Chiropractors have historically been interested in returning patients to normal function rapidly. Many of us have long avoided "blanket" recommendations of bed rest, immobilization and extended time off work. Our approach is now supported by recent research on neck and back problems and injuries, which emphasizes the benefits of active treatments.1-9 "Active" procedures are defined as treatments done by the patient, while "passive" treatments are done to the patient. One of the major difficulties with recommending active exercises is compliance. The active approach is effective only if the patient performs the exercise and/or stretching procedures. Patients often do not want to put a lot of work into getting themselves better. The following are a few ideas and concepts which have been found to be particularly useful in encouraging this active approach in patients.
Printed Exercise Instructions
While printed handouts are commonly available, the likelihood that a patient will do the exercises correctly based on an instruction sheet (and do them more than just a couple of times) is slim. Without direct supervision, only a small percentage of patients (usually dedicated athletes) will perform exercise recommendations regularly. Most will invest their energy only in proportion to the effort expended by the doctor. Here's the hierarchy of results that can be expected (from lowest to highest):
A generic series of exercises. It's very unlikely that these exercises will be performed more than once or twice, and it's quite possible that the patient will do them improperly.
A customized series of exercises. Using copiers and computers (or checking exercises in a booklet), some doctors design a specific set of exercises based on each patient's exam findings or symptoms. These tell a patient that the doctor has put some thought and effort into the exercises, and they are more likely to be done at least a few times.
An exercise videotape. This allows the patient to follow along at home and helps ensure better performance of the exercises. If it's generic (i.e., a "back" tape), the patient will be less likely to continue for more than a few days. Using more awkward procedures, some doctors do make customized videotapes, but these can be expensive and time-consuming.
Discussing the importance of the exercises with the patient. If the chiropractor takes some time to explain the reason for each exercise, the patient often is more motivated, and the exercises may be done several times.
Demonstrating the exercises, with observation and correction of the patient's performance. While somewhat time-consuming, this is the best way of ensuring that a patient will do the exercises and do them correctly. In fact, when the doctor (or a trained assistant) goes through the exercises with the patient, not only is there a much greater chance of the patient performing them several times, but this is an additional professional service which deserves an additional fee.
Supervision vs. Self Direction
The only way of ensuring that a patient will do any recommended exercises is to have someone monitor the patient going through the prescribed routine. A supervised exercise program has been shown to be much more effective (in terms of decreased pain, decreased disability scores and increased fitness) than unsupervised exercising in the treatment of low back pain, primarily because supervised patients complete more of the recommended exercise sessions.10
However, supervising an exercise program is a time-intensive and expensive form of treatment. The doctor must do everything possible to minimize the costs of such supervision while still making sure that the time spent in designing an active program is not wasted. This balance of supervision and cost-effectiveness can be achieved by regular monitoring of home exercise programs.
A chiropractor has a distinct advantage in overseeing an active exercise program, since the patient is usually seen for a series of treatments. These regular visits provide the perfect opportunity to monitor the home exercises. However, it is only with repeated follow-ups and some supervision that any real compliance with home exercises can be expected. The doctor must ask on every visit whether the patient is doing the exercises, and if there are any problems or difficulties. Regular "rehabilitation reviews," during which the patient is asked to demonstrate the exercises, are highly recommended. These should probably be done weekly in the early part of the treatment program. You'll quickly find out whether the patient has really been doing them! This is also a good opportunity to present additional or advanced exercises as the patient progresses. (These rehabilitation reviews are billable services for which the doctor deserves an additional fee).
Support and praise from the doctor (and acknowledgment from the staff) go a long way toward ensuring the patient will cooperate in performing the recommended exercises.
Floor-Based Exercises
Experience shows us that some people resist doing exercises which require them to lie down on the floor. The exception to this is during the early stages of an acute episode (and even then, getting down and then back up from the floor can be quite difficult). In spite of this, many doctors and therapists recommend floor-based exercises.
We must remember that lying down is not generally a functional position for the neck and back. Therefore, it may not be the best position in which to only exercise the spine. This is the well-known concept of "specificity of exercise," which means that only what you exercise improves.11 Exercises done exclusively on the floor may not necessarily improve the total function of the back when it is upright and the joints and muscles are bearing weight. Additional results can be achieved when patients are instructed to exercise in weightbearing, upright positions of sitting and standing. These exercise positions require postural awareness, giving the exercises the opportunity to stimulate and coordinate the proprioceptive control of the involved spinal support muscles.
Axial vs. Extremity Exercises
I continue to be amazed at the amount of time some patients spend doing exclusive exercises with their extremities, when their problem is primarily weakness of the muscles of the axial skeleton. It is the axial skeletal muscles which stabilize, support and move the spine. Especially in the early stages of rehabilitation, it is very important to establish good strength and coordination of the core muscles around the spine and pelvis. Patients have a limited tolerance for exercises and a limited amount of time they can devote to them. The focus of a health care professional should include the stabilization of the spinal support musculature.
That attention can later be directed to a general overall body strengthening program.
Doctors of chiropractic are in an excellent position to design and monitor active exercise procedures. With some thought and planning, it is not difficult to integrate an effective spinal rehabilitation program into most chiropractic practices. Ensuring compliance with active treatment procedures will always be a challenge, but the concepts discussed above should be of some help.
References
When sports chiropractors first appeared at the Olympic Games in the 1980s, it was alongside individual athletes who had experienced the benefits of chiropractic care in their training and recovery processes at home. Fast forward to Paris 2024, where chiropractic care was available in the polyclinic for all athletes, and the attitude has now evolved to recognize that “every athlete deserves access to sports chiropractic."
It is estimated that 61% of patients with CTS avoid taking surgical options due to postoperative complications and costly surgical procedures. Chiropractic care offers a comprehensive and effective treatment for carpal tunnel syndrome, addressing the condition from multiple angles. Recent studies also have unveiled a game-changing adjunct to chiropractic treatments for CTS: nerve flossing.
Some doctors thrive in a personality-based clinic and have a loyal following no matter what services or equipment they offer, but for most chiropractic offices who are trying to grow and expand, new equipment purchases help us stay relevant and continue to service our client base in the best, most up-to-date manner possible. So, regarding equipment purchasing: should you lease, get a bank loan, or pay cash?
