Principles of Rehabilitation

Any localized pain will act reflexively at the spinal segmental level. Interaction between muscles, joints, skin, and viscera can potentially occur. A painful disorder at the periphery will cause a central response whereby a motor pattern will form to spare the painful part.

The typical reaction in the periphery to pain is increased tension or inhibition. The central reaction is an altered motor program. A chain reaction occurs following a certain hierarchy starting with viscera, segmental, muscle, and lastly skin. Relapses at the periphery are usually due to central programming errors or less commonly to a visceral disturbance.

The locomotor system is the most common source of pain. The key is the functioning of the locomotor system and its possible disturbance (i.e., segmental restriction or disturbed motor pattern). A disturbed motor pattern also relates to state of mind or psychology, especially in cases of anxiety, fear-avoidance, or depression.

Rehabilitation is primarily concerned with restoration of impaired function even if there is underlying structural pathology. The greatest obstacle is a lack of understanding the principles of functional pathology and reflex changes. Diagnosis is not sufficient to decide on treatment. Analysis of functional pathology is necessary. After treatment, re-examination is necessary to judge our clinical hypothesis. If treatment is successful examination, results should change; thus, treatment will change rather than be monotonous.

There Are Predictable Muscle Imbalance Patterns

In chronic patients Janda tested muscles and found many muscles participated in certain movement patterns. Constant patterns emerged with some muscles tending to hypertonia (postural muscles) and others to hypotonia (phasic muscles). Paresis in upper motor neuron lesions selectively occurs in these phasic muscles, while spasticity in diseases like cerebral palsy mostly affects the postural muscles. Common syndromes were discovered such as the upper and lower crossed syndromes. These patterns function as part of a chain reaction and can be facilitated by afferent stimuli. Special attention should be paid to the fingers and toes (i.e., lifting the big toe facilitates walking). In a similar way the eyes are facilitative of trunk motor control: looking up facilitates straightening.

Modern society encourages a muscle imbalance between postural and phasic systems by favoring the postural system. Our typical workstations lead to decreased mobility and overburden the patient with excessive static muscular effort. When we understand the predictable nature of these chain reactions we can clinically expect to find certain functional pathologies in our patients. The following table shows an example of this.

Typical Functional Chain Reaction with Forward Head Posture

• stiff upper thoracic kyphosis
• tight pectorals
• tight upper trapezius
• weak lower trapezius
• increased scalene tension
• elevated thorax with respiration

Utilize Exercise in Selected Patients: Set Realistic Goals

The initial conservative care trial when rehabilitating muscle imbalances and motor programs is about two weeks. This is the time necessary to uncover a chain reaction and treat various links in the chain in an attempt to find a "key link." It is especially important to contrast remedial exercise with manipulation.

• Manipulation is quick; exercise is time consuming;
• Manipulation corrects segmental dysfunction or joint blockage; exercise corrects motor patterns.

Due to the time factor, the relevance of exercise must be established or else it can be "a waste of time." Just like joint blockage, faulty motor patterns are very common. Thus, finding a faulty pattern is not enough to determine if exercise is necessary. A few criteria follow:

• patients who are suffering frequent relapses or in whom relapse is predicted;
• patients who are motivated.

If we select patients who are good candidates, then our time is likely to be better spent. It is important not to attempt to teach ideal locomotor patterns. Limit your goal and only treat the patient for a few weeks rather than months or years. In chronic cases, besides giving manipulation for segmental restrictions, and exercise for faulty patterns, advice about work place modifications is crucial to success.

References

• Lewit K. Manipulative Therapy in Rehabilitation of the Motor System. 2nd edition. London: Butterworths, 1991.
• Lewit K. The role of manipulation in spinal rehabilitation. In: Liebenson C. (ed.) Rehabilitation of the Spine: A Practitioner's Manual. Baltimore: Williams and Wilkins, 1996.

Craig Liebenson, DC
Los Angeles, California