According to Lewit, segmental dysfunction is the key reflex change associated with pain.1 Thus, assessing and treating joint dysfunction is the first line of treatment. Unfortunately, many times relapse occurs due to the sources of joint overstrain having gone undiagnosed. By far the most important such perpetuating factor is the presence of faulty movement patterns. Thus, remedial exercise and activity modification advice are the second line of treatment after manipulation.
In recurrent or chronic cases, Lewit says the key is to identify the faulty pattern (gait, lifting, respiration, spinal statics, etc.), then find the "key link" that is "chained up" to the pattern.1,2 Many of these patterns can be assessed through simple tests of key movement stereotypes developed by Janda (hip extension, hip abduction, trunk flexion).2 Recent evidence showing the relationship between key stabilizers, such as the multifidus and transverse abdominous and back pain, lends credence to this approach.3-8
A continuum of care incorporating a gradual transition from passive to active care approaches can be used to facilitate a "weak link." Passive, semi-active, and active approaches might include:
Rehabilitation involves a comprehensive prescription of advice, manipulation and exercise.2 The goal of advice is to reduce strain on the locomotor system. The goal of manipulation is to restore function in a "key link" (i.e., segmental movement restriction) which is "chained up" with the pain generating structure (i.e., myofascial trigger point). The goal of exercise is to stabilize the osteoligamentous system: in other words, to reduce stress at key joints/discs that is caused by abnormal movement patterns. Abnormal movement patterns should be viewed as the main perpetuating factor of both segmental movement restriction and myofascial trigger points.
Faulty movement patterns are common in our modern society with the prolonged time spent in constrained postures. This static overload causes predictable muscle imbalances and joint overstrain. For instance, we have all observed tight upper trapezius, pectorals, and suboccipital muscles in our patients. At the same time, we have observed head forward, round shouldered, and stiff upper thoracic kyphosis frequently. That these are tied together is obvious. Manipulation of the stiff upper thoracic kyphosis is needed. But, in many cases there will be relapse. Thus, it is also necessary to retrain static posture (i.e., Bruegger advice) and restore muscle balance.1,2
Palpation of the barrier in joints, muscles, fascia and skin is fraught with uncertainty. Notoriously poor interobserver reliability is considered the norm with our palpation. Fortunately, intraobserver reliability and thus responsiveness of motion palpation has been shown to be more promising. Nonetheless, in rehabilitation, since measurable improvements in function, especially reduction in activity intolerances is our goal, manipulation has a vital role to play: in particular, manipulation of some "key link" which has been determined to be related to faulty function in our patients activities of daily living or job demand.
A classic example is a movement restriction of the sacroiliac joint impairing forward bending movements. Identification of a joint restriction must precede manipulative therapy or else treatment is "blind." Also, palpation must feel the "release" that occurs when manipulation has been successful. In thrust techniques we hear the cavitation and can perform a post-treatment palpation to confirm the improvement. However, palpation of release becomes a sensitive ally in PIR, fascial and skin techniques as well. For example, in PIR or muscle energy techniques for joint restrictions we first take up the slack and engage the barrier. Then we ask the patient to gently contract against our resistance away from the barrier. After a brief isometric effort, usually combined with synkinetic breathing and eye movements, the patient is asked to relax and we wait. We wait for a release of the barrier; when we feel it, we follow by taking up the slack to the new barrier.
Manipulation is essential to rehabilitation of the motor system. "Remedial exercise is time consuming and time should not be wasted." It is the manipulation of some "key link" which is related to the activity intolerance that is the most economical and often efficacious treatment. Obviously, if abnormal movement patterns are "programmed," relapse may occur and remedial exercise aimed at restoring muscle balance and healthy movement patterns in one's ADLs and DE will be necessary.
References
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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?
