1) Case management
(detailed integration & prioritization of treatment protocols
muscle & joint dysfunction)
Sub-acute, chronic, or recurrent pain patients who have no
"red flags" of
serious disease should be treated with the aim of reducing
intolerancerquote s (1,2). Manipulation of joints or
self-generated end range
joint mobilization procedures such as McKenzie methods may be
acute syndrome to relieve pain, restore function, and reduce
(2). Starting as early as 2 weeks and certainly no later than 6
exercise to address specific muscular performance or motor
control deficits is
Chiropractors wanting to address muscle and joint dysfunction
as part of a
comprehensive approach to rehabilitation of the motor system
should be aware
the proven relationship between dysfunctions of endurance or
motor control and
various pain syndromes. For instance, poor static endurance of
extensors has been correlated with first time episodes of lower
back pain as
as increased recurrence rates (5,6). Deep neck flexor weakness
posture has been found to discriminate either chronic or
from individuals without headache (7,8). A faulty scapulohumeral
found to correlate with shoulder pain (9). These are just a few
of the relationship between muscular or motor control dysfunction
joint pain syndromes.
The three key methods of treatment are advice, manipulation
Advice is the basic starting point for reducing the strain modern
on our musculoskeletal system. Manipulation is the treatment of
specific tissue dysfunction involving reduced mobility or adverse
joint blockage, trigger points). Remedial exercise is the
treatment of choice
faulty movement patterns.
The goal of remedial exercise is to improve motor control in
daily living (ADL's) and demands of employment (DE). The problem
is that it is
time consuming. Therefore, the indication must be carefully
determined or else
both patient and therapist will be frustrated. Indications for
prediction or history of relapses and the presence of faulty
related to symptoms.
When training a patient there are certain stages to keep in
the patient how to isolate their "functional training
range". This is the
painless movement they can produce & control with good
is to expand it to include their ADL's & DE.
Motor control starts with kinesthetic awareness on a conscious
teaching a patient to maintain their lordosis when lifting &
automatic or subcortical motor control. An example of the latter
posture during sitting, standing or walking. This subconscious
motor function is important because injuries usually occur due to
4 keys to Training
1. Postural advice to learn to produce & control simple
movements within the functional range
2. Manipulation to expand the Functional Range
3. Sensory Motor training for reflex activation of improved motor
4. Stabilization training to learn to produce & control
challenging movements within the functional range
Common errors that occur during many rehabilitation routines
are easy to
avoid. Strengthening exercises should be avoided until
control of the functional training range is demonstrated.
imbalances will be exacerbated since overactive, shortened muscle
for weakened muscle during strength training. Relaxation of
muscle tension by
adjustment or Post-isometric relaxation (PIR) procedures should
any strength training. All activities should be evaluated for
pattern, in particular their proximal stability
Advice generally includes recommendations about sitting,
Manipulation may include any manual intervention which
addresses a specific
tissues mobility restriction or adverse tension. Examples of such
might include thrust to a joint fixation, PIR to a muscle housing
point, or fascial release to fascial restriction.
Sensory-motor training usually incorporates exercises on
as rocker or wobble boards. The patient is usually instructed to
functional posture especially at the foot/ankle ("small foot" or
lumbopelvic regions. The addition of unexpected perturbations can
Spinal stabilization training is the most challenging
treatment for the
patient. Progressively more difficult motor skills are attempted
coordination, strength and endurance are all trained. Manual
techniques incorporating PNF principles such as passive modeling;
assistance, concentric, isometric and eccentric resisted efforts
In addition, patient positioning, proprioceptive contacts, and
verbal cues are
all specifically used to help the patient to produce and control
their functional range. Stabilization exercises may begin in a
weight bearing position, but are progressed to functional, whole
which mimic ADL's and DE as closely as possible.
1) Stanley J. Bigos, MD, Rev. O. Richard Bowyer, G. Richard Braen, MD, et al.
Acute Lower Back Problems in Adults. Clinical Practice Guideline No. 14.
Rockville, MD: Agency for Health Care Policy and Research, [AHCPR Publication No. 95-0642].
Public Health Service, U.S. Department of Health and Human Services; 1994
2) Waddell G Feder G, Mclntosh A, Lewis M, Hutchinson A (1996)
Evidence Review. London: Royal College of General
3) Haldeman S, Chapman-Smith D, Petersen DM. Frequency and
In Guidelines for chiropractic Quality Assurance and Practice
4) McGill SM. Low back exercises: prescription for the healthy
recovering from injury. ACSM Resource Manual. 3rd ed. Williams
Baltimore (sched 1997).
5) Biering-Sorensen F: Physical measurements as risk
trouble over a one-year period Spine 1984;9: 1 O6-l19.
5) Luoto S, Heliovaara M, Hurri H, Alaranta H. Static back
risk of low-back pain. Curt Biomech 10:6;323-324, 1995.
7) Watson, DH, Trott PH. Cephalgia 1993:13;272-284.
8) Treleaven S, Jull G. Cephalgia 1994:14;273-279.
9) Babyar SR. Phys Ther 1996;76:226-238.
10)Liebenson C. Rehabilitation of the Spine: A Practitioner's
Liebenson C (ed.). Williams and Wilkins, Baltimore, 1995.
A well- conceived rehabilitation management plan is the
foundation of a
rehabilitation program. The most successful assessment tool for
rehabilitation program is functional assessment which focuses on
all phases of
human movement. This should reflect the priorities expressed by
family, should be based on the results of a baseline clinical
medical conditions and neurological deficits, and should be
capabilities of the particular rehabilitation setting. The
includes a clear description of the patients impairments,
strength; explicit statements of short-term and long term
specification of treatment strategies to achieve the goals.
be clearly established among goals, especially in patients with
deficits. When developing an exercise program, three major goals
included in the patients overall health. These goals include
strength, aerobic power, and flexibility. When dealing with
musculoskeletal dysfunction, the primary goal is to increase
strength. Other factors that should be taken into account are
what stage of
healing is the patient in and is the condition acute, sub-acute
These factors will directly relate to what modalities and/or
patient will be given.
rehabilitation of the spine, Williams and Wilkins, 1996.
Acute Low Back Problems in Adults, AHCRP Guidelines No. 14,
Baechle, T. Essentials of Strength and Conditioning
B) Basic Science
2) Clinical biomechanics of vehicle trauma and
When assessing the
injuries that may have been sustained in a vehicular accident,
mechanical and biomechanical features related to the vehicle and
within the vehicle must be established as clearly as possible in
order for the
clinician to arrive at reasonable conclusions regarding the
These factors include:
1. The effects of vehicular impact; When a pulse of
impact energy is
generated from one vehicle to another or from a vehicle to a
solid object, the
vehicle may undergo sudden acceleration and/or deceleration in
motion. The speed at which the vehicle is accelerated and/or
significant implications on ultimate bodily injury of the
vehicle, and is often dependent upon factors of inertia.
2. The resultant body movements of the occupants within
Based on the presumed effects of vehicular impact, reasonable
drawn based on an understanding of biomechanics and studies on
results, of the likely movements of the occupant within the
Determination of whether various body parts underwent flexion,
compression, distension, bending, shearing, torsion, etc. can be
3. The ultimate effects to specific body tissues and
With the above two factors reasonably identified, and with an
human anatomy and biomechanics, an astute clinician can draw
conclusions of the effects the above factors may have had on
tissues. When attempting to arrive at a clinical determination
tissue damage, other mechanical and biomechanical factors must be
such as position of the occupant within the vehicle, the
preparedness at impact, application and position of seat belts,
shoulder harnesses, air bags and other vehicular protective
devices, and pre-
existing/pre-morbid physical, psychological, and social
4. The patient's complaints and the providers physical
Several recent investigations have identified a significant
increase in the
number of claims for nonexistent and exaggerated injuries of
accidents in recent years. Therefore, the veracity of patient
and disability often comes under scrutiny. The above factors, can
whether the patient's complaints and physical signs are
consistent with the
presumed tissue damage that likely occurred as a result of the
movements of the occupants within the vehicle that occurred as a
Severy DM, Mathewson JH, Bechtol CP. Controlled Automobile
Collisions: An Investigation and Related Engineering and
Can Services Medical Journal 11: 727, 1955.
Navin FPD, Romilly DP. An Investigation into Vehicle and
Subjected to Low Speed Rear Impacts. Proceedings of the
Safety Conference IV, Fredericton, New Brunswick, June 5-7,
White AA, Panjabi MM: Clinical Biomechanics of the Spine.
Lipincott Company, 1978.
Foreman SM, Croft AC; Whiplash Injuries: The Cervical
Acceleration/Deceleration Syndrome, 2nd Ed. Baltimore; Williams
Carroll S, Abrahamse A, Vaiana M. from Rand-The Institute for
Cost of Excess Medical Claims for Automobile Personal Injuries.
Derrig RA, Weisberg HI. A Report on the ABI Study of 1993
Protection and Bodily Injury Liability Claims; Coping with the
Suspicious Strain and Sprain Claims from the Automobile Insurers
-orofascial System/TMJ - Mastication
The orofascial system has mechanical and central complexities
and feed forward with problems of the locomotor system. It has
influence on 3 of the 4 basic functional reflexes as described by
are mastication, prehension and respiration. The masticatory
bodily functions; mastication, swallowing, speech, respiration
expression. The trigeminocervical nucleus is a key synapse for
information of the orofascial and neck regions.
Mandibular function requires muscle balance for the movements
depression and protrusion. Faulty movement is best observed
opening. The stabilizing role of the submandibular musculature
vital for efficient function. The temporomandibular joint (TMJ)
component which must be considered and whose function is greatly
locomotor function and postural presentation of the head, neck,
pelvis. Its anatomy consists of a two joint system where both a
motion are performed. There are three main ligaments and an
teeth and their occlusion play a minute role in comparison to the
from the cervical spine, muscles, and myofascia and nervous
Janda V. Some
aspects of extracranial causes of facial pain. Joum of Prosthetic
Vol.56, No. 4, Oct.1986
Okeson, J. orofascial Pain: Guidelines for Assessment,
Management. Quintessence Books, 1996.
Kuwahara, T. Chewing pattern analysis in TMD patients with and
internal derangement: Part II. Journ of Craniomand Pract 1995;
Rocobado,M. Biomechanical relationship of the cranial,
cervical and hyoid
regions. Crania 1983; 1:3
McNamara JA. Journal of orofascial Pain, 1996; 9: 73-90.
Gonzalez, H. Forward head posture: Its structural and
the stomatognathic system, a conceptual study. 1996; 14:1