Whenever a new patient comes in, especially one suffering with chronic pain, I get excited about the opportunity to find out what's ailing them and what I can do to help. There never seems to be enough time to spend with new patients - I have to verify/clarify the diagnosis; determine what phase of the healing process the patient is in; decide which treatments will help decrease pain, improve joint function, decrease muscle compensation patterns, and improve movement skills and strength; assess body composition; discuss metabolism, diet and nutrition; plan the recovery/regeneration strategy; and provide emotional support and work on psychology. It gets me excited knowing all of the possibilities and interventions that I can apply.
Here's an example of what takes place during a typical in-office rehabilitation session. Let's say the new patient has chronic slight or slight-to-moderate pain. Whatever the diagnosis, they have created muscular weakening and tightening through a lack of physical activity. Previous attempts at exercise caused a flare-up of pain. The patient's activity levels have gotten less and less, and they are actually afraid of exercise at this point.
This deconditioned effect has created restricted motion, stiff hypomobile joints, muscle atrophy, loss of endurance, tightening of connective tissues, inhibition of neural outflow, and eventual loss of cardiovascular fitness. So, how do we deal with atrophic muscles and muscles subject to recurrent spasm? The overall template is pretty much the same for each client; however, I customize each session. It may take six to 12 sessions just to complete the following list and orient the patient to the process of therapeutic lifestyle changes, but it's worth it. Every patient is unique and needs to learn at their own pace. My rehab template is based on those used at the National Academy of Sports Medicine.
1. Mobilize to loosen up joints and muscles: I use standard chiropractic procedures like mobilization/manipulation and fascial release techniques. I prefer to teach patients how to use the foam roll and perform self-myofascial release. Some patients get deep muscle stimulation over specific trigger points or fascial restrictions.
2. Activate of isolated muscles that are underactive: I use elastic bands, body-weight exercises or a cable resistance system. Exercises engage the muscles that help activate the neuromuscular system.
3. Whole-body exercises: After the warm-up movements and range-of-motion maneuvers, I introduce integrated whole-body exercises to specifically build up or transition to the strength training session. After years of using free weights with my clients, I have switched to using the kettlebells more and more. In my practice, kettlebells have replaced barbells, the squat rack, lever bars, medicine balls, grip devices and cardio equipment. The good news is that you don't need to spend thousands on expensive equipment. Two or three different-sized kettlebells are all you need to work effectively with most of your clients.
Kettlebells also do not take up much space, so you can train in a small area. Patients are happy to buy the right-sized kettlebell so they can do this type of training at home. In the office, you can create a great workout in a limited space while improving strength, agility and stamina.
Follow-up visits are for reviewing previously taught material, practicing, or teaching new routines. At the end of each session, I tell my patients what I expect might be sore over the next 24 to 48 hours. Soreness (within reason) is not a negative. It tells me I targeted the right muscles. I give the client time to recover or regenerate and prepare for the next session.
I don't need clients to perform cardio in my office. I live in Southern California. If my patient isn't walking, running or biking, or doesn't have access to a gym, I just get them to do more kettlebell swings. This takes care of the cardio in the way I like it to be performed - interval training style. (See previous articles on interval training.)
Most clients need some muscle pliability improvement. The question is: Should they be adjusted or manually mobilized? Should the client stretch, loosen up, perform self-mobilization, or use the foam roller? If you are not familiar with the foam roll, I highly recommend you try it. The foam roll will change the pliability of the muscle tissue; enhance the ability of the muscle fibers to slide and glide; decrease the amount of friction and adhesions in muscle tissue; mobilize the muscle belly; and change the neural feedback loop. I teach every one of my rehab patients how to use the foam roll at home. This session takes approximately 20 to 30 minutes, and patients are given a handout of the specific maneuvers to perform at home. A foam roll costs approximately $30.
Should you stretch or loosen a muscle? I loosen up clients for full range of motion and flexibility, as well as mobilize for action and movement. In my office, my clients also stretch. These are meant to be corrective exercise stretches targeted toward overactive muscles. Make sure you decide what you are stretching: the muscle, tendon or nerve.
Activation of isolated muscles turns on nerves and muscles; enhances the excitability of the neuromuscular sequence; improves the recruitment of the bundles and fibers; enhances muscle sequencing; and improves internal coordination, especially of diagonal movements; increases ROM; enhances movement patterns; and prepares the body to handle acceleration and deceleration forces. Activation of isolated underactive muscles is often overlooked in rehab. However, it is a necessary step in the rehab continuum. It helps to bridge the gap between stretching drills and whole-body movements.
What is the most common pattern in my low back patients that I am trying to activate? Without a doubt, it is the gluteus medius. The stretching or lengthening patterns are often directed toward overactive adductors, abductors, hip flexors, posterior shoulder and upper thoracic spine. Make sure you check the joints for hypomobility, especially the ankles, hips, thoracolumbar junction and cervicothoracic junction.
