A Changing Paradigm

Rehabilitation and the biopsychosocial model have clearly established themselves as cornerstones of musculoskeletal medicine in the future. This model was given its catalyst by a series of books and articles released in the early to mid 1980s. The leading figures were Janet Travell, Karel Lewit, Vladimir Janda, Tom Mayer and Gordon Waddell. Each is an international authority on a different aspect of this revolution.

The paradigm shift got its first big shove when Travell and Simons' Trigger Point Manual was published in 1983. They not only detailed each and every trigger point, but educated us about the all important perpetuating factors. In 1985, Lewit's book Manipulative Therapy in Rehabilitation of the Motor System was finally translated into English. Lewit incorporated trigger points and joint dysfunction with a broad approach to locomotor system dysfunction, including abnormal movement patterns and remedial exercise. The abnormal movement patterns were the brainchild of Lewit's Czech colleague, Janda. Altered movement patterns, muscle imbalances, and joint dysfunction are now all seen as key perpetuating factors of trigger points.

In 1987, two papers were published which would have dramatic effects in both North America and Europe. In the Journal of the American Medical Association, Mayer published the excellent results of his functional restoration protocols on chronic low back pain and disability. Waddell received the Volvo award for his paper published in Spine on the biopsychosocial model for back pain. Together they emphasized the importance of recognizing psychosocial factors as crucial in the epidemic of disability. Additionally, great emphasis was placed on restoring function through exercise and early activation, while the importance of pathoanatomical findings was deemphasized.

On a personal note, this was a tremendous time to be first learning about chiropractic and musculoskeletal medicine. I was a student at LACC and wrote to Lewit in 1994, inviting him to visit our campus. In 1986, LACC played host to the first of five interdisciplinary symposiums which I organized with the help of Dr. Alan Adams. The first program included Lewit, Irvin Korr, Scott Haldeman and Ron Gitelman. Our second meeting included Travell's first appearance at a chiropractic college. She was joined by Janda, Phil Greenman, Mayer and others.

These events turned the tide in education about rehabilitation of the motor system for chiropractors. It has now been just over one decade since Lewit and Janda starting visiting LACC. Literally dozens of workshops with them were held at LACC, with most occurring between 1987-1991. In 1991, LACC launched their rehabilitation diplomate series and in 1995 CMCC followed suit. Some of our finest teachers like Donald Murphy, John Hannon, Jerry Hyman, Ron Lefebvre, and Curtis Rigney emerged from the early training with Lewit and Janda. A second wave of instructors began to emerge in the early 90s, including Scott Chapman, Natalie Gluck, Carol Defranca, Gary Ierna, and Clayton Skaggs.

As we pass the decade mark since Lewit and Janda's first visits to LACC, a number of landmark events have occurred. First, 10 day courses have been offered annually in Prague since 1995. This gives our chiropractic rehabilitation instructors and most motivated course participants a chance to see the Czech school of manual medicine on their "home turf." Second, our education in the diplomate series at LACC is gradually becoming "problem-based." This allows course participants a window to see how the new rehabilitation skills they are learning can be incorporated into "day to day" chiropractic practice.

Third, I have worked closely with AECC on developing their 1996 launch of a chiropractic MSc in Europe. The huge success of their first program in Bournemouth has led to plans next year to expand to a second British program and one in Sweden/Norway.

Finally, undergraduate curricula at a number of schools are now teaching active rehabilitation within the regular curriculum. LACC, National, and now Logan and Bridgeport are leading the way with a full 50-hour physical therapy course. Western States and New York have flirted with this model, and AECC is expected to fully integrate the new paradigm into their entire curriculum within two years.

Active care, outcomes measurement, and early identification of psychosocial predictors of chronicity are benchmarks of the rehabilitation paradigm. Chiropractors are strategically positioning themselves for battle in the managed care marketplace by integrating these skills into their practices. "Blue chip" PPOs from all over the United States are beginning to recognize that quality is as important as cost in the highly competitive negotiations they now find themselves in.

Chiropractors are without a doubt leaders in musculoskeletal medicine. By incorporating the rehabilitation paradigm into our practices we can guarantee that we stay competitive. Let's strengthen ourselves by learning all we can about the functional restoration revolution that is occurring.

References

• Travell JG, Simons DG. Myofascial Pain and Dysfunction: The Trigger Point Manual. Vol 1, Baltimore. Williams and Wilkins, 1983.
• Lewit K. Manipulative Therapy in Rehabilitation of the Locomotor System. 2nd ed. Oxford, Butterworth-Heinemann, 1991.
• Waddell G. A new clinical model for the treatment of low back pain. Spine 12:634, 1987.
• Mayer TF, Gatchel RJ, Mayer H, et al. A prospective two-year study of functional restoration in industrial low back injury. JAMA 258:1763, 1987.
• Ebrall P. A chiropractor's reading list. Chiropractic Journal of Australia 1996;26 (4):142-43.
• Liebenson C. Rehabilitation of the Spine: A Practitioner's Manual. Baltimore. Williams and Wilkins, 1996.