tests, 78-79. 79-R0 litig..nion,392
diagnostic critcria. 117 cxtension, 237 reporting to third pari)" payor. 38
disturbed flexion, 236 risks for developing, I (I 1
description. 116.217-218 protrusion, 236 sellsory motor slilllu];llion. 321
in musclc dysfunction. 116 rctr'lction,236 device.s ilnd 'lids
pelvic di~tortion. 221 static tests, types. 239 halance balls. 320
normal, diagram.~ of. 115 traction. 206 balance shocs. ~20, 321
visllal impeetion, 113-114 Ccr.·icobrachial syndrome. ctiology, 376-378 Fillcr. 320, 321
back "icw. 113-114, 1/4 Ccrvicolhol<ldc outlet syndrome. thrust lll;ll1ipu- minitr;llTJpoline. 320. 32/
front view, 1/5 I.nions. 215. 2/6 rocker bo;ml. 320.320
side view, 114. 1/4. 116 Chair twister. 320
view from above. 115 proper posHlre, 178.178 wohblc board. J~O. 320
Bone, immobilization effects. 15 technique for rising from. /89 indications for, ~21. 321
Bone scan Chiropractics mOlor leaming slages. 319-320
indications for, 342 back school .~hort foot
low back pain diagnosis. 341 back safety training. 157, 160 (Jc.~cription. 322
Borg verbal r.lIing pain ~eale back training and exercise progr'lllls. exercise program, ~22
dcscription.61 156-157 fOntl:ltion of. 323
illustration. 63 California, 155 half step forward stance. 323
Bradykinin. releasc Juring ischemia. 19 Canadian Back Education Units, 155 illustration, 322
Briuge e:>;ercise, 295. 374 company interview. 159-160 passive Imxlclill~. 322
description. 300-301. 301 curricululll. 158 sllhst;ll1cC ahusc ;1I1d. ;'9;'i-':W()
Bnl.~hing teeth. improper and proper posturc. 186 di~'lbility prevention. 8 syndromes
Cardiopulmonary sy.~tem. immobilization cr- formats, 157-159 charactcristic_~. 39;;
fen~. 15 inj~:ry response training. l57
www.bodywork.su prognosis. 35. 16:'1

__________________________d.
Chronic pain--{,"O/1/iJll/cd Deconditioning Dorsal h,'m scn~iti/:lIi(lI1. ~~
tesl hallt:ry, }99-4fX) altered movelllent patlems..\ 1.3 J asso..:i:~l<.'d ncural dl;lIl~"" :'.'
trt:atlllel\t charactcristics. 13 caus,". ~3
.ICUptllKture, 40 I defined. 402 ddin,:d.14
behavinr;llther~\py, 40 I joinl hyperscnsitivity. 21-22 p;lin ;~:ld. 17
biofeedhack, 401-402 llIuscular imbalances. ~ I. 3 J pallw:·i1ysio]ogy or. 25
cognitivt: lherapy. 401 neurophysiologic clements. 17 DOT. IS,.,. Diction;!ry of O,,'I:l':lli(1:l:d Till<.' j
family therapy. 402 pain relict. 167 l)\luhk k,: raise. f(lr p.... h'h: ,!:<.'n~\I1I'·'I. .\(J
~')~IL,. }:{. ..:no pathophysiology. 14 n,,\\,af:cr', hump. !7lJ
hypnosis, 401-102 Dcprcssion, chronic pain and. 392. ;'(l.:~.w5 [)y.Shlll'li(ln syndrome. Illc(harlIL'al ;tI1d ' : mpl(l-
pharmawtherapy. 'HJ2 Derangemcnt syndromc. lllcc!l;l1lic;ll :md sympto- malic rc';:,onses. ,0 IO:lding. ]':2. 2,14-~.l(,
rdaxatiol\ therapy. 401·...4 02 matic rcsponses, to loading. 2-1'2. 246-~50 classitkations, 24:;
Chronicity hehavior nomenclature. 24X-249 lI1anipulativc therapy. 250
detinet!,25 behavior·toJlogr.lphy-dcfonllity nOI11<.'nel,,- EecclIlriL' contractions
risk f;l(:tors. 34, /66 ture.249 defined. 50
Cognitive therapy, chronic pain trt:atlllenl. 401 manipulative therapy. 250-251 training specificity, 51
Compression injuries, in alhletes. }43 p;trtial pattern.s. 249 Education programs
Concentric conlractions Descartcs. Rene. view.s on pain. (} B:lCk school
deli ned. 50 Desk. proper height, 167 Cl!iforni::. 155
training spt:cificity. 51 Diction.try of Occupation:ll Title Cm;ldi;1l1 Back Educalion Units. 155
COIll,:llrrent \·;llidity. of pain queslionnaires. 60 functional c;lpacity :Ind worl\ capacity eorn::la- or.
origins 154
Conncetivc lissuc tions,93 principal goals. IS]
lesions of. palpalion lesting. 200. ZOO joh listings. 93 purposc, 15,\-154
osteopathic cccentric muscle energy procc- Diga,~lricus. postisomClric relaxation. 208 results. 154-155
durcs. 258 Disahility pronc palient. protllc. 36 Swedish. 155
Conservative care. (St'" also Passive care) Disability questionnaires history of. 154
aggrcssive. 36. 165 pnin measurement types. 5H patient. (Sa P:nient education)
low back pain. 6-7 reliahility, 59 Elbo\\". extension tests. for hyperl1lohilil~ e\'allla~
nonspecific back p'lin. 360 types. 58 tions. //0. III
primary gO;:JIs, 32 validity. 59-60 ELC. {Sa EPIC Lift CapaCity Tesll
rehahilitation and. comparison. 3 1~32 Diserimin.mt validity. respomivity. 60 Electromyography. muscular imbalan<.'e J:lla.
sciatica. 5. 360 Disk 26-27.27
surgery and. comparison, 5 biochemistry. immobilization cffeet.~. /5 EMG. (See Electromyography)
trealment methoJ.~. 6 hernialions Endurance training. effect on ml1sck. 4~--19
Constitutional hypermobility, symptoms. III description, J71 Engram. defined. 26
Construct validity. of pain questionnaires. 60 ill'lstmtion. /76 Environmenl, paticnt and. 405-406. -106
Cuntr;lcl-renex technique low back pain and, relationship. 3 EPIC Lift Capacity Test, description. jJ<.}
lower seapuhH: fhators. 28H, 29/ spontaneous recovery. .3 Erector ~pinae
middle trapezius, 2SH. 290 illustration. /70 hypertrophy. 107. 368
principles. 254, 258 intervertehral. injury mechanisms. 3·B inhibited. cv;l1uation of. 109
shoulder joint. 2H7. 288 spinal ncrve TOots and, 170 po~tisomelric rd:lxation. 268. 270. :;, :-0-
Contract-relax antagonist contraction. 25H syndromes, rehahilitation management. 271.373
Convergcllce. defined. 24 ]69-:nO referreJ pain. 2(1:-;
CR techniquc. (S('(' Contract-relic x tcchnique) Disk eXlmsion. surgery for. 5 sci f-jXlstisometric rcla\~ltion. 27:;'
CRAe. (Set' Contr;lct-rclax antagonist COII- Distal crossed syndrome. charaelcristics, 97 self·metching. 270. 27/,373
tractioll) Distr,lction force. joint surfacc separalion shortened. tcst for. 370
Crcep. ti.ssue. dellned, 16 and,2/5 thor;;cic, 206
Crilcrion v;lIidity. of pain qucstionn;lires. 60 DistraetioflS. as abnormal illncss beha\ior tighmess evaluation. I(}O. 10-1
Crossed .syndromes sign. 73 trigga poi illS. 265. 367
diS!;11.97 Disturbed hody slatics Ergunomics. wor\.;s\;ltion
lower descriplion. II(l, 217-21~ eh;;ir ~ellil\gs. 167. /79
illustration. 28 in muscle dysfunelion. 116 computer, /7Y
posl\lral signs. 363 pelvic distortion, 221 headache rdict". 375-376
pelvic. 106 Disturbed l1lovemcnt rauans ERGOS work simulator
proximal. 97 asscssrnell! of lk,uiption. l·n
Curvc rcversal normal, 117. 1/7 illu'\ration, 1.17
detined. 23~ shortened muscles. 117-11 g Exer~·i'C. actin:. j\lr low back pain. ~
l.lbslructions to. 232 weakcned muscles. 117-118 Exercise hall. (Sa Gymn<io,tie hall \
Cut;ll1eous hypocsthcsia dlle to m\lscle dysfunclion Exerci~e seien~·e. lllCO[llolor pcrforl1lan,.... physio·
detincd. 23 biceps femoris. 122. 122 logic categories . ..\7-49
symptoms. 23 gluteus rnaximus. 120 Exerci'es. (S('(' also Trainingl
Daily acti\'ities. (Sn' Activities of daily' stcrnocleidoll1as\(lid. 137. /37 abdominals
living) Di'l.l.iness ,Iisordcrs. 3X;,-,i:-;4 crunch. 30·1
De;I(I-Bui' excrcise Dormant lIluscle. 29(l dead bug
dc.seriplioll, JOO. 301 Dorsal fascia. harrier phc11l1l1JCnon. palpation of. dcscripti(lll . .100. 30/
illustration. 347. 382 201. 2a! illustratioll. 347. 382
www.bodywork.su
 Excn::i:-e:--'nUlfillll('t! i:..:";,-,,, ..... ,IIU<.:,ii... ,,'l11. ,k..,-riptillll. ..\(I_.J' 1:IIIKliulI;11 \·;lr.I~·lty c\·aluathlll
isomelric. 306. 307 h'lal 1"I"";lillll. illll~Ir.II"'Il, ,SO alll1lill; .. II~III"n ,It. 7-1-7:'i.
SI:lhiliz.:llion, 303-3Q.1, ](N-J05 Fihnlhb"l~. .'il:;lr (llflllal1\>Il, I.' l:ill\lj'llllll'nb "i. 1-1.,
gymnastic ball. 307, .lIO-.HI Fihll!;l. 1lltlhiliZ;lIilln I,·,hlliqu,'. : /4 lTili..·;11 f;l~'I"t, Inl". 75
chronic paill al!c\·i:l.Iion. 39 Fill,' 1'I)~lt1r:l1 sYStl'lll liIllL·litlll;lltl"b. 77
cOlllpliealing factors, 359-360 IIll'1Ih l\lll'''·lI!(l~h,·kl.d t"L1l1,·liot\:t1 :1'1"'..,·1'. 75
cndurance, erfect on muscle, 4S l'\l":l'llCcptivl·. J2'1 'lh.k..·li\',· qll:lI1l11i:lhk 1\:sIS
force, effecl on nHlscle, 4t\ llJ,lIIiplllalillll or.
.~.~2 '.'.'.' lk-,ihilil~

gymnasllc h,ll1 I"SIS. 3:\5-3;;(>. }.'5_. 1.'" l::'.. tn ....·F1..' ll\lll'. S~-S3 . .';.J.
b~I'::': ,,:oc:c!:. ~I~.
3/5. 37-1 1,,:uIIIIl10111r. 3J>.~".;. 333 h'IIII,11I11':. SI..';1
hridgc, 307, 3M-3/O pl'llll;lr. U3 hip Ikwr. SO-XI.,'\1
dorsal cx.lcnsion, 3 [3, 3 J.J pn 'pritlCept i\"C. .l2 'J kllt't' 11..'\11111. S:!. 81
fronl rolls. 313, 3/4 ml:llurs Icst, 33-1-.1.;:' pdvil: 1111. Sl,: ,)y, ZI),,-}IJI. ';,';2
iIImar.nion. Jo.'~-3/2 :-pill;11. .l\2 I\.'t·!th fClllnri ... XU-Xl. ,,1

lumbar clttcllsion, 31), 1/-1 \'i~u;ll. 3'N-.'30 Sl\kll~, S.'. ,<';5

scc-saw,)11.3/3 lllamlihlliar inlerft'r":Il..·l' •.H.'i rall~e 111 lIltlllOIl

shoulder rehahililation. 381-38~ musdc 1011<:, 330 (t'rvi..',,1 .. pint', iX-7\). ill_SO
squ;l{S, 313, 3 J3-3/4. 374 orttltlplics contrihmi\1I1", Y;7 hip rolall{111. X~. 82¥,'.;,'
"sullCrm:tn:' 309. .lIZ. 374 pO~lural swaying..';;0 lumh:lr ~plll~. 76. 77
types. 306-.:\07, 309 l)u~lUr:l1 tr.linin!; pl;U(llflll..'.11\•.;j,'\ th(\r;I~'k "pm,'. 7X. 7.'\
imprtlpcr form -.tahillll1\elry lrun" rut:llllHI. 7:\. 71)
hC:l:d rorw;mj posture, 187 t.baiptioll.337 ptl rrost'. 7-1
low hack h)"pcrelttension, /85 Rumberg's quotient..'\.\7. 337 qualiliahlc IC'I-.
politural faults from, .MI ue;l11ncnl follow-up..'.'6 hip ;,h{\m;titlli. XX-St}, WJ
waisl slumping, 187 Fittcr hip t',\l..:n .. loll. 91. 1)2
kneeling d..:~crirli(Jn. 3~O . .1:26 ncd-; 11c.~i\lIl, X7. l}()
dc.~criplion. 30J illu~tr;l1i(\Il, 32/, 327 Ollt' k~ "l:lIldill,~ 1..',,1, x.;,,vJ
illustr'llion.303-304 Fk:o:ihility pd\"ic lilt. Xli. ,'';N 3,';1
locomotor system rC:l.Cti\'ation, 53 dclincd. -Iii n:Spir.llion ,"nnrt.lill:llilln. XX-S9. IJO
pro~ralll erc;llion, criteria. 52 lo~ses in, low hack pain ;lIld, 15 shuuldcr ;lbtJUl:tiOll. X.'i. ,'\.'01
role of muscular qualities in. 48 tc,IS of sqllat .\lfCn~lh, S-I-S5. 8i .. ~

singk knee and double knee. /87 ~;I~trocnell1ius.S::!-~O. )j.J Sl:lntllil kn..:clicsi. X3-S-I. ,VI ;
Extcnsor:> hamstring. 81. ~ I slenlf.x:lcidlllua'luid. S7-KX. YO
cervical. postisomctric rdalt<1tion, 200 hip Ilcltor. 8Q-8I,l'i1 tnlllk IIc.\ion, X7. WJ
"nee, mechanism disorders, 382-383 knce. 82, tiZ lrunk sid..: rai"ing slrcnglh. 'JO--9 J. 'JI
wrist, postisonlclric relaxation, 204 qu,ldriceps, S2, 82 W(lrk c:lp.1cil>· and. 93
External dem:md, functiona: c:lpacity <lnd, rela- rcctus feJl1oris. 80-81. 81, 110 FUlIl:lional ddicit,"
tionship, 16, /68 Flexion Illw h;ll:k p:lin :mt!. rcl;ltillll.. hip. IfI
External stress, reductions in. 36 prolonged. crf...'C1 on lifting injury. 167 tIU;llItilic;l1itlll (If. fum:lilln:ll (;Ip:ll:lty C\';IIU;I·
EJl:leroccp{(JO', function, 329 vulncr.Jh1c positions. 171 linn, n
Eyc. Ill(WCmCn!s of. fIOslisomctric rcb.\<llioll ;lIld. Food in lake, musclc dysfunction, /97 IrCalmC1lt tlf, 7~
20+-205 FOOl Funeti(ln:11 pro.;:rt..... qll:lluilic:uion. -',Ii
face \"alidily. uf p:till qU~lionnaircs. 60 dorsillcxion, for hypcnnobilily c\·~llualinn~. Functiollal r.mgc.l.'if'c' Tr:linillg r:logc)
Facel joim l;yndromc 111.11/ Functiollal rC"llJr:lIi'lll
dl.":!'cripliOll,366..·)67 proprioceptive rcccp\()r~. 3~O chronic pain and, -1{)~-4U~
di:lgno"is. 3 Foolball. lumbar spine injuries. ;;51-;;5~ [tlCOllllllor -,y .. lt:1Il
palho!clgy, 345 Fol'\;c, dclinilion of. for tr:lining l,lad delcrmina- lI1UScul,lr illlh:llanccs. ~62
rchahilitationlllanagclllcnt. 36l-i li(ln~. -Il-i p:lth(lkine,ology.3h2
Iriggcr points..M7 Force lraining, cffecl 011 lIlu:-ck. 4S-t9 pa:icnt da..,ilic;ltiull. 361
Facct joints, oricn!:llion of. 341 Force·angle curve sl,in.. 1 !'o1;.Jhilily. :'I61-:HI2
Fadlit:ltcd scpncnt, defined. 22 fle~criDlion. 51 lIlullitlisciplin;.Jry
F;ul1ily thcrapy. chronic pain IrC:ltmcm, -102 illu!'olration,52 indlcalioll\ ..\2. J6
Fascia Force-velocity CUf\·C SChCIll;llic. Ij
!:lan-ier phenorncpc1ll. ~Ol. ZOI de~cripli()n. 50 p:llil.'lll SCkClill)l. }.'i.'i
Cl.":rvical. 20Z illllstr:l\itlll.51 secondary
dorsa!. ~Ol. 20/ impMwnce to rehabilitation. 51 "'lll\llltlllt'fll~ 01', .'01, IS
ghue;ll. ~Ol. 2()J 1Jlccl!;lllislilS of. 50 funcl;llu:11 (,·;IP:~l'iIY c\'aIU:llioli. X
hllllt"ocl(\(1f:'al,3-12 For""ard bending. Ic~t. for hypcrlll\lhiliIY. lIlutur sy:-h~lIl rc!mhililalioll. X
Fast-twitch fibers II J, III palient Cdut·;.lion. N
char:lCtcristic~. 27,28 Free lifting. cvalll;llioll of. 413 p-"'ydUNl(;ial f;ll"lurs idt'ntiliGllillll. S-t)
tr.lining eneels. 27 FS. (.'iff; Function;11 ~I:lhilil.;lliun) FUIl..·linll:l1 -",lahilizOllillll
r::Ili!!-uC" curve. illUSlr.ltiOIl. 17 Fukuda-Untcrb!:rJ;cr Stcpping Test dilliGl1 applic;llicUl ..2t)(,_'21)7
I:CE. (St·t'.Fllflclional cap;ld:y evaluation) iIIuslrilliOll,332 ....\cf,·i"c chcd:li~t. J 1(1-317
Fcedhaek Illcch;lnism pathologic asymtnl.:lry, 331 cxcr'!.'ise If:llmn;!. 295
hdlavioral syslems and :\pproach, 47 Function;tl c:lpacily factors Ihal arkcl. ]/)(,
descriplion.47 cJl:tcrrtal dcrn,md and, rcl:llio1lship. IfI, /68 cxercises
llItJ\'t:Illt'1lI eorreclivc Iev::!s, 47 work capacity antI. corrclmiuns h~'I\\'ccn. 9J ahdlllllinal .... .103-JU·\. 304-31J5
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 423

Functi'1ll3! '!<lhil!1.;,'i"Il-.·,''I!il··~:·,/ ".'11' 'Iretdlin~. 26.". 1.6S It.,," t'>;l.:k p:,in OIlld. rdalil.n.;hip. 3
hicycle. 315. 3/fJ .'l'lhili/.;l\illn c.\er~·i~cs. 3U 1_.llJ.;. 30~ _}I,.; sl',onl;lIll.'OIl" rCl'l\\·ay. :;
brid~l:. J()(}-JOI. 301 \\'cakcncll Hip
"dl:ad bUf:' 300, 301 hody ll\lllil\\' dlau~c~. I ~O. J2/J "bdlKlillll
SYllltlJ~tic hall Ilisltlr11o\:d Il1OI"r pallerns. I ~H all.::r...d p:l1Ierns. ~63-J(w. 36-1
\1;lt:k str.:lch. 31 J, 3/5 d.~turh ...·(l :-1:IIK.';. liS. J1'1 ("1".Irdill:llio!l I<:st, :-;9, Y!
hridl:'l'. 307.309-3/0 Cilul<:U:- 1lI..'dilh !i~l:llle ...... .c\·;llu;llitlll. 1)1). 101. /05
dm:>al ":.\Icll~iun, .\1 3.31': l:Killtalll'IlI\·dull'jll\·:-. !I)(I. :!lJl ;uldul'l:on. ligllll1<:s~ C\·:IIUalilln.lJlJ. 100-101
fWlIl rolb-. 313. 3/./ Fill"'r Il~~'. J~; e~I\~n:-II'U. (S{'c nix" Bicep' lel1lori,1
illll.~lr;l:i(ln. 308-3/2 t'tll1<:tiOll. 102 :Ilh:rcl! p:lllems. :\(1.\ 3(j3
lUlllh;lr .:xlcnslnll . .' 13.3/.1 '1;lhilil.alillll c.\..·r..·I'~·'; ..\OtJ-.'U5 . .WI ."'. l'(II.'Hlin<llio1l1cst. 91, 92
~c·saw. .lII. 313 (iltl1l'u.~ lIIiuilllll'
! shnulda rch;lhililalion. J8J-3~~ flllH.:liol1. IO!
for gail cycle cvaluation. 101. 1(15
Illll."dc contr;lction. 122

,i S4U:lls. 313. 3IJ-J /4

"sur::m1:ln:' 309. 3/2. 37-1
rdcrrcll p;,in. 175
slahili/.;uiull c:\~·n:i .....s. JtMI-.\tl I. 301
in p:llit:nt wilh shortcned quadr.tlu!: IUl\1-
borum. 128. 130
J tYll<:S, 306-307. 309 G\.J1f, lumhar spille injuri<:s. 55.2-:\5.; hypcre.\ICnsipll lest. 371

I, kneelin};. 303. 303-304

lumbopch"ic.298-300
Gothic shuulder. de'crilllitlll. 109-110
Gravity
1Il1lhili/alillil I'roCl..'durc:<.. JlOSli:<.omclrie rebx-
alion. ~8-1-285. :?X6
flIl:i1iotl. r,mge (If m(llillllleSI.~. 82. 8?-s.~
i
-~
lunge. 305. )05
11ron.... 30i-3o:!, 302
clTcet 011 Ir;linint: lll,al d..:lcrlllillalilll1\. J~
usc in poslisnmclri;; rdax.uillll. 20:'-21)-. ~:;s 1lip n....\\Or'
~
pullcy.315 Gr.tvity inloler-mee. }1}6 Ikxlhilily lcst. SO-SI. ,~I
! squats. 305. 306 Gynmastic b:tll c~cfcises ll1(lVelllenl pallern ilnpairmcnl
~] ).
styrofoam. 306.306-307 bolC!.; slrclch. 313. 315. 3i.J pinformi" shortening. /27. 128
go,lls of. 291 bridge. 307. 309-JJ() lemm fasci;u: I"lac .o;horlcning. [24. 125
~
~ "j principles. 293. 295 dorsal cx-tension. 313. 3/./ fK1Slis(llllctric r..:lax;111nn. 262. 263

1 routines. 296
spinal position. 297-298
e.>;tension.349
fronl rolls. 313. JJ.:
.o;llllrlcned. It:sl for, 3fi9
tighlllC~\ \:\"alu;,tiot!. ~S-99. fJ9-IOO

I training range, 294-295 illustration. 30.'~-JJ2 Hip internal Wl:llors. !l(lslismnclric relaxation,
•! Function;I) tesling
funcliom.356
lumbar cxtensiun. 313, J 1./
pdrti;ll sit·ups. 3~Cj
267.268
Hip joill1. f'K"ll"II111Ctric rc!:lxali(lll, ,in
i lunge IC~L 296
purpose. 356
scc-saw. 311. 3/3
shouldcr rchabilil<ltion. 3S 1-382
History. pdticllt
cffect on Ireatlllt:nl plan. J~4
*~J I),JX·s.297 sqU31S. 313. 31.1-314. 37./ form~l, 397-39:\

I,I Gain
primar)". 393
secondllry. 393
ler1iary.39.l
Gail
evaluation of. 97
hip extension cvaIUalion!'i. 101. /05
"supcnn=tn." 309. 3/2. 3i.J
Iypes, 306-307. 309
Gyrnn:lstics
lumbar spine injuries. 350
spina bilid:t occurrence, 350
spondylolysis incidcncc. 350
Hamming. (Set' Cltso Dicep~ fellloris)
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
~ :<.lilllCC phJ.St:. 197 improper cll;erci~e proccdure. 372 secondary, (Sa Refcrred p:lin)

•I swing phase. 197

Gail :1IlJ.lysis
po.~liso1l\ctrie rclaxalion. 258-259. 259.373
refcrred p:lin. 258
symplOrns. 23
Hypcr.lll;csic Wllc.. .. skin drag di:lgn(l~i~. 198.200
hip movcmenlS. altercd sclf·strelching. 259. 260..i73 Hypcrmobility
~ alxluClion. 363 .\llOrh:n::u. tcsl for. 370 :lsseS~ll1cnl of. I I I
~ cx-Icnsion. 363 lightncss C\':tluation. 99. /01-102 con!>titutional. III

I neck flexion. 365

purpose. 30
lrigger points. 258
fbwthor!lc cffcct. 406-407
dCl'cription. III
cvalwlllvc IC~IS

iI
rcspir.llion. ahcrcd. 366 dclillcd.59 c!buwextension. 110
seapulohumeral rhYlhm. altered. 365 in pain diaric~. 63 fOOl dor~inc:\ion. JJ1
1m Ilk nexion. altered, 3(..1 HAZ. (Sn' Hypcr..llgc~jc WlIes) forward hCllding les!. III
lrunk lowering, 366 HCild I1cxi(ll1 thumb hyperlell~i()lI. J10
G;l.slrocllcllliulo ahcr...:d movement. 365 H ypcrlonu.\. 2{W
f1c:<ibilil)' ICqs. 82-83. ....ol inhillitcd muscle!' cvaluation. 102. IWi defincd. 113
~
in palient with ~hnr1encd slcrnoc!cidof1l;:-YJitl.

i,
jX1;lisoll1clric rdaX;lli(ll1. 284. 2!H vi.\u:ll impcclinll rllr. 1I(i
rcrern:d pain. 2S~ 137. lJi I-Iypcnruphy. cfecl(lr spina..: muscle.. , /0-. 3(iS
sclf·slrelching. 2M. 1.'\5 HC:ld poslure. J7IJ l-Iypllo~j:-. chronic 1};.IIl IfC;lllllcnt. 401-t(l~

I lightl1cs~ c\";dU:llilln. 10./

trigg.er point!>. 2H'-
Glenohumcral mOl ion. :<'c:lpulohumcr:,1
rhyllHll, 3foiU
Hcad:ldlc
ahnormal rcspirOllion and. :>7(1
manip\llalivc Illl:r..lPY. 2n-~23
rchabilil:llioll Jllilnagcll1l.'lIt. ~7U-37 I. 3i)-37b
Hypoc~lhe\i;l.
ddincd.23
symptom...
Hy~lJ,:rc\is
CUI:JJ1C\1\IS

~:t

1 Gluteal fasci;l. barrier pheuCllllenon. palp:lli(lll of.

'201. 201
types. 370
J'lcallh chills. chiropraclors ;md. rclmjoll'hlp.
dclinel.1. 1(1
illustration. using slrcs!J"tr.tln CU(l'~'_ J:;-

I
Ghneus ma.'(imu;;; 360-361 lIluscle injury du<: to. 1(1
funclion:ll :l/I:11omy. lIS Hernialiolls. disk lBQ. {St"(: 1II11c."s Bch"~'i(lt QUCSliollll;lir..··'
gcna'll Ch,Hilclcrislics, I' 8 dc.~cripli(lil. 171 IliopsoOl\

I poslisoll\ctric rcl;lx-ation, 2(1) iIIustr.II;OIl, 176 lh:xibilily tesls, Xl

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i....;\.
, .,. .=*-----:---------------------------
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~ ~ \.

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I~,'<.l~ llaillic testing, Illlllhar ~pill"'. -11.,-114 ~clf-~ln:tdlillg, 275, "27(,
]1ostisometrir rdaxatioll. "2(11-2(,3. :r,: 1~I,illl..'rtial. isometric and l'I'klnelic. n'nlp:tll· tightn",.\s cvaluation, %. V8. lO8. 109
263,372 SUIl. J50 triggcr poinls, 275
rderred pain. 173. IN. 261 l,,'ith.'rli:ll testillg LIDO lift. is,lkinClic testing, /,18
sclf-strctching. 263, ](,3. 373 \kfllld, 145 Lifestyk, p;tlicill. ljllestionnaires. 74
tightncss cvaluatioll. %. 9'1 m;l\III11ltll ;lr~'qllabk\\"I,:I\\ ;IP!'II';ldl. [.-IS l.il'ting
trigger points, 2(,2 h"kinc·iic· t,'"sting dctined, 14.1
trunk (uri up cvaillatitills, 102. /(/5 ,"I'lh·,'pl illln,duclil'l1. I·:" !l;lIId PO~ili(lllil\g, 144
Illness Bchavillr QUL:stilltlll;lire. ,kWI-il'tl\\I\. (,I) d,·tin,·d. 145 hl\\~·tillg ;lIld. cOlllp:lrisoll, 1,13

Illness hchavi('rs i','m,·tri,' ;lIld i~oilh.'nl;d. ,·'llllp;lri,ol1, 1511 fr"qUL:llcy linlit;ltions. 144
abnormal uno lirt. 1-18 "'lcGill's rules. 1(}7
deli ned, () lUllIh;11" spin~', ·11 ~ 1~'..:lll1i(llIeS, 16()-1(}7. 181-·-182
indications for, 6 r,'luhilityof. I-IS .. 112 vcnical displae"'lIlell1. 144
pain and, 17 1~1'11l,·tn..: ":('lltr;I":li(ltI~ Liftillg ':;lpacity
Wadddl's signs I'f, 7J d,'llll,',1. :'i0 factors th;lt affect, 14.'-14:'i, /-/5
normal. 18 tlallHllg SIl<:citicity.;=; I sll'l.'llgth tl.'Sls. 92-93
psychosocial indi(es hom":lrI": stn.:ngthL:llillg, ill llL:ulral positioll. 346 ~'\ll1lp<lri~on of. 150
Back Pain Classilication Scale. (15 J~\1l11,'tri~' testing typcs, l·~;=;
Illness Behavior Questiollllair"" (1<) (klill..:d.145 WEST-EPIC test. I_P}, 1-1V
nonorgank signs. 69 ,k,;,:,iptl(ln, 146 II.'sting oL 143
Sitkn",ss Impact Prohk, ()I) isokinL:lic and iSI,inl.'rlial, ..:omp;lris\lll. l,'if) Ligaments
rok in patient eV'llu'llion. 57 rdi;thiJityof. 14(1 imnl\lhilil.atiol\ dfects, /5
ImmobilizatiOll safct~ o!'. 146 stre.\slstrain curve, 10
biochemic,,1 changes. l.J S(lr..:nSllll t..:st, ·11·1 Li~tl.'llillg, a'S component of p;ltient care, 4(l5-Hl6
low back p"in <lll",viatioll. 345 Ja\'din throw. lumbar spinc injuries. 3;=;2 Load
musculoskcletal. effects of. f.J. 17 Job di~"l1isr;ll.'tion, questi(lfln;lires, 7-1 .:ITcd on Hlllsde fatiJ;ll<.·, 1(1, 17, 19
negativc effects. 13-15. 15 Joh~. DOT dassiti":;ltion~. 9.' Illlriwlltal displ,lcem~'nt, 143-144
Impingcmcnt syndromc Joint mubili/,atiol1. description. 209-211 Loading
description. 380 Joint receptors. stimulation of. effect on mtlsdes. amplitude, 22:-;
scapulohunwral rhythm, 380 19,21 dynamic. 22:-;
Industrial Case History, 160 Joinb frequency,22K
Inflammation afferent excitation studies, 22 intensity, 228
in joint, ncuronal cvents. 22 ~·eni..:;ll spine, rderreo pain. 7B-79, IY··80, m",chanical responses
mcdiating factol'S, 18 /75.376 properties of. 2~0-2~3
soft tissue healing. 13 dysfunction. 2 I-22 syndromcs
Infraspinatus myofasciJI trigger pIJints ;Illd, differential di, der:lI1gelllelll. 2-12. 246-250
postiso!lletric relaxation, 208. 2B2, 283 agllosis, 366 dysfunction. 2-12. 244-246
referred pain. 283 facel. 341 po.stural, 242, 243-244
trigger points, 283 fixed (Je:"ioll, contrihuting factors. 23 111<.l\"t.'lllelll planes. 22S-229
Inhibition, musclc, effect on musck fmigability. functions, 45 posture, 229
19.21 imlJ1obilil.ation cllects, J5 sour",,,,s. "229
Injured worker inflammation, neuronal events, 12 spin:l!' 227
risks for injury. 161 lumbar spine. rden"ed pain. /75 st<ltic, 228
total management guidelines, 162 IllU'Clcs and, functiona! illler;lctions. 30 symptoll1:ltic re.~p(ll1sl.'s
Injury recl..'ptors. (."'·(·i> Joinl receptors) p;lrametcr~ or. 2.'()·"·2~J
lumbar spine, (Set' Lumbar spine) sacroiliac syndromcs
mild to moderate, trcatmcnt stages. 37. 3.'N ;Idjustlllents pr, dfect on rellcx r",sp(lnse~. 4 7 d",rangelllenl. 2-12. 246-250
modemte to severe, trc;llment stage.~. 38. 384 mohilil.ation techniques. 210 dysfunction, 2-12. 244·-24(1
severe, tre,Hment stages, 3."14 Jumps postural, 2-12, 243-244
subacute phasc. 34 description, 323 Loading strategy. COlllr(lIlent.~, 229-230
Injury prcdictors, 161 illu>,tration.315-320 Locolliotor system, (S('(' also Molor system)
Inspection, visual sensory motor programs. 323 chain reactions in. 359
back view Kincsiophohia.295 ll)wer crossed syndrome . .'62-363, 363
lower extremity, 114 Kinetic chain, functional pathology, 3.W uppl.'r crossed syndrome, 364-3(,(1
spille. 113 Knee extensor.s, lllcchanism disord~·rs. 3S2-}X} dysfulletioll, 196
uppcr eXlremity, 113-114 Knee l1c,xioll fUIKtional restoratitll1
from view, II () flexibility, objcctive quantiti<lhk t,'SlS, S2. 82 nlllSClilar illlbalanc~'s. 362
purpose. 1IJ tightncss evalualion. <J9. lOr; path()kine.~ology. .'62
side view, 114, 114. 116 Knceling exercises patient cla_ssilic;lti,)l1, 361
vicw frOIll above. 116 description. 303 ."pinal stability. .'61-362
Imerva1 .s~·ale. of pain measurement illustration. 303-304 fUll~'ti()ns of, changes in, 196
description. 58 Kypho~is, lllobilil.atlon, 2 J3 fUlll!amcnt:ll unit'S
example. 58 Lactic acid. production. 49 anatomic cOmpOl1<::l11s, 45
Intervertehral disk. injury mechanisms, 343 (...It pUJl,dowll, improper form, !YO fUllctional c01l1pon~'llts, -15--4(}
Ironing, improper and proper posture, 180, 371 Layer syndromc. illustration. 2<) IlIl.'chanical cOllll',lnell\s, 45
Ischemia LevalOr scapulae motor control
caus('~. 21 posiisolllctl'ic n::laxation, 27-1, 27)-;'76 kedb;lck,47
c1"(el;t (Ill lIl11sde tunc, 19 www.bodywork.su
rcf<.:rfcd p<lilt. t7l, 275 fc'l.'df(lrwanl cOllln,l ..1(1----,17
 425
,1
J ,p,·.,tll,llllr ' ) ,Il'lll .. , • ";::,::,,,,1 rl'~nhllipn p..:rccnl:lgcs. 7 pole vaulling. 351
Illll,,'k ...· ••1111'•• 11 ...· 1\\- n:lttm II' .1'1,\c clllplllym.:nl p.:h·~nl:lgcs. 3. oJ lennis.353
... 'lIll;'...·lh>JII~I'\>. ",. "'1"'"1·,\'1:1":'1. '.'>C'I' I.lilllh:lr srm,:. ~IXlns ;l11d) water sports. 351
d~,flllh:ll"th. )~-~_; ... t;lhilllll1~·lrl' dala. R(llllb~r{s qUlllit:IlIS. weight lifting. 351
..·\...· l\·i".: ;111.1 ll';tlllin:: ,'r...· '.:rll1lilllh. )~ ,\.'1..;.17 static lest..
l~ll, ··;lll::k ...· tH,\'. ~ 1 'UIKlur;,l p.llhtlllll;il..' liHdll1l;.....~-1. 13 illu~amtion. 2-/0-24 I
1.,l, ··n'I".·Il~ . .·UT . . :. ~n~:'il lI<:;lhlll'nl f" .• I...• .13. ~(,_.~i types. 239
111,'1\11' lIlIll_ ..1'1 -5·' ;1!;:"fllhm.35 lhrust manipulatiolls. 213-215. 217
1l;llHlll:: 'l'l·l'i1i,·Il~. .;! ·';;2 ... lral,·~i,:, ..;3. ·11-1. -J /(, Llll1lbodorsal fascia
1'.lllh,k H'""l"I,,~~, .:1': trunk 'lr~'n;:;h':llil1~ llnt<!I~lIlb ..~..t&_.t·17 muscle control <If. erfe.:! 011 srillal Slress ill·
I'h~,"",I'l.;!I\· 1111;1111 ..., I.Hwo:r (." .......c:J ... ~·lld"Itlh.· juries. 3-12
1l1ll_(lIbl'. .IS Illll~(r:lli(ll1. ::'" Icars of. 345
tlf;:;lIIil', .IS IltlSlllr:.tl ,il=u,_ 3(13 Lunge coordin:uion lcst, (Sec Sland to kneel t..:st,
l..... r,·..:pllnllll\llpl. ':'~"":"I 1.\lw,,:rs·:-.1r':lllily Lunges
:-trul·Hlr;llllalh"I\,~~. !'}- -19X h'llly ...1;llic m~a'iUr"'IllCllts uf. 11-1 description. 323
1.\111~ loop n..'lk\.-17 sn"'nJ.:ltl.... ning of. 347 as funclion"l r.mgc lest, 296
L'lr.lt',i,' ptlsilion. f'}t, 1.11\\·.:rillg illustration. 314. 374
LlIW h;I\:1( p;\in.tSt"· ,Ill.. 1.lImh:lf "pilll:J ddill\·d. 1.1_~ sensory motor programs. 323
;l(!i,,' l·:\~n:+.c h,'I1..:lll_. '\ lifting :l1ld. i,·CHllpMisoll. 143 Slabiliz:ltion exercise. 305. 305
hinp,~dlO_'lh:ial ,ll'pr, ., .. h. \j frt:qut:n(:~ limitalions. l,j4 Mandibul:lr interference
,";tf.: '-':lllllanis..\.'-.~(,. ii," l.umhar disorder... surgical trcalllt~f1I. 5 cffcct on po~tural system. 335
,';1 .. ..: llI;lI\'I:':'::IIIClil LI1I11t'tar hypcrlordosis. 141 testing procedure, 335
pnl:;lul",,,. J·I··.16 LUlllll;lr lordo~j~. 106 Manipulative therapy. (Sa a/so Active care)
rql<lrl 01' lilHlin~,. _'('-,n Lumh:tr spine. (See II/SO L(lW b:Kk pain) barrier phenomenon. 198-199
\';1\,-,,-,, "f. 17U-171 alhlelcs and benefits of. 222
d:l",ilil·;lliIlIlS. 3.~(, ;It;mhk conditiollin~. 348-3.19 facet joint syndrome. 368
l·olb,n";lliv..: l';lr,. (,-: age· related f:1Cwrs. 3:;2 for low back pOlin. 7. 36-37. 165.359
(O"b ;t~_~o,:iall'd wllh. ,J b:ll:lllce reqcration. )49 McKenzie approach and. 225. 250-25 t
comp·,;u:-:llioll. Y. .: !x'd rest. )-l6 rccon:ry mtcs. 166
n:ducliol1:' ill. 15.1-155 common ~yndrol1lcs. 345 thrust 213-215, 217
di,\gno~is uf. 3:! coordination. 349 1\-'lanualll1cdicine. (See Chiropr.Jctics)
agl··rc1;}ll'd I'Klnr...~..t~ diagllosi~. 341 ~hnll:ll r~sist:lllCC techniques
hun..: scali. 3.11 injury mccho.nis1l\'" _~·C choice of. therapeulic goals. :!j8
disk hcrni:ui,lllS ;Illd. r;:J;,lillnship..' m;lOagcmcnt guidelines. 353 clinical :lppliCalions. 255-256
cxer,;i,;:s fnr. (Sn' E'<:rcl,csJ nonClpcrati\"c care. 3.15-346 f:lcilitation techniques. 256
f:u:lorlo lhal pn:di..:t. .W(, p:ltient hi~to~·. 344 goals of. 25,5
funclional diSl1rucrs. 6. l:i physic;]1 c.'taminalioll. J-W-3..t5 neuromuscular basis. 253
high risk p;llicnls. IMI predisposing faet()~. ~.I1 postf3Ciliiation stretch. 25.1
manipul:llin: Ih",r;tp~ re,uh~. 7 rehahilitation programs, 348 procedural sleps, 257
mi=,uiagnnsis hiulIll'Ch:mi.:... J4J-3-4 postisomclrie relaxation, (SCt' PostisOmclric re-
prc\":Jknc..:. 3. -I 11isk pres'ur.:. /76. laxalion)
Mruclur.11 di:I~lliNs. ]-1 dynamic tc'l<. proprioceptivc neuromu;..;ular facilit;ltioll.
symplom r":cllfr,,,ncc. 3 illustration. 2-/0 253-154.254
mislIlanagemcnt IYllCs. 2':'(1 purposc.253
o\·crus..: Ill' surgery. =- injury mechanisms. :U.' w;:tys to maximize. 257
prol(lng..:d h",d r.:'1. .1-5 is\lkinc1ic lcsting... I ~ M:Jsticatioll. muscles of
p"ychogcnil' ,li;ll;f1O'l" 5-6 joims. referred pain. 175 dY!ifunClion. 197
lIlusck "lr.:nglh ;llItl. rd::tiollship. 15 IH;t(lin~ or. \lcKcllzie ;Ipproach. 237. 237-2JS postisomctric rcla,,:Hioll. 20t
nonspccilil: IIltlhilizaliclIl proCl.:duro:s MAW. (S('c r-.bximum aeccptahk weight)
C,I~C rnall:tg":llIelll. 3"(1 poslisolTlctric rclax:lthlll. 285-286. 286 M:udmlllll acccptOlblc wcip.IH. iSllincrti:L1 test·
sources of. 36 self· stretching. 2S6. 1.... 7 ing.148
prc\"akncc (11'. 1:'3 1H11\(11l<.:r,lli\c Ire;lltltcnl plan... 3SCJ McGill P:lin Questionnaire
prevcnlive 11IC:lsur..:, radiugraphic imaging Il·.:hniqut:. 219 description. 61
b:lck sch~xll. ISn' Bad.: wh('(I!) r:lI1ge of mr,IIIOJl tests. 76. 77 p:lin diagram SC(lre~ and. c~'rrL'lali()l1 be-
cla,\i(" j,OdY.SlliL ,\lJ:-; cxl':lhion. 137 tween. 61
litll":SS cCIII..:r. ·If!X lkxion.2)7 reliabilily.61-62
psycho..ocial pn.:dilcctmn. IJ side-gliding Iclt 238 validity. (l2
qualilY ("an: appwac!H:' side·gliding ri!;hl. 238 !,lo'leKcIl7.ie :IJlproach
primary ctlllscr\';lli\l: c;m~. b-7 rhythmic U(lclion eriteri... 225-227
rril1l:l~' prL·v",nliun. (, pril/le. 216. 2/7 t1clin",d. 225
SdU:lllalic. 6 slIpim:.1I7 . manipulalil'c Ihcr(lr~' and. 22;'
second:lry fUIH-'linnal rcslllr:llillll. 7-1-: sp{)n~ <lml rncclwnic,tl and symptolll:\li,' rc~r(J:1SCS. In
Quebec Til..k Furo.:c. 3(j1 11:llIel. 350-351 loadillc.
",ilh radicular symptoms. L'arc .,I;H)(l:mh. 3-l-35 b;lsen:Jll. 353 c":r\~c:Ll spine studies. .23(>-.237. 236-137
\. rc:con:~'. faclOr:- lil;11 illay pn:dil·t. 3·1 fool hall. 352-353 dyn:lmic 1ests. 237-2:W
recurrence risk f:u;lun. 15 goll'er,,35>353 lumbar spine slucJies. 23"7. ::37-238
( rcdUl;lioll IIlctllll(b. ,lrl;ss/\lr;lin rs·l!ucliclll. gYlIllla.. tic... 350 pallent history. 2J5-2~6
16-li
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II \kKl'lll.it.' :ll'prl\:1..:h-nmlillunJ
SI;,tic Il'St.., ~37-2.'R
,~ndf(lrnc r:tllCm."
conservative 1r'::'Illl1cnt ;md. comp'lf\!>C'tn.
.ll-:l2
fU11llalll':lllah. ~55-35~
wasling.21
we"kne.s...
anhrogcnic. ~9 \
dinic:!l rca,oninl: ;lnd 11lililY. ~·ll :-'hllelllclIl correclion, kvcls (If. 47 disturl'lcd statks, 116-117
1 tkrangcmClll. 2-12. ~46~2:,n :-'\ll\·O:llICllIll:lltCnI." stretch. 28-29
,\ dysfunclkm. 7·r:. ~.I.t-2j(> .11t...r..:d tightness. 2R
Il\l...lmal. 2.J~. 2..1:\-244 .m",
l'hrmli" pain ~5-2(1 trigg..:r roint. 29
,ul\lIliary. ~J2 efkt.:t of chroni l' pain. 25-26 Musel..: dysfunction
P;llhtl;lIl;I!U"'~ :U1.1. 226' Il\u~ular imh;lbIK'e :llld, j I types. 255. 255
:1 ~"lcrinri aPJ'n'~lc·h. 22(, Ir..:allllCIIl for. :II \'isu.lI inspecliun
n:hahililalioll :lIld, 2:;1··]."2 l'nmpk:c lIS h:1Ck vicw. 11J-114 ,
~·1r.:Kclll.i.: RI..'IX·'. _'~') di~tu'l'lcd e;l~': study. 1.J0--141 I "
Measurement ,\':.k,. Ill' pain :lssCSSlllent of Muscle energy procedures. 253
hi:L"; sour........ ;q
dc.;niptiull. ;'0:--
mJnllal. 117. 1/7
shonencd musdcs. 117-118
Muscle Energy Technique. 212
Muscle libers
\~;
type.". 5S. 58 wcakened muscle.~, 117-1\8 fast·twilch, 27
\kch:lI1ic:llly il1l!,\:dcd cild r:lIlgc due ttl l1lusde dysfunction slow· twitch. 27
tlclllH:d. 2~2. 2.~-l biceps fClIIori:>.. 122. 1'22 stiffness of. 254
Ilh,lrUCh:d. 235-
rC';lrh.'IL'd.2.·.1-2.'.1
gltllcus lIla:-;imus. 120
.~tcmockidoll1astoid. 137. 137
Muscle iml'lalancc
:Jlten:d movement patterns and. 31 ,.
""'10,

suhjecli\"c ~rccplilln. 233 dieet on skills. 358-359 analysis of. in standing position
1\'kchaunfcct:pwr :Jffcrcnts. pain Cfl.':tlioll, 24-25 Movcmcnt rl:'llles. loading :md. 228-22') from behind of patient, 106. 108-109
\ktlicinc b:.tll, (St'(, Gylllll'I.'lic hall J ~1o\'cnlents from front of patient. 110-111
MEl', (SC(' lvhl."ck energy proccdurcq control. reeducation, ) I dinic:!! features. ~6-30. 362
MEr. (Sl'(' MIN:!.: Encrg.)" 'I\:chniqtlc) involulll:lry. cerebellar error conlrO!. 26 compcnsalOry actions. 116
Mctaholk c:lpaciIY. cllcl:1 on lifting c:l.p'H:ity. I.tJ \'oluntary. cerebellar pathway.... 26. 46 consequences of. 29
MClaC;Jrpophal:lOg<.'~1jllint. manipulali\'e (her· :-'IP. (See Myofaseial pain) defined. 97
allY. 115 MPQ. (5('(' McGill Pain Quesliollllairc) cx;mlplc of. 30-31
Mkr()f:lilur..:. ()\:'lJm:I1I.:C~, 15-16. 16 MRT. (Sa Manual resistance techniques) inhibiled muscles. 97
:"lilit'll")' PO~IUfo:. i/7 ~1uhindi.lumhar. postisometrk rcla:l;mion. ~71. c\'alumion nl.:thods
Minilrampolin..: 1i2-273. .213 head flexion. 102. 106
de~riplion. J2(1. 32~ :-'lusclc. (Sa aha specific mllsclt"sJ hip exten!':;on, 101. W5
fuur point kneeling. J2N contr.lction... push up. 102. 105
illu!'tr.uion. .121 accelerations in. 320 shoulder abduction. 102. /07 \J
walking on. 32i energy sources. .J9. 50 trunk curl up. 102. 105
r-.'lilll1e.~ola Mullipha~ic Personality Index functional conditions for. 50 seientiflc evidence for. 362
chronic pilin predictions. 398-399 joint protection, 319-320 tight muscles cvaluation
pain dia!;r;um .:md. corrcl:nioll hctwecn. 61 function . .:5-4(1 erector spin:lc. 100. I()J
!'calc.~. 399 ease study .:mulysis. 140-141 g<lstrocncmius. 104-
l'\'linnesola Multiphasic Personality In\'cmury. :L" imbal;mcc. (Set' Muscle imbalance) h<lmslrings.99. 101
dis."Ihility pre<liclOr. 9 illllllobili7.:llion erfects. t5 hip ne,~ors. 98-99. 99-/00
MMPI. (See Minnc~ola MlIllipha~ic Personality inhihition. 19.21 iliopsoas. 98. 99
Inde:-;; Minnesola \'luhiph;l.~ic Per.~ol1.aljly joinls .md. functional interactions. 30 levator SC;lpu!:le. 98. 9R, 108, 10<)
II1\'cl1to1)') Ienglh pcctor.J1is major. 98. Wi. 110
Mohili;r':l!ioll effect on muscle ~pindle impulse fre· pirifonnis. 100. tOJ "
joinl. 209-211 quency. 19 quadt:ltu!': lumborum. 100. 103 ..$
cer\'ic.t!. 212 hip alxluction. altered. and. 363 r..:ctus femoris. 98. tOO
C()l1lITlamk 210-111 hip e:-;lension. altered. :mtl. :\63 ~(lleus. I()..J
sacroiliac, 210-211 neck flexion, altered. 365 sternocleidomastoid. 98. 99. liD
kyphosis, 213 rcspir:ltion. altered. 366 tensor fasci:lc btue. 98. 100. 110
ncuromuscul:ll" techniques. 210-.211 scapulohulllcral rhythm. altered. 365 thigh adduClors. 98-99. 100
side·bending, .2 1l. 2II leSlS of. 30 triceps surae. lOt. I().I
Modified 1l10111a~ Ie'\!. SU. 93 trunk flexion. altered. )(,.1 upper lr.tpczius. 98. 9."1. 109-110
~'1ood dislUrbanccs, chronic pain and. 39.J low back. (Sec EreelOr spinae) Muscle qualities. of locolliutor perfnflll:lm·e. .ts
Mowr cnlllrol motor units Muscle spindle
defined. 24 ddincII. 49 effect of rnusl'k streich on. 50
feedback mcchanism ..17 tYllCS :Iud characteristics. .19 impulse freqth,'nt:y. muscle length in:!\!·
fecdforward mech:mism, ';(1----17 pain cycle. 18-19 ences. 19
nCllromuscular ~truclllr.:s :md pathways. 0/6 pha.... ic. 26 Musdc tcnsion. 19
symptoms. 24 poslUrnl. 26 c1assificalions.155
Motor learning, concepts of, 319-320 ~honenecl. disturbed slatics. 116. II R mechanisms ilwtllved ill, 20
ro.-lotnr pallcrn.~ ..(SI.'I.' MO\,":l1lcnt p:rttcrns) strength, effeCl on low back pain recurrence, 15 treatment fer. ~55
MOhlr syslem. <Sl'e oho Lt}ColTlOl0r sy."tel1l) ~lressJstr:.lin curves. 16 MuS'.:le lone
cVlllponcnlS of. 25 tighlncss organ of. 19
dcclmdilioning ~ynttwlne. 13-15 spa..~llI'lIld. differential di;l~l1usis. 97 rol<ltors test. 33J. 334-335
rehabilitatiun lrealment of. 97 r-.'1uscultY.'kclet:l1 function
aClive :10(1 passi\'e t:ar..:. 32-34 trigger points, 28 cfl\:l.:\ UIJ liftill~. 145
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~ 111,~·uh"i.,,,·kl;d hllH:lillll-., ";luWI'II (k'uIOll1ulor input. to fine poslUral syslem Pain diary
.." :lIII,llh>n I,'.b. 7·1 7~ ';tw of scmicircul.H can:lls. :\:"0. 333 illustmtion.64
I..l'~ .1'I'o:,:h, 75 prism Iherapy. 332-3:n. ,U3 purpose. 63
:\l\I"III,,,\..c·kl:ll paill s~·lldr,'m~,. lllll'lllllptil':lt<:d 01:1', (Sc'/' Opcrati0l1011 Lift T;l.~k) Pain Disit!>ilit)' Index. description. 65
,,,l'lli".'ll'" ll\:IIl:lgl'lIl\:1I1 ;,:ul,ldin....... 36 On..: leg ."landill!= lest I':lin queslionnaires
:\111',"ul'h\..d.:t:,1 slrlll:llIr...... \'\k'nlal {klll:llld ;IIHI dcscril'ti(ln,S" bias sources. 59
11l1l,·II"11.l1';tp:Kily. rd:llllllbhl!,. Iii Illuslratinl\.86 description. 5S
:\ 111,,11\, '1.1>:11\. PO\ti"'IlWlt'h.' r"i.: x;llion, ].oS Operational Lifl Task. isoinertialll,,,ting. 141) for localizing pain. 60-(11
:\l~.'l;l"r.,l p:UIl "'yndrtlllw. 1;,':,1I1II.'nl. ]9:". :;66 Ordinal scale. M pain lllC;ISUTClIlellt lllcasllrcmelll SC:lIeS. 5&
:\'~'\';Kll" f,'lk\ ..17 ~kscriJllioll. $80 for pOlill inlcnsity, 61. 62-63
NI >1. 1.\,-," :'\,.... 1.. !>i..;,hility Illdn I cxalllplc.58 for pain qualilY. 61-63 .
N,'d. Dr",l-lIlly Illd....\ Organic qllalilic~, of lot"()lllotor p.:rforl1l'lllcc. 48 reliability. 59
,'r..'all<'l1 uf.lIt") Onhoplks. dfect on lillc poslur:ll SySt..:lU. 337 lypes.58
d..·\"fll'Il"ll. (IS On!Jo."t;llic pl,)~\ure validit)'.59-60
illu"lr.llnlll. tiS ;lsYll1mo:tries oj Pain r<:ferr:ll, (Sel' Referred pain)
;\,..'cJ.. 1l,",iOIl. (Sa olso Ccni,";d (k.\i.1I11 p:l1lwlogic, 3.11-:\32 P,llp,l\ion
:lltef..'1! ,"ourdin:lli(lll. 377 phy.siolo~k. HI description. 198
:1111:1','" llI(l\"l:lIICllls, 305 line poslur.ll system. 329-330 iliustf:l\ion, 198-199
.. lrt:llglhl·ll;ll~ c.'\CrL';scs. 3.'\' fineness of. 330 lriggcr points. 205
l..''-h. ~i. lJ(). 9:! O.,t":(Jjlmhic myof'lsd.l! rdc:lsc ltlCtlllxl, 256 Pa.ssive care. (Sl!l' alJtJ Conscrv:ltivc car..:)
N..:d.. lIIu_..:k:-:. (Sn'ol.WI Cl::ni"::llll1ll.~dt::-::Sl\.'r· o.sw~stry Low Back I'ain Inc!;::x J.clive care and, comparhon. 3S4
n"..:kid'llIl;t:-:lOilil descriplion.65 deconditioning syndrome and. 13
do:..:p ill\lSlr.tlion,66 role in rehabilitation. 32-34. 33. 251
pr\lprio.:qllnrs ill..\20 Oulcome assessmcnt Pa.<;sive prepositioning. deflr:d. ~l))
li!=hlnl::." c\"alualitlll, 9S. lJ<I d":\'c!opment of. n Palhokinesiology. in kinetic chain. 358
p\ISIUral dl":(I:-:, IiI) f:lctors lhal 'lfrecl. 1(.1-162 POIlhologic asymmetry
n:.~i~lanc..: ..:x.:n:iso:s, .17 I}-.1Xf) functional change docuOlcntillion. 37 Fukudtl-Urllcrbergcr Stepping Test. 331
Ned: rdkxo:s. mO:;lsuro:mcllt (lL 3.11-.1~~. 332 Ovcrhead re:lchint;. IS2. 371 neck rellel( measuremenlS. 331-332
Nc!=ali\'~ work. tr:lining wilh. r1~k (If injury, 51 Overpressure POItient
N..:uromuscular len:-:i('11 defined,228 chronic pain
..:ausr.: tlf. 21' usc in dynamic and slatic t..:sting, 239-240, 241 education, 39
cxampk.. ol'..?S Overrc:lctlon. a~ ahnumlal illness bchal:ior ways 10 confront, 38-39
N..:uro!lluscul'H Will.', n(l(.'iccp\l\c slil11ubtioll. 18 sign. 73 dis."1bilily prone, profile. 36
NClIron~ 1';110 environment and. 405--406, 406
motor. r,,;cipf()c<ll inhibition uf. 2i acute. chronic pain and. transitional steps be- pain behavior asscssmcnt tools
wide d~nJmic ranfc. Ih:Uro~lhic pain ;md. 25 twcen. IS Oswcstry Low Back Pain Indc)\.. 65. 66
Ncurop;l\hic pJill :tvoidance n'rSU.f confrontation of. 38 Pain Disability Index. 65
C:luse" of. n tJarricr phenomenon. 199 Rohll1d Moms Scale. 65, 67
ddincd, 22-2:3 chronic. (5('(' Chronic pilin) Systcmic Beha\'iof:ll Observ:ltIOl1. 64-65

iI lleurochemislry uf. 2-l-2:,

p;ltho.lnJIOll1lc chal1l;c~. 25
simil:lriti(.'s tI.l olh..:r condition'-. 13-24
cortic:lli7.alion of. 25-26
Ildincd.57
c.\aggcrated perceptions of. .J8
pain questionnaires
bia... sources, 59
description, 58
Neurophysiologic rt:actiofls. li'-~ue Slrcss. pOlin intcnsity SC'lleS, 61. 62...(;3 for IOCillizing pain. 60-61
I cycle, Ii-IS
No:uropla~li<.'it)'. rcf..:rred pain ::nd. 2..1
l(lCallOIl of. measurcment modalilies for. 60, 6/
Inw tJ:lck. (Sr'l' Low txu:k pain)
measurement St"'I!cS. 58
for pJ.in iutensit)·. 61. 62-63

I No:ulral po"ilion isometric slrengthr.:nill,!; ..'..1(,

Nocir.:cpwrs
museu!:lr rcactions to, 21
rnyofasci'll. 195
for pain quality. 61-63
reliability. 59
., ,i irrit'llion of. crfccl Ull muscle tonc. 20 psychogl::nic diagnosis :llld. 5-6 t}'p<:s. 58
I)aill gencr;ltion. :\0
,.J i N(lll1inal data, in paill measur":Hlenl st.'aks. 5S
Nnllopr.:r:ltivc can.::
queslionnaires. (Sec Pain questionnaires)
referred, (S('C Referred pain)
relief posilion. 196
\·:llidily.59-60
Palient education
(uncliOll31 r..:slorollion, 167, J5S
for low bJ.ek pain. 3..15-J.t6. 35" Slrolin and, rcJiltionship t'!Clwecn. 196 lining tcchtliquc.~. 166-167
neurologic delicil incrc;t'es. 3":6 word origin. 18 mOlivalion increases. 167-1(,3
NOllorganic sigll~, of abnormal illne~s bL'ha\', P:dn behavior. assessment 100is rehabilitation. 165
ior.69 Bur~ verb:11 rating pain scalc. 61. 63 rcinjur)' avoidance. 37
Nono... idat;vc llICt;tbolislll. (If mu,cle ..:,ll1tr:H;· OswcSlry Low Back Pain Index. 65. 66 subjects for. 165
lions. ,11) Rol;md Morris Sc:.tk 65, 67 .....orkst<llion ergonomics. 167
N\lll~pr.:dfic back p:lin Systemic Behavioral Obscrvation. 64~65 P'lliell( history
t";J~e management. J6(} P:lin cyclc effect 01\ tre:llment plan. 34~
p,tlknt cla'silic:l1icllls, J(II clements in~'oJved in. 21 forlllat. 397-398
sources of. 36 cXislclIccof,17-IS for low hack pain cvalu:ltion. ;\-14. J57
N(Jrmal i1lJles.~ bcli;lvior. th~uc protecticII1, 11' illuslriltion. JR. 40J pain drawing. 399
NUS. (S('t' Numerical Rating Sc;tle) P.lin di;lgram Palicnt-doclor rdalionship
Nucleus pulposlls. 171 desaiption.60 obtaining patient confllJclIce..107
description. 3~ I illusIT:ltion, 61 patiellt sclf·rc~peci. 407-40S
Numcric:L1 Rating Scale. p,lin intensity I\l~'asure­ outcome .\.s,scssmellt. f,O principles of. 405-406
lIlenl.61 reliahilil)'.60-(11 spirihl:llily issues. 409-410
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 ......... ,........ '1""\, ''-'I't '-'. "1l.. ~r 11'\11:;. ,.., l""M.I·H.... 1IIIUl'lt:n;:, MJ-\I'lUJ-I.L

PI)!. IS,',- !'ain Di:,,,l;Iilily Ind~..'(,)

1\'d,'r:\li" 11l0ljor
f;lCililalilln lechnique:-. lower l\Carulac lix;lIors.
287 . US. 380
Postural Ionic aSYnlnletry
identifying. 331-332
I
1",~ti~{lIllClric rcla:":llioll. 2i'J-2SU. :;.... 1 gr:wil)' and. 205-207. lOS p;l!hnlogic.331
physiologic. HI
rl"i.:rrl.'d pain. 279
111=hIU:=S.<; evalu;l\iIIH, q:-:. IfS. 1111
hip illlcrnal rolalors. 267. 2ftS
il\lli~;'lil\tls for. 257 PoslUra1 trnining p!;)tfonn. for POSlUr.\1 rehahilita-
\
tri~fL'r POiIlL\. 27 1) j(lilll lIlohili/,;lliol1 fl~X'~'durl's linll. 33S. J.N"
I'C"II'r.lli" minor. p\lsli~"I11"'lri~' tc!as.;lli,'n, hip. 2S4-2S5. 286, 372 PO~ll1r~
lumh;,r spine CXIl,'ll.sinn. 28.'i-2H(,. 286

I
2~1)·,:;;; I. 282 drivinc:.lii-I7R
Pdt ;~, ":ll)\sed 'ymh.1lI1,·\. lIlIl''':!..: illlh;I!· rih. 2:-6-21\7, 2SS rurward·dr.lwll. 203. 203. 223. .MS
;1I1('~'. 106 I1It1!'d..:s Ih':;lJ. .lXI

I
rd\'k \.hliquilY ;ttlduC'IIlTS. 2~9-:!61. 1M head rorw;Hd. 376
i!lu'lfalion. :!lo ccrvh;al. 206, 271-27:! impropcr cxerci~c ronn .md. 361
ph~~iolo~i\." real·tim". ~IS lIi,gasuic:us. 20.Ii lumhar disk prc;"sure and. 176. 176-177
1','I\'k!!!t It.·:-I cn:clor spinile. 268. 270. 270-271. .f73 lumhopclviC', 110
~ Ik,,·npti(ll1. Xfl, 81) gasIT("I(,:ncmius. 28..\, 28..1 military correction, 177
!
illll~lr:lti(ll1c :fJ.'';,",WI. 382 gluteus maxirnus, 265 neck,381
P,·lvi;,. i"lm,'lri,' 111allll:tl1r:K'lion, 2{)fJ h;llllsiring. 258-259. 259, 373 neck muscle activity and. 177
!\'r~"'l':i\llllllltl1r qU:llilie'. (If IIX'1)1I1\I10r rl<,:rfnr· iliI1p.was. 261-26~, 262-263. 372 onhoslatie
m;ll1'·~· . .lX---4\) infr:lspinalU$. lOS, 2.'\2. 283 ;(synllilctric~ of. :\31-332
l'... rf'.rll1;lllc...·\."onlilluulIl Ic\"alor S4.-apulae. 2N. 275-276 fine poslUral systcm. 329-:\30
ilhl'lr:l!ioll. 53 !l1asticatory.207 fin~ncss of. :\30
\\ IIldlll\" of Ilplimal a("!i\·iIY in. 52 multifidi. lumbar. 271. 272 roor. signs of. 177
I'cri,"h:allisslIc. h;lrrier phCIlUIllCIl(lll. p:llp;ltiun mylohyoideus. ZOS rehabilitation or.
postur.JI tr.lining platform.
I'f. 21.11-202 pectoralis Illajor. :!79-2S0. 281 HR. 3.~8:
!·... riph.:r:ll cOlltrllJ. (Sa Fecdh:n;k mechanism) pectoralis minor. 280-281, 2S2 sitting
I'cripher:tl nerve emr:l]llllen:. J-'l1 piriformis, 208. 264-265.265-266 erect, 167
Peripheral nerve injltfY, lYpes: 342 quadr:ltu.~ IUlllhorul1l, 207, 210, 267-268. imJ1H1pcr. 167, 179
Pcriphcrali/.ation respon;;e. 250 268-269 prolonged. low h.'lck pain and. 341
l'er;,cll1aliIY. ;ISre\'I~ (If. JOti qU:ldric~ps. 265.167 proper. 17R-179. 378
PFS, '.'ire Po\lf:l\."ilitaticltl ~uelChl rcclu~ f~nloris, 262, 263.372 slumped. 177, 177
Ph:lftl1;ICOlhcr.tpy. dlf(,nk p:lin IrC:llmenl . .:IO::! r~srirator)' synkinesis and. 205, 206 Posture disonkrs. psychologic aspc:ets. 33S
Pha,lC l1lu,t.:k~ :-c.l1cncs. 207. 218-279. 179 floslurolo,gists. hisl0l)' of. 319
e,\:l1nples of. 16 scmispin.:llis C.:lpilUS. 272. 272 POSIUl"\",:!;;:;;::
lil""r type. 27 scmispinalis ccrv;cu~, left, 272. 273 basis of
Phy,ical ac:ivily redUClion. ISc,'c' Immohilization) solcus. 284, 286 ccntrnl integral ion. 329-330
Phy,ical c.~all1il1alh1n splenius capilus, left, 272, 273 fine poslural system. 321)
~'rih:ria filL 3·1.1 stcmoclcidolll;lstoiJ, 276-278, 277-278,378 limits of. 331
for low had pain.. 357. .197 suboccipitalis. 276-277. 379 Power. ddined. 48
PILE. I.)e~· I'rol=r.:ssi\·c Isoinertial Lifling sub~aflul3ris.2m~. 282. 283-28" Praycr stretch. nO
E\":llualinn) supraspinalus.281-28) Pr~po.~itioning
Pillow. pl'lI.:CJIlelll durinr !ilccp. , .... , tensor rasciae 1.1Iac. 263-264. 16-1-265 active. 295
IlJR. {S~·t· PostisolllClric relaxationl thoracic erector ~pin3e. 2;)6 pas!\ive. 295
Pirifunni.. uppcrtr.tpcl,ius, lOR, 210. 273. 27:\-275 Pr~ssurc .,Igameter. soflli!i~llt: lendemess '1uan·
flJllclinn;]1 an;\!\lJllY. 124 .....risl extensof":', 204 lilic:ltiol1.74
gcnt:ral cham,'lerislics, 12.:1 origins of. 203 Primary prevention. strall'gks, fr,lr low had
PI)qi\{Ullelrk rclas.alion, 208. 264-265, procedural sleps, 257 pain. 6
265-26fJ release IIlcch:mislll. 20J Prism tesls. I'm oculoll\OInr I\l\l.~des. 332-.1.1.".
referred p;,in. 174. 2(>4 lechniquc description. 2n..l 333. J:\5-;\36
,horlened l'ostisomctric traClion. cervical spinc. 206 Progressi\'e hoincnial Liflln~ Exaluali(lll
body cnlllilur ~h:lIlf:c!-. 125. /27 Postur.tl :malysis Cylx:\ Uflask :md. I<lS
lli~IUrhc(1 hlll.1y stalics. 125. 126 hip movcments. altered (lc.~cription. 149

dfcel on hip Ucxion mo\'cment pancrns. abduction. 363. 363-36-1 Proprioccption. ddined. :lIt)
127. 12:3 extcnsion, 363 Proprio,:cpti~·c lleur<Jmu:,cular fa("ilita·
ligh:ness c\"alu:\linn. 100, 103 il1ustmlioll. 29 tion.25.1
trigger rnilll~. 26:; neck lle:doll. 365 exercises \(I illt.:rcasc. .1~~
Planl",r inpul purpose. 29 inhihililry lcchnique.... 2:'·1. ~5.J
!C.) line (1(lslllr:11 syslem. 333 respiration. altercd. 366 Propritx'epwrs, 47, 329
11l:lllipubliull of. :05 st::lpulohumeral rhyUun. altered. 365 Pro\'('C::lli\"c tc'liog. 92
1'i'F. lSi'(' I'f(lpril\(cpli\"c ncurOlllu,~cul:tr facil· lrunk l1exion. altered. 36-1 Pro:c:il11al crtl!-"cd \ymlrtllll..... dl:tr.lC'leri.<;·
il,llion) Po.<,turnl exercises. rounded shoulder:-:. 18f) lie!;. 97
Pole v;mltin~. lumhar spine injuric!:. 351 IlOS\llr.11 muscles I·!:oas. {SC'l' Iliop,oa<;.l
P,)\ICOlllr-:lClioll inhibitioll. principles. 253 examples of. 26 Psychol,:ellic di:lgllu,is. lllW ll;ld pain.. 5-6
I'o\tf;lcilitati(\l\ str.:lch, 254 liber t)·PC. 27 P... )'chos~>cial f'''lOr<;
procedural steps. 257 lr,lining r~qllireme111s. '18 chronic p;rin
f'(I~li<;ot1lelric r... I:l,'\(01lion, 201 Postural syndrome. mechanical ilnd .~Ylllptnrnalic alcxilhyllli'J. 393
('crvical spille . .Ii!) respon:'>Cs, 10 loading. 242. 243-244 nllllp.... lIsalion, 392
eye II\Cl\'~llll.'n1S lUld. 2n4-205 Poslurnl syslcm. line. (S('(' Fine (1(lstural syslem) Ctlmpli:mcc. 3t)2:
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....
,
 INDEX 429

I',~..:h""\l\:ial faCltII'S-I"I1III;ml,"/} R:llio ~ale, of (l<,in mC;)"t:urcmcnt Regional disturballccs. as ahnormal illm:ss behav-
lkpr..:."sinn ..")2 desCription, 58 ior sign. 7J
~ain. 39.' ex:nnplc.5B Rehabilitation. {St'" (d,w Atti\'e carel
liligalillll, 392 Receptive fields. referred p:lin and. 24 accelcr'\lion-dccclcration syndrome. 3'78-379
Illllliv:ltiol\. :\I)~ RI,'Ciprocal inhibition. principles. 2;i:\ hiomechanic:tl (actors, 15-17
r':ClIgn iii Ilil. ,N:I- :"\1)': Rl'condilioning dcconditioning. syndromc. 13
"f tli ...;lhilily limn... Il;'licnl, 36 ftlllctiOllal stabili7d,tion. 29:\ dl'fincd.195
1l1~'lh{l\I" tl\ jlklllil'y. X-9, IS lrcatment stralcgies. 169 funt'lion:\l lesting. 355
1I\I~"<'li\llln;tin:s. iJ Recovery period fUllctions. ~S6
1'1I11·d\'\\I~> illlpnllX'f
lilflll. /WJ eomplicaling (:I\;um;. 356. H()-j57 lunge teSI. 196
I'ulljn~. Ill\..:alc
mcthlllis. '84 factQ~ 111>11 prcdict, 166 PllllXlSC.356
I I'lhh lip. illhihih:tllllusd:, l:\';llualilll1, timdillcs for. ul1colllplic:lIcd injur· types. 297
1O~. 105 ies. 38 goals or. 355. 358, J 1-1-.t 15
Pu,hc, Rectus ahdominus hcadache. 370-371. 3'75-':;76
\ illllslrali('11.325 gencr:ll charnclcristics. 131 imlllobili7.ation

,i J
pmprlocc[llivc intrc:Lscs, 323
I'u\hing. uns;,fe methods, n;-/
wC:lkcl1cU
hody contour changes. 13:\. IJJ
biochemical changes_ loJ
musculoskelelal. eO'cels of. 14. /7
PY~lIIJIi(ll\ cO"eel. de-fincLl. 59 disturbed body Slatics. 131. 1.12 ncgativccffccts.I3-15.15
QL {Sl'(' QU;ldr:lllls lumborullll dislurbed movcmcnt patterns. 133 mOlor system
()u;ulralll., IUllllxlrulll ReclUS femoris 3ctivc and pat:sivc Can!. J·2-34. 33
fum:liull. Ill:! nc.'(ihility Ics!, 80--&1. 81 ,onsc['\':lli,'c treatment and. cOlllparison.
fUlKlinnal ;mal\lIllY. 128 POSCiSOlllCtriC rcl:lll:alion. 262. 263. 3n :;'1-31
l;.:n.:ral l;hanlch:ri.stics. 128 lightness evalualion. 98,100. 110 fundall1cnloils, 355-358
postisolllctric rcl:lxmioll. 207. 2/0. 267-2NI. Red l1ags patient selectiou. 355
2Mi-16f) dcfined.355.393-394 primary goals. 32, 33. 39
rdcrr.:d pain. /73.2(17 diSlllrbances of mood. :\94 nonspccilie back pain. 360
sdf,wclching. 268. 2M cxamin:ltion of mood. 394 ou"omcs measures. attributcs of. 58
sh(lth:n..:d in history. 394 passi,'c physical thcrapy :l.nd. 3S5
body comour ch:mg..:s, 128, 130 p!'iycho!'iocial i~t:ucs. 394 patient cduc.:lIion. 165
disturbcd body stalics, 128, 1'29 typc.t:. .156 pfll,(:ralll creation. 367
effecl OJI rmwcmcnl paHcrns Reference lines. body slatic assessment scialica. 360
, )
hip extel\:-ioll. 12~, 130 b:lck view. 113-11-1. 114 Rdlatoilit:llion c)(crciscs. mu~,.'ular quality dch:r-
lrunk !lcxion cXlensiun, 13L 131 fronl vicw. i i 3. i i 6 minaliQlls. -lS
ti!=II1IlCSS c\'alO:ltiull. UK), 103 siue vicw. 114. IN. 116 Rcimt>un;cmcnt, ways IQ cn~uro:::. 37-38
trigger rx)ims. 265 vicw from abm·c. 115. 1I 6 Reinjury. ways to avoid. _~6
\
Quadriceps Refcrred pain Rcl:tth'c n:st. defined. 37
-1 postisornclric rcl:IX>ltion, 265, 26i defined. 24 Rcl3.'I::uion therapy. chrl,'lni.: rain treatment,
sdf.stre1ching. 265. 167 early discussions of. 22-23 401~O:!

.sl:lbilizalioJl exerciscs, 300-301. 301 crector spinac. 367. 36'7-368 Rclia!:lility

str..:ngthening exercises. )47 facct syndromes. 367, )67-36.." intl'r-c:<.:aOlincr.5Q
) QUOldrupcd tr:lck exerciscs ncuropi:lslicil)' ano. 2-1 paill :md disability qlll'~ti"llnaircs, 59
descrip1ion. 302-303 quantific:llion of. 74 pain inlensity sCll1cs. t> I
jllu.~lralion. 302, 381 sourccs 1l.'i't·r~·lcsl, 59

Qud)Cc Task Force :lod.ucton;. 259 Rcrm'toiliz:uion, Ircal1l\l'n! ~Ir:llr.:fics. 169

.. ~ pUf]lQse. -l I 5-1 16
spinal disorder classifications, 361
cl'rvical musclcs_ 271
cerviC:ll spine joints. /75. .lio
Rr.:p.:tition, effect on Illu:-..-k- fatigue, 16. 17
Rl'p..'litiyr,: ,qrain, dclin"d. :~
I whiplash classilic:ttions, 361 erector spinae, 26S Rc~i:'lal1cr,: exercisc,", ell,'.:t ('n muscle. 49
), Questitlllll<lircs. (SC't' Dis<lhilit}· questionnaires; gastrocnemius. 284 Rcspir:llion
, pain qUC!'iti<llluaires) t;luteus llliniUllls. 175 :tlt,'ro:::d. 366, 366
i
R:ldicubr pain. with low back pain hamstring. 258 h... ;H.bdlcs and. 376
I
carc Sland:lrds. 34-35 iliopsoas. 174. 261 lillill~ tllora)( :11. J9;
olltcomc :lsscssmcnl, 165 infr<lspin:1lIls.253 R~'spir:\lion toordinali\l[) l,·~t, d,·scription. 8S-

'. }
Radiculop;llhy. indications for, 3-l-l
Rangc of ltl(ltiol1
joints, 22. 1'71
lev,lIor stapUlaL'. 172. 27;i
S9,9(1
RL'~rira[(lry synkinesis
funclion:11 c:lp:u:ity c\'alu:llion Icsls lumbar spine joints. 175 d,·,in..-t.I.205
cervical spinc, 78-79, 79 ....')0 peclor:lli.s m:ljor. 1'7 1) ll~" in pmlisomclri..- rd,l.,\,\li"'II. 206. '216

,) hip mlaliun. };2, ,\j2-1U piriformis. 17oJ. :!(I·l RF. ~S<l' Receptive lield~'
lumbar spinc. 70. 77.411-41'2 qU;[dr;tlll.~ lurnborutn. /7.( :!67 RhYlh1lliL' ,"labili~.ali{ll1. f,'r ~lh'\llder. 287, 289
thoracic spille. 78. 7,"j scalencs. 172. 2'7s Rl. \Sl'l' Reciprocal inhit>iti"lll
lrunk TOlmil'Il, '7S. 7lJ soleus. 284 R\X'k\'r ",.ard
l<iss of. 2)·1 stcrnoclciliomaslOill. /7.1. 277 d,·:'"Tiplion.320
lumhar spinc lesr.s sulx>ccipilillis, 276 ill\l._lr:llio!l. 320
cxtensi(lll. 2.li ~lJhsc:lpularis. 21\.1 Rol:llIJ \lorris SC:llc, \k~~·rii'ti\'n.lt5. 6;
nc.\;,ion.237 ~upraspinatlls. 2S1 RO\1. IS..c· R:lOge of 11I,'li,'I\'
,,): side-gliding left, 23X ICIIStlr faseine blac. 26:\ Rllll\b<.'r~·~ quotiClI1
I side·gliding right. 238 upper lrapczius. /7/. 27,1 lk·h-ripliu!l. 33CJ
<-)! IUlllhop~h'ic. 298-299. 19c'1-.100 symptoms.2 J l\'w b:ll:"- pain i[)lPfl""~','nl" :md. :'137 . .!}i
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 nCnl"\Oll...1 11-\1 IUN VI'" I Ht:. ~P1NE: A PRACTITIONER'S MANUAL

R01:llOr cuff syndrome. (Sa Impingcmenl Semicircular can"ls, law of, description, 333, 333 Skin dr'lg
syndromc) Semispil\3lis capitulO, POSliSOItlClrie relaxation. causes, 200
ROlmors test 272,272 hY()I=rnlgesic zone diag.nosis, 19:-;. 200
~rformanec of. 33<1, 33-1 Sem;spinali!' ccr"icus, poslisolllctrie rel;l;'<.at;on. Skcping
purpose. 334 272,273 felal posilion. ISO
Running.. hnnbrlr spine injurict', 352 Sen!'jti1..:l.Iion, dorsal horn ideal poslure. IRO
Sacr.ll ot.liqui(y, illustr.uioll. 220 associated neural cli:lIIgc!', 25 pillow pl;l\.·clllelil. 1.~1
Sacroiliac joint Syl1drolllC delincd.24 Slouching, 240
allered hip atxluctiol1 ;ll1d. 363 P:llhophpiology,25 Slow,l\\'iICh lihers. dl.lr:ll.'lerislk~, ~7,:!S
description, 366-3(,7 Sensory motor slimublion Slumping, i76. In-liS
di;lgnosis, ) device... :md :lids SOAP notes. ddincd. :;8-1
palhology, ~45 bal:lncc balls, 320 Soft ti.~suc
$acroili,IC joints ~Iancc shoes. 320. 321 fmigue levels, 17
adjustmcnll' of. effect on reflex responses, 47 Fillcr, 320, 321 healing pha.'ic.~, 3-1
mobili7"'ltion techniqucs, 210 minitfilmpoline. 320, 321 inlbmmatioll. 1:-. 37
Scalenes ' rocker board, 320, 320 remodeling. 14-15.38
posli50lUclric relaxalion, 207. 278-279. 279 Iwister.320 repair, 14,37
rdel'Tcd rain, 171, 278 \\'obble board, 320, 320 lc~iol1.'i, p:llpation teqing'
sclf-pol'lisoltletric rdaxation. 280 indications for. 321. J2t connecti\'c 'issue, 200
sdf-slretching, 279, 280 motor learning Slages. ~ 19-320 skill,20{)
trigg.er points, 278 short fool m:lIlu,,1 resislance h.'chniques. ~55-256 "
Scapula description, 322 pain syndromes .;
conlr:.lcl-rdax techniques, 288, 291 eltercisc: program, 322 b:uncr phenomenon. 203
facililation lcchniqucs, 287, 28R_289 fonnation of. 32~ managelllent guiddine~:. 36
stabilizers, stfCngthening exercise. 3S I half step forward stance. 323 lendemess
winging of, lOti, 109 illustration. 322 grading schefm'. iJ
Scapulohulllcral rhythm passive modeling, 322 qunnlificntillll, iJ
altered Shcrringlon's Law of Reciproc:l1Inhibition, tension type~. 19
de.'icription, 365 26,27 Soleus
gail analysis. 365 Shon foot poslisolTlctric rclaxalion. 284. 18fi
trealmcnt npproach, 365 descriplion, 322 referred pain. 284
glenohumer.ll mOl ion, 380 exercise program, 322 ~c1f-strclehin,g. 28..1. 2R6
impingcmcnt syndrome and, 380· formation of, 323 tighlnes.~ cvnlualion. 10-1, IOi .-~

h.M step forward l'tance, 323

:7
Scheunnann's disease. etiology, prolonged sit- trigger points. 28-1
ting.3<11 iIlu~trntion, 322 Somatiz:lliun
Scialie ncrye, referred pain, 176 passive modeling. 322 defined, 391, 393
Sciatica Short leg double mes.~;lges of, 395
case management. 3(10 pelvic obliquity (ronl. 220-221 Somali7.:nion dialhe<;i~
enuses, 171,345 sacral obliquity frolll, 22()"221 abandonment 396
conservntivc care, 5. 360 Shortened muscles. 118 abuse, 396
etiology, 3 Shoulder abduclion alcoholi.~m. 396

illU:'Ir:.ttion. 176 components of. 102-103 description, 393

SCM. (Sec Slcmoclcidl)mn.~IOid) coordination lcsl, description, 85. 88 surgical outcome. 396
Scolimis, illustr:ltioll. 2]0 inhibited nluscles evaluation. 102. 107 Sorensollicst. for lumbar spine, 41-1.
Sce-~,,\\' e~ercisc, 311. 313 in paliellt with shortened upper uapc7.ius, Spa:;m
$el.f-strclching 135. 135 misdi<lgnosis of. 28
guidelincs for. 258 Shoulder hl:ldc. ~tahilizalioll of. cV<lluation melh- poslisomclric relax <Ilion. descripli(11l. 203-204
joint mobilization oOl', 102, 105 lishtncs:; ;md. differential diagnosis. 97
lumbar "'pinc cxtem;ion. 286, 2Si Shoulder girdle, sl:lbili1":ltioll of, e\'alunlioll melh· Spccl.'h, muscle dysfunction. 197
rib. 286-287, 288 ods. 102. 107 Sphinx c:o;crcisc, ISf)
thoracic spine extension. 286. 288 Shoulder joinl Spina bifid:t. illCidcn('c in J;)'llInal'l:'. 350
muscles n:habilitation nl:lnagel1lcnl. 381 Spinal column, (S{'(' Spinel
OldduClOrs. 261, 262 rhythmic slnbiliz:uioll. 2S7, 289 Spinal cord. J;.r.I), matter. "irritable ()('llS." 2J
erector spinae. 270, 271. 3i3 Shoulder Shn.lgging, 190 Spinal cre~'wrs.lighlnc'~ cv;,llIali\m, 100. /(U
g;\strocllelllius, 284. 285 SI-JR. (Sa ScaplJ]ohunlcml rhythm) Spirwl IO;ldillg. deli ned. 227
gluteus maximus, 265. 26S 51, (S('(' Sacroiliac joinl syndrome) SpiMI l1cr\'c roots. di~~: :md, rdnlitmt'hip he-
h'llnstring. 259. ]fIO. 373 Sickncl's hnpaci Profile. 6J twcen. 170
iliopsoas, 26~, 263, 373 description, 69 Spinal pain, (.·:i('t~ 1.0\\ back pain)
levator scapulae, 275, 276 Side-£liding, 228. 230. 249 Spinal st:lhili'l.alinll.ISu Functional sl:lhilizalion)
piriformis. 265, 266-267 Simulation, as ,lbnonl1;11 illness hch<l\'ior sign. 73 Spine
quadr:llUS lumborum, 26&. 269 SIP, (Set' Sickness Impact Profile) an:ltonlY of. 341-3..12
quadriceps, 265, 267 Silling hndy slillics, 113. 217
rcclUS femoris. 264 crect. 167 cer\,;c;ll. (Sa Ccrvical spine)
t'ealcllcs, 279, 280 improper, 167,179 columns (If. ~41
soleus. 284, 2S6 prolonged. low back pain :tnd. 341 descriptiun. 170
lensor fasci,le latae, 264 pror'lcr, 178-179. 378 illustralitl!1. 169
uppcr tmpezlUS, 274,275 Sit-ups, improper technique. 190 lumhar. (SI'e' Lumb~r 'ipinc)
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Spi 11\,'--':'(1/" ;11/11,/1 Slimulus·rcspon$C rd:uionship. receptor il1\'Ol\"c- rcfcl'Tcd p-,in, 26:.
pll.~tllr;)1 disorders. :n I lIlcnt in, 47 sclf·strelchillg. 26..~
poswral tonk ;lsyllilll"try. 331-:'U2 Straight leg misl: lest, 81. 8/ shoncllcd
st:,hilit:>.361-362 Simin lxx.Iy conlour CIl;IO£CS, 12·:' /:!4
I'l{lr.ll'i~·, (SI'e 'Jlltlr;,ck spine) pOlin :ind. rdOlliollship between. 1% disturbed body statics, /13. 11..-
) Splenius ':ll,iIIlS. p!.lstisollJ"tric rcl;lltalioll. n::pclilin: hip r.cxion mO\"ClUcnl impail111\'lu". 11-1. 1::5
~n.27.l defined. 3S ligh!ncsl' c\"llualion. 9~. 100, 110
SI"ll1dyloli"lhcsis pOlin :lnd. 293 lrigger point:-. 26·\
dl;lr.ll'I,'ri\lics, .142 Slrcngth (ontilluum, as cxampk (If l1I11s(ul;lr Tcs\·retcsi rdi;lbilily
nlllllllnll sit....s fl.r. J42 t;~.d:!k::.·1S ~;:f;;;::d. 59
htllmi,', .I·e Sirength mea.~urclllents. nomlal funClion aud, 75 of McGill P,lin Quc:'liol1n~lirc. 61-6~
lu\\' h;Kk p:.in tlCCUITCl":C • .3 Stl\..-Ss!SIt:lil1 cur\'c TR... (Sec Tcnsor fasciae I:II:1c)
Ire.llmenl plan. 3-'2 dcfincd. 16 Thigh adductors
Splllldylulysis hysleresis illustr'.ltioll. /7 inhibitcd, evaluation of. lOS
ch:lraCh:ristics. 3~2 for ligamenls. 16 poslisottlctric relaxalion, 259-261. Z6/
CllllllllQll sites for. 341 Stretching tightness cvaluation, 98-99. /00, /02
inciucllI:c of cOlll1ecli\'c lissuc...., 258 Third rally pa)'or. rcimburscmcllI from
ill gylllllasts, 3S0 c!cctrornyographie dala or. 27 <]u:\ntification of symptomatic ,and funclional
ill weight lifters. 35 J manu:11 rcsht.mee techniques and, 256 progress. 38
Sporb. (St',' dho Athkll:s) safety rulcs, 257 ways 10 ensure. 37-3S
lumhar spine injuries self. (See Self·stretching) Thixolroph;c bcha::ior. 254
h311cl. 350-351 Subacule pha...e. of injury. 34 Thoracic crector spinac muscle. postisomctric rc·
h:ls..:I:I:.II. 353 funclionaltcsling.74 la:talion. 206
foolll;11!. 351-352 Subjecll\'e factor!', of polin, methods to me:l· Thoroldc outlet syndromc. postural effcct.~.
golfers. 352-353 sure, 74 376-377
t;.Ymnastics. 350 Subluxalion. dclincd. 22 Thoracic.: spine
ja\'c1in throwers. 352 Suboccipit::llis mobiliz:ltion proccdurcs
pole \".:luhing. 351 paslisomelric relaxation. 276-277. 379 poslisomctric relaxalion. ::!S6. 287
running, 352 refcrred pain. 276 sclf·Slrctching, 286. 288
lennis. 353 Iriggel' points, 276. 376 strelching exercises, 383
W'ller sports, 351 Subsc<lpul::lris r.lngc of motion tests. 78. 78
weight lifting. 351 POl'liS(lmClric rcl:U:l\ioll. 108. 282, 283-284 Thor.\columb;n junction. forward-dr.lwn posture
Spurts medicine. 411 r.:fcrrcd flain. 28:\ and. 222. 213
principles. 415 triggcr points. 283 Throat. c\"alualion of. suprahyoid muscle tight.
Spray and Stretch. indic:llion~ for. ::!56 Substan<.:c abuse. chronic pain patients anti. ness. 110
Squat strength tcst. descriplion. 84-85. 87 395-396 lllru~t manipulation
Squats Supcrliciallcndcmess. as abnonnal illncs!' beha\,· lumbar ::pinc. 2/7
<IS stabiliz.ation exercise. 305, 306 ior sign. n proper technique. 213-215
using gymnaslic ball. 313. 3/3-314.314 "Supcnn:m" e;(crci..c Thumb, hypcrcxlcn~ion \CSls. (N hypcrmobilily
Squatting, ::IS lifting. It..-dmiquc, 1M description. 311t) eV;llu:ltions. /10, II'
Swbilization ill(l.~tr:ttioll. 309, 312. 374 Thumbs test
dyn:unit·. 295 Supmh)'llid mu~de. lightncss c\'aluatinn. 110 dcscriplillll. 336
(ullclional, (Sel' FUllclional slabiliz;llioll) Supr:t'ipill:!tu, illuslr:ltillil. 336
Ire:lImcn( str;Ltegics. 1r,C; pnsli!'\\IllClric.: rclaxati(lII. 281-2SJ Tighlnes.... muscle. ,S('(' Mu:"ck. tightnc!<-:)
Swhili7-'llioll progralll, foal,. 293-::!9-1 n:fcrrcd p.. in. 281 Tighlness \\·..· "knc..:.. defined. 9i
St:lbilornclry, line postural ~y~tCl1l Illl:a· trigger point~. 282 Ti..suc
smemcllls Surgery illllllObiJj~.c<1. injury risks. 17
description. J:n n1Jlscr\,;lti\"c C:llC .md. cumparison. 5 :o.of1. (Sa Suflli.. ~uc,
Romberg's quoliclll. 33;, 337 disk cxtru_~i(ln. :' Toc louche:.. improper tcchniquc. /S9
SlilllCC phal'e. of ~ait. IIJ7 frcqucncy uf. 16t) Tor(IUC Illl·asurcmcnt\. lumb..r :--pine. -112
Siand to kneel tel'l fllr !lIW back P:lill. IWO:1'\lSC. 5 Torsimla' Slfcs:-ors, ) .( 1
descriplion. 83-S4 Suslaincd fX)~iti()nillg. 2:!.l:i 1'05. (St'/' Thoracic Ollliet syndrolllc)
illustr:ltion, .% Swing phaw. of gail. 197 Tmcli<lll
Slatic nll.'(;hanicl'. locomutor syslelll. cllmpo· S)'ltlr<lthetic ~)'llIpWlllS iSOlllctrk Ill.mua!. (If pch-is. ~O(j
nenls. 45 dclin..:d.2-1 rhyllullil' prune
Stemoclcidoma...loid. {51'(' al\(} Nel:k l11u:"'l:k,) di:lgntlstic le't, 2·' dcscriptioll. 2 j()
functional analOllly, 136 Sy.\l~lllic hcha\illral I)h~cr\'ati(m. pain h<:lla\'ior illustratilllJ, 2/7
gener:ll charaCleristic.... 135 ~1.~.scSSl1\elJt, 6-1,-(») Tr'lilling
poslil'omelrie rda;(;Ition. 207, 2/0. "!76-278. ·lennis. lumbar \pinc injurics. JSJ cndur:mce. eff..-ct on IIlllsc!.::'. J<)
177-278. J7R Tellsih: stres~()r~. 343 flln.:e . ..:tleet on rnu~ck~. 4".1
rderro:d pain. 173. 27i. 377 TCIISil>l1 IOC(ll11l'lI}r system rcacli\".ttil\ll. 5.1
shorlened 111t1sdc. da\\ifit:atiull of. 255 pmg,ra1ll crealion. criteria. 5~
body c.:on!our change'. 137,137 palp~ltioll. 1~!K rcsistillll.:.... clrcct on lJlusck~ ..11)
disturbed bod)' stali", 136. f.l6 Tensor faSCiilC hlt~lC Traiuill!! I\};ld. eOlllwl lllctlwd:--
s!renglh leSI. description, 87-88. 90 ftllKtiunal ~11:ltlIIl1Y. 122, 124 delillitilill Ilf furce. ~x
tightness C\'illuatiorl, n. YV. 110 general ch:l(;lcteristics. 112 gravity In~lnip\1]i\ti\Ill~. 4S
!rigger poi nil'. 177 pusliso1l1ctric rd.u;~uiull. 2(13-26-1. 2(J-I-265 traillil1~ lhrc:-hold. .::~

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 " .... , , ........ ' .... ' , ..... , ' V U VI " , ... O)r ,,~t:, ,... rnt\\..< I I I lVI~r::,n ,::) IVlt\I'llUt\L

Tr:lining range supraspin;ltus. 282 ,;;,';,II:X,: 11I"'<':111\:'" I""i""., :,~:;

dl::;;lcd. 295 lensor fasciae 1;lI:.Il'. 2{H Iri~f..:r I'llilll'i."273
funclional s.t.abilizmion. 29-1-295 uPI'll.:r tr.tpc1.ius. 27.' V"lidity. u{ pain ami di:-;loility llu",tioll'
lumbopclvic. 298-299. 298-300 lI1yofascial. joiut dysfun.:tioll :lIld.lIilTerenliJI naires, (1(1
methods. 10 identify. 295 t.liagnu.~is. 366 VAS. (Sf'<' \'[,u:lI ;llIalo~ SC;tll')
movcment sensitivities and. 29~ ned; l1c.xioll, 36.'\ V...rhal \k,,·ripliv... sC;lk~. Bm~. p.lin illt":lI~it~
Training tllTc~hold. defined. 48 flalp;ltion or. 205 l11C,I~llr"'lll~'lIl, (.1. (,.I

Tr.lpcl.iu~ rl:~rir;lli(}ll. Olilercu, .'66 V":I:-idillllx·1. ;.cwbi,· hcnl'!its ..,-1')

lo\\'er sl'apulohumeral rhylhm. alt..:reJ. 3h5 V":11\.'hrall'\,lulIlli. \S,·,· Spill")
s~~fl !issu~' "~"I!d~•. ~!e·.'" :!Il,~ VCrlchr..1j'lilll'. /7l1
faeilil:uion techniques. )80 !rullk flexion. altered. 36-1 Ve:-tihular :lpp:lr;lltb. fUlleti"n..~2'1
hume exercises. j,li2 !rullk Il1wcring frum push.up. .l6(i Ve~tihul..r dl"luJas..\~3-3:\J
.''\
miLh.lk. we;lkm:ss, ddillcd. ~9 Veslihlll:lr neuritis
contr;lct·rdax tcchnique. 288. 290, 290 Tri>. (5.,,· Trigger pl.\int~) postural ~\\ <lying. 330, 33/
facilitalion techniques, 288, 290, 380 Trunk st:ltllkille~igral\l ar":;lS, 33/

home exerciscs, 382 body st;ltic dislllrb'\Hces. 217 Visioll. intcgration dismd..:rs . .:129.-,'1,1 I
upper dead bug exercises, 346-3~7 Visllal analog ~eak
referred pain. /71 ..:xtensor enduranc..:, 37/ pai,1I i,llellsilY 1I1easurCIllCllt. (.1, 62,7.\-7·1
tightne$$ e\'alu:nil:lI\, 98, 9.~, 109-110 fh:~i()11 paill llH.:;I:-urClllClll. :'is
Tre:ltmcllt ;lpproachcs. dtronic pain allcr..:d mO\'ClllClll. .'6-1, JfJ.J vi,w:,i IIlSPC":llllll. pllrj1usC', II.' )
acupuncture. 401 ill P;lliclll with shorlcncd qua<lr:llus lum· W:ller Spllrb. Iumoar spine illj\lrie~. 351
b<::havioral thcr.lpy. 401 borum. 131. 13/ \VCE. (Sa Work e:Ij1:1city e"';llu:ulml)
biofcwback, 40\ -402 lowerins froll~ push.up. treallllcut ;Jr- \VUR ncurons, (Sn' Wide d)'lIanllc r:mge
cognitive {hcmpy. 401 proach.365 nCUWl\s)
')
family thempy. ~02 r.lngc of motion te.~l.~. rotation. 7S. 7V "Weak link:' :-trenfthC'lling, 37
,
goals, 38. 400 Mabilization rtlutinc:-. 196 \Ve"klle.~:-, lIlu~l;lc
hypnosis. 401-402 :-Ircngth tcsts anhrogenlr.:. 29
m:mipulmi\'c thcf:lpy. (S('(' M:mipul:'lIi\'c ,,:xlcnsion. 92. 91 slrC'lell, :!S-21J
thef:lpy) Ik~ion. 87. 90. lJ2 tighlllCS:-.28
phamI3colher::apy.402 side raising. 90-91. 9/ tri~~cr point. 29
rdaxation thc~lrY. 401-102 :-ucngthclling pmt;r.:.nlS..'';6-:U7. 3·JS Wei£ht lifting. lumh;ar spine injuric:-. J51
Triceps sur;te. tighmcss c\'aluation. lUI. /0-1 dl:ad·hug. 346-3H. 3.J7 WEST st;md:lrd cvahl'llioll. dc.~(:ripti\m.
Trigger poilll~ 1()'\ :-lr..:lching excrcisc~. 3-1S IJl'i-I-l'J
facet p<lin, 367 Trunk curl up wEST·EPIC urI Capacily Test
hip Il1(Welllents. <lllered illustrmion, 20-1 dcscripti~ln, 149
;loouction, 3~ for muscle tighlllCS:- cqlu:ltiolls. illllstration.149
extension, 363 Training I(lad. control methods Whipl:ISh. Quebec Task Force studies. 361
manual resistance tedllliqu.::s. 255 102. 105 Wide dynamic r:mgc lIcuruns. lleurop:.nhk pain
po~tisometric relaxation :Illd. 204 Twistcr amI. 25
musclcs
;Idductors. 259
cervical. 265
dc:-criptlon. 320. 326
purpose. 32(1
Upper crossed syndrome
Willd{lW o{ optimal ;It:li\'ily. ill pcrrorman.....: ,'t.IlI-
tillmllll. 52. 53
Wind·lIp.256-257
.":i

Wohhle OOard. dcscriplion. nil

erector spinae. 265. 367
gastrocnemius, 2tN
pastur.1I signs. JM
scapulohumcrJI rhythm, 365.365 Work eap:Icity evaluatioll
J
h"lIl~tring. 258 Upptr c:(tremity fUllction:d capacity ;lIlU, cOrTl..'lalil'lIs be-
jliopso;\~. 26:! body static lllcasurcrnCnl~ uf. 113-114 twc..:n. is.
infr.l~pinatus. 2S~ prehcnsion. 197 purpo:-c. is
Icvator ~l;:'lpula..:. :!75 :-Irengthcning. of. 3J 7 \Vmkstalinll ert:0ll(lllli{'!i
p..:cloralis major. 279 UPi'll.:r trapezius dt;lir :-euing:-. 167. /79
piriformis, 165 pustisolllctric rd;lx"linn. 208.2/0. 27J. C(llllpuicr. /if)
.,
)
<Iu:ldratus lumOOrulll. J:65 273-275 lte:lIlachc rdil':f, :\75-:n(1
scalenes. 278 refcrrcd pain. /71, 273 Wri.~t. C:c.ICIl'orS, postismlletric n:la.'('llioll. ::0·1
~okus. 28-1 ~clf·strclching, 27./, ::!i5 Writill,t: wcuge. 178
~t.::rnocleid(Jmasltlid, 277.37·/
suboccipitali~, 276. 376
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:-hortcncd
body C~H\!llur chan!;c~, /J.I, 1.15
wSI:. (Sa WEST standanl cv,llll:ltioll)

sub~eapulilrj~. 28) diswrbed body st;.IIic,. 133, 13.J

.,
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