A.)  GENERAL

1)    Functional pathology of the motor system

The term functional pathology of the motor system refers to the interrelationship and interaction between dysfunction of the muscular, articular, & motor control systems. These three systems are not separate, but function as a single entity to allow movement, load carrying ability, and protection of underlying structures. As a result, a lesion or dysfunction of one component system produces a cascade of adaptive responses throughout the entire locomotor system. Therefore, local clinical problems or pain syndromes should not only be evaluated locally and regionally, but also evaluated in light of adaptive changes that occur throughout the entire locomotor system. Examples of functional pathology include deconditioning syndromes or adaptive locomotor changes such as muscular imbalance problems (see #14) that may develop between postural and phasic muscle groups (e.g. the "lower crossed syndrome").

• Panjabi MM. The stabilizing system of the spine. Part 1. Function, dysfunction, adaptation, and enhancement. J. Spinal Disorders 1992; 5:383-389.
• Liebenson C. Integrating Rehabilitation into Chiropractic Practice (Blending Active and Passive Care). In Rehabilitation of the Spine: A Practitionerrquote s Manual, Liebenson C (ed). Williams and Wilkins, Baltimore, 1995, p. 13-44.
• Lewit K. Manipulative therapy in rehabilitation of the motor system. 2nd edition. London: Butterworths, 1991.

An approach which recognizes that pain is influenced by factors other than anatomical or physiological parameters. Pain has biological, psychological and social aspects. This model recognizes that suffering and illness behavior frequently accompany the painful experience and should be addressed in patient management.^(1,2)

Taking a biopsychosocial approach to case management results in early identification of important risk factors of chronicity and disability. Chronicity risk factors have been summarized by Mercy⁽³⁾ and the British Guidelines.⁽⁴⁾ Examples include past history of greater than four episodes, severe pain intensity, and low job satisfaction, among others. Disabilty predictors have been identified by Cats Baril and Frymoyer⁽⁵⁾ to include work status and job satisfaction, injury viewed as compensible, past hospitalization, and education level. Waddell correlated the presence of three of five physical examination signs with abnormal illness behavior.⁽⁶⁾

Risk factor identification impacts treatment by accelerating the transition from passive therapies to the less dependency producing active care approaches. In addition, it facilitates appropriate referral for behaviorial medicine co-management.

Subacute, chronic, or recurrent pain patients who have no "red flags" of serious disease should be treated with the aim of reducing activity intolerances.^(1,2) Manipulation of joints or self-generated end range joint mobilization procedures such as McKenzie methods may be appropriate in the acute syndrome to relieve pain, restore function, and reduce activity limitations.⁽²⁾ Starting as early as 2 weeks, or as soon as possible, active exercise to address specific muscular performance or motor control deficits is appropriate.^(1-4)

Chiropractors wanting to address muscle and joint dysfunction as part of a comprehensive approach to rehabilitation of the motor system should be aware of the proven relationship between dysfunctions of endurance or motor control and various pain syndromes. For instance, poor static endurance of the trunk extensors has been correlated with first time episodes of lower back pain as well as increased recurrence rates.^(5,6) Deep neck flexor weakness and forward head posture has been found to discriminate either chronic or post-concussional headache from individuals without headache.^(7,8) A faulty scapulo-humeral rhythm has been found to correlate with shoulder pain.⁽⁹⁾ These are just a few proven examples of the relationship between muscular or motor control dysfunction and specific joint pain syndromes.

Case management considerations for all subacute, chronic or recurrent pain patients should include a prescription of active care addressing relevant muscular or motor control issues. These may be linked to specific joint dysfunctions and the ultimate goal of therapy should be to promote joint stability.

4)    Quality assurance guidelines, risk management & facility development

After rigorous methodological review of the scientific literature, guidelines for care have emerged in Canada, the U.S. and Britian.^(1-3) Conclusions about frequency and duration of care have been drawn. Essentially, approximately 90% of uncomplicated acute mechanical pain syndromes have a natural history of 4-6 weeks. Thus, treatment of noncomplicated acute pain problems should only exceed that time frame occassionally. Mercy summarized factors that may predict a longer recovery.⁽⁴⁾ Patients who do require more than 4- 6 weeks in order to recover activity tolerance are at risk of developing physical and psychological deconditioning, and thus management should focus on functional restoration.

Risk factors of chronicity can be identified on the first day of patient contact. These factors have been summarized in both the British low back pain guidelines and the Mercy guidelines.^(3,4) The patient who presents with "red flags" of serious disease (i.e. tumor, infection, etc.) can be identified with a thorough history and physical examination. Confirming imaging or laboratory tests can be ordered and and appropriate referral made.⁽²⁾ Patients with cardiopulomonary risk factors should be identified so they may be instructed not to exert themselves inappropriately during an exercise program.⁽⁵⁾

Evaluation should be based on tests that are reliable, sensitive, and specific (See #12).

Facilities should be able to provide active care advice and training. This does not necessarily require expensive equipment, but does require space for simple measures. A stationary bicycle, gymnastic balls, pulleys, hand weights, medicine balls, rocker boards, and stretching mats are examples of cost- effective rehabilitation tools that should be a minimum requirement for a rehabilitation specialist.⁽⁶⁾ Other rehabilitation instruments may include computerized and noncomputerized isomachines.⁽⁷⁾

It is recognized that 60 to 80% of the general population will suffer lower back pain at some point in their lives.^(1-4) Most noncomplicated acute pain patients recover within six weeks, but 5-15% are unresponsive and have continued disability.^(5-6) This smaller group is expanding and accounts for up to 85% of the total cost of lower back pain.^{(7- 10)}

According to AHCPR and British back pain guidelines, patient reassurance, pain-relief methods, and exercise should be included in case management.^(11-12) Active care/functional restoration programs should concentrate on quantification of functional deficits, exercise, education, early return to work, and psychosocial intervention. Management should be driven primarily by functional findings (i.e. elimination of activity limitations), and not solely upon changes to the local area such as the stages of tissue healing (histological remodeling of fibrils).

Overutilization of expensive imaging techniques to make a structural diagnosis should be avoided. Strict criteria for prescribing acute pain care such as passive modalities, bed rest or surgery should be maintained. Passive modalities are appropriate during acute pain episodes, but should not be used as an end in itself, rather as agents to facilitate active rehabilitation or functional restoration. Prolonged use of passive modalities tends to promote patient dependency.

Furthermore, the concept of doctor dependency should be recognized. This may be manfest in an number of ways, for example: (1) what is commumicated to the patient concerning the nature and prognosis of their disorder; and (2) whether the patient is provided the tools necessary to liberate themselves from professional care.

Appropriate management includes patients education about the benign nature of pain, the dangers of deconditioning, and encouragement about the benefits and safety of becoming more active. Home care/self-care instructions should be in the form of activity modifications and should be provided from day one.

B.)   BASIC SCIENCE

6) Clinical biomechanics (stress/strain curve)

Anatomical structures are subjected to a variety of different types of load - compression, torsion, shear, and tension. Loading of ligaments or joint capsules leads to deformation, creep and hysteresis. Different mechanisms of injury correspond to different tissues. In the lumbar spine for instance different types/durations of load are responsible for injuries involving vertebral end plates, annular herniation, neural arch damage, facet shear, ligament tear & avulsion, etc.⁽¹⁾

The loading of biologic tissues produces a characteristic stress/strain curve demonstrating the amount of stress (loading) required to produce a set amount of strain (percent elongation or deformation).⁽²⁾ The stress/strain curve explains the mechanics of the relationship between external load (stress) and tissue deformation (strain). When work or activity demand exceed a personrquote s functional capacity, microfailure (fatigue) and eventual injury result.

Gait is a complex locomotor function which involves muscles and joints primarily of the lower extremity kinetic chain.⁽¹⁾ There are 2 basic phases of gait - swing and stance. Stance phase is usually evaluated in light of mechanical events occuring at the subtalar joint which dramatically change from early, mid-stance to terminal stance or toe off.

Key concepts to learn about for an understanding of normal and abnormal gait mechanics are pronation, supination, windlass mechanism, rearfoot and forefoot varus or valgus, and tibial torsion. Kinesiologically speaking, the function of the gluteus medius during mid-stance and gluteus maximus during terminal stance (toe off) are considered to be of key importance.^(2,3) Normal gait is dependent on adequate joint mobility especially in the 1st metatarsal/tarsal (dorsiflexion), ankle (dorsiflexion), knee (external rotation) and hip (extension) joints.⁽¹⁾

Normalization of faulty foot/ankle proprioception is also considered crucial to optimization of gait mechanics.^(4,5) Propriosensory balance training has been found to not only improve balance but to increase the strength of many different lower extremity muscles faster than with isotonic strength training.⁽⁴⁾ Reaction speed of lower leg muscles such as the peronei has been discovered to successfully discriminate ankle instability from normal function.⁽⁵⁾

Exercise Science includes the integration of concepts and relevant scientific information to provide a foundation for understanding the basic physiologic processes of exercise training, nutrition, and energy transfer. Muscle strength, endurance, aerobic fitness, and motor control aspects are all essential. Further, the SAID principle (Specific Adaptations to Imposed Demands) is crucial for understanding how to link an exercise prescription with a patientrquote s functional goals.

Along with specificity, concepts of threshold, overload, progression, frequency, volume, intensity, duration and recovery are important. Further, concepts basic to neuromuscular physiology and the neural control of movement including muscle fiber types, muscle action types, length tension relationships, viscoelasticity, proprioceptive functions, and aerobic verses anaerobic exercise are all important.

Nutritional considerations include the relationship between diet, fitness and performance; dietary patterns, body composition, and review of current scientific knowledge relating to nutritional supplementaion during rehabilitation.

• McArdle WD, Katch FI, Katch VL. Exercise Physiology: Energy, Nutrition, and Human Performance. Lea & Febiger, 1991.
• Rutherford, OM. Muscular coordination and strength training, implications for injury rehabilitaiton. Sports Med 5:196; 1988.
• ACSM Guidelines for Exercise Testing and Prescrintion. 5th Ed, Williams & Wilkins 1995. AHCPR
• Boucher J. Exercise Science in Rehabilitation of the Spine: A Practitionerrquote s Manual, Liebenson C (ed). Williams and Wilkins, Baltimore, 1995, pages 45-56.
• Bucci, L. Nutritional Guidelines. Rehabilitation Guidelines for Chiropractic. Chiropractic Rehabilitation Association, 1992, pges 42-43.
• "Concepts and Applications of the Exercise Sciences" in Essentials of Strength and Conditioning, Baechle TR editior, National Strength and Conditioning Association, Human Kinetics pub, 1994.
• Stone, MH. Nutritional Factors in Performance and Health" in Essentials of Strength and Conditioning, Baechle TR editior, National Strength and Conditioning Association, Human Kinetics pub, 1994.

There are basic stages of motor learning. An individual learns a new skill by first gaining kinesthetic awareness or conscious perception, then demonstrating volitional control, then practicing good coordination, and finally an automatic engram will form in the cerebellum.^(1,2)

1. Kotke FJ. From reflex to skill: the training of coordination. Arch Phys Med Rehabil 1980;61:551-561.
1. Hyman J, Liebenson C. Spinal stabilization exercise program. In Liebenson C (ed) Spinal Rehabilitation: A Manual of Active Care Procedures. Williams and Wilkins, Baltimore 1996.

Abnormal illness behavior (AIB) is defined as a patients inappropriate or maladaptive response to a physical complaint. AIB is an important complicating factor of neuromusculoskeletal problems and requires a multidisciplinary biobehavioral approach.

Behavior modification commonly involves the application of operant conditioning principles to alter the emmision of responses. Events which increase the occurrence of behavior are defined as "rewarding" and those that decrease the occurrence of behavior as punishing.

In addition to the behavioral model and the biopsychosocial model (see #2), the cognitive model should be discussed. Converting patients from pain avoiders to pain confronters is a key. Poor coping strategies are present in individuals with high levels of anxiety, depression or catastrophizing tendencies. Achieving adherence, compliance, and motivation rests on a number of factors. Appropriate goal setting, objective feedback, differentiating between "hurt and harm" are all important considerations in helping reactivate psychologically deconditioned patients.

• Pillowsky I. A general classification of abnormal illness behavior. Brit J Med Psychiat 1979; 51:131-137.
• Jensen MP, Turner JA, Roman JM, Karoly P 1991. Coping with chornic pain. A critical review of the literature. Pain 47, 249-283.
• Block A. Presurgical Psychological Screening in Chronic Pain Syndromes (CH 2). 1996. NJ Lawrence Erlbarum Asociates, in press.
• Troup JDG. The pereception of musculoskeletal pain and incapacity for work; prevention and early treatment. Physiotherapy 74:435, 1988.
• Turk DC, Rudy TE. Neglected topics in the treatment of chronic pain patients - relpase, noncompliance, and adherence enhancement. Pian 44:5, 1991.

C.)  ASSESSMENT

11)    Functional testing (physical performance of isolated muscles/joints)

For the purpose of outcomes management as well as rehabilitation prescription, evaluation of physical performance is a crucial step. According to the North American Spine Society, "a major factor underlying disability is an actual physical inability to perform certain tasks because of lost muscle strength, lowered endurance and aerobic capacity, or decreased mobility and coordination." p 2063.⁽¹⁾ Physical Performance Assessment (isolated muscles/joints) includes range of motion, strength, and endurance tests.^(1,2,3)

No strength measurements are performed in Acute patients. Depending on diagnosis and condition severity, subacute patients may have strength tested. Low-tech tests have been shown to be reliable and valid. Further, normative data on simple, inexpensive, squatting, trunk flexion, and trunk extension tests has also been established.^(4,5) Waddell and Newton after reviewing the scientific literature said, "no convincing evidence supports that iso-testing has greater utility than clinical evaluation of impairment, isometric testing or other simple tests." ⁽⁶⁾ Grip is assessed by the use of a Jamar grip dynamometer.⁽⁷⁾

Spinal ROM should be measured on day one.^(8,9) The effect of motion on pain should be noted. For instance, does pain increase or decrease with motion and do symptoms centralize or peripheralize with motion? Subacute patients (around 2nd week) may have key tight muscles such as hip flexors, hamstrings, gastrocnemius, and soleus measured.⁽¹⁰⁾

The purpose of outcomes management is to quantify progress/status with reliable, valid measurements. This can be used to document medical necessity, provide patient feedback, and often aid the doctor in clinical decision making.

Outcomes management can be acheived by gathering both subjective information (questionnaires), as well as objective data (physical performance testing - see #11). The subjective tools include the following:

1. general health questionnaires (SF-36); ⁽¹⁾

2. pain assessment scale (VAS - visual analogue scale, numerical pain scale); ^{(2, 3)}

3. condition specific questionnaires (Oswestry, ^{(4, 5)} neck disability index, ⁽⁶⁾ headache quesionnaire, ⁽⁷⁾ and others);

4. psychometric questionnaires (SCL-90-R,⁽⁸⁾ Beckrquote s Depression Screen,⁽⁹⁾);

5. patient satisfaction questionnaires (Chiropractic Satisfaction Questionnaire⁽¹⁰⁾);

6. disability prediction questionnaires (Vermont Q,⁽¹¹⁾ Sorensonrquote s test,⁽¹²⁾ NIOSH tests⁽¹³⁾)

In addition, a soft tissue tenderness grading scheme has been described which can "objectify" palpation.⁽¹⁴⁾

The criteria for a good outcomes assessment test are the following:

1. Safety

2. Reliability

3. Validity:

4. Normative Database

5. Cost

6. Time factor

Common tasks have been identified by the Dictionary of Occupational Titles and include such items as standing, sitting, walking, carrying, lifting, balancing, etc.⁽¹⁾ Standing and sitting are mostly static behaviors which rely on posture. Walking, carrying, or lifting are examples of dynamic activities which involve coordination, strength, and endurance.⁽²⁾

Mechanisms of injury vary from task to task, but a general rule is that injury results from prolonged or repetitive activities involving smaller loads rather than single events involving a high magnitude load.^(3.4) In particular most anatomical tissues are injured when loaded at end range, and preventive ergonomic, educational, or exercise training strategies are designed to train neutral joint positioning and/or antagonistic muscle co- contractions.^(4-6)

Mechanisms of injury related to acute trauma (e.g. grades I through IV ligament sprains) are often unrelated to a history of pre-existing repetitive strain. Cervical whiplash may result from Acceleration/Deceleration trauma. A torn ACL or other exremity ligament injury may result from a sport specific trauma such as can occur from soccer, football, basketball, etc.

When a movement arc occurs with a broad or erratic center of rotation around a joint, or the center of mass cannot be maintained over a stable base of support, injuries are more likely.^(7-9) For instance, if the scapulae moves superiorly in the early part of an arm raising activity (the "setting phase") this has been correlated with shoulder pain syndromes.⁽¹⁰⁾ Similarly, when a forward head posture is present a greater incidence of headache can be predicted.^(11,12) Lower back pain patients are distinguishable from non-sufferers by having poor control of anterior to posterior body sway on a balance board as well as by having an erratic sagital movement path after prolonged resisted trunk flexion/extension movements.^(7,9)

Muscle imbalance describes the situation in which some muscles become inhibited and weak, while others become overactive. Muscles may be categorized according to their tendency toward developing tightness (e.g. hamstrings and upper trapezius) or inhibition (e.g. the gluteal and abdominal groups). Muscle weakness and tightnesses do not occur randonly; rather, typical "muscle imbalance patterns" are described. These imbalance patterns may not remain limited to the local symptomatic region, but facilitate a chain reaction effecting other regions of the locomotor system. For example, the proximal crossed syndrome is a muscle imbalance pattern characterized by development of overactivity or tightness in the sternocleidomastoid, suboccipitals, upper trapezius, levator, and pectoralis major; and inhibition of the deep neck flexors and lower scapular stabilizers. This pattern of muscle imbalance produces typical changes in posture and motion that can be evaluated by observation of muscle tone, postural analysis, gait analysis, muscle length testing, and movement pattern evaluation (see #15 below).

An alternative way to view muscle imbalance is the relative strength, power, or endurance of one muscle or muscle group in relation to an antagonistic muscle or muscle group. For instance, the relationship betreen hamstring verses quadriceps, or trunk flexors verses trunk extensors.

• Janda V: Muscle strength in relation to muscle length, pain and muscle imbalance. In Harms- Rindahl K (ed): Muscle Strength. New York, Churchhill Livingstone, 1993.
• Janda V: Muscle Spasm - a proposed procedure for differential diagnosis. J Manual Med 6:136, 1991.
• Janda V. "Evaluation of Muscular Imbalance, In Rehabilitation of the Spine: A Practitioner's Manual, In Liebenson C (ed). Williams and Wilkins, Baltimore, 1996, pp 97-112.

• White SG, Sahrmann, SA. A movement system balance approach to management of musculoskeletal pain. Ruth Grant (ed.), Churchill Livingstone, 2nd ed, 1994.
• Wathen D. "Muscle Balance" in Essesntials of Strength and Conditioning, Baechle TR editor, National Strength and Conditioning Association/ Human Kineticspb, 1994.

These are movements which typify the fundamental activities of humans such as sitting, standing, gait, prehension and forward bending of the trunk. Certain key movement stereotypes have been shown to be reflective of these primary functions. These movement patterns include hip hyperextension, hip abduction, supine trunk flexion, neck flexion, arm abduction, push-up and forward bending of the trunk while standing.

Movement patterns may be altered by the presence of pain, muscular imbalance, trigger points, or joint dysfunction. Left uncorrected, abnormal movement patterns may be memorized just as normal gait or bicycle riding is memorized.

When a movement pattern is altered, the activation sequence or firing order of different muscles involved in a specific movement is altered. The prime mover may be slow to activate, while synergists or stabilizing muscles substitute or become overactive. Biomechanically, the result is a change in the fulcrum (center of rotation) used for a particular movement. The problem may be perpetuated since inefficient or uneconomical movement patterns create further muscular imbalances and joint dysfunctions that are commonly associated with movement pattern abnormality.

Simply put, movement pattern evaluation describes assessement of motor control. For example, on the Kendall test for side lying abduction, both the tensor fascia lata (TFL) and the gluteus medius can raise the leg. If there is substitution of a dominant TFL for an inhibited gluteus medius, the movement pattern will be altered as the leg flexes excessively. Visual observation of the movement pattern quality is the key, not the degree of achieved resistance (quantity). Movement pattern evaluation is based upon the timing or sequencing of muscle activation, and the degree of activity of the prime movers and synergists, allowing the clinician to evaluate pertinent abnormal substitution of muscle groups during testing protocols. For example, movement pattern evaluation allows the observer to note that hip extension may occur with the axis of rotation in the lumbar spine ("false hip extension") rather than in the hip joint.

This assessment when coorelated with other aspects of muscle imbalance analysis (such as gait and postural analysis) leads to the development of patient specific treatment concerning which overactive or tight muscles need to be relaxed, which weak muscles need to be facilitated or strengthened, and what joints must be be adjusted.

• Janda V. "Evaluation of Muscular Imbalance, 1996, pp 97- 112. In Rehabilitation of the Spine: A Practitioner's Manual, Liebenson C (ed). P. 29-31. Williams and Wilkins, Baltimore, 1995.
• Kendall FP, McCreary EK. Muscles: Testing and Function. Williams and Wilkins, Baltimore, 1983, p.10.

Muscular strength refers to the maximal force that can be generated by a specific muscle or muscle group.

Before evaluating muscle strength, consideration should be given to the patient's clinical condition since strength assessment involves maximal efforts and could result in injury or exacerbation. Appropriate body mechanics and warm-up are crucial.

Strength may be evaluated by static assessment (i.e. isometrically) measuring force generated against a force plate or tensiometer. Static strength assessment is performed without joint movement. The peak value is expressed as maximum voluntary contraction (MVC). Due to the specific fixed joint angle and the muscle tested, these static tests are minimally functional but have high reliability. The utility of this assessment is improved when isometric tests are performed at multiple angles/positions through a jointrquote s range of motion.

Strength may also be evaluated dynamically, utilizing isotonic equipment with the movement of a load through a range of motion. The simplest and safest measurement of dynamic strength is the performance of a 10 RM (repetition Maximum), where the 10 RM equals the maximal amount of weight an individual can lift 10 times. A 1 RM (repetition maximum) can also be performed and represents a greater value and indication of the individual's strength; however, again, it is a maximal test and good clinical judgment of the patient's condition should be used.

Less commonly, isokinetic machines may be used where the velocity of the movement remains constant, and the amount of torque an individual can generate is measured. These machines are relatively expensive and, like the isometric machines, bear limited resemblance to "real world" movements found in everyday life.

• American college of Sports Medicine's Guidelines for Exercising Testing and Prescription - Fifth Edition, Williams & Wilkins, 1995.
• Essesntials of Strength and Conditioning, Baechle TR editor, National Strength and Conditioning Association/ Human Kinetics pub, 1994.

Muscular endurance is the ability of a muscle or muscle group to execute repeated dynamic contractions over a period of sufficient time/duration to cause muscular fatigue or to statically maintain a specific percentage of MVC (generally not to exceed 40% MVC) for a prolonged period of time.

There are several simple tests of muscular endurance that have normative data bases that are particularly useful and applicable to the practitioner of rehabilitation (see #11). These tests have also been shown to be associated with the presence of low back pain in individuals. These tests can be helpful in establishing bench marks for evaluating a patient's progress during a spine rehabilitation program.

• American college of Sports Medicine's Guidelines for Exercising Testing and Prescription--Fifth edition, Williams & Wilkins, 1995.
• Ito, et al., Lumbar Trunk Muscle Endurance Testing; An inexpensive Alternative to a Machine for Evaluation, in archives of Physical Medicine and Rehabilitation, volume 77, January 1996.
• Alaranta H, Hurri H, Heliovaara M, et al: Non-dynametric trunk performance tests: Reliability and normative data. Scand J Rehab Med 26:211, 1994.

Although flexibility is considered synonymous with range of motion, it is more correctly considered a combined result of musculotendenous and articular function. The most accurate tests for flexibility are those in which a goniometer or inclinometer is used to measure the actual degrees of rotation of various joints. In the spine, movement is best measured using inclinometers which accurately measure the movement between anatomic landmarks.

Tests are specific to each joint, muscle group and connective tissue area. Flexibility/ROM is assessed several ways: (1) Active ROM: the patient moves the limb or involved structure and measurements are taken. (2) Passive ROM: the examiner moves the limb or involved structure with the patient providing no assistance. In addition, manual examination of joint play and end-feel will add specific information about individual joint function.

Objective quantification tests of specific tight muscles or stiff joints are a part of physical performance testing (see #11). Certain muscles, when tight, may interfere with movement patterns. For example, in the evaluation of low back pain, evaluation of trunk flexion, extension and lateral bending is a typical starting point. Specific muscles which can be evaluated include hamstrings, rectus femoris, iliopsoas, and tensor fascia lata. These measurements provide important important baseline measure and helps document therapeutic outcomes.

• AMA Guides to the Evaluation of Permant Impairment, 4th Edition.
• Rehabilitation of the Spine: A Practitionerrquote s Manual, Liebenson C (ed). P. 73-95 Williams and Wilkins, Baltimore, 1995.
• Alter, M. Science of Flexibility and Stretching. Human Kinetics, 2nd edition, 1996.

Aerobic capacity is synonymous with cardiorespiratory endurance. These terms relate to the ability of the heart, lungs, and blood vessels to acquire, transport, and deliver oxygen to the muscles followed by elimination of waste products. The criterion used to measure cardiorespitory endurance is VO₂max, which is how many milliliters of oxygen the body can use per kilogram of body weight per minute. The greater this value, the greater the level of cardiovascular fitness.

Aerobic capacity can be measured directly in laboratory settings measuring the volume of expired gases exhaled or, more practically, by indirect measures utilizing heart rate terminations at a specific power output or test protocol.

Given the expense and risk associated with maximal cardiorespiratory testing, submaximal testing is much more commonly done. Submaximal cycle ergometer tests are probably the most practical for most patients, and two common protocols are the YMCA protocol and the Astrand Reiming protocol. Treadmill tests include the Bruce and Balke protocols. The three-minute step test is inexpensive and has been used for mass testing. There are also field tests, including the Cooper 12-minute test, the 1.5-mile test (run) for time, and the rockport one-mile fitness walking test. In fit individuals, VO2 max should be tested using the same or similar aerobic activity that the patient uses (e.g. a bicyclist should be tested on a bke, not a treadmill).

To attain maximal gains in cardiovascular fitness, an activity must incorporate large muscles and be performed for a prolonged period of time in a continuous fashion. Examples include walking, swimming, jogging, and cross- country skiing.

Before an individual is put on an exercise program cardiopulomonary risk factors must be assessed. The PAR-Q can be used to identify patients for whom physical activity might be inappropriate or should have medical advice. The patient should be evaluated for signs & symptoms suggestive of cardiopulmonary disease or coronary artery disease. These include ischemic pain; discomfort in the chest, neck, jaw, arms; shortness of breath at rest or with mild exertion; dizziness or syncope; orthopnea or paroxysmal nocturnal dyspnea; ankle edema; palpitations or tachycardia; intermittent claudication; known heart murmur; or unusual fatigue or shortness of breath with usual activities. Other coronary artery risk factors that should be screened for in the history, examination, and with laboratory tests include the following: age - men >45, women > 55; family History - MI or sudden death < 55 yrs of age in father/brother or <65 in mother/sister; current cigarette smoking; hypertension -> 140/90; hypercholesterolemia - total serum cholesterol > 200 mg/dL or HDL < 35 mg/dL; diabetes mellitus; or a sedentary lifestyle.

Patients risk with exercise can be ranked by the following stratification approach: (1) Apparently healthy: asymptomatic & no more than 1 major coronary risk factor; (2) increased risk: signs & symptoms of cardiopulmonary and metabolic disease or two or more coronary risk factors; or (3) known cardiac, pulmonary or metabolic disease. Patients with increased risk or with known disease must first be cleared for rehab by appropriate physician. Electrocardiogram is obtained for patients at risk.

To achieve a cardiorespiatory training effect, it is necessary to train at 50 to 85% of VO2 max. However, unfit individuals should begin at approximately 40 to 50% of functional capacity (VO₂max) and gradually increase training intensity over time. This may vary greatly in the clinical population dependent upon the degree of deconditioning and initial level of cardiovascular fitness. Because a direct relationship exists between heart rate and exercise intensity, heart rate can be effectively utilized to prescibe and monitor intensity. Training range may be estimated by the Karvonan method, or assessed during exercise stress test.

• ACSM Guidelines for Exercise Testing and Prescrintion. 5th Ed, Williams & Wilkins 1995.
• Hornberg, J. Exercise Physiology Guidelines. Rehabilitation Guidelines for Chiropractic, Chiropractic Rehabilitation Association, 1992, pages 11- 18.

ADLrquote s are defined as activities causing physical demands that occur on a regular basis due to the patientrquote s lifestyle, home-life, hobbies, or demands of employment.^(1,) Repetitive micro-trauma from home or occupational overstrain (e.g. lifting, sitting, material handling, etc.) is a major factor in soft tissue injury (see biomechanics #6).

Patients should be educated about how to modify their ADLs of demands of employment (DE) at the outset of care. Advice and education are important in the treatment process.⁽²⁾ Advice about body mechanics and posture; chairs and work stations; sleep positions, pillows, matresses; lifting and carrying techniques; pushing and pulling; and common household chores.

Appropriate lifting technique should be taught to patients. This may include advice about maintaining the normal lordosis; not lifting after prolonged flexion or rising from bed; co-contracting back and abdominal muscles during lifting; reducing the lever arm; and avoidance of twisting ^(3). Ergonomic workstation advice might include suggestions about seat and arm rest height; seat angle; use of a document holder; computer monitor height; light source and screen glare; etc.⁽⁴⁾

The dangers of deconditioning and the positive effects of activity should both be emphasized. Reassurance about the benefits of low-stress activities like swimming, walking or biking should be recommended as soon as possible.^(2,5)

History taking is the most important part of the diagnostic process. History alone can reliably carry out diagnostic triage with a high degree of sensitivity and specificity. The goal of the diagnostic triage is to classify patients into meaningful treatment categories. For instance, in the lower back, history can rule out lquote Red Flagsrquote of disease, diagnose relevant pathoanatomy (e.g. Nerve Root Compression) and determine if pain is of a mechanical origin.

Red Flags of infection, tumor, severe trauma, or cauda equina syndrome should be identified. Cancer or infection should be suspected as a cause of musculoskeletal pain if any of the following are present - past history of cancer, unexplained weight loss, fever over 100 deg F, immunosuppression, recent infection, IV drug use, prolonged use of corticosteroids, back pain not better with rest, or age over 50.

Spinal fracture should be suspected if there is a history of significant trauma, recent mild trauma in an individual over the age of 50, prolonged use of steroids, osteoporosis, or anyone over the age of 70. Any patient with red flags of serious disease should be either referred to the appropriate specialist, emergency room (e.g. cauda equina syndrome), or have appropriate laboratory or imaging tests performed.

Nerve root compression can be concluded if in the history it is discovered there are leg symptoms below the knee and in the examination there are + nerve root tension signs (e.g. + SLR or M,S, R exam).

Vital signs include blood pressure, pulse, temperature, respiration, height and weight. These serve as general screen in the clinical decision-making process.

Imaging decisions can usually be postponed until after the first month of treatment. X-rays & lab tests are generally unnecessary in the 1st month unless a "red flag" is noted.

When taking a history of a patient who may be put on an exertional exercise program, it is important to screen for cardiopulmonary risk factors (see #19).

The McKenzie protocol ^(1,2) is a rehabilitation approach that explores patient generated movement and positioning strategies during both the acute and chronic phase. The McKenzie approach predicates treatment on mechanical and symptomatic responses to dynamic and static spinal loading. Consistent with the principles of rehabilitation, independence through self-care is the primary goal. Activity therapy, especially in the acute phase, minimizes the potential for the physical and psychological sequela of disability (deconditioning and abnormal illnes behavior).

Based upon mechanical and symptomatic responses to loading, it is determined if a patient can be included in one of three syndrome patterns of conditions amenable to "mechanical therapy" that McKenzie terms the posture, dysfunction, and derangement syndromes.

In the McKenzie protocol, end-range loading is used as both a diagnostic and therapeutic tool. Progression of treatment is provided with progressive increase of forces, as necessary, providing continuous passive spinal motion strategically performed by the patient.

• Jacob G, Barenburg D, Starler S, Therapeutic Loading Criteria; Aspen Publishing (in press)
• Jacob G, McKenzie RA. Mechanical and Symptomatic Responses to Spinal Loading. Chapter in Rehabilitaiton of the Spine, C. Liebensen editor. Williams & Wilkins, 1996.
• McKenzie, RA. The Cervical and Thoracic Spine: Mechanical Diagnosis and Therapy. Waikanae, New Zealand. Spinal Publications, 1991.
• McKenzie, RA. The Lurnbar Spine. Mechanical Diagnosis and Therapy. Waikanae, New Zealand. Spinal Publications, 1981.

D.)  REHABILITATION TREATMENT

23)    Stabilization exercise

Stabilization exercise refers to trunk exercises which maximally activates key stabilizing muscles while minimizing joint strain. The focus is on reducing overstress within the locomotor system so that spinal segmental stability can be re- established.

The goal of spinal stabilization is to promote spinal stability during activities of daily living and demands of employment. This is accomplished by training the patient to control posturally destabilizing forces by reconditioning key spinal stabilizers through a series of progressively more complex movements focusing on neuromuscular re-education (coordination, balance), endurance training, and strength.

Spinal stabilization is generally initiated during the subacute stage. Exercises progress from nonweight-bearing stable positions to functional weight-bearing positions. Labile surfaces such as rocker board or gymastic balls are utilized to increase the stabilization demand. Exercises initially focus on the promotion of lumbar and lumbopelvic stability and then progress to exercises involving distal mobility. The objective of initial training is the development of motor control: speed of contraction, coordination and endurance. Through repetitive training, motor control progressively improves until contraction of the spinal stabilizing muscles becomes automatized during activities of daily living and demands of employment.

Exercises are presented in a track format for ease of learning. The track provides a pathway for gradually

progressing to more challenging exercises. Should the patient loose appropriate motor control with the progression to more advanced exercises, the doctor can prescribe that the patient "peel back" to easier movements within the track.

A simplified example of a spinal stabilization track is the progression from an isometric co-contraction of deep abdominal and spinal muscles, to co- contraction combined with arm movements, to progression involving alternating elevation of opposite arms and legs ("the dead bug").

• Hyman, J. and Liebenson, C. "Spinal Stabilization Exercise Program" in C. Liebensenrquote s Rehabilitation of the Spine: A Practitionerrquote s Manual, 1996, pp 293-317.
• McGill SM. Low back exercises: prescription for the healthy back and when recovering from injury. ACSM Resource Manual - 3rd ed. Williams & Wilkins, Baltimore (sched 1997).

Proprioceptive neural facilitaiton (PNF) focuses on neuromuscular control of movement. It's signature phrase is proximal stability before distal mobility. The workhorse techniques of PNF are specific Manual Resistance Techniques (MRT) that promotes or stimulates the response of the neuromuscular mechanism through stimulation of appropriate proprioceptors. More specifically, PNF promotes normal, natural neuromotor response in individuals who display identified neuromuscular deficiencies. The physiologic principles of this therapy include: (1) Autogenic Inhibition, (2) Reciprocal Inhibition, (3) Successive Induction, and (4) Irradiation. In a clinical context, PNF techniques are commonly used to relax overactive muscles or stretch shortened muscles and their fascia. Depending upon the clinical application, a number of techniques may be used. Two of the most common are hold-relax and contract-relax. PNF techniques may serve as a bridge to active care since they are easily tolerated like passive methods, but also involve the patient in an active way, thus limiting patient dependency.

A number of facilitation techniques are utilized. These include patient pre-positioning, hand contacts, tissue stimulation, and verbal cues or commands. To progress a patient, procedures are used which include passive modeling, active assistance, isometric holds vs resistance, concentric motion vs resistance, and eccentric motion vs resistance.

• Voss DE, Ionta MK, Meyers, BJ: Proprioceptive Neuromuscular Facilitation , Patterns and Techniques. 3rd Ed. Harper and Row, Publishers; Copyright 1985, Page xvii.
• Liebensen, C. "Manual Resistance Techniques and Self Stretches for Improving Flexibility/Mobility" in C. Liebensenrquote s Rehabilitation of the Spine: A Practitioners Manual, 1996, pp. 253-292.

Proprioception is the ability to determine joint position. Proprioceptive ability should be a major consideration when developing a rehabilitation program.⁽¹⁾ because proprioception is central in performing physical skills correctly and safely. ^(1,2,3,4)

Conditions that may affect the relative proprioceptive skill of a patient include age, joint degeneration, joint laxity, and prior injury. Although physical awareness at a conscious level may increase performance and avoid medical problems,^(5,6) many patients are not conscious of proprioceptive information after a skill pattern is learned.⁽⁷⁾ This awareness returns to conscious control when the patient has altered efferent information that affects a skill pattern.^(2,6) Biofeedback that differs from the healthy norm could create motor patterns that are not used with the healthy body, leading to problems when the patient is returned to their activities of daily living.⁽²⁾

Proprioceptive training is designed to produce concentrated stimulation of mechanoreceptive afferents from the foot/ankle region to the central nervous system in order to re-educate subcortical motor programs. This training was originally proposed by Freeman and Wyke⁽⁸⁾ in rehabilitating ankle sprain patients. The basic training involves stable positioning of the foot (i.e, "the small foot") in order to simulate proprioceptors and mechanoreceptors with the aim of re- educating both lumbar and cervical spine pain patients who have faulty postural patterns. ⁽⁹⁾ Treatment objectives include re- programming basic sensory-motor pathways and increasing the speed and response of reflex muscle contraction. Specific procedures and protocols include training on labile surfaces such as balance boards, balance shoes, trampolines, exercise balls, Styrofoam rolls etc. Therapeutic applications of unexpected pertubations. i.e, pushes to the patient facilitate the training.

Muscle imbalances are noted by the presence of both tight and weak muscles in an individual. The first step in the restoration of normal muscle balance is to adjust/mobilize dysfunctional joints to normalize neuromuscular pathways. This is followed by stretching or relaxation of tight or hypertonic muscles. Then the patient may be taught strategies they can utilize to more effectively carry out movement patterns in a coordinated fashion. Facilitation techniques such as rhythmic stabilization may be necessary prior to the institution of these strategies.

If tight muscles and weak muscles are not improved by the above measures, then subcortical reflex training may be necessary (see #25).

• Lewit K. Manipulative therapy in rehabilitation of the motor system. 2nd edition. London: Butterworths, 1991.
• Liebensen, C. Active Rehabilitation Protocols. In Rehabilitation of the Spine: A Practitionerrquote s Manual, Liebenson C (ed). Williams and Wilkins, Baltimore, 1995, pages 355-390.

Strength is the capacity of a muscle or muscle group to generate force.⁽¹⁾ Training involves applications of resistance protocols designed to increase ones capacity to exert a higher maximal force against a known resistance. Strength is dependent upon both neural and muscular function. Initial strength gains are the result of neural changes, with secondary strength gains the result of muscular hypertrophy.^(2,3) Components for the prescription of a strength training protocol include frequency, intensity, volume, and duration of training, and mode of activity.^(4,5) Depending on the clinical goals of the protocol, these variables may be manipulated in such a way to elicit different training effects persuant to the SAID principle (specific adaptation to imposed demands) which recognizes that the human body responds to given exercise demands with a specific and predictable adaptation. ^(5,6)

Strength training can be provided a number of ways^(5,7) depending upon clinical objectives:

(1) Isometric training is performed against fixed resistance without movement of the joint. The muscle maintains a fixed length, with the tension generated equal to the resistance encountered. Isometrics are probably the least effective form of strength training, but is the safest because there is no joint motion. Strength gains occur at the joint angle plus or minus 10 degrees due to physiologic overflow. Therefore, multiple angle isometric training to strengthen a joint through ROM is required.

(2) Isotonic means a joint is moving through a range of motion against the restance of a fixed weight. Isotonic work consists of concentric and eccentric contractions. Concentric occurs when the joint angle decreases, the muscle shortens and the weight is lifted. Eccentric occurs when the muscle resists its lengthening and the weight is lowered. Eccentric contraction is more stressful than concentric, but also results in greater strength gains.

Application of isotonic protocols are divided into constant or variable resistance. An example of constant resistance isotonic exercise is the use of barbells. As the weights are lifted and lowered, the resistance remains the same. Variable resistance isotonic exercises requires use of commericial machinery such as Nautilus or Eagle that are engineered with a cam to cause change in the length of the lever arm. Although the weight is fixed, resistance varies through the range.

(3) Isokinetic exercise is an accomodating variable resistance, in which the speed of motion is set and the resistance accomodates to match the applied force.

Strength training is dependent upon threshold/overload and progression. An overload stimulus demands that the exercised region work harder than normal. Strength gains are expected if a muscle is trained at or above 90% of the MVC for the muscle.⁽⁸⁾ This provides both neurofacilitative and hypertrophic benefits. Progression allows for the gradual increase of overload across time. There are a variety of protocols such as Delorme- Watkins and Zinovieff, among others, that manipulate the above variables in order to accomplish desired clinical objectives.

The employment of strength training in the rehabilitation of functional pathology places special emphasis on trunk function. In the normal spine, a "hierarchy" of torso strengths exist with extension > flexion > lateral bending.⁽⁹⁾ The agonist/antagonist strength ratios for the trunk musculature vary by assessment ratio (isokinetic, isometric, etc.) but the most commonly cited ratio of trunk extensor to flexors is 1.3:1 for healthy individuals.⁽⁹⁾ Isotonic and isokinetic machines can be used to facilitate torso strengthening. Training should be as specific as possible to prepare for activities of daily living and employment demands.

Strength training a patient is different than training a healthy individual due to risk of reinjury. Proper form must be trained so as to maintain proximal joint stability and thus avoid high repetitive strain to vulerable joints. In particular, abnormal muscle substitution patterns should be identified and corrected before either resistance or repetitions are increased to injurious levels.(10)

Muscular endurance is defined as the ability of a muscle or muscle group to work at less than a maximal level for an extended period of time.⁽¹⁾ Improvements in endurance are demonstrated from a conditioning program that applies low resistance and high repititions against the muscle. Endurance training should occur with resistance of less than 40% of MVC. The development of adequate levels of muscular endurance affords the patient the ability to to perform repeated muscular contractions or work tasks for a prolonged period of time. As with strength, endurance training follows the SAID principle.

One example of muscular endurance training would be circuit weight training, performing 10 to 15 repetitions at each station with a 15 to 30 second rest between stations. There are minimal cardiorespiratory or aerobic training benefits from this activity; however, there can be significant increases in muscular endurance.

• Amierican College of Sports Medicine is Guidelines for Exercising Testing and Prescription-- Fifth Edition, Williams & Wilkins, 1995.
• Ito, et al. Lumbar Trunk Muscle Endurance Testing: An Inexpensive Alternative to a Machine for Evaluation, in archives of Physical Medicine and Rehabilitation, Volume 77, January 1996.
• Alaranta H, Hurri H, Heliovaara M, et al: Non-dynametric trunk performance tests: Reliability and normative data. Scand J Rehab Med 26:211, 1994.
• Boucher, JP. in Rehabilitation of the Spine, by Craig Liebenson(ed.) Aspen Publishers, 1996; Pages 48-49.

Flexibility training refers to exercises aimed at enhancing muscle relaxation, myofascial extensibility, and joint mobility. Traditional methods include static stretching, dynamic/ballistic stretching and proprioceptive neuromuscular facilitation techniques. Further, joint mobilizaton, traction, and joint manipulation are often used to improve joint mobility.

Exercise progression begins with passive range of motion, moving to passive assistive, passive resistive, active assistive, and active resistive.

Recent approaches to improve flexibility emphasize both post-isometric relaxation and reciprocal inhibition techniques. Static and ballistic stretching have been de-emphasized (see PNF #24)..

Appropriate techniques require precise psychomotor skills in patient positioning, application of resistance (force, duration and vector) and doctor position.

• Evjenth, O, Hamberg J. Muscle Stretching in Manula Therapy. Volume 1 and 2. Alfta Rehab, 1984.
• Liebenson CS. Manual Resistance Techniques and Self-Stretches for Improved Flexibility/Mobility in Rehabilitation of the Spine: A Practitionerrquote s Manual, Liebenson C (ed)., Williams and Wilkins, 1996, pages 253-292.
• Alter, M. Science of Flexibility and Stretching. Human Kinetics, 2nd edition, 1996.

Aerobic conditioning is the performance of activities that use large muscle groups in a continuous and sustained manner at 60 to 90 percent of an individual's maximal heart rate for greater than 20 minutes at least three days per week. Examples include distance running, aerobic dance, cycling, fast walking, distance swimming, rowing, etc.

Benefits from aerobic conditioning include decreased risk for heart disease, diabetes, hypertension, obesity, stroke, peripheral vascular disease, cancer, osteoporosis, and low back pain. The physiologic effects of aerobic conditioning include increased oxygen uptake, increased cardiac output during exercise, decreased resting heart rate, increased stroke volume, increased cellular sufficiency (A -V02 difference), decreased concentrations of LDL, and increased HDL cholesterol.

• American College ot Sports Medicine's Guidelines for Exercising Testing and Prescription--Fifth Edition, Williams & Wilkins, 1995.

McKenzie protocols explore self-treatment movement strategies. The principles underlying treatment for those patients who can be classified within one of the McKenzie syndromes are the "3 Rrquote s," Re-education of posture for the Postural syndrome, Remodeling adaptively shortened tissue for the Dysfunction syndrome, and Reducing deranged tissue in the Derangement syndrome.

Both diagnosis and treatment is based upon mechanical and symptomatic responses to static and dynamic end-range spinal loading. The treatment protocol progresses from active, patient-generated movement to mobilization, to mainipulation.

• McKenzie RA. The cervical and thoracic spine: mechanical diagnosis and therapy. Waikanae, New Zealand, Spinal Publications, 1991
• McKenzie RA. The lumbar spine: mechanical diagnosis and therapy. Waikanae, New Zealand, Spinal Publications, 1981

Patient education involves the utilization of various clinical methods to teach patients that they have to assume responsibility for their own health and serve as a critical member of the health-care team if significant and positive changes in their long-term health status is to be reasonably anticipated.

According to AHCPR, patient reassurance, advice, and activity modifications, are the cornerstones of early care.

If no red flags are detected during evaluation, patient education begins with reassurance that there is no serious medical disease and that the natural history of the conditon is excellent. The second step is to educate the patient that the goals of care are both pain relief and reduction of activity intolerance. Finally, the patient is educated that recovery does not mean absence of pain but rather restoration of function. In fact, recurrences are to be expected. However, the patient will be taught self-treatment for control of their symptoms.

Advice about activity modificaitons should be given at the beginning of care. Such advice includes sitting and lifting recommendations. Depending on the clinical presentation, patients should be encouraged that walking, swimming, biking, and other similar activities are generally safe and that bedrest is an inappropriate treatment. Bedrest should only be recommended if it is the only position that offers relief. It is not a treatment for pain, but rather a result of severe pain.

Therapeutic procedures that are physically provided by a care-giver. These include manual procedures such as chiropractic adjusting, trigger point therapy, and cross friction massage. Passive modalities include all procedures applied by a care-giver to a patient who "passively" receives the care. Examples include ultrasound, heat, and cold. Passive modalities have specific proven or theoretical physiologic effects. Their application should be consistent with therapeutic effects and objectives of each phase of recovery. The physiologic effects and derived clinical benefits of passive modalities are time and intensity limited. Intensity is generally inversely proportional to patient recovery.

An overemphasis on passive modalities beyond the early stages of acute care reflects the dichotomy between typical chiropractic practice and emerging rehabilitation standards. Passive modalities such as thermal or electrical physical agents applied for pain relief or to reduce inflammation have a limited role in the management of musculoskeletal problems. There is a definite tendency to overemphasize the promotion of tissue healing and reduction of inflammation which results in overutilization of these approaches. The danger of the injury/inflammation model is that it promotes overutilization of physical agents which in turn promote patient dependency, illness behavior, and both physical and psychological deconditioning.

The overuse of passive modalities combined with protracted treatment regimes is a direct result of the failure to apply the principles of rehabilitation from day one. The Mercy document says, "It is beneficial to proceed to rehabilitation phase as rapidly as possible, and to minimize dependency upon passive forms of treatment/care." (p110) The implication is that patient dependency is to be avoided by transitioning as early as possible to self-treatment approaches. This is especially true if two suggested trials (1-2 weeks each) of manipulative (manual) therapy fail to produce any positive results. "All episodes of symptoms that remain unchanged for 2-3 weeks should be evaluated for risk factors of pending chronicity. Patients at risk for becoming chronic should have treatment plans altered to de-emphasize passive care and refocus on active care approaches^{." (1, p.125)}

The British Clinical Standards Advisory Group Back Pain Guidelines are even stronger in their opposition to the prolonged passive care.⁽²⁾ "At present, the main emphasis of physical therapy for back pain is on symptomatic relief of pain, despite evidence that many of the modalities used are ineffective. Symptomatic measures to control pain are required but this should be used to embark on active rehabilitation rather than be seen as an end in itself."⁽²⁾ They recommend that "there should be a change of emphasis and redirection of resources from symptomatic treatment, to the provision of active rehabilitation."

The Agency for Health Care Policy & Research actually had less direct advice about this controversy.⁽²⁾ But, it is clear that physical agentrquote s role is being reduced. "Physical modalities such as massage, diathermy, ultrasound, biofeedback, and transcutaneous electrical nerve stimulation (TENS) also have no proven efficacy in the treatment of acute low back symptoms."^{(2, p.12)}

Once subacute,the patient should be transitioned from passive modalities to stabilization/motor control exercises (see # 23) followed by other components of rehabilitative care including torque production (strengthening) technniques.

Conditions that may arise while the patient is under care in the facility; these conditions may be pre-existing (e.g. a patient with diabetes mellitus), or may be caused by the rehabilitative care itself. Treatment may range from simple first aide such as ice application for acute strain, to basic life saving techniques such as CPR for heart attack or the Heimlich maneuver for airway obstruction.

All rehabilitation facilities should have a pre-existing, established course of action for any health care problem that may arise, with appropriate equipment and personnel trained in emergency care available at all times.

• Arnheim D. Modern Principles of Athletic Training, Times Mirror/Mosby, 1996.
• Armitage-Johnson SL. "Preparing for Emergencies" in Essentials of Strength and Conditioning, Baechle TR editor, National Strength and Conditioning Association/Human Kitetics pub, 1994
• Heartsaver Manual: A Student Handbook for Cardiopulmonary Resuscitaiton, American Heart Association.

E.)  MANAGEMENT TOPICS

35)    Timeliness, indications & contraindications in the rehabilitation of condition specific spinal disorders

Overall rehabilitative case management follows a quality assurance model for common spinal disorders. Diagnostic triage should occur at the initial evaluation. History and examination should evaluate for risk factors, rule out serious pathology and distinguish nerve root problems from simple back pain. Management of spinal disorders should gradually move from passive applications to increasingly greater active intervention as quickly as possible. For example, depending upon clinical presentation, active care may begin in the acute phase with McKenzie applications, or in the subacute phase with stabilization exercise.

According to a recent North American Spine Society consensus paper on rehabilitation, tertiary care facilities are defined as being interdisciplinary; having a large, behavioral component; and utilizing ongoing outcomes assessment. They should be considered for referral in patients who have remained symptomatic for 4-6 months and have failed treatment efforts which included a trial of manipulation, rehabilitation, psychological referral & alternative symptomatic procedures. This constitutes about 5-8% of the pain population.

Office composition refers to considerations such as those listed below for the development of a rehabilitation facility. The following elements help to define these issues:

a. Equipment needs.

b. Optional testing instrumentation.

c. Space requirements.

d. Staff Considerations and training issues.

e. Multi-disciplinary options in a rehabilitation setting.

f. Patient file management.

g. Referral source communication/marketing issues.

h. Third-party payor and industrial contracts.

i. The use of waiver/release forms.

j. Use of questionaires and special tests to reduce risk.

k. Database implementation.

1. The use and development of clinical guidelines.

m. Patient scheduling logistics.

n. Quality control/Assurance Issues.

Other considerations include:

Facility Development: Logistics necessary to prepare the physical structure/plant to be able to efficiently deliver rehabilitation-related services.

Practice Management: The component necessary for health care professionals to implement in order to increase their ability to deliver their specitic services to individuals who meet selection criteria for that specific service.

Legal Issues: Methods for reducing the potential for risk/liability in the rehabilitation setting.

Outside Referrals: The appropriate referral procedure for a patient to enter a rehabilitation facility, or for appropriate supportive outside services.

• Mayer TG, Polatin P, Smith B, Smith C, Gatchel R, Herring SA, Hall H et al. Contemporary concepts in spine care: spine rehabilitation - secondary and tertiary nonoperative care. Spine 20:18;2060-2066, 1995.

Appendix A:

Participants who attain a certificate for 100 hours postgraduate study in rehabilitation will master the following:

1. Will be able to introduce effective, time-limited active care into their practice profile.

2. Will be able to rehabilitate common NMS problems of spinal origin (this will include early activation of the acute patient, as well as subacute, chronic and chronic recurrent conditions).

3. Will be able to render rehabilitative care in a low tech, office-based environment.

4. Will know when and how to refer to a tertiary rehabilitation facility and how to co-treat with other health care professionals (e.g., psychotherapists).

5. Will be able to successfully transition patients to unsupervised exercise programs at home or in a health club environment.

6. Will be able to manage cases based on reliable and valid outcome measures.

7. Will be able to demonstrate a working knowledge of appropriate consensus-based management guidelines.

8. Will be able to effectively educate patients concerning basic activities of daily living.

9. Will have attained a basic competency in the psychomotor skills specific to the variety of evaluation and treatment procedures outlined in the core curriculum.

Core material for the first 100 hours of rehab course work consists of the following topics. The American Chiropractic Rehab Board (ACRB) maintains multiple examinations for this course. Among the examinations, the distribution of test questions from each topic area averages:

I) General

1 -    1) Functional pathology of the motor system (the interrelation between dysfunction of the muscular, articular, & motor control systems)

4 -    2) Biopsychosocial approach: identification of physical & psychosocial risk factors/predictors

3 -    3) Case management: introduction to assessment/treatment protocols which integrate muscle & joint dysfunction

3 -    4) Quality assurance guidelines, risk management & facility development

2 -    5) Cost effectiveness: ethics of health care & co-dependence issues

II) Basic Science

3 -    6) Clinical biomechanics (stress/strain curve)

3 -    7) Principles of human locomotion, including arthrokinematic events & kinesiology

4 -    8) Exercise science

1 -    9) Motor learning

1 -    10) Behavior modification

III) Assessment

4 -    11) Functional testing (physical performance of isolated muscles/joints)

4 -    12) Outcomes management: objective measurement of soft tissue injury

4 -    13) Biomechanics & kinesiopathology of common tasks, including mechanism of injury, ergonomics & repetitive strain.

4 -    14) Evaluation of muscle imbalance (identification of tight & weak muscles)

5 -    15) Evaluation of motor control/movement patterns

4 -    16) Evaluation of strength

3 -    17) Evaluation of endurance

3 -    18) Evaluation of flexibility

3 -    19) Evaluation of aerobic capacity/fitness, including cardiorespitory risk factors with exertional activities

1 -    20) Activities of daily living & Health habits

1 -    21) Diagnosis: history, vitals, imaging

2 -    22) Introduction to McKenzie principles & assessment

IV) Rehabilitation Treatment

4 -    23) Stabilization exercise

3 -    24) PNF (psycho-motor skills development)

3 -    25) Propriosensory training

4 -    26) Rehabilitation of muscular imbalances

4 -    27) Strength training

2 -    28) Endurance training

2 -    29) Flexibility training

2 -    30) Aerobic conditioning

1 -    31) Introduction to McKenzie protocols

3 -    32) Patient education: transformation from passive recipient to active participant -- how to improve compliance & motivation

3 -    33) Manual procedures: chiropractic adjustments, soft tissue procedures (e.g. trigger points) & time limited passive modalities.

2 -    34) Urgent care issues in the rehab facility

V) Management Topics

2 -    35) Timliness, indications & contraindications in the rehabilitation of condition specific spinal disorders

2 -    36) Functional restoration/ multidisciplinary (office composition, outside referral)

Appendix C

Sample Test Questions:

Delphi Topic 6. Answer A.

The stress/strain curve for a viscoelastic tissue such as a ligament:

b. does not give any indication of the strength of the structure.

c. does not give any indication of the stiffness of the structure.

d. does not give any indication when microfailure of the structure may start to occur.

The molecular basis of muscle contraction involves:

a. active shortening of the sarcomere as a result of actual shortening of ONLY the myosin filaments.

b. actual shortening of ONLY the actin filaments.

d. coiling of the sarcomere, but not shortening of the sacromere.

Which of the following is an example of a "General Health Questionnaire?"

a. Oswestry LBP Disability Questionnaire

b. Neck Disability Index

c. Beck Depression Index

Pelvic crossed syndrome is characterized by which of the following muscle dysfunction?

a. tight hip flexors/tight hip extensors & strong gluteals/strong abdominals

c.weak hip flexors/weak lumbar erectors & tight abdominal/tight gluteals

d. tight gluteus medius/tight quadratus lumborum & weak hamstrings/weak quadriceps

In a faulty (altered) shoulder abduction movement pattern, the muscle likely dysfunction would be:

a.tight/overactive lower trapezius and weak/inhibited upper trapezius & levator scaplae

b. tight/overactive lower trapezius and weak/inhibited deltoid

c. tight/overactive deltoid and weak/inhibited lower trapezius

According to the 4th edition of the AMA Guides, which of the following assessment techniques MOST accurately measures lumbar ranges of motion?

(A) Visual

(B) Goniometric

(C) Inclinometric

(D) Tape measure

Which of the following is a major coronary risk factor according to the 4th edition of the ACSM Guidelines for Exercise Testing and Participation?

c. family history of coronary heart disease in parents or siblings over the age of 50

d. elevated total cholesterol above 200 mg/dl

According to the AHCPR, xray studies of the low back are not recommended during the first month of symptoms EXCEPT if:

(A) they are provided as part of a comprehensive full spine study

(B) examination reveals loss of lumbar range of motion

(C) red flags are present

(D) the patient is pregnant

A patient whose pain is not provoked by any examination procedures but is worse after prolonged static activities is classified with which of the following McKenzie diagnosis:

(A) derangement syndrome

(B) postural syndrome

(C) dysfunction syndrome

(D) ligamnetous syndrome

In a spinal stabilization program, all of the following will be trained except:

(A) kinesthetic awareness

(B) coordination

(C) strength

(D) flexibilty

Delphi Topic 25. Answer D

To best improve sensorimotor coordination, exercises should be performed until:

(A) post-exercise soreness develops

(B) volitional muscle fatigue

(C) heart rate reaches aerobic minimum

D) patient is unable to maintain proper form

During which set of the Delorme-Watkin technique of isotonic resistance exercise does the patient attempt to perform 11 repititions?

(A) first and third sets

(B) second and third sets

(C) third set only

(D) fourth set only

Delphi Topic 29. Answer A.

b. muscle tightness

c. interneuron dysfunction

d. limbic system dysfunction

Which of the following BEST describes why measuring exercise heart rate during aerobic activity is an effective means by which exercise intensity can be measured?

(A) There is a direct relationship between basal metabolic rate and cardiovascular function.

B) Oxygen uptake and metabolic function must be elevated to that the heart can accommodate systemic circulation.

(C) There is a linear relationship between heart rate and oxygen uptake.

(D) As the work demand increases, heart rate may remain unchanged, thus effecting oxygen uptake.

Centralization of sciatic radicular pain:

(A) is rarely effected by spinal loading stimuli.

(B) is a common consequence of postural neglect.

(C) that occurs as a result or therapeutic exercise is a good sign.

(D) is a red flag according to AHCPR guidelines.

Rehabilitation of disabling chronic back pain:

(A) Is more difficult with degenerative disc disease.

(B) Monitors progress with qualifiable outcomes.

(C) Commonly incorporates passive modalities.

(D) Should include functional goals that promote return to work.

Appendix D:

TOPIC & REPORTING AREAS

Successful completion of the ACRB examination is attained with a minimum score of 70%. If this level is not achieved, to facilitate further study, the testing agency will report to the candidate the relative scores of Delphi topic areas. For purposes of reporting, the 36 Delphi topic areas are combined into 15 "reporting areas" as follows:

35, 36 15

Appendix E

DELPHI PROCESS

Began in 1994 when it was suggested that a Delphi process be utilized to achieve concensus on the educational requirements for chiropractic rehabilitation.

On May 13, 1995, the first Delphi meeting on Chiropractic rehabilitaiton was held in Dallas, Texas under the direction of John J. Triano, DC. Representatives of all chiropractic College offering post-graduate study in rehabilitaiton were invited to attend. Participants included 11chiropractors including representatives from NWCC, CMCC, WSCC, LACC, Palmer, NYCC, Parker, and Cleveland-KC. At this meeting the concensus process was outlined with agreement on the following future steps:

• create matrix of rehabilitation course information taught from syllabi & outlines
• meet to prioritize matrix by nominal group process
• Contact Subject Matter Experts (SME) for content information
• Create operational definitions of Delphi items
• Incorporate multidisciplinary SME suggestions into Delphi process
• Establish knowledge, skills, and attitudes necessary to be a rehabilitation specialist in chiropractic
• Publish a candidates guide of the minimum competencies required for the Diplomat status

Following this meeting, syllabi & outlines were collected from all colleges teaching rehab as well as other related educational programs (i.e. CARF, APTA specialty council, NSC curriculum).

At the July 3, 1995 (Washington D.C. Centennial) meeting:

• Was attended by representatives of NWCC, CMCC, WSCC, LACC, Palmer, and Cleve/Parker.
• Matrix presented & Matrix items voted on by nominal group process resulting in Delphi topics for each of the three 100 hundred hour programs
• Agreement from all participants to invite SMErquote s to flush out definitions, references & a key outline for each Delphi topic.
• Agreement to meet again as soon as SME material was collated.

Following the July 3, 1995 meeting , SME material began flowing in throughout the rest of 1995 and early 1996. The Delphi topics were forwarded to the newly established ACRB on December 13, 1995 at the request of ACA Rehab Council President in order to facilitate implementation of the Delphi topics into the testing process. On December 30, 1995 confirmation was received from the the ACRB president that his board recommended the Delphi committee proceed with Delphi work.

After additional SME input, it was determined by that SME material was sufficient to allow for collation of the material and the next Delphi meeting was scheduled. At this meeting:

• Representatives from NWCC, CMCC, WSCC, LACC, Palmer, Parker, Cleveland-KC, and ACRB attended.
• Delphi items were moved, merged, added or deleted.
• Learning objectives were established for each of the three years.
• Operational Definitions with references were assigned to Delphi committee members with ACRB liaison appointed facilitator. Selected references based upon representative literature from indexed-peer reviewed sources.

Since the meeting:

• Input was received and sent back to each member for review
• Input and critque of input was collated into the document
• To ensure fairness in the process, the document was sent for approval to rehab board members (Diplomates of the ACRB) and the chairperson of college rehab programs.

At the current time (December, 1996), all rehab course instructors have been requested to review the document. Their input will be included in the proceedings of the next Delphi meeting later in 1997.